Successful testicular sperm extraction and paternity in an azoospermic man after bilateral postpubertal orchiopexy

Fertility potential in adult men treated for uncorrected bilateral cryptorchidism: A systematic literature review and analysis of case reports

OBJECTIVE

Reports of adult orchidopexy for bilateral undescended testicles (bUDT) are sparse, and fertility outcomes are not well established. Our aim was to determine prognosis for restoration of spermatogenesis among adult men (≥18 years) undergoing orchidopexy for bUDT.

METHODS

A systematic literature review, conforming to the PRISMA statement, was conducted using the PubMed/MEDLINE and EMBASE databases through March 2020 using search terms "adult" AND "bilateral orchidopexy" OR "bilateral cryptorchidism." Relevant referenced articles from non-indexed journal were identified by Google Scholar search and additionally included.

RESULTS

Fifty-seven publications including adult men with uncorrected bilateral UDTs were identified. Baseline semen analysis was reported in 157 men, all of whom demonstrated azoospermia. Testosterone values were reported in 82 cases and were normal in 89%. Germ cells could not be identified in 72.6% of histologic specimens from 62 testicles. Abdominal testicles more frequently lacked germ cells (90%, p = 0.038) on univariate analysis. Eleven cases identified ejaculated spermatozoa following adult bilateral orchidopexy (8 publications). Sperm extraction (TESE) during orchidopexy or orchiectomy was reported in 13 men without success. Delayed TESE (median 10 months) was performed in 22 persistently azoospermic men with success in 10 (45.5%), none of whom had abdominal testicles prior to orchidopexy. Six men experienced successful paternity via natural conception (3) or assisted reproduction (3).

CONCLUSION

Fertility is possible in adult men with inguinal bUDT following orchidopexy. Subsequent sperm retrieval may involve ejaculated specimens or delayed TESE. TESE performed prior to or at time of orchidopexy is unlikely to be of benefit.

Modified stepwise mini-incision microdissection testicular sperm extraction: a useful technique for patients with a history of orchidopexy affected by non-obstructive azoospermia

Non-obstructive azoospermia (NOA), which is defined as the absence of spermatozoa in the ejaculate secondary to impaired spermatogenesis within the testis, may be caused by a variety of etiologies, including varicocele-induced testicular damage, cryptorchidism, prior testicular torsion, post-pubertal mumps orchitis, gonadotoxic effects from medications, genetic abnormalities, chemotherapy/radiation, and other unknown causes currently classified as idiopathic (Cocuzza et al., 2013). The microdissection testicular sperm extraction (micro-TESE) technique involves a meticulous microsurgical exploration of the testicular parenchyma to identify and selectively extract larger seminiferous tubules that carry a higher probability of complete spermatogenesis (Schlegel, 1999). The Cornell group evaluated the efficacy of micro-TESE in 152 NOA patients with an associated history of cryptorchidism. In their series, spermatozoa were successfully retrieved in 116/181 attempts (64%), and the resulting pregnancy rate was 50% with a delivery rate of 38% (Dabaja and Schlegel, 2013). Franco et al. (2016) described a stepwise micro-TESE approach in NOA patients, which was considered to reduce the cost, time, and effort associated with the surgery. Alrabeeah et al. (2016) further reported that a mini-incision micro-TESE, carried through a 1-cm equatorial testicular incision, can be useful for micro-TESE candidates, particularly in patients with cryptozoospermia. We conducted a retrospective study of 20 consecutive NOA patients with a history of orchidopexy from May 2015 to March 2017.

Management of cryptorchidism in adolescent and adult males

Background

In developing countries, it is not unusual for patients with undescended testes (UDT) to present in adulthood and the late detection of UDT can be problematic. The limited contribution to fertility and increased potential of malignancy seen in UDT have swayed many authors towards recommending orchidectomy, rather than orchidopexy, for the adult patient presenting with cryptorchidism. With conflicting data, and most guidelines aimed at first world countries with pre-pubertal patients as their focus group, a lot of uncertainty exists regarding the management of adults who present with cryptorchidism. This may result in variation in the approach to management of this patient population.

