The treatment of obstructive azoospermia in male infertility--past, present, and future

Trps1 acts as a regulator of Sf-1 transcription and testosterone synthesis in mouse Leydig cells

Infertility has attracted global concern, and disruption of testosterone is a common cause of male infertility. Exploring the critical factors in testosterone biosynthesis may provide new insights for disease research and clinical therapy. Research on trichorhinophalangeal syndrome-1 (Trps1) gene has recently been focus on cancers; it is yet unknown whether Trps1 produces a marked effect in the male reproductive system. In the current study, single-cell RNA sequencing analysis of trichorhinophalangeal syndrome-1 gene (Trps1) expression in mouse testes and cleavage under targets and tagmentation and RNA sequencing were utilized to investigate the functionality of Trps1 in mouse Leydig cells. Knockdown of Trps1 increased testosterone synthesis in vitro and vivo using adeno-associated viral delivery and conditional knockout models. The results showed that Trps1 was abundantly expressed in Leydig cells. The expression levels of both steroidogenic factor-1 (Sf-1) and steroidogenic enzymes (Cyp11a1, Hsd3b, Cyp17a1, and Hsd17b3) as well as testosterone secretion were increased after Trps1 deficiency in vivo and vitro. Furthermore, disruption of Trps1 reduced histone deacetylase 1/2 activity and increased histone H3 acetylation in the Sf-1 promoter, thereby promoting testosterone secretion. Interestingly, Sf-1 also regulated the transcription of Trps1 through activating transcription factor 2. These results indicate that Trps1 targets Sf-1 to affect steroidogenesis through histone acetylation and shed light on the critical role of Trps1 functioning in the mouse Leydig cells.

ALWAYS ICSI? A SWOT analysis

PURPOSE

Intracytroplasmatic sperm injection (ICSI) is a common procedure used to improve reproductive results, even among couples without male factor infertility. However, the evidence available is still uncertain on the possible advantages and deficiencies that this procedure may have in patients with no formal indication for ICSI.

METHODS

A SWOT (strengths, weaknesses, opportunities, threats) analysis examines the possible advantages and deficiencies of performing ICSI in these patients with no formal indication.

RESULTS

The evidence suggests that ICSI is not justified for non-male factor infertile couples requiring in vitro conception. One of the major strengths associated to the procedure is the virtual elimination of cases further complicated by total fertilization failure and a combination between IVF and ICSI on sibling oocytes has been advised in the literature. Greater technical difficulties, higher costs and performing an unnecessary invasive technique in some cases represent some of the weaknesses of the procedure, and questions regarding safety issues should not be ruled out.

CONCLUSION

Despite the widespread use of ICSI in patients without a formal diagnosis of male factor infertility, evidence demonstrating its effectiveness in this population is still lacking. Additional large and well-designed randomized controlled trials are needed to clarify definitive indications for ICSI in non-male factor infertility.

The evolution and refinement of vasoepididymostomy techniques

Obstructive azoospermia secondary to epididymal obstruction can be corrected by microsurgical reconstruction with vasoepididymostomy (VE). Although alternative management such as epididymal or testicular sperm aspiration in conjunction with intracytoplasmic sperm injection is feasible, various studies have established the superior cost-effectiveness of VE as a treatment of choice. Microsurgical VE is considered one of the most technically challenging microsurgeries. Its success rate is highly dependent on the skills and experience of the surgeons. Various techniques have been described in the literature for VE. We have pioneered a technique known as longitudinal intussusception VE (LIVE) in which the epididymal tubule is opened longitudinally to obtain a larger opening to allow its tubular content to pass through the anastomosis. Our preliminary data demonstrated a patency rate of over 90%. This technique has been widely referenced in the recent literature including robotic-assisted microsurgery. The history of the development of different VE approaches, the preoperative evaluation along with the techniques of various VE will be described in this article.

