Use of frozen-thawed testicular sperm for intracytoplasmic sperm injection

Sperm Selection Procedures for Optimizing the Outcome of ICSI in Patients with NOA

Retrieving spermatozoa from the testicles has been a great hope for patients with non-obstructive azoospermia (NOA), but relevant methods have not yet been developed to the level necessary to provide resolutions for all cases of NOA. Although performing testicular sperm extraction under microscopic magnification has increased sperm retrieval rates, in vitro selection and processing of quality sperm plays an essential role in the success of in vitro fertilization. Moreover, sperm cryopreservation is widely used in assisted reproductive technologies, whether for therapeutic purposes or for future fertility preservation. In recent years, there have been new developments using advanced technologies to freeze and preserve even very small numbers of sperm for which conventional techniques are inadequate. The present review provides an up-to-date summary of current strategies for maximizing sperm recovery from surgically obtained testicular samples and, as an extension, optimization of in vitro sperm processing techniques in the management of NOA.

The management of obstructive azoospermia: a committee opinion

Infertility due to obstructive azoospermia may be treated effectively by surgical reconstruction or by retrieval of sperm from the epididymis or testis, followed by in vitro fertilization with intracytoplasmic sperm injection. This replaces the ASRM documents titled "Sperm retrieval for obstructive azoospermia" and "The management of infertility due to obstructive azoospermia," last published in 2008.

Comparison and outcomes of nonobstructive azoospermia patients with different etiology undergoing MicroTESE and ICSI treatments

Background

The purpose of the study was to compare clinical, laboratory, histological features, microdissection testicular sperm extraction (MicroTESE) and intracytoplasmic sperm injection (ICSI) treatment outcomes of nonobstructive azoospermia (NOA) patients of various etiologies, and to investigate ICSI outcomes using fresh and frozen thawed sperms from MicroTESE, so to explore an optimal MicroTESE-ICSI procedure for NOA couples.

Methods

A retrospective analysis was made in 595 NOA patients undergoing MicroTESE from January 2013 to December 2017. The men were classified into six groups based on etiology. Patients' age, history, hormone profile, testis volume, testicular histology, sperm retrieval, fertile and pregnancy outcomes of ICSI were included for analysis.

Results

A total of 595 NOA patients were included in this study, with 446 (75.0%) were idiopathic NOA, 66 (11.1%) were Klinefelter syndrome (KS), 34 (5.7%) with microdeletion of the AZFc, 33 (5.5%) cases had the history of cryptorchidism, 13 (2.2%) had a history of mumps orchitis, and 3 (0.5%) cases underwent chemotherapy. The overall sperm retrieval rate (SRR) was 40.3% (240/595), SRR of the cryptorchidism (84.8%, 28/33) and mumps orchitis (84.6%, 11/13) groups were much higher than that of other groups, the SRR of idiopathic group was the lowest (31.8%, 142/446). One hundred and ninety-eight ICSI cycles utilizing MicroTESE sperm were retrospectively analyzed, including 155 fresh MicroTESE ICSI cycles and 43 frozen-thawed MicroTESE ICSI cycles. Fertilization rate, cleavage rate, and clinical pregnancy rate of fresh sperm group were slightly higher than those in frozen thawed MicroTESE sperm group, but high qualified embryo rate of fresh sperm group was lower than frozen thawed group. The differences were of no statistical meaning.

Conclusions

Etiology may be an effective prognostic factor for SRR in NOA patients. NOA of definite etiology, such as cryptorchidism, has high SRR, while idiopathic NOA, the most common type of NOA, has the lowest SRR. Using of frozen thawed sperm from MicroTESE had similar pregnant outcome to that of fresh sperm, so cryopreservation of testicular sperm seems to be more suitable and of great benefit in these cases and good results can also be expected when oocyte retrieval and ICSI are not performed at the same time.

Microscopic varicocelectomy as a treatment option for patients with severe oligospermia

Purpose

Many studies have shown improved semen parameters after varicocele surgery; however, the benefit in terms of improved pregnancy rates and live births is still disputed in cases of severe oligoasthenozoospermia (OAS). The present study evaluated the outcome of microscopic subinguinal varicocelectomy in terms of the spontaneous pregnancy rate in patients with severe OAS.

Materials and Methods

This was a retrospective, observational, analytic study of 56 men with OAS who underwent microscopic varicocelectomy at our center between 2008 and 2015. The subjects were followed for a mean period of 12.4 months. Outcome was compared among groups of men with mild (sperm concentration, 10.2–19 million/mL), moderate (5.7–9.5 million/mL), and severe (<5 million/mL) OAS who were operated on during the same period.

Results

A total of 13 of 35 men (37.1%) with severe OAS achieved spontaneous pregnancy. Mean sperm density increased from 2.29 million/mL preoperatively to 14.09 million/mL postoperatively. The mean time to pregnancy from the date of surgery was 8.5 months. The spontaneous pregnancy rate in men with mild and moderate OAS was 62.5% and 46.2%, respectively.

Conclusions

Although pregnancy rates after varicocele surgery are lower preoperatively in men with severe OAS than in men with mild or moderate OAS, the spontaneous pregnancy rate of 37.1% still compares very favorably with outcomes after a single attempt at in vitro fertilization.

