In-vitro fertilisation for men with obstructive azoospermia

Intracytoplasmic sperm injection using microsurgically retrieved epididymal and testicular sperm

OBJECTIVE

To evaluate treatment of couples who are infertile due to unreconstructable obstructive azoospermia with microsurgical epididymal sperm aspiration or testicular sperm and intracytoplasmic sperm injection (ICSI).

DESIGN

Prospective.

SETTING

The Egyptian IVF-ET Center in association with Cairo University.

PATIENTS

Twenty-three couples who are infertile due to obstructive azoospermia in which reconstructive microsurgery failed or was not possible.

INTERVENTIONS

Microsurgical epididymal or testicular sperm retrieval and ICSI in 24 cycles.

MAIN OUTCOME MEASURES

Fertilization and pregnancies.

RESULTS

All 24 cycles had successful fertilization and reached the ET stage. In microsurgical epididymal sperm aspiration cases, fertilization rate per metaphase II oocyte was 63% (109/ 172). Six patients became pregnant, including one set of twins and one set of triplets. One pregnancy resulted from the use of cryothawed epididymal sperm. In testicular sperm aspiration cases, the fertilization rate was 59% (32/54) and four clinical pregnancies resulted.

CONCLUSION

The use of microepididymal sperm aspiration or testicular sperm aspiration in conjunction with ICSI provide a highly precise and efficient procedure for achieving pregnancy in cases of unreconstuctable obstructive azoospermia.

Epididymal micropuncture with in vitro fertilization and oocyte micromanipulation for the treatment of unreconstructable obstructive azoospermia

OBJECTIVE

To provide fertility to couples in whom the man has surgically unreconstructable obstructive azoospermia.

DESIGN

Prospective.

SETTING

Hospital-based IVF unit, including associated division of urologic microsurgery.

PATIENTS

Couples referred to our fertility unit for treatment of men with surgically unreconstructable reproductive tract obstruction, including congenital absence of the vas deferens.

MAIN OUTCOME MEASURES

Fertilization, pregnancies, and live births.

RESULTS

Of 51 cycles in which sperm and eggs were retrieved, 67% (34/51) resulted in fertilization and 27.5% (14/51) developed clinical pregnancy. Clinical pregnancy rate per couple was 33% (14/43). A total of 15 live births have been obtained in 11 couples with one ongoing pregnancy. Epididymal length was the best predictor of sperm quality and pregnancy results. For couples with at least the corpus epididymis present, 41% (9/22) of cycles resulted in clinical pregnancies.

CONCLUSIONS

Pregnancy rates are optimized using sperm retrieved from the epididymis by micropuncture and when micromanipulation is available for use during IVF.

Results in the United States with sperm microaspiration retrieval techniques and assisted reproductive technologies. The Sperm Microaspiration Retrieval Techniques Study Group

Improved methods of urological microsurgery and of various assisted reproductive technologies have resulted in the ability to achieve pregnancies with sperm aspirated microsurgically from men with bilateral congenital absence of the vasa deferentia or with ductal obstructions that cannot be surgically reconstructed. A survey was conducted of the results of such procedures performed in the United States during approximately 2 years. Female partner ovarian stimulation was initiated in 219 instances at 22 centers. Of the 219 procedures 23 (11%) were terminated without attempting any form of gamete fertilization or insemination of the wife for various reasons (no sperm or too few sperm retrieved, poor to absent sperm motility or poor quality eggs). The etiology of azoospermia in the 219 procedures was congenital absence of the vasa deferentia in 115 cases (52%), other congenital conditions in 15 (7%), failed vasectomy reversal in 37 (17%), infection in 4 (2%), other conditions (mainly ejaculatory dysfunctions that did not respond to electroejaculation and complex ductal obstructions) in 26 (12%) and not specified in 22 (10%). When only patient sperm was used pregnancy was achieved in 12 of 115 wives (10%) of those men who had congenital absence of the vasa deferentia and in 0 to 14% of the wives of men whose azoospermia was caused by other conditions. Of the 219 menstrual cycles in which ovarian stimulation was initiated pregnancy occurred in 24 (11%) with patient sperm and in 9 (4%) with donor sperm. Of these 33 pregnancies a full-term, live delivery occurred in 17 (52%), while 8 (24%) were ongoing at the time of reporting, 2 (6%) miscarried, 3 (9%) were chemical pregnancies, 1 (3%) resulted in a stillborn child and the outcome was unknown in 2 (6%). This new therapy offers only a modest chance of pregnancy. However, it affords men with azoospermia the opportunity to achieve paternity with their own sperm when other therapies are not available or applicable.

A new device for microsurgical sperm aspiration

A new device for microsurgical aspiration of seminal fluid is presented. It is simple to use, flexible, and watertight, allowing maximum retrieval of seminal fluid.

