Unilateral or bilateral testicular biopsy in the era of intracytoplasmic sperm injection

Comparison of unilateral and bilateral microdissection testicular sperm extraction (MD-TESE) in patients with non-obstructive azoospermia: a prospective study

OBJECTIVE

To compare sperm retrieval rates between unilateral and bilateral microdissection testicular sperm extraction (MD-TESE) procedures in patients with non-obstructive azoospermia and to contribute to the literature by comparing them with literature data.

METHODS

This prospective study included 84 males with primary infertility who had azoospermic NOA, who had been married for at least one year, and whose female partners did not have a history of infertility. The study was conducted between January 2019 and January 2020. MD-TESE was applied bilaterally to 48% (n:41) (Group 1) and unilaterally to 52% (n:43) (Group 2) of the patients, and sperm retrieval rates were compared.

RESULTS

There was no statistically significant difference between Group 1 patients and Group 2 patients in terms of sperm availability (61%, 56.5%, p=0.495, respectively). In addition, while no complications were observed in unilateral MD-TESEs, 3 complications were observed in bilateral MD-TESEs.

CONCLUSIONS

In our study, it was determined that there was no significant difference between the groups in terms of sperm availability in patients with NOA. Considering the operative time and complication rates of bilateral MD-TESE in patients diagnosed with NOA and the possible MD-TESE procedures that may be performed later, we believe that unilateral MD TESE is a more preferable procedure for the patient and surgeon in this patient group.

Deficient Expression of DGCR8 in Human Testis is Related to Spermatogenesis Dysfunction, Especially in Meiosis I

Introduction

DiGeorge syndrome critical region gene 8 (DGCR8) contributes to miRNA biogenesis, and defects in its expression could lead to defects in spermatogenesis.

Methods

Here, we assess gene and protein expression levels of DGCR8 in the testicular biopsy specimens obtained from men with obstructive azoospermia (OA, n = 19) and various types of non-obstructive azoospermia (NOA) including maturation arrest (MA, n = 17), Sertoli cell-only syndrome (SCOS, n = 20) and hypospermatogenesis (HYPO, 18). Also, samples of men with NOA were divided into two groups based on successful and unsuccessful sperm recovery, NOA+ in 21 patients and NOA− in 34 patients.

Results

Examinations disclosed a severe decrease in DGCR8 in samples with MA and SCOS in comparison to OA samples (P < 0.001). Also, the results showed DGCR8 has significantly lower expression in testis tissues of NOA− group in comparison to NOA+ group (p<0.05). Western blot analysis confirmed that the DGCR8 protein was not expressed in SCOS samples and had a very low expression in MA and HYPO samples.

Discussion

The results of this survey showed that DGCR8 is an important gene for the entire spermatogenesis pathway. Moreover, DGCR8 gene plays an important role in the diagnosis of NOA subgroups, and also the expression changes in it might contribute to SCOS or MA phenotypes. This gene with considering other related genes can also be a predictor of sperm retrieval.

Upregulation of the RNF8 gene can predict the presence of sperm in azoospermic individuals

Objective

In this study, specimens from testicular biopsies of men with nonobstructive azoospermia (NOA) were used to investigate whether RNF8 gene could serve as a biomarker to predict the presence of sperm in these patients.

Methods

Testicular biopsy specimens from 47 patients were classified according to the presence of sperm (positive vs. negative groups) and investigated for the expression of RNF8. The level of RNF8 gene expression in the testes was compared between these groups using reverse-transcription polymerase chain reaction.

Results

The expression level of RNF8 was significantly higher in testicular samples from the positive group than in those from the negative group. Moreover, the area under the curve of RNF8 expression for the entire study population was 0.84, showing the discriminatory power of RNF8 expression in differentiating between the positive and negative groups of men with NOA. A receiver operating characteristic curve analysis showed that RNF8 expression had a sensitivity of 81% and a specificity of 84%, with a cutoff level of 1.76.

Conclusion

This study points out a significant association between the expression of RNF8 and the presence of sperm in NOA patients, which suggests that quantified RNF8 expression in testicular biopsy samples may be a valuable biomarker for predicting the presence of spermatozoa in biopsy samples.