New Promising Strategies in Oncofertility

INTRODUCTION

Approximately 70,000 adolescent and young adults (AYA) are diagnosed with cancer each year. While advancements in treatment have led to improved prognosis and survival for patients, these same treatments can adversely affect AYA reproductive capacity. Localized treatments such as surgery and radiation therapy may affect fertility by removing or damaging reproductive organs, and systemic therapies such as chemotherapy can be toxic to gonads, (ovaries and testicles), thus affecting fertility and/or endocrine function. This can be traumatic for AYA with cancer as survivors often express desire to have genetic children and report feelings of regret or depression as a result of infertility caused by cancer treatments.

AREAS COVERED

Emerging technologies in the field of assisted reproductive technology offer new promise for preserving the reproductive capacity of AYA cancer patients prior to treatment as well as providing alternatives for survivors. The following review revisits contemporary approaches to fertility preservation as well newly developing technologies.

EXPERT COMMENTARY

There are several advances in ART that hold promise for patients and survivors. However there are challenges that inhibit uptake including poor communication between providers and patients about risks and fertility preservation options; high costs; and lack of insurance coverage for fertility preservation services.

Validation-verification of a highly effective, practical human testicular tissue in vitro culture-cryopreservation procedure aimed to optimize pre-freeze and post-thaw motility

PURPOSE

The aim of our paper was to validate a testicular biopsy procedure that simplifies handling, processing, and cryopreservation, while at the same time optimizes sperm motility before freezing and after thawing.

METHODS

Two prospective studies were conducted to verify, optimize, and understand the virtues of pre-freeze testicular tissue IVC at different temperatures (21, 30, or 37 °C). Testicular tissue was obtained from clinical specimens designated for whole tissue cryopreservation (i.e., intact mass of tubules) and/or for fresh use in IVF-ICSI cycles. Whole testicular biopsy pieces (1-3 mm(3)) were diluted in glycerol containing freeze solutions, slow cooled to 4 °C and then rapidly frozen in LN2 vapor. Fresh and post-thaw testicular biopsy tissue were evaluated for changes in the quantity (%) and pattern of motility (I-IV: twitching to rapid progression, respectively) over a 1 week duration. The clinical effectiveness of IVC-cryopreserved whole testicular biopsy tissue was also validated analyzing fresh embryo transfers.

RESULTS

More reliable recovery of motile testicular sperm was achieved using whole tissue freeze preservation combined with IVC (24-96 h) post-acquisition at an incubation temperature of 30 °C compared to ambient temperature (21 °C) or 37 °C. Up to 85 % of the pre-freeze motility was conserved post-thaw (+3 h) for easy ICSI selection. Sperm longevity was optimized to fresh tissue levels by implementing testicular biopsy sucrose dilution post-thaw. Favorable clinical outcomes were proven using frozen-thawed testicular biopsy sperm for ICSI.

CONCLUSIONS

By employing minimal tissue manipulation, integrating pre-freeze IVC processing at 30 °C and the freezing of whole testicular biopsy tissue, we have reduced the labor and improved the efficacy of processing testicular tissue for freeze-preservation and subsequent ICSI use.

A step-wise approach to sperm retrieval in men with neurogenic anejaculation

Normal fertility is dependent on intravaginal delivery of semen through ejaculation. This process is highly dependent on an intact ejaculatory reflex arc, which can be disrupted through any type of trauma or disease causing damage to the CNS and/or peripheral nerves. Neurogenic anejaculation is most commonly associated with spinal cord injury. This aetiology is especially relevant because most men with spinal cord injuries are injured at reproductive age. Assisted ejaculation in the form of penile vibratory stimulation is the first choice for sperm retrieval in such patients because it is noninvasive and inexpensive. In patients in whom vibratory stimulation fails, electroejaculation is almost always successful. When both methods of assisted ejaculation are unsuccessful, sperm retrieval by aspiration from either the vas deferens or the epididymis, or by testicular biopsy or surgery are reasonable options. In such cases the most inexpensive and least invasive methods should be considered first. The obtained semen can be used for intravaginal or intrauterine insemination or in vitro fertilization with or without intracytoplasmic sperm injection.

The development of cat testicular sperm cryopreservation protocols: Effects of tissue fragments or sperm cell suspension

In endangered animals that have been found dead or sterilized for medical reasons, testis is the ultimate source of haploid DNA or sperm. Thus, preservation of testicular sperm may be performed to rescue their genetics. The aim of this study was to evaluate protocols for testicular sperm freezing: as tissue fragments or cell suspension in domestic cats as a model. A pair of testes from each cat (n = 9) were cut into eight equal pieces. Four randomly selected pieces were cryopreserved as: (1) tissue pieces using two-step freezing; (2) tissue pieces using a slow passive cooling device (CoolCell); (3) sperm suspension after single-layer centrifugation (SLC) through colloids; and (4) sperm suspension without being processed through SLC. A testicular piece from each cat served as fresh control. Testicular sperm membrane and DNA integrity were evaluated before, and after, the cryopreservation process. In addition, spermatogenic cell types (testicular sperm, spermatogonia, spermatocyte, and spermatid) present in the suspension samples were counted before and after SLC. The results found that testicular sperm membrane integrity in the suspension after SLC process was higher than that in the fragment form neither using the two-step nor CoolCell freezing, both before and after freezing (before freezing: 92.3 ± 3.4 vs. 81 ± 4.5 and 80.0 ± 7.0; after freezing: 84.5 ± 4.6 vs. 71.2 ± 12 and 76.2 ± 4.6; P ≤ 0.05). Testicular sperm DNA integrity was, however, not different among groups. Furthermore, the samples processed through the SLC had higher ration of sperm cells: other spermatogenic cells than those were not processed through the SLC (88.9 ± 3.8 vs. 30 ± 7.9; P ≤ 0.05). In summary, testicular sperm cryopreserved as a minced suspension is considered suitable in terms of preventing sperm membrane integrity, and SLC is considered a selection tool for enriching haploid sperm cells from castrated or postmortem cats.