Methods

A retrospective review was conducted of patients with cryptorchidism, aged 12 years or older at the time of surgery. The following data were retrieved: patient’s age, medical and previous surgical history, clinical features of UDT (laterality, position and size), date of surgery, intra-operative findings and procedure performed. Management decisions were compared to the most recent guidelines.

Results

The mean age of the 106 subjects was 25.4 years. An orchidectomy was performed in a total of 30 (24.2%) of the 124 testicular units. The majority of testes, 91 (73.4%), in this group were preserved. Of these, 43 (47.3%) were older than 18 years of age, 33 (36.2%) were reported as having unilateral UDT with a normal contralateral testis and in 9 (9.8%) of these cases, the preserved testes were described as being atrophic. The majority (59.7%) of UDT in the post-pubertal group (> 18 years) were managed by orchidopexy.

Conclusion

Contrary to the recommended treatment for this group of patients, there was a general tendency towards testicular preservation. The decision on surgical management was made by the attending surgical team. This not only demonstrates variation in the management of UDT, but could also be a reflection of the lack of sufficient guidelines as to the management of the post-pubertal patient presenting with UDT. Further studies, following cryptorchidism through adulthood, are needed to refine guidelines for the optimal management of this group of patients.

Transitional Urology for Male Adolescents: What Adult Urologists Should Know

In recent years, there has been increasing interest in transitional urology, or how to best prepare patients with major congenital urologic diseases, such as bladder exstrophy and neuropathic bladder, to manage their own health care with adult urologists. However, common pediatric urologic conditions may be encountered by the adult urologist with more regularity. This review focuses on three relatively common conditions which may be identified in childhood, the consequences from which a patient may seek help from an adult urologist: cryptorchidism, varicocele, and Klinefelter syndrome.

Individualized Treatment Guidelines for Postpubertal Cryptorchidism

Cryptorchidism is a well-known congenital anomaly in children. However, its diagnosis is often delayed for reasons including patient unawareness or denial of abnormal findings in the testis. Moreover, it has been difficult to establish an optimal treatment strategy for postpubertal cryptorchidism, given the small number of patients. Unlike cryptorchidism in children, postpubertal cryptorchidism is associated with an increased probability of neoplasms, which has led orchiectomy to be the recommended treatment. However, routine orchiectomy should be avoided in some cases due to quality-of-life issues and the potential risk of perioperative mortality. Based on a literature review, this study proposes individualized treatment guidelines for postpubertal cryptorchidism.

Clinical characteristics and treatment of cryptorchidism in adults: a single center experience

PURPOSE

We evaluated the clinical and therapeutic characteristics of adult cryptorchidism, which have been difficult to establish, given the small number of patients presenting to outpatient clinics.

MATERIALS AND METHODS

A retrospective study of 20 adult patients with cryptorchid testis was performed. We analyzed their palpation of testis, location, surgical method, marital status, number of children, histologic findings, and semen analysis.

RESULTS

In 17 cases with unilateral cryptorchidism, the mean age at surgery was 31.1±12.5 years. Fourteen patients had a palpable, small cryptorchid testis. The location of the testis, as verified, was inguinal in 14, prepubic in 2, and intra-abdominal in 1, respectively. We performed orchiopexy in 14 out of 15 patients who sought to have this procedure. Four among 6 married patients had children. Testis biopsy was performed in 12 patients, and all showed abnormal histologic findings. Three among 4 patients, performed semen analysis, showed abnormal findings. In three cases of bilateral cryptorchidism, the mean age at surgery was 35.7±12.5 years. All of these patients had palpated cryptorchid testes in the inguinal area and sought to have a bilateral orchiopexy. Two patients have been married but had no children. All showed abnormal findings in both testis biopsy and semen analysis. No testicular neoplasm was detected during the duration of follow-up.