Novel method of histopathological analysis after testicular sperm extraction in patients with nonobstructive and obstructive azoospermia

Objective

To assess whether the “testicular pool” could be used for histological analysis and whether it gave more accurate information than the standard testicular biopsy.

Methods

Between January 2017 and March 2018, this single-center prospective study included 60 azoospermic men undergoing conventional bilateral testicular sperm extraction. Six samples were excised from each testicle and transferred to an embryologist. One additional biopsy was randomly taken from each testis for a histological analysis. After processing, the testicular pool was also sent for a histological analysis, which showed normal spermatogenesis (NS), hypospermatogenesis (HYPO), maturation arrest (MA), Sertoli cell-only syndrome (SCOS), and tubular atrophy (TA).

Results

Twenty of the 60 patients (33.3%) had obstructive azoospermia (OA), while the remaining 40 (66.6%) had nonobstructive azoospermia. Their mean age was 40.5 years. All patients with OA had previously undergone unsuccessful testicular fine-needle aspiration. Successful sperm retrieval (SSR) occurred in 93.3% of patients. Histological analysis of the testicular biopsy revealed NS in 12 patients (20%), HYPO and TA in 28 patients (46.6%), MA in eight patients (13.3%), and SCOS in 12 patients (20%). The testicular pool analysis showed NS in 12 patients (20%), HYPO and TA in 44 patients (73.3%), MA in four patients (6.6%), and SCOS in no patients. In four patients with MA (6.6% of the total sample) and 12 patients with SCOS (20% of the total sample) according to the standard testicular biopsy, the embryologist found SSR with cryopreservation. Overall, in 44 patients (73.3%), the testicular pool analysis confirmed the histological findings of the standard testicular biopsy. In the 16 cases (26.6%) with a discrepancy between the single-biopsy histological findings and SSR, the testicular pool analysis confirmed the embryological data on SSR.

Conclusion

The testicular pool proved to be easily analyzable, practical, manageable, and more accurate for predicting sperm retrieval than standard testicular biopsy.

Relevance of testicular histopathology on prediction of sperm retrieval rates in case of non-obstructive and obstructive azoospermia

Introduction:

The aim of our research was to establish the relevance of testicular histopathology on sperm retrieval after testicular sperm extraction in patients with non-obstructive azoospermia and in patients with obstructive azoospermia, who already underwent a previous failure testicular fine needle aspiration.

Methods:

We evaluated a total of 82 azoospermic men, underwent testicular sperm extraction, referring to the Assisted Reproductive Technology Centre of the University of Florence, Italy between January 2008 and March 2017. A general and genital physical examination, scrotal and trans-rectal ultrasound, semen analysis, hormone measurements, including follicle-stimulating hormone, luteinizing hormone and total testosterone, were collected.

Results:

Successful sperm retrieval was obtained in 36 men of total (43.9%). Successful sperm retrieval was 29.5% in non-obstructive azoospermia patients, while men with obstructive azoospermia, who, underwent a previous failure testicular fine needle aspiration, had sperm retrieval in 86% of cases. Mean luteinizing hormone was 6.55 IU/L, total testosterone 4.70 ng/mL, right testicular volume 13.7 mL and left testicular volume 13.6 mL. Mean Follicle-stimulating hormone was 13.45 IU/L in patients with negative sperm retrieval and 8.18 IU/L in men with successful sperm retrieval. According to histology, 20.7% had normal spermatogenesis, 35.3% hypospermatogenesis, 35.3% maturation arrest and 8.5% Sertoli cell-only syndrome. Successful sperm retrieval was 88.2% in patients with normal spermatogenesis, 24.1% in the maturation arrest group and 48.27% in patients with hypospermatogenesis, while negative sperm retrieval was reported in Sertoli cell-only syndrome patients. Seven cases with maturation arrest showed a successful sperm retrieval.

Conclusion:

Testicular histopathology after testicular sperm extraction offers important information on prediction of sperm retrieval and can guide the surgeon in choosing the more suitable therapeutic practice.

The validity of testicular aspirate cytology and DNA image-analysis of the aspirate in the assessment of infertile men

Objective

To assess the possibility of using cytological examination and DNA image-analysis of testicular fine-needle aspirates instead of open surgical biopsy in the investigation of infertile men, as testicular biopsy has long been used for investigating infertility but the interpretation of histological slides is usually subjective.