In vitro fertilization/intracytoplasmic sperm injection for male infertility

Progress in the field of assisted reproduction, and particularly micromanipulation, now heralds a new era in the management of severe male factor infertility, not amenable to medical or surgical correction. By overcoming natural barriers to conception, in vitro fertilization and embryo transfer (IVF-ET), subzonal sperm insemination, partial zona dissection, and intracytoplasmatic injection of sperm (ICSI) now offer couples considered irreversibly infertile, the option of parenting a genetically related child. However, unlike IVF, which necessitates an optimal sperm number and function to successfully complete the sequence of events leading to fertilization, micromanipulation techniques, such as ICSI, involving the direct injection of a spermatozoon into the oocyte, obviate all these requirements and may be used to alleviate severe male factor infertility due to the lack of sperm in the ejaculate due to severely impaired spermatogenesis (non-obstructive azoospermia) or non-reconstructable reproductive tract obstruction (obstructive azoospermia). ICSI may be performed with fresh or cryopreserved ejaculate sperm where available, microsurgically extracted epididymal or testicular sperm with satisfactory fertilization, clinical pregnancy, and ongoing pregnancy rates. However, despite a lack of consensus regarding the genetic implications of ICSI or the application and efficacy of preimplantation genetic diagnosis prior to assisted reproductive technology (ART), the widespread use of ICSI, increasing evidence of the involvement of genetic factors in male infertility and the potential risk of transmission of genetic disorders to the offspring, generate major concerns with regard to the safety of the technique, necessitating a thorough genetic evaluation of the couple, classification of infertility and adequate counseling of the implications and associated risks prior to embarking on the procedure. The objective of this review is to highlight the indications, advantages, limitations, outcomes, implications and safety of using IVF/ICSI for male factor infertility to enable a more judicious use of these techniques and maximize their potential benefits while minimizing foreseen complications.

Alterations in the human blood-epididymis barrier in obstructive azoospermia and the development of novel epididymal cell lines from infertile men

Post-testicular sperm maturation requires a specific luminal environment in the epididymis that is created, in part, by the blood-epididymis barrier. There is limited information on gene expression in the epididymis of infertile obstructive azoospermia (OA) patients due to the difficulty in obtaining tissues. The objectives of this study were to determine if epididymal tight junction proteins are altered in OA and to develop cell lines that could serve to elucidate alterations in the epididymis of infertile men. Epididymal claudin (CLDN) 1, CLDN4, and CLDN10 mRNA levels were altered in OA downstream from the obstruction site. Epithelial cell lines derived from the caput epididymidis of one OA patient were developed (infertile human caput epididymal cell line [IHCE]). IHCEs were composed of homogenous populations of diploid cells that ultrastructurally resembled in vivo principal cells. The cells expressed cytokeratin, SPAG11B, CLDN2, CLDN3, desmoplakin, and vimentin. However, the cells did not express several other epididymal markers (CRISP1, SPINLW1, NPC2, CD52, or DCXR) or junctional proteins (CDH1, CDH2, CLDN1, CLDN4, CLDN7, or CLDN8). Further studies using IHCE1 and transepithelial resistance indicated that the cells were unable to form tight junctions. Microarray analyses comparing gene expression in IHCE1 and a recently developed fertile human caput epididymal cell line revealed differential expression of genes encoding junctional proteins, cell junction regulators, and epididymal proteins. Together, these data indicate that epididymal cellular junctions appear to be altered in OA.

Congenital agenesis of seminal vesicle

Congenital agenesis of the seminal vesicle (CASV) is frequently associated with congenital absence of the vas deferens (CAVD) or ipsilateral congenital vasoureteral communication. We reported two cases of a rare condition that the vas deferens open ectopically into Mullerian duct cyst associated with agenesis of the ipsilateral seminal vesicle. The diagnosis was confirmed by vasography. Transurethral unroofing of the Mullerian duct cyst was performed in both patients with favourable results, however, assisted reproductive technology (ART) was still necessary for them to father children.

Minimal invasiveness and effectivity of subinguinal microscopic varicocelectomy: a comparative study with retroperitoneal high and laparoscopic approaches

AIM

The standard management of varicocele repair is the subject of ongoing controversy. We retrospectively evaluated three surgical methods of varicocele treatment to determine the minimally invasive and most effective procedure.

METHODS

We performed 144 varicocelectomies on infertile patients with left clinical varicocele. Of the patients, 50 were treated with retroperitoneal high ligation under lumbar anesthesia, 33 with laparoscopic ligation under general anesthesia, and 61 with subinguinal microscopic ligation under local anesthesia. Operative time, hospital days, and clinical outcomes were compared between these techniques.

RESULTS

The operating time and hospitalization period required for subinguinal microscopic ligation was signi fi cantly shorter compared to those for the other procedures. All patients treated with subinguinal microscopic ligation could achieve normal activity as soon as they returned to their rooms. Postoperative complications were observed in fi ve (10.0%) cases treated with high ligation and three (9.1%) laparoscopic cases, but were not observed after the subinguinal procedure. There were six cases (12.0%) of recurrence in the high ligation group and six (6.1%) in the laparoscopic group, but none in the subinguinal group. Sperm density was signi fi cantly improved in all procedures postoperatively, but sperm motility was not improved. The two-year pregnancy rate calculated by the Kaplan-Meier method was 35.8% for high ligation, 40.4% for laparoscopic ligation and 50.9% for subinguinal microscopic ligation, although there were no statistical differences between the three groups.