CONCLUSIONS

Most adult patients with cryptorchidism preferred orchiopexy to orchiectomy. However, most of patients showed abnormal histology of the testis and semen analysis. Therefore, orchiopexy with regular scrotal examination may be considered a suitable treatment options for adult cryptorchidism.

Microdissection testicular sperm extraction: an update

Patients with non-obstructive azoospermia (NOA) were once considered to be infertile with few treatment options due to the absence of sperm in the ejaculate. In the last two decades, the advent of intracytoplasmic sperm injection (ICSI), and the application of various testicular sperm retrieval techniques, including fine needle aspiration (FNA), conventional testicular sperm extraction (TESE) and microdissection testicular sperm extraction (micro-TESE) have revolutionized treatment in this group of men. Because most men with NOA will have isolated regions of spermatogenesis within the testis, studies have illustrated that sperm can be retrieved in most men with NOA, including Klinefelter's syndrome (KS), prior history of chemotherapy and cryptorchidism. Micro-TESE, when compared with conventional TESE has a higher sperm retrieval rate (SRR) with fewer postoperative complications and negative effects on testicular function. In this article, we will compare the efficacy of the different procedures of sperm extraction, discuss the medical treatment and the role of testosterone optimization in men with NOA and describe the micro-TESE surgical technique. Furthermore, we will update our overall experience to allow counseling on the prognosis of sperm retrieval for the specific subsets of NOA.

Aspects cliniques, biologiques et thérapeutiques de la cryptorchidie diagnostiquée à l’âge adulte: analyse d’une série de 69 cas

But

Rapporter les aspects cliniques, biologiques et thérapeutiques de la cryptorchidie chez l’adulte et discuter de l’intérêt de l’abaissement du testicule non descendu (TND) chez l’adulte.

Patients et méthodes

Il s’agit d’une étude rétrospective colligeant 69 patients âgés de plus de 18 ans pris en charge au service d’urologie-andrologie du CHU Aristide-Le-Dantec pour cryptorchidie entre janvier 1999 et décembre 2007.

Résultats

L’âge moyen de nos patients était de 31,04 ± 8,4 ans (extrêmes 18 et 55 ans). Les principales circonstances de découverte ont été l’infertilité masculine (38 cas), la vacuité des bourses (21 cas) et la dégénérescence maligne du TND (six cas). La cryptorchidie était unilatérale dans 69,5 % et bilatérale dans 30,4 % des cas. Le spermogramme effectué chez 60 de nos patients a montré une azoospermie dans 46,6 % des cas, une oligozoospermie dans 38,3 % et une numération de spermatozoïdes normale dans 15 % des cas. Tous les patients ayant une cryptorchidie bilatérale avaient une azoospermie. À l’exploration chirurgicale, le TND a été retrouvé dans 95,6 % des cas (66 patients). Le principal type de traitement réalisé a été l’abaissement testiculaire. L’histologie des pièces d’orchidectomie sur testicule non tumoral (n = 7) a trouvé dans tous les cas une atrophie testiculaire sévère avec absence complète de cellules germinales. Les types histologiques des cancers étaient le séminome (n = 3) et le carcinome embryonnaire (n = 3). Parmi les patients ayant une azoospermie (n = 28), aucun cas d’induction de la spermatogenèse après abaissement testiculaire n’a été observé. Parmi les patients ayant consulté pour infertilité masculine, trois d’entre eux ont eu des enfants après abaissement testiculaire, soit un taux de paternité de 7,8 %.

Conclusion

Dans la cryptorchidie de l’adulte, l’abaissement du testicule a peu d’impact sur la fertilité masculine. Mais, vu les progrès actuels de l’assistance médicale à la procréation (AMP), le dogme d’orchidectomie systématique devant un TND diagnostiqué à l’âge adulte doit être reconsidéré.

Congenital genitourinary anomalies and sexual function

Congenital urologic abnormalities in males may contribute to sexual dysfunction seen in young men. It is the purpose of this paper to review some of the more common congenital urologic anomalies and their impact on sexual and reproductive function.