Patients and methods

Thirty-three men (aged 22–36 years) were evaluated for infertility and underwent both open biopsy and fine-needle aspiration of their testes. Subsequently, the needle aspirates were assessed histopathologically and cytologically, and by DNA image cytometry. The percentages of haploid, diploid and tetraploid cells were determined for each patient.

Results

The cases were divided into four categories: (1) Complete spermatogenesis, with a DNA pattern of 1n > 2n > 4n; (2) Maturation arrest, with a DNA pattern of 2n > 4n with no haploid cells; (3) Sertoli cell-only syndrome, with a DNA pattern of only 2n, with no haploid or tetraploid cells; (4) Hypospermatogenesis, with a variable DNA pattern, i.e. mild with 1n > 2n, moderate with 2n > 1n > 4n, and marked where the DNA pattern was 2n > 4n > 1n. From the cytological and DNA image-analysis of the aspirate a diagnosis was possible that had a strong correlation with the histological diagnosis of the same case. From image analysis we could exclude interstitial cells, Sertoli cells and sperms on the static image, and differentiate between spermatozoa and spermatids based on morphological characteristics in the cytological smear. This technique can therefore be used to quantitatively determine the percentages of various cell types within the seminiferous tubules. By coupling image ploidy analysis and cytological examination of a cytological smear, spermatogenesis can be assessed accurately.

Conclusion

Image cytometry could be used to exclude interstitial cells, Sertoli cells and sperms on the static image and so produce an accurate assessment of spermatogenesis. A combination of ploidy and cell morphology characteristics in cytological smears provides an accurate, reproducible and easily used alternative to open testicular biopsy.

How Harmful is Contralateral Testicular Biopsy?—An Analysis of Serial Imaging Studies and a Prospective Evaluation of Surgical Complications

OBJECTIVE

Testicular biopsy has recently gained a role in early detection of testicular cancer. However, its use is still limited mainly because of the fear of untoward consequences. There is a paucity of data regarding unfavourable effects of testicular biopsy. Therefore, we systematically looked to the consequences of the procedure by using clinical observational methods and by modern imaging techniques, respectively.

PATIENTS, METHODS

1874 patients with testicular cancer enrolled in a nation-wide contralateral biopsy study were prospectively analyzed in regard to surgical complications. Serial scrotal imaging was performed by scrotal sonography (7.5 Mhz) in 55 patients and by magnetic resonance tomography (1.5 Tesla machine, surface coil, contrast media) in 60 patients, respectively. Imaging examinations were done preoperatively and again at 1 week, 6 months, 12 months, and 18 months respectively. Imaging results were tabulated according to an abnormality score and analyzed by descriptive statistics.

RESULTS

52 patients (2.78%; 95% confidence intervals 2.05-3.60) experienced surgical complications. Forty minor complications were managed conservatively. Twelve patients (0.64%) required repeat surgery; 1 testicle was ultimately lost following a sequence of unfortunate events. No pre-existing clinical parameter was associated with complications. One week after surgery, abnormalities were detected in 33% by sonography and in 45% by MRI, respectively. Importantly, the abnormalities resolved in 96% of the cases, as found in both of the imaging modalities in the serial scans.

CONCLUSIONS

Testicular biopsy is associated with a low burden of clinically significant complications. However, scrotal imaging discloses intratesticular abnormalities in a high proportion of cases one week after the biopsy. These changes represent focal haematoma, oedema or circumscript injury to vascular supply. Most of these lesions resolve with time and are thus not significant, clinically. Evidently, testicular biopsy is a safe procedure provided the vascular anatomy of the testis is respected upon surgery.

Possible predictive factors for ICSI? Molecular biology techniques in combination with therapeutic testicular biopsies

Applying intracytoplasmic sperm injection (ICSI), the selection of an unsuccessful spermatozoon results in great emotional consequences for the couple. Therefore, there is a need for a prognostic parameter to estimate their chances for successful fertility treatment. This review summarizes both the main reasons for spermatogenic impairment, and possible predictive factors for successful sperm retrieval applying testicular sperm extraction and outcome of ICSI. While basic sperm parameters, aetiology and type of spermatozoa, and serum follicle-stimulating hormone and inhibin levels have been shown to be unrelated to the outcome of ICSI, Y-chromosome microdeletions are known to have a negative influence on the fertilizing capacity of spermatozoa. Recently, a significant correlation has been reported between the protamine-1 to protamine-2 mRNA ratio in haploid spermatids of testicular biopsies and the ability of spermatozoa for successful fertilization of an oocyte. In future, both the outstanding role of the haploid spermatids and the involvement of molecular biological techniques will improve the role of therapeutic testicular biopsies.