Management of male neurologic patients with infertility

Many aspects of fertility rely on intact neurologic function and thus neurologic diseases can result in infertility. While research into general female fertility and alterations in male semen quality is limited, we have an abundance of knowledge regarding ejaculatory dysfunction following nerve injury. Normal ejaculation is the result of coordinated reflex activity involving both the sympathetic and somatic nervous systems. Nerve injury can result in retrograde ejaculation, and anejaculation. With retrograde ejaculation, the ejaculate is propelled into the bladder instead of out through the urethra. In mild cases this condition can be reversed by sympathomimetic medications and, in more severe cases, sperm cells can be extracted from the bladder following ejaculation. With anejaculation, the ejaculatory reflex is not activated by normal sexual stimulation. In such cases, the first choice of treatment is assisted ejaculation, preferably by penile vibratory stimulation. If vibratory stimulation is unsuccessful, then ejaculation can almost always be induced by electroejaculation. In cases where assisted ejaculation fails, sperm can be retrieved surgically from either the epididymis or from the testis. Once viable sperm cells have been obtained, these are used in assisted reproductive techniques, including intravaginal insemination, intrauterine insemination, and in vitro fertilization/intracytoplasmic sperm injection.

Sperm recovery and IVF after testicular sperm extraction (TESE): effect of male diagnosis and use of off-site surgical centers on sperm recovery and IVF

Objective

Determine whether testicular sperm extractions and pregnancy outcomes are influenced by male and female infertility diagnoses, location of surgical center and time to cryopreservation.

Patients

One hundred and thirty men undergoing testicular sperm extraction and 76 couples undergoing 123 in vitro fertilization cycles with testicular sperm.

Outcome Measures

Successful sperm recovery defined as 1–2 sperm/0.5 mL by diagnosis including obstructive azoospermia (n = 60), non-obstructive azoospermia (n = 39), cancer (n = 14), paralysis (n = 7) and other (n = 10). Obstructive azoospermia was analyzed as congenital absence of the vas deferens (n = 22), vasectomy or failed vasectomy reversal (n = 37) and “other”(n = 1). Sperm recovery was also evaluated by surgical site including infertility clinic (n = 54), hospital operating room (n = 67) and physician’s office (n = 11). Treatment cycles were evaluated for number of oocytes, fertilization, embryo quality, implantation rate and clinical/ongoing pregnancies as related to male diagnosis, female diagnosis, and use of fresh or cryopreserved testicular sperm.

Results

Testicular sperm recovery from azoospermic males with all diagnoses was high (70 to 100%) except non-obstructive azoospermia (31%) and was not influenced by distance from surgical center to laboratory. Following in vitro fertilization, rate of fertilization was significantly lower with non-obstructive azoospermia (43%, p = <0.0001) compared to other male diagnoses (66%, p = <0.0001, 59% p = 0.015). No differences were noted in clinical pregnancy rate by male diagnosis; however, the delivery rate per cycle was significantly higher with obstructive azoospermia (38% p = 0.0371) compared to diagnoses of cancer, paralysis or other (16.7%). Women diagnosed with diminished ovarian reserve had a reduced clinical pregnancy rate (7.4% p = 0.007) compared to those with other diagnoses (44%).

Conclusion

Testicular sperm extraction is a safe and effective option regardless of the etiology of the azoospermia. The type of surgical center and/or its distance from the laboratory was not related to success. Men with non-obstructive azoospermia have a lower chance of successful sperm retrieval and fertilization.

Microtubule organisation, pronuclear formation and embryonic development of mouse oocytes after intracytoplasmic sperm injection or parthenogenetic activation and then slow-freezing with 1,2-propanediol

The goal of this study was to investigate the effect of cryopreservation on oocytes at different times after intracytoplasmic sperm injection (ICSI) and parthenogenetic activation. The study was performed in mouse oocytes fertilised by ICSI, or in artificially-activated oocytes, which were cryopreserved immediately, one hour or five hours later through slow-freezing. After thawing, the rates of survival, fertilisation–activation, embryonic development of oocytes–zygotes and changes in the cytoskeleton and ploidy were observed. Our results reveal a significant difference in survival rates of 0-, 1- and 5-h cryopreserved oocytes following ICSI and artificial activation. Moreover, significant differences in two pronuclei (PN) development existed between the 0-, 1- and 5-h groups of oocytes frozen after ICSI, while the rates of two-PN development of activated oocytes were different between the 1-h and 5-h groups. Despite these initial differences, there was no difference in the rate of blastocyst formation from two-PN zygotes following ICSI or artificial activation. However, compared with ICSI or artificially-activated oocytes cryopreserved at 5 h, many oocytes from the 0- and 1-h cryopreservation groups developed to zygotes with abnormal ploidy; this suggests that too little time before cryopreservation can result in some activated oocytes forming abnormal ploidy. However, our results also demonstrate that spermatozoa can maintain normal fertilisation capacity in frozen ICSI oocytes and the procedure of freeze–thawing did not affect the later development of zygotes.

