Techniques for surgical retrieval of sperm prior to ICSI for azoospermia

Testosterone levels among non-obstructive azoospermic patients 2 years after failed bilateral microdissection testicular sperm extraction: a nested case-cohort study

PURPOSE

To define the risk of hypogonadism following microdissection testicular sperm extraction in cases of non-obstructive azoospermia. While sperm retrieval by open testicular sperm extraction can be associated with an increased risk of hypogonadism, there is limited data addressing which procedures and which patients harbor the greatest risk.

METHODS

We report on a community-acquired, nested, case-cohort of non-obstructive azoospermic patients referred to one clinic after failed bilateral microdissection testicular sperm extraction. Patients were health-matched (1:2) to surgically naïve controls and divided into 2 cohorts based on risk factors for hypogonadism. Among microdissection patients, we compared total testosterone and gonadotropin levels before and > 6 months after surgery. Biochemical hypogonadism was defined as a total serum testosterone level ≤ 300 ng/dL. Hormone levels were compared to risk-matched controls. Comparative statistics were used to assess hormone levels within and between cohorts.

RESULTS

There were no significant differences in baseline testosterone levels between microdissection patients (n = 26) and risk-matched controls (n = 52). At a mean of 26 months (range 6.2-112.8) post-procedure, mean testosterone levels decreased significantly (73 ng/dL or 16%; CI - 27, - 166; p < 0.01, paired t-test). Among microdissection patients with baseline testosterone > 300 ng/dL, 8/22 (36%) experienced hypogonadism post-procedure. There was a corresponding increase in follicle stimulating hormone (p = 0.05) and a trending increase in luteinizing hormones (p = 0.10).

CONCLUSION

A durable decrease in testosterone levels occurs after failed microdissection testicular sperm extraction regardless of baseline risk of hypogonadism. In addition, a significant proportion of eugonadal patients will become hypogonadal after failed testicular microdissection procedures.

First reported deliveries in Ireland using surgically retrieved sperm for non-obstructive azoospermia

Couples presenting with male factor infertility comprise an important proportion of clinical reproductive endocrinology consultations. Indeed, a problem with the male is the only cause, or a contributing cause, of infertility in ~40% of infertility evaluations. Here we present the first published deliveries obtained from IVF utilising surgically retrieved sperm in Ireland; pregnancy and delivery are also described following transfer of cryopreserved/thawed embryos derived from such sperm. Finding no sperm from a semen analysis in a man without a vasectomy can be a devastating event, and substantially influences the scope of the reproductive endocrinology consultation. Successful treatment of non-obstructive azoospermia is possible without reliance on anonymous donor sperm.

Practical approaches to the diagnosis and management of male infertility

Male infertility affects 10% of couples of reproductive age worldwide, and is treatable in many cases. In addition to well-established etiologies, genetic causes of male infertility are now diagnosed more commonly, as our knowledge of genomic medicine advances. Using principles of evidence-based medicine, this review outlines diagnostic and treatment algorithms that guide clinical management. In order of importance, randomized controlled clinical trials, basic scientific studies, meta-analyses, case-controlled cohort studies, best-practice policy recommendations and reviews from peer-reviewed literature were incorporated into algorithms that provide organized and timely guidelines to the current management of male infertility. The strength of the evidence for treatment recommendations is also classified when appropriate.