Results of orchiopexy for the undescended testis

The undescended testis is one of the most common congenital abnormalities of the genitourinary system. Outcomes of orchiopexy include (1) having a viable, palpable testis in the scrotum, (2) fertility, as measured by paternity rates or semen analysis in adulthood and (3) risk of testicular cancer. Multiple operative techniques have been described and are associated with various success rates. In the past decade, success of orchiopexy for inguinal testes has been >95%. For abdominal testes, success for orchiopexy has been >85-90% in most series with single stage orchiopexy or two stage Fowler-Stephens orchiopexy, both with open surgical or laparoscopic technique. However, having a palpable testis in the scrotum does not assure fertility, as there are iatrogenic factors that may adversely affect the outcome. In adult men with a history of unilateral orchiopexy, fertility is nearly normal, but is significantly reduced following bilateral orchiopexy. The risk of testicular carcinoma is increased by a factor of 3.7 to 7.5 times. Tumor type is most commonly seminoma if the testis is undescended, whereas tumors that occur following orchiopexy are much more likely to be nonseminomatous.

Low sperm recovery from the undescended testis with testicular sperm extraction in postpubertal cryptorchids: preliminary report

As postpubertal cryptorchid testes are generally atrophic and have high malignancy risk, orchiectomy is recommended as the treatment method. However, a few case reports advocated orchiopexy due to finding sperm afterwards. The present clinical study aimed at determining the possibility of finding spermatozoa in postpubertal cryptorchid testis with testicular sperm extraction (TESE). Initially testicular biopsy and later TESE was performed in the undescended testis of 22 unilateral postpubertal cryptorchids and in one of the testes of three bilateral postpubertal cryptorchids. Histopathological assessment of testicular biopsy specimen showed that three patients had maturation arrest and 22 had seminiferous tubular atrophy. By TESE, spermatozoa were found in only one specimen of 25 testes. Our results show that the expectancy to find spermatozoa in postpubertal cryptorchid testis is extremely low by current sperm recovery methods and orchiectomy is still the accurate method of treatment.

INSL3/LGR8 role in testicular descent and cryptorchidism

Cryptorchidism, generally referred to a failure of testicular descent into the scrotum, is the most frequent (up to 3-4% at birth) congenital anomaly in newborn boys. Cryptorchidism is closely associated with impaired fertility, and represents an established risk factor for testicular cancer. Like other genital defects, cryptorchidism is believed to be caused by either endocrine or genetic abnormalities, or both. Recent elucidation of the molecular mechanism of the rodent testicular descent, and, in particular, the critical role of Insl3 (insulin-like 3) and its receptor Great/Lgr8 encouraged the search for naturally occurring mutations in the human homologues of these genes in the affected patient population. Genetic analysis revealed several functionally deleterious mutations in both INSL3 and GREAT/LGR8 genes. However, although some of mutations were found only in cryptorchid patients, it remains to be verified whether there is a causative link between the presence of mutations in INSL3 or GREAT/LGR8 and the undescended testis phenotype in men. The data and analysis of published studies indicate that mutations in these two genes might account for only a small portion of all cases of this disease in the human population.

Outcome of testicular sperm recovery and ICSI in patients with non-obstructive azoospermia with a history of orchidopexy

BACKGROUND

Little is known about sperm recovery and ICSI using testicular sperm from men with non-obstructive azoospermia who had a previous orchidopexy. We therefore studied the sperm recovery in this subgroup and evaluated clinical parameters predicting successful sperm retrieval and the outcome of ICSI.

METHODS

A total of 79 non-obstructive azoospermic men with a history of orchidopexy underwent a sperm recovery procedure. The predictive value of clinical parameters such as age at sperm retrieval, age at orchidopexy, testicular volume, FSH, FSH/LH ratio, testosterone and androgen sensitivity index (LH x testosterone) for successful testicular sperm retrieval was evaluated using receiver operating characteristics (ROC) curve analysis. A comparison between 64 ICSI cycles performed in these couples and 92 cycles performed in couples in which the men had an unexplained non-obstructive azoospermia was carried out.