Birth and clinical pregnancy from fresh and frozen oocytes fertilized with cryopreserved testicular spermatozoa

This is the first report showing a second clinical pregnancy of a couple who already have a baby from a previous frozen embryo transfer cycle when the embryos were generated from fresh oocytes that were fertilized by intracytoplasmic sperm injection (ICSI) using frozen testicular spermatozoa (the couple have unsuccessful fresh and frozen embryo transfer cycles). Fifty-two months after the first IVF/ICSI cycle the couple had their second IVF/ICSI cycle, but the collected oocytes (n=8) were frozen because no spermatozoa was obtained from the frozen testicular tissue samples which were cryopreserved prior to the first IVF/ICSI cycle. New testicular tissue samples were obtained and frozen. Finally, 58 months after the first IVF/ICSI cycle all of the 8 frozen oocytes of the couple were thawed and fertilized by ICSI using frozen testicular spermatozoa obtained from the newly cryopreserved testicular tissue. Three embryos were transferred and the couple has an ongoing pregnancy, which is in the 20(th) week of pregnancy. Our case report shows that: 1) developmentally competent embryos can be generated by ICSI of frozen-thawed testicular spermatozoa into both fresh and frozen human oocytes, and 2) clinical pregnancy and a healthy baby can be conceived from both frozen and fresh oocytes fertilized with cryopreserved testicular spermatozoa.

Increased fertilization rates after in vitro culture of frozen-thawed testicular immotile sperm in nonobstructive azoospermic patients

Objective. To optimise the use of freeze/thaw testicular immotile spermatozoa from nonobstructive azoospermia patients and to analyse the outcome of intracytoplasmic sperm injection (ICSI) of such spermatozoa. Methods. Testicular specimens were retrieved and cryopreserved from forty patients with nonobstructive azoospermia and underwent one cycle with thawed spermatozoa (Group I) that led to pregnancy in sixteen cases. Twenty-four patients of group I underwent treatment with the same batch of thawed spermatozoa (Group II). For the first ICSI attempt, injection was performed when motile spermatozoa were found. In group II, injection was performed when maximum motility was reached. We compared mean of fertilization rate, embryo quality, clinical pregnancy rate and embryo implantation rate. Results. The mean percentage of motility was significantly higher in the group II than in the group I (18, 6 versus 8, 2). Group I showed a significant decrease in fertilization rates when compared with cryopreserved testicular spermatozoa in group II (54% versus 72%, P < 0.05). No difference was noted between the cleavage rate, embryo quality, clinical pregnancy rates and implantation rates among group II and I. Conclusion. Fecundation rate can be significantly improved after in-vitro culture and sperm selection of frozen-thawed immotile testicular spermatozoa in patients with nonobstructive azoospermia.

Male sexual dysfunction and infertility associated with neurological disorders

Normal sexual and reproductive functions depend largely on neurological mechanisms. Neurological defects in men can cause infertility through erectile dysfunction, ejaculatory dysfunction and semen abnormalities. Among the major conditions contributing to these symptoms are pelvic and retroperitoneal surgery, diabetes, congenital spinal abnormalities, multiple sclerosis and spinal cord injury. Erectile dysfunction can be managed by an increasingly invasive range of treatments including medications, injection therapy and the surgical insertion of a penile implant. Retrograde ejaculation is managed by medications to reverse the condition in mild cases and in bladder harvest of semen after ejaculation in more severe cases. Anejaculation might also be managed by medication in mild cases while assisted ejaculatory techniques including penile vibratory stimulation and electroejaculation are used in more severe cases. If these measures fail, surgical sperm retrieval can be attempted. Ejaculation with penile vibratory stimulation can be done by some spinal cord injured men and their partners at home, followed by in-home insemination if circumstances and sperm quality are adequate. The other options always require assisted reproductive techniques including intrauterine insemination or in vitro fertilization with or without intracytoplasmic sperm injection. The method of choice depends largely on the number of motile sperm in the ejaculate.

[Azoospermia: management and results: a series of 90 cases]

OBJECTIVE

To report our 15-year experience in managing azoospermic males at the Brest University Hospital.

PATIENTS AND METHODS

From 1996 to 2010, 90 azoospermic males were followed: 41 with non-obstructive azoospermia (NOA) and 49 with obstructive azoospermia (OA). Surgical methods proposed for retrieving sperm were Microsurgical Epididymal Sperm Aspiration (MESA) for men with OA and microdissection Testicular Sperm Extraction (mTESE) for those with NOA.

RESULTS

Spermatozoa were retrieved in 56.1% of the testicular biopsies for NOA. The embryo transfer rate per cycle for injection intracytoplasmique d'un spermatozoïde (ICSI) with epididymal spermatozoa (OA) was higher to that of ICSI with ejaculated spermatozoa (93.2% vs. 86.6%, P<0.05), but the rate was lower for ICSI with testicular sperm (NOA) (70.2% vs. 86.6%, P<0.01). The rate of clinical pregnancy per embryo transfer was 31.4% following ICSI with epididymal spermatozoa but it was of 24.2% with testicular sperm and 23.1% with ejaculated sperm.