Introduction to methods for collecting human gametes in assisted reproduction

The first objective of IVF is the collection of oocytes and spermatozoa. This article reviews the methods of choice for each sex. Collecting oocytes involves laparoscopic puncture and ultrasonographic puncture via transabdominal/transvesical and periurethral/transvesical, transvaginal methods. Male gametes are collected by masturbation, or by aspirating spermatozoa from the epididymis or from the testicle. Sperm collections can be taken from patients with disorders of ejaculation. A brief review of each approach is presented, with a critical analysis of each method.

Histological evaluation of multiple testicular biopsies helping assisted reproduction

Because of the fall in population in Europe, the evaluation of causes of male infertility is becoming more and more important. Testicular biopsy is a useful method of examination in the area of assisted reproduction. Testicular biopsies of 85 infertile males were evaluated histologically. According to the sperm count, 31 patients had azoospermia, 22 oligo-astheno-teratozoospermia (OATS), 29 oligozoospermia, and 3 astheno-teratozoospermia. The biopsies were carried out by atraumatic microsurgery. Samples were taken from the upper inner and lower outer quadrant of both sides. Bouin-fixed, paraffin-embedded blocks were cut and HE slides examined. Samples taken from azoospermic patients showed atrophy, maturation arrest, normal histology or Sertoli cell-only syndrome. Oligozoospermic patients presented maturation arrest, hypospermatogenesis or normal histology. In the OATS group maturation arrest hypospermatogenesis and atrophy were found. The spermatogram groups showed significant correlation with the homogeneity of the spermatogenesis. The sperm count alone is not sufficient in assessing spermatogenesis. Four samples give more adequate information than just one, because spermatogenesis is not homogeneous in the testis. After evaluating diagnostic biopsies, tissue for TESE can be taken from the most appropriate location in the testis.

Serial ultrasonography, hormonal profile and antisperm antibody response after testicular sperm aspiration

BACKGROUND

In many fertility centres, intracytoplasmic sperm injection (ICSI) with epididymal or testicular spermatozoa is a routine treatment for men with azoospermia. In this prospective study, the physiological consequences after testicular sperm aspiration (TESA), using suction and a 19 gauge needle, were evaluated.

METHODS AND RESULTS

Thirty-five consecutive men with azoospermia underwent TESA. Testicular ultrasonography with Doppler flow imaging was performed and testicular volumes were evaluated pre-operatively and 3 months after aspiration. If focal testicular lesions were found, further examinations were performed 6 and 9 months after TESA. Serum FSH, testosterone and antisperm antibodies (ASA) were analysed. Focal testicular lesions were seen in four out of 61 testes (6.6%) at the 3 month investigation point. Three lesions were resolved after 6 months and all after 9 months. Testicular echogenicity remained unchanged in 50 cases (82%) 3 months after TESA. Four men (11.4%) reported severe subjective discomfort post-operatively, but only one had a medical consultation where an intratesticular haematoma was diagnosed. There were no significant changes in FSH and testosterone after surgery and testicular volumes were similar after 3 months. There were three borderline cases of ASA in serum, but none was classified as ASA-positive.

CONCLUSIONS

The puncture method of testicular sperm aspiration seems to be a safe method for sperm retrieval, with minimal physiological consequences.

Histopathological mapping of open testicular biopsies in patients with unobstructive azoospermia

OBJECTIVE

To evaluate, in patients with unobstructive azoospermia, the heterogeneity of spermatogenesis within the testes and thus whether there is any region of advanced spermatogenesis. Patients and methods Seventy infertile men (mean age 34 years, SD 5.01) with no varicoceles or testicular atrophy had bilateral open testicular biopsies taken from six different sites. For each biopsy specimen the number of seminiferous tubules and of tubules with sperm maturation were counted (by light microscopy at x 400). The ratio of tubules with active spermatogenesis to the total number was calculated for each biopsy sample.