CONCLUSION

We concluded that subinguinal microscopic varicocelectomy could be a minimally invasive procedure compared to the other two techniques and a worthy method for treating male infertility due to clinical varicocele.

The difficult MESA: findings from tubuli recti sperm aspiration

PURPOSE

To investigate sperm quality aspirated from the tubuli recti compared to that obtained from microsurgical epididymal sperm aspiration (MESA).

METHODS

Sixteen patients with congenital bilateral absence of the vas deferens (CBAVD) underwent MESA. Six MESA procedures were difficult, and therefore sperm were retrieved from the tubuli recti ductules. Intraoperative sperm parameters, recovery after freeze-thaw, and ICSI outcomes were analyzed and compared between tubuli recti and MESA sperm.

RESULTS

Mean initial sperm concentration was similar in both groups (18 vs. 16 million sperm/mL). Initial sperm motility was significantly higher in the tubuli recti group (35%) than the MESA group (25%). However, post thaw motility was higher with MESA compared to tubuli recti sperm (8.7 vs. 1.5%). ICSI fertilization rates after sperm freeze-thaw were 66% for tubuli recti sperm and 71% for MESA sperm.

CONCLUSIONS

Tubuli recti sperm may provide an attractive alternative to testis sperm extraction. Poor sperm recovery after freeze-thaw should be expected.

Retrieval and cryopreservation of sperm from spermatocele fluid

OBJECTIVES

To evaluate the amount, motility, and viability of sperm in fluid aspirated from naturally occurring spermatoceles and to investigate the effect of cryopreservation of sperm retrieved from spermatoceles. Assisted reproductive technologies have led to successful pregnancies and deliveries using sperm harvested from the epididymis and/or testis of infertile men.

METHODS

Aspiration of spermatocele fluid and analysis of the fluid obtained was performed on 20 patients before elective spermatocelectomy. Randomly selected samples (n = 5) were washed using a 70% Percoll gradient, and repeated semen analysis was performed. The washed specimens were cryopreserved in liquid nitrogen, and repeated semen analysis was performed on the thawed specimens.

RESULTS

All spermatoceles (n = 20) had viable sperm present (count range 54 x 10(4) to 326 x 10(6)) and 16 (80%) of 20 contained motile sperm. The average percentage of motile sperm was 5%. The average sperm motility and average percent viability of sperm recovered after Percoll gradient improved compared with sperm in the initial spermatocele aspirates (motility 5%, range 0% to 25% and viability 36%, range 2% to 91% before Percoll vs. motility 13%, range 2% to 38% and viability 39%, range 10% to 92% after Percoll). Sperm retrieved after cryopreservation demonstrated reduced motility and viability; however, motile and viable sperm were recovered from all washed and cryopreserved samples.

CONCLUSIONS

Our results suggest that spermatocele fluid may contain sufficient numbers of sperm for use with assisted reproductive technologies. Motile and viable sperm can be recovered after cryopreservation and storage of sperm obtained from a spermatocele. Spermatocele fluid may be an additional source of sperm for assisted reproductive technologies.

Influence of interstitial fibrosis on spermatogenesis after vasectomy and vasovasostomy

This study focused on the testicular interstitial fibrosis after vasectomy and the intraseminiferous status [i.e., Johnsen's score, proliferative cell nuclear antigen (PCNA) expression] following vasectomy reversal. Testicular biopsy specimens from 21 consecutive men were obtained at vasovasostomy. Percent of interstitial fibrosis was determined quantitatively by NIH-image after Masson Trichrome staining. PCNA-labeling index (LI) was calculated on each testis. The associations between the obstructive interval and each parameter were examined. These parameters were also analyzed on whether patency or pregnancy was achieved or not. Significant decrease in PCNA-LI and increase in interstitial fibrosis were observed along with the obstructive interval (p <0.0001, p = 0.0005, respectively). Interstitial fibrosis of the patients without patency/fertility was significantly greater than that of the patients with patency/fertility (47.5%/39.0% versus 33.4%/32.3%, p = 0.02/0.04, respectively). PCNA-LI and Johnsen's score did not predict the treatment outcome. Interstistial fibrosis, but not the extent of germ cell differentiation or DNA synthesis, reflects the treatment outcome after vasectomy reversal. Interstistial fibrosis contributes to the irreversible damage of vasectomized testes.