CONCLUSION

ICSI are usually difficult in NOA because they are done with very few spermatozoa. When spermatozoa are retrieved from surgical techniques, more than 50% of the OA couples and almost 30% of the NOA couples conceived at least one child.

Deliveries from embryos fertilized with spermatozoa obtained from cryopreserved testicular tissue

AIM

The data of 167 TESE-ICSI-ET cycles performed with fresh or frozen, motile or immotile testicular spermatozoa were analyzed, retrospectively.

METHODS

The outcome measures studied were state/condition of spermatozoa, fertilization, embryo developmental, implantation and pregnancy/delivery and abortion rates.

RESULTS

No differences were found in fertilization, implantation and pregnancy rates of oocytes injected with fresh or frozen spermatozoa. However, difference was obtained in the fertilization rate of oocytes injected with motile vs. non-motile spermatozoa (72% vs. 62%; P < 0.04). Difference was also observed in embryo development between oocytes injected with fresh vs. frozen spermatozoa (83% vs. 75%; P < 0.03). But, no difference was obtained in embryo development between oocytes injected with motile vs. immotile spermatozoa. No difference was also found in the implantation rate of embryos developed from oocytes injected with motile vs. non-motile spermatozoa. No difference was found in abortion rates either.

CONCLUSIONS

State/condition of injected testicular spermatozoa has impact to fertilization and embryo development. Pregnancy/delivery can be achieved with frozen/immotile spermatozoa.

Sperm harvesting and cryopreservation during vasectomy reversal is not cost effective

OBJECTIVE

To determine whether sperm harvesting and cryopreservation at the time of vasectomy reversal is cost-effective.

DESIGN

Model of actual costs and results at five institutions.

SETTING

Multicenter study comprising five centers, including university hospitals and private practices.

PATIENT(S)

Men undergoing vasectomy reversal.

INTERVENTION(S)

We established two models for vasectomy reversal. The first model was sperm harvesting and cryopreservation at the time of vasectomy reversal. The second model was sperm harvesting at the time of IVF only if the patient remained azoospermic after vasectomy reversal. Vasectomy reversal procedures modeled included bilateral vasovasostomy and bilateral epididymovasostomy. The costs for each procedure at the five institutions were collated and median costs determined.

MAIN OUTCOME MEASURE(S)

Median cost of procedure and calculated financial comparisons.

RESULT(S)

The median cost of testicular sperm extraction/cryopreservation performed at the time of bilateral vasovasostomy was $1,765 (range, $1,025-$2,800). The median cost of microsurgical epididymal sperm aspiration or testicular sperm extraction with cryopreservation performed at the time of epididymovasostomy was $1,209 (range, $905-$2,488). The average of the median costs for percutaneous sperm aspiration or testicular sperm aspiration for those patients with a failed vasectomy reversal was $725 (range, $400-$1,455).

CONCLUSION(S)

Sperm retrieval with cryopreservation at the time of vasectomy reversal is not a cost-effective management strategy.

Medical treatment to improve sperm quality

Approximately 30% of cases of couple infertility are due to a male factor. Several conditions can interfere with spermatogenesis and reduce sperm quality and production. Treatable conditions, such as hypogonadism, varicocele, infections and obstructions, should be diagnosed and corrected, but many aspects of male factor infertility remain unclear. Various agents have been used in the attempt to increase the fertility potential of subjects with idiopathic oligoteratoasthenozoospermia. The rationale of medical treatment to improve sperm quality in these subjects has been questioned by the introduction of assisted reproductive technologies. However, there is now growing awareness of the importance of good quality spermatozoa for embryonic development and higher birth rates. Confounding factors in assessing the efficacy of male infertility treatments have erroneously inflated the superiority of assisted reproductive technologies over conventional approaches. A systematic review is given of relevant randomized controlled trials and effects on semen parameters. The analysis reveals that although results are heterogeneous, gonadotrophins, anti-oestrogens, carnitine and trace elements may be beneficial in improving sperm quality, although their effect on pregnancy rate remains controversial. The most common drug regimens are compared and an estimate of the results expected from these treatments provided.

Outcomes in couples undergoing ICSI: comparison between fresh and frozen-thawed surgically retrieved spermatozoa

We retrospectively evaluated the impact of cryopreservation on spermatozoa obtained from patients with azoospermia and used for intracytoplasmic sperm injection (ICSI). Frozen-thawed epididymal spermatozoa (FTEPS) was used in 34 couples, whereas frozen-thawed testicular spermatozoa (FTTS) was used in 50 couples for ICSI during assisted conception, and these results were compared with results using fresh spermatozoa for ICSI in the same individuals. The fertilization rate (FR) was significantly lower for FTTS (65.8%) but not for FTEPS (73.1%) compared with the FR using fresh spermatozoa (72.3% and 73.2% respectively). In contrast, neither the implantation nor the pregnancy rate was altered when FTEPS or FTTS was used. In conclusion, our results indicate that surgically retrieved spermatozoa can be efficiently used for ICSI after freezing and thawing without compromising the outcome.