RESULTS

The mean (SD) right and left testicular volumes were 19.82 (7.8) and 18.84 (7.89) mL, respectively; the patients' follicle-stimulating hormone level was 8.34 (1.17) IU/mL. On sextant biopsy spermatozoa were detected in 42 of the 70 patients (60%). The mean (SD) ratio of tubules with spermatozoa was 5.23 (0.8)% for the right and 5.37 (0.76)% for the left testes. There was no statistically significant difference in the ratio of seminiferous tubules positive for spermatozoa at the different biopsy sites in either the right or left testis. Spermatozoa were identified in only one to three biopsy sites in almost half of those with maturation arrest; this ratio increased to 74% in patients diagnosed as having Sertoli-cell-only syndrome with focal spermatogenesis. Conclusion There is no region of the testis that is rich or advanced in spermatogenesis in patients with unobstructive azoospermia. Without multiple testicular biopsy it is possible to miss advanced spermatogenesis in some unobstructed patients. The sextant testis biopsy is a reliable method for detecting the presence and exact location of seminiferous tubules with spermatozoa in patients with unobstructive azoospermia.

Microsurgical inguinal varicocele repair in azoospermic men

OBJECTIVES

To evaluate the efficacy of microsurgical inguinal varicocele repair in nonobstructive azoospermic men with palpable varicocele and to determine predictive parameters of outcome.

METHODS

After standard diagnostic evaluation, 24 pellet (-) completely azoospermic men and 14 pellet (+) virtually azoospermic men underwent microsurgical inguinal varicocele repair. Testicular core biopsy was also performed perioperatively in all patients. The outcome was assessed in terms of improvement in semen parameters and spontaneous pregnancy.

RESULTS

After a mean follow-up of 13.4 +/- 4.7 months, motile sperm in the ejaculate could be identified in 5 (21%) of the completely azoospermic patients, and these patients were rescued from invasive sperm extraction techniques when referred to intracytoplasmic sperm injection. Testicular histopathology of these patients with postoperative improvement revealed maturation arrest at spermatid stage (n = 3), Sertoli-cell-only (SCO) pattern with focal spermatogenesis (n = 1), and hypospermatogenesis (n = 1). None of the patients with pure SCO pattern or maturation arrest at spermatocyte stage had improvement after varicocele repair. However, improvement in semen parameters was observed in 12 (85.7%) patients with virtual azoospermia, 4 (28.6%) achieved a total motile sperm count greater than 5 million, and spontaneous pregnancy occurred with 3 (21.4%) of them.

CONCLUSIONS

Microsurgical inguinal varicocele repair offers completely azoospermic men the chance to provide motile sperm via ejaculate in 21%. Moreover, 28.6% of virtually azoospermic men are rescued from ICSI procedures as an initial treatment modality. Results of varicocele repair in azoospermic men also reveal that a certain threshold of spermatogenesis, requiring the presence of at least spermatids, is necessary for effective varicocele repair.

A comparison of the histopathological findings after open and percutaneous needle testicular biopsy in adult male rats

OBJECTIVE

To define the histopathological changes occurring as a result of open and percutaneous needle testicular biopsy in adult rats.

MATERIALS AND METHODS

Percutaneous needle and open testicular biopsies were taken from 35 male albino rats (120-140 days old). Nine of the rats were killed 10 days after the biopsy, eight after 30 days and the other eight 60 days after the biopsy. A control group of six rats underwent orchidectomy with no preceding testicular biopsy.

RESULTS

Significant tubulitis and obstructive findings were detected 10 days after needle biopsy (P < 0.05); epididymo-orchitis was frequent after open biopsy during this period. At 10-30 days after needle biopsy the mean seminiferous tubule diameters were significantly greater than in either the control group or after open biopsy (P < 0.05). The histopathological damage recovered 60 days after open and needle biopsy.

CONCLUSION

Although percutaneous, a needle biopsy (as an alternative to open biopsy) causes tubulitis and frequent obstructive findings in the early period; therefore, repeat testicular procedures should be planned after these changes have resolved.