RESULTS

Testicular spermatozoa were recovered in 41 patients (52%). The mean age at orchidopexy of the patients with a positive sperm recovery was 10.6 years [95% confidence interval (CI) 7.3-13.8] versus 15.5 years (95% CI 11.3-19.8) for those where no spermatozoa were found. The mean testicular volume of the largest testis of patients with spermatozoa found was 10 ml (95% CI 8.3-11.9) versus 8.5 ml (95% CI 5.8-11.1) in patients with no spermatozoa found. The mean FSH and testosterone value for patients with successful and unsuccessful sperm recovery, respectively, was 24.1 IU/l (95% CI 17.9-30.3) and 4.4 ng/ml (95% CI 3.7-5.1) versus 28.8 IU/l (95% CI 19.4-38.2) and 3.4 ng/ml (95% CI 2.2-4.5). All clinical and biological parameters examined failed to predict the outcome of the testicular sperm extraction. No differences were observed between the orchidopexy and unexplained group for the number of oocytes retrieved, fertilization rate, embryo quality, pregnancy rate and implantation rate.

CONCLUSIONS

As in the population of men with non-obstructive azoospermia, the sperm recovery rate for patients with a history of orchidopexy is approximately 50% and there are currently no clinical parameters predicting successful sperm retrieval in this subpopulation of patients. The outcome of the ICSI cycles is comparable with that in the population of men with non-obstructive azoospermia.

Testicular sperm extraction with intracytoplasmic sperm injection is successful for the treatment of nonobstructive azoospermia associated with cryptorchidism

PURPOSE

We evaluated the results of testicular sperm extraction (TESE) with intracytoplasmic sperm injection (ICSI) in men with nonobstructive azoospermia (NOA) associated with cryptorchidism.

MATERIALS AND METHODS

A total of 321 TESE attempts were done in 275 men with confirmed nonobstructive azoospermia to recover spermatozoa for ICSI between November 1995 and December 2001. Of these patients 38 with a diagnosis of cryptorchidism underwent 47 sperm extraction attempts. The remaining 237 men with a total of 274 associated TESE attempts had various other etiologies for NOA. The outcome measures studied were the sperm retrieval, fertilization, pregnancy and miscarriage rates after ICSI. Serum follicle stimulating hormone (FSH), testicular volume and age at orchiopexy (in the cryptorchid group) were examined as predictive factors for sperm recovery.

RESULTS

In the cryptorchid cohort spermatozoa were successfully retrieved at 35 of 47 TESE attempts (74%) with fertilization in 214 of 347 metaphase II oocytes (62%). Clinical pregnancies resulted for 16 of 35 cycles (46%) when sperm were retrieved, with ongoing pregnancies or deliveries in 15 of the 35 (43%). Spermatozoa recovery correlated with testicular volume (p <0.05) and patient age at orchiopexy (p <0.001) but it was independent of serum FSH. In the noncryptorchid subgroup spermatozoa were successfully retrieved at 160 of 274 TESE attempts (58%) with fertilization in 983 of 1,657 metaphase II oocytes (59%). Clinical pregnancies were documented for 71 of 160 cycles (44%) when sperm were retrieved, with ongoing pregnancies or deliveries in 58 of 160 the (36%). Spermatozoa recovery was independent of testicular volume and serum FSH. Patients with a history of cryptorchidism had better TESE sperm retrieval rates (p <0.05) but no significant difference in the fertilization, pregnancy or miscarriage rate.

CONCLUSIONS

TESE with ICSI is a successful treatment modality for men with NOA associated with cryptorchidism. Spermatozoa were retrieved in 74% of attempts with a resulting clinical pregnancy in 46% of these cases. These results are comparable if not better to those in noncryptorchid patients with NOA. Testicular volume and age at orchiopexy were identified as independent predictors of sperm retrieval for men with a history of cryptorchidism.