Cumulative pregnancy rate after ICSI with cryopreserved testicular tissue in non-obstructive azoospermia

The aim of the present study was to describe a simplified and inexpensive method of testicular tissue freezing, to assess the cumulative clinical pregnancy rate (CPR) by this technique, and to provide useful information for counselling couples with non-obstructive azoospermia. One hundred and sixty-five couples with non-obstructive azoospermic males pursuing assisted conception, from December 1995 to December 2002, were included. In all cases, the testicular tissue retrieved by open multiple-biopsy (both sides, by testicular sperm extraction) was frozen using a simple liquid nitrogen vapour freezing technique and was stored in liquid nitrogen thereafter. Only mature spermatozoa were used for intracytoplasmic sperm injection (ICSI) after thawing. Expected CPR were calculated using the Kaplan-Meier survival analysis. A total of 281 cycles were performed resulting in 53 clinical pregnancies. Crude and expected CPR (95% confidence intervals) after three cycles were 32.1 (25.7-40.1) and 55.7% (37.0-74.4) respectively. In conclusion, this simplified method for freezing testicular tissue resulted in a satisfactory outcome after ICSI in cases of non-obstructive azoospermia.

Should diagnostic testicular sperm retrieval followed by cryopreservation for later ICSI be the procedure of choice for all patients with non-obstructive azoospermia?

BACKGROUND

This was a retrospective study to determine if diagnostic testicular biopsy followed by cryopreservation should be the procedure of choice for all patients with testicular failure.

METHODS

The first part of the study analysed 97 ICSI cycles scheduled with frozen-thawed testicular sperm for 69 non-obstructive azoospermia (NOA) patients. The second part focused on a subgroup of 32 patients who underwent 42 ICSI cycles with frozen and 44 cycles with fresh testicular sperm. Sperm characteristics, fertilization, embryo quality, pregnancy and implantation rates were evaluated.

RESULTS

Part I: The average time needed to find sperm was 113 min per cycle and 17 min per individual sperm. Fertilization rate, embryo transfer rate, ongoing pregnancy and implantation rates were 58.4%, 83%, 20.8% and 11.3%, respectively. Part II: The search time per sperm was higher (P=0.016) in frozen (18 min) than in fresh suspensions (13 min). A higher embryo transfer rate was observed in fresh cycles than in frozen cycles (93.2% vs 76.2%, P=0.028). Fertilization, ongoing pregnancy and implantation rates were comparable for the two groups.

CONCLUSIONS

Even in a programme with low-restrictive criteria for patient allocation and for sperm cryopreservation, diagnostic testicular biopsy followed by cryopreservation can be the procedure of choice for patients with testicular failure.

Causes of azoospermia and their management

Azoospermia may occur because of reproductive tract obstruction (obstructive azoospermia) or inadequate production of spermatozoa, such that spermatozoa do not appear in the ejaculate (non-obstructive azoospermia). Azoospermia is diagnosed based on the absence of spermatozoa after centrifugation of complete semen specimens using microscopic analysis. History and physical examination and hormonal analysis (FSH, testosterone) are undertaken to define the cause of azoospermia. Together, these factors provide a >90% prediction of the type of azoospermia (obstructive v. non-obstructive). Full definition of the type of azoospermia is provided based on diagnostic testicular biopsy. Obstructive azoospermia may be congenital (congenital absence of the vas deferens, idiopathic epididymal obstruction) or acquired (from infections, vasectomy, or other iatrogenic injuries to the male reproductive tract). Couples in whom the man has congenital reproductive tract obstruction should have cystic fibrosis (CF) gene mutation analysis for the female partner because of the high risk of the male being a CF carrier. Patients with acquired obstruction of the male reproductive tract may be treated using microsurgical reconstruction or transurethral resection of the ejaculatory ducts, depending on the level of obstruction. Alternatively, sperm retrieval with assisted reproduction may be used to effect pregnancies, with success rates of 25–65% reported by different centres. Non-obstructive azoospermia may be treated by defining the cause of low sperm production and initiating treatment. Genetic evaluation with Y-chromosome microdeletion analysis and karyotype testing provides prognostic information in these men. For men who have had any factors potentially affecting sperm production treated and remain azoospermic, sperm retrieval from the testis may be effective in 30–70% of cases. Once sperm are found, pregnancy rates of 20–50% may be obtained at different centres with in vitro fertilisation and intracytoplasmic sperm injection.

Cryopreservation of sperm: indications, methods and results

PURPOSE

We review the history of the cryopreservation of human sperm. The current methods of cryopreservation and indications are highlighted, and the success rates of the various uses of cryopreserved sperm are reviewed. Potential adverse sequelae of human cryopreservation are also discussed.

MATERIALS AND METHODS

Indications for cryopreservation include several applications, namely homologous and donor insemination, cryopreservation prior to surgical infertility treatment, intraoperative cryopreservation, postoperative cryopreservation, cryopreservation prior to treatment for malignancies and nonmalignant diseases, as well as premortem and postmortem cryopreservation.

RESULTS

With the use of intracytoplasmic sperm injection, open microsurgical epididymal sperm aspiration and testicular sperm extraction with cryopreserved sperm in men with obstructive azoospermia yields pregnancy rates similar to those using fresh sperm. Intraoperative cryopreservation is recommended for complex reconstructive cases with lower patency rates, including vasoepididymostomy and vasoepididymostomy to the efferent ductule. In addition, sperm banking is strongly recommended for all patients with malignant disease who may wish to have children, since a small but significant percent of these men later use their banked semen. Although there is concern about the transfer of genetically damaged sperm after cryopreservation, no proven increase in genetic or phenotypic abnormalities in offspring has been identified.