Congenital absence of the vas deferens. The fertilizing capacity of human epididymal sperm

BACKGROUND

Congenital absence of the vas deferens has been considered a virtually untreatable cause of male sterility. Furthermore, sperm that have not passed through at least the head of the epididymis have been thought to be incapable of causing pregnancy. We attempted to determine whether human sperm that had never passed through the epididymis could fertilize eggs in vitro and whether the technique could be used for men with congenital absence of the vas deferens.

METHODS

Twenty-eight men with congenital absence of the vas deferens underwent microsurgical aspiration of sperm from the epididymis and vasa efferentia for attempted in vitro fertilization of their wives' oocytes, with subsequent transfer of embryos. Thirty-two treatment cycles were begun (four were repeat cycles).

RESULTS

The most motile sperm were found in the proximal epididymis, at or near the vasa efferentia. Embryos were obtained for transfer in 21 cases (66 percent). Ninety-three embryos resulted from 352 mature oocytes (fertilization rate, 26 percent). Clinical pregnancy was achieved in 10 of the 32 treatment cycles (31 percent). Seven women delivered normal infants, and three miscarried. One of the seven live births was of twins. There were six girls and two boys. When fewer than 10 eggs were retrieved, no pregnancy occurred. When 10 or more eggs were retrieved (20 cases), the pregnancy rate was 50 percent.

CONCLUSIONS

Sperm from the proximal caput epididymidis and even sperm from the vasa efferentia (which have never passed through the epididymis) can fertilize the human oocyte in vitro and result in pregnancy with live birth.

In defense of a function for the human epididymis

In view of reports that the human epididymis may play no role in human fertility, literature on the fertilizing capacity of epididymal spermatozoa was reviewed. The survey indicates that under the circumstances of their retrieval, human epididymal and testicular spermatozoa may have the ability to fertilize human eggs both in vivo and in vitro. Although the "fertility profile" of the normal epididymis cannot be explored in man, a fair assumption would be that fertilizing capacity develops fully in the distal part of the tract, judging from the higher motility and egg fusing ability of sperm taken from these regions of unobstructed tissue. Motility and fertilizing capacity observed with IVF or artificial insemination, in which sperm are obtained from obstructed ducts, may occur at a level in the tract more proximal than normal, as in animals. The pregnancies resulting from aspiration of spermatozoa from, or anastomosis of the vas deferens to, the efferent ducts are of great clinical interest, but the pathological state of the tissue precludes definitive statements about the functioning of a normal epididymis. In the former case, the immediate origin of the fertilizing spermatozoon and the nature of the secretions previously bathing it are unknown and in the latter case the time needed before pregnancies occur is much greater than anticipated had fertile sperm been present in the proximal epididymis. The evidence supports neither the view that testicular sperm are inherently fertile nor that a simple aging of sperm cells is sufficient for the fertilizing potential of spermatozoa to be realized. It emphasizes, rather, the importance of the environment to which the sperm cells are subjected. Under abnormal conditions other accessory glands may secrete compounds that are necessary for the maturation of spermatozoa. Before more information is known of the exact situation existing, or having existed, in pathological human tissues from which fertilizing human spermatozoa can be obtained, great caution should be exercised in interpreting the results of pregnancies arising from the in vivo and in vitro insemination of testicular or epididymal spermatozoa.

Vasa aplasia and cystic fibrosis

Bilateral vasa aplasia is considered an invariable finding in cystic fibrosis, but such patients are rarely seen in male infertility clinics. The improved survival beyond 20 years of age is likely to change this. In a clinical study of a group of male cystics the vasa were absent in 8 of 11 boys and epididymal abnormalities were palpable in the majority. The main cause of infertility appears to be mechanical obstruction. Whether the absence is due to a primary failure of mesonephric duct development or secondary to luminal obstruction and subsequent atrophy is not known.

Oligospermic infertility treated by in-vitro fertilization

A series of 451 couples receiving treatment in an IVF programme were classified according to the quality of semen produced by the male partner, and were regarded as either severely oligospermic (less than or equal to 5 X 10(6) motile spermatozoa/ml X n = 29), moderately oligospermic (5.1 to 11.9 X 10(6) motile spermatozoa/ml; n = 46) or normospermic (greater than or equal to 12 X 10(6) motile spermatozoa/ml; n = 376). Despite similar insemination numbers, a significant reduction in the proportion of oocytes fertilized was seen when the normospermic group (1,314/1,815; 72%) was compared with the moderately oligospermic group (134/239; 56%) and the severely oligospermic group (57/190; 30%) and there was a progressive increase in the proportion of couples with total fertilization failure in the 3 groups (18/376, 5%; 10/46, 22%; 12/29, 41%) respectively. In addition, 10 couples with severe oligospermia chose to divide the oocytes collected for insemination by the husband and a donor. The fertilization rates achieved using the husband's spermatozoa (9/31; 23%) are significantly lower than with donor (26/35; 74%), despite similar insemination densities, suggesting a functional defect in the spermatozoa of oligospermic husbands. Nonetheless, the pregnancy rates following embryo transfer were similar for all groups, suggesting that once fertilization is achieved, all embryos have the same potential to result in a successful pregnancy.