Use of electively cryopreserved microsurgically aspirated epididymal sperm with IVF and intracytoplasmic sperm injection for obstructive azoospermia

OBJECTIVE

To investigate the efficacy of using intentionally cryopreserved epididymal sperm in selected cases of obstructive azoospermia.

DESIGN

A retrospective, nonrandomized study.

SETTING

Academic research environment.

PATIENTS

One hundred forty-one couples undergoing first-time IVF/ICSI using either fresh or cryopreserved epididymal sperm.

INTERVENTIONS

The epididymides were microsurgically aspirated.

MAIN OUTCOME MEASURES

Clinical pregnancy rates.

RESULTS

Motile sperm were obtained from all men. For the fresh group, the mean total sperm aspirated was 99 x 10(6) with 5.5 vials frozen per patient after ICSI and 82 x 10(6) with 4.7 vials frozen per patient in the cryopreserved group. No statistically significant difference in oocyte fertilization rate or number of embryos transferred was noted between groups. Of 108 patients using freshly aspirated sperm, 72 (66.7%) achieved clinical pregnancy. Of 33 patients in the group using cryopreserved sperm, 20 (60.6%) achieved clinical pregnancy (P=0.47).

CONCLUSIONS

In selected ideal cases of unreconstructable azoospermia, elective open microsurgical epididymal sperm aspiration with cryopreservation yields pregnancy rates similar to that employing fresh sperm. The advantages of this method are: (1) Use of cryopreserved sperm obviates the logistics problems associated with the use of fresh sperm. (2) Abundant high-quality sperm can be cryopreserved in a single procedure for all future attempts at IVF/ICSI. Rarely, viable sperm will not be present after thawing, and fresh retrieval will be necessary.

Testicular biopsy in patients with obstructive azoospermia

The present report studies the testicular biopsy lesions (histologic and semiquantitative) in a series of 48 patients with obstructive azoospermia of known etiology (vasectomy, congenital absence of vas deferens, herniorrhaphy, hydrocelectomy, Young's syndrome, and ejaculatory duct obstruction) in order to establish objective testicular data that permit the pathologist to diagnose an obstructive process, which should not be mistaken with a primary testicular lesion. The semiquantitative study included determinations of the average numbers of spermatogonia, primary spermatocytes, young spermatids (Sa + Sb), and differentiated spermatids (Sc + Sd). According to this study, the testes were classified into the following groups: (1) normal testes whose germ cell numbers were within normal limits (27 testes); (2) testes with lesions in the adluminal compartment; these lesions comprise two subgroups: (2a) late sloughing of primary spermatocytes (both spermatid types were greatly reduced in number while the other germ cell types were in normal numbers) (45 testes); and (2b) early sloughing of primary spermatocytes (normal spermatogonial number, reduced number of spermatocytes, and scanty spermatids) (9 testes); and (3) lesions in the basal compartment; these lesions comprise two subgroups: (3a) pure hypospermatogenesis (a proportionate decrease in the numbers of all germ cell types) (8 testes); and (3b) hypospermatogenesis associated with sloughing of primary spermatocytes (decreased numbers of all germ cell types with a very scanty number spermatids) (4 testes). Two testes appeared hyalinized and one testis was removed owing to cryptorchidism. The most frequent testicular lesion observed (alteration in the adluminal compartment of seminiferous tubules) seems to be related to the increase in hydrostatic pressure in the tight compartment formed by seminiferous tubules, rete testis, efferent ducts, the epididymal duct, and the initial portion of the vas deferens. The severity of the lesions is probably related to the cause and span of the obstruction. In addition, two azoospermic men without obstructive azoospermia and whose testicular biopsy study revealed meiotic anomalies (with the subsequent bad prognosis) were also studied for comparison. The semiquantitative study of these patients permitted the differential diagnosis between two lesion types. Testes with meiotic anomalies had a disproportionately elevated number of primary spermatocytes, and an extremely low number of young spermatids.

Role of the urological surgeon in the age of intracytoplasmic sperm injection

In the last few years, it has been demonstrated that intracytoplasmic sperm injection is an effective procedure for treating patients with severe male infertility. Before this technique was available, the urological surgeon involved in the reproduction field dealt mainly with reconstructive (vasoepididimostomy, vasovasostomy) or endoscopic surgery of the seminal duct as well as varicocelectomy. Nowadays, the urological surgeon continues to participate in the field of reproductive surgery by applying methodologies which enable natural conception, and has to be involved in all aspects of sperm retrieval techniques.