CONCLUSIONS

Sperm cryopreservation has revolutionized the field of assisted reproduction. Cryopreserving sperm avoids the need for additional surgery in couples undergoing repeated in vitro fertilization/intracytoplasmic sperm injection cycles. Moreover, it provides hope for men undergoing chemotherapy, radiation or radical surgery who once had no chance for future fertility.

The impact of early testicular sperm extraction or cryopreservation on the outcome of intracytoplasmic sperm injection--a randomized controlled study

PURPOSE

To compare the outcome of sperm extraction 24 h before ovum pickup and on the day of oocyte retrieval.

METHODS

A controlled study was performed to compare the outcome of 90 sperm extractions and in vitro sperm injection cycles performed in 54 patients.

RESULTS

Available fresh sperm for the sperm injection procedure and cryopreservation obtained on the day of ovum pickup were similar to sperm collected 1 day before (33.3% vs 39.4%, respectively). Fertilization rate obtained with fresh sperm was also similar (48.9% vs. 54%), respectively. Clinical pregnancy rate was 38% vs. 22% per embryo transfer, respectively (P = 0.235). When comparing an additional 24 cycles with cryopreservation of sperm retrieved on the day of ovum pickup, as well as a day previously, no significance was noted in the parameters.

CONCLUSIONS

Sperm retrieved 24 h before oocyte retrieval and used as fresh or frozen-thawed for sperm injection are as effective as those used on the day of ovum pickup.

Clinical and endocrine follow-up of patients after testicular sperm extraction

OBJECTIVE

To evaluate the risk of testicular damage from testicular biopsies that are carried out for testicular sperm extraction (TESE) in infertile men.

DESIGN

Prospective controlled clinical study.

SETTING

Academic hospital.

PATIENT(S)

Forty infertile males with azoospermia. Examination of the clinical, endocrine, biochemical, and sonographic data in average after 18 months after TESE was performed.

MAIN OUTCOME MEASURE(S)

Measurements before and after TESE: hormone values, testicular size, morphologic characteristics, and power Doppler after scrotal sonography.

RESULT(S)

Comparison of preoperative and postoperative values of basal testosterone, FSH, LH, and estradiol levels did not reveal any differences. Twelve of 26 patients had subnormal testosterone values before TESE; 14 of 39 patients had subnormal levels afterward. Postoperative sonographic measurements showed no significant difference of the testicular volume as compared with the preoperative values. Results of power Doppler sonography revealed pathological conditions (n = 5) in patients with former iliacal or testicular operations.

CONCLUSION(S)

Endocrine testicular function and testicular size were not impaired after testicular biopsy when compared with preoperative data. However, patients with nonobstructive azoospermia seem to be at risk for androgen deficiency due to primary testicular failure after repeated testicular biopsies.

Effects of cryopreservation on testicular sperm nuclear DNA fragmentation and its relationship with assisted conception outcome following ICSI with testicular spermatozoa

The objective of the study was to investigate the effects of freeze-thawing on testicular sperm DNA fragmentation, fertilization rates and pregnancy rates following intracytoplasmic sperm injection with testicular spermatozoa (TESE). This ongoing prospective study included 88 couples attending for infertility treatment where the man presented with obstructive azoospermia at the Regional Fertility Centre, Belfast, UK. Patients were allocated to receive TESE treatment with fresh or freeze-thawed spermatozoa. Sperm aliquots were stored in liquid nitrogen at -196 degrees C following static phase vapour cooling or cooling at controlled rates using a programmable freezer. Samples were thawed at either room temperature or 37 degrees C. Sperm nuclear DNA; assessed by the alkaline Comet assay, was significantly damaged by slow freezing followed by fast thawing. Pregnancies were more likely to be achieved with spermatozoa displaying markedly less DNA damage. However, no differences were observed in the fertilization rates, the number of blastomeres or the cumulative embryo score between TESE cycles using either fresh or frozen thawed testicular spermatozoa. The pregnancy rates tended to be higher following fresh TESE cycles (30%) compared with TESE cycles using frozen-thawed testicular spermatozoa (26%), although this difference did not reach statistical significance. It is concluded that cryopreservation of testicular spermatozoa may reduce pregnancy rates, although this will only be confirmed by a much larger multi-centre trial.

The diagnosis and treatment of the azoospermic patient in the age of intracytoplasmic sperm injection

Microsurgical reconstruction remains the treatment of choice for men with reconstructable obstructive azoospermia. Sperm retrieval techniques performed with ICSI are highly effective for men in whom reconstruction is not feasible. In men with nonobstructive azoospermia, the optimization of spermatogenesis with hormonal therapy and, when appropriate, microsurgical varicocelectomy can result in the appearance of adequate sperm in the ejaculate for ICSI. In men with persistent nonobstructive azoospermia, TESE with ICSI has provided encouraging results. Caution must be used when this ART is applied in couples in whom genetic aberrations are detected given certain inheritance of these anomalies, as the genetic consequences of this procedure have not been thoroughly elucidated. Just as the possibility of ICSI was thought to be inconceivable several decades ago, the advent of future sentinel discoveries will present the possibility for realization of achievements that now seem incredulous.

Retrospective multicentre study on mechanical and enzymatic preparation of fresh and cryopreserved testicular biopsies

BACKGROUND

Isolation of sperm suitable for ICSI from fresh or frozen-thawed testicular sperm extraction (TESE) can be facilitated by mechanical or enzymatic processing of the samples.

METHODS

A retrospective multicentre study was initiated to compare these two approaches. Eleven German centres provided data on their TESE cycles performed during the period 1996/1997. Quality of retrieved sperm, fertilization rates of injected oocytes, embryo quality, resulting pregnancy rates and evolution of pregnancies were evaluated.

RESULTS

The percentage of cycles with at least some motile sperm available for injection was higher after mechanical preparation. Independent of the preparation method, fertilization rates were higher for motile compared with immotile sperm or elongated spermatids in all groups and in general higher for cryopreserved versus fresh samples. Embryo quality was significantly better after injection of motile sperm for all treatments and in particular after enzymatic versus mechanical processing of biopsies. Pregnancy rates were identical for embryos derived from sperm prepared mechanically or enzymatically from fresh or cryopreserved testicular samples. The abortion rate (32/172, 18.6%) and the rate of multiple implantations (32/140, 22.9%) were not different from results reported in the literature for ICSI using ejaculated sperm.

CONCLUSION

In this retrospective multicentre study, no unequivocal advantage of one over the other preparation method could be identified in 839 ICSI cycles using testicular sperm from 549 patients.

Efficiency of using frozen-thawed testicular sperm for multiple intracytoplasmic sperm injections

PURPOSE

To compare fertilization and pregnancy rates of fresh and frozen-thawed testicular sperm injections (TESE-ICSI).

METHODS

Sperm collected from the testes of 28 azoospermic patients by an open testicular biopsy technique was used for initial ICSI or cryopreserved.

RESULTS

Fresh-sperm ICSI treatment (28 cycles) resulted in a 58.1% fertilization rate and a 32.1% clinical pregnancy rate per embryo transfer, while frozen-thawed sperm (24 subsequent cycles) had rates of 54.5 and 29.2%, respectively. The PR was lower using frozen-thawed sperm from nonobstructive azoospermia patients (9.1%) than from obstructive azoospermia patients (46.2%). PR declined to 0% upon the fourth ICSI attempt.

CONCLUSIONS

Fertilization, embryo cleavage, and pregnancy rates were unaffected by fresh or frozen-thawed sperm use. A 57.1% cumulative clinical PR was achieved using the latter. The PR was significantly lower using frozen-thawed sperm from nonobstructive azoospermia patients than from obstructive azoospermia patients.

Cancer and male infertility

An increasing proportion of boys and young men with cancer will survive their disease and desire fertility. Unfortunately, the cancer treatment, and in some cases the malignant disease itself, may have a negative and permanent impact on the individual's fertility potential. This effect is highly dependent on the type and dose of therapy as well as the age at which it has been given. Basic knowledge in this field is necessary to enable oncologists and fertility specialists to counsel these patients about their fertility prospects and, if appropriate, advise them to take precautions (e.g. the cryopreservation of semen) to safeguard their fertility. Another aspect of the relationship between cancer and infertility is the possibility that men with testicular dysfunction may have an increased risk of testicular cancer. Screening for early testicular malignancy may therefore be advisable in some groups of men with poor semen quality.

Identification of CYP4F8 in human seminal vesicles as a prominent 19-hydroxylase of prostaglandin endoperoxides

A novel cytochrome P450, CYP4F8, was recently cloned from human seminal vesicles. CYP4F8 was expressed in yeast. Recombinant CYP4F8 oxygenated arachidonic acid to (18R)-hydroxyarachidonate, whereas prostaglandin (PG) D(2), PGE(1), PGE(2), PGF(2alpha), and leukotriene B(4) appeared to be poor substrates. Three stable PGH(2) analogues, 9,11-epoxymethano-PGH(2) (U-44069), 11, 9-epoxymethano-PGH(2) (U-46619), and 9,11-diazo-15-deoxy-PGH(2) (U-51605) were rapidly metabolized by omega2- and omega3-hydroxylation. U-44069 was oxygenated with a V(max) of approximately 260 pmol min(-)(1) pmol P450(-1) and a K(m) of approximately 7 micrometer. PGH(2) decomposes mainly to PGE(2) in buffer and to PGF(2alpha) by reduction with SnCl(2). CYP4F8 metabolized PGH(2) to 19-hydroxy-PGH(2), which decomposed to 19-hydroxy-PGE(2) in buffer and could be reduced to 19-hydroxy-PGF(2alpha) with SnCl(2). 18-Hydroxy metabolites were also formed (approximately 17%). PGH(1) was metabolized to 19- and 18-hydroxy-PGH(1) in the same way. Microsomes of human seminal vesicles oxygenated arachidonate, U-44069, U-46619, U-51605, and PGH(2), similar to CYP4F8. (19R)-Hydroxy-PGE(1) and (19R)-hydroxy-PGE(2) are the main prostaglandins of human seminal fluid. We propose that they are formed by CYP4F8-catalyzed omega2-hydroxylation of PGH(1) and PGH(2) in the seminal vesicles and isomerization to (19R)-hydroxy-PGE by PGE synthase. CYP4F8 is the first described hydroxylase with specificity and catalytic competence for prostaglandin endoperoxides.