ICSI outcomes in obstructive azoospermia: influence of the origin of surgically retrieved spermatozoa and the cause of obstruction

Comparing the clinical and singleton neonatal outcomes in male infertility patients with Oligoasthenospermia, OA, or NOA following fresh ICSI-ET using different sources of sperm

Objective

To investigate clinical and singleton newborn outcomes in fresh cycles of embryo transfer after intracytoplasmic sperm injection (ICSI-ET) with diverse sperm sources (ejaculate, epididymis, and testis) in patients with Oligoasthenospermia, obstructive azoospermia (OA) or non-obstructive azoospermia (NOA).

Methods

Patients who received fresh ICSI-ET for the first time at the First Affiliated Hospital of Zhengzhou University Reproductive Medicine Center between June 2011 and June 2021 were selected for this 10-year retrospective cohort analysis. After propensity score matching, only 1630 cycles were included in the investigation of ICS-ET clinical and singleton newborn outcomes in patients with Oligoasthenospermia, OA, and NOA using sperm from diverse sperm sources.

Results

After propensity score matching, our data revealed a negligible difference in baseline and cycle parameters among groups. In patients with Oligoasthenospermia and OA, different sperm sources do not appear to influence clinical pregnancy rates and live birth rates, nor do they influence newborn outcomes, such as newborn weight, premature birth rate, and neonatal sex ratio in singleton births, except for OA patients who use epididymal sperm having higher low birth weight (LBW) rates in singleton pregnancies than those who use testicular sperm. In addition, clinical pregnancy rates, live birth rates, singleton gestation birth weights, premature birth rates, and neonatal sex ratios were similar between patients with Oligoasthenospermia, OA, and NOA using testicular sperm.

Conclusions

Regardless of the type of male infertility (Oligoasthenospermia, OA, NOA) or sperm sources (ejaculate, epididymis, testis), a successful ICSI-ET procedure can result in similar clinical and neonatal outcomes, such as clinical pregnancy rate, live birth rate, abortion rate, neonatal birth weight and sex ratio of singleton pregnancies.

Microscopic Epididymal Sperm Aspiration (MESA) Should be Employed Over Testicular Sperm Extraction (TESE) Sperm Retrieval Surgery for Obstructive Azoospermia (OA)

INTRODUCTION

 Testicular sperm extraction (TESE) has been widely used as a sperm extraction surgery for azoospermia even for obstructive azoospermia (OA) because it does not require surgical skill. However, there are postoperative pain issues, and subsequent testicular atrophy and decreased testosterone levels may occur with TESE. This study examines the usefulness of microscopic epididymal sperm aspiration (MESA) for OA.

METHODS

 We studied 108 patients diagnosed with OA and treated with MESA at our institute between April 2004 and December 2021. The MESA was performed using a micropipette with a micropuncture technique under an operative microscope. When no sperm were present or motility was not observed, additional punctures to the epididymal tubule were performed.

RESULTS

 Motile sperm were recovered in all cases (108 cases). Of these, intracytoplasmic sperm injection (ICSI) using frozen-thawed sperm was performed in 101 cases and the normal fertilization rate was 76.2%. A total of 436 embryo transfer (ET) cycles were performed. The implantation rate per transfer cycle was 47.9%, the clinical pregnancy rate was 41.0%, and the live birth rate was 23.7%. The per-case live birth rate was 84.8%.

CONCLUSIONS

 MESA-ICSI has a very good fertilization rate, clinical pregnancy rate, and delivery rate. Furthermore, the patient's postoperative pain is less, the number of sperm collected is larger, the burden on the embryologist who processes the collected sperm is less, and ICSI can be easily attempted after frozen-thawed sperm. MESA rather than TESE should be employed for the OA subjects.

Does ICSI outcome in obstructive azoospermia differ according to the origin of retrieved spermatozoa or the cause of epididymal obstruction? A comparative study

Purpose

To determine whether ICSI outcomes are affected by sperm source or genital tract inflammatory status.

Methods

A retrospective cohort study was conducted in all consecutive obstructive azoospermia patients who underwent testicular sperm aspiration (TESA) or percutaneous epididymal sperm aspiration (PESA) and ICSI between February 1, 2017, and December 31, 2020. Couples were excluded if they were diagnosed with monogenic disease, abnormal karyotype, or had female uterine malformation. The primary objective was to determine whether ICSI outcomes are affected by the use of testicular or epididymal spermatozoa, and the secondary objective was to explore the effect of granulocyte elastase on ICSI outcomes using epididymal spermatozoa.

Results

Compared with TESA, inflammatory and non-inflammatory PESA patients exhibited a better high-quality embryo rate, with significant differences among the three groups (49.43 vs. 55.39% and 56.03%; odds ratio, 6.345 and 6.631; 95% confidence interval, 0.340–12.350, and 1.712–11.550; P = 0.038 and P = 0.008, respectively). The fertilization rate, clinical pregnancy rate, live birth delivery rate, and congenital anomaly birth rate were similar in patients who underwent TESA or PESA (with or without inflammation).

Conclusions

The high-quality embryo rate in PESA patients was higher than that in TESA patients. After successful pregnancy, ICSI outcomes did not differ between patients with obstructive azoospermia who experienced TESA or PESA and those with or without genital tract inflammation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11255-022-03350-x.

Does acquired obstructive azoospermia have less impact than congenital azoospermia on ICSI results? Systematic review and meta-analysis

An electronic-based search was performed with MEDLINE bases through PubMed, Cochrane through Central, and Embase until August 2020 for the purpose of evaluating the impact of the aetiology of obstructive azoospermia on ICSI cycles. In the final analysis, there were 15 cohort studies included, comparing a group of patients with acquired azoospermia and others due to congenital bilateral absence of the vas deferens submitted to ICSI. Those 15 articles within 4,480 couples were analysed, and similar fertilisation rate (65.1% vs. 65.3%; p = .38), pregnancy rate per cycle (40.0% vs. 43.1%; p = .06) and live birth rate (29.6% vs. 30.0%;p = .76) were found between groups. Comparing specifically post-vasectomy azoospermia and congenital groups, both presented a similar fertilisation rate (62.4% vs. 53.4%, respectively; OR 1.10; 95% CI, 0.79, 1.54; p = .56; I²  = 89%) and pregnancy rate per cycle (39.4% vs. 35.6%, respectively; OR 1.26; 95% CI, 0.96, 1.66; p = .09; I²  = 0%). However, a higher live birth rate was identified in the congenital group compared to vasectomy group (28.4% × 19.5%; OR 1.54; 95% CI, 1.11, 2.15; p = .01; I²  = 0%). The reasons for that are unclear and factors such as couple age and sperm DNA fragmentation should be considered.

How do we counsel men with obstructive azoospermia due to CF mutations?-a review of treatment options and outcomes

Obstructive azoospermia (OA) is a rare cause of male infertility, with Congenital Bilateral Absence of The Vas Deferens (CBAVD) being a major cause. A wealth of literature has established an irrefutable link between CFTR mutations and CBAVD, with CBAVD affecting almost all men with cystic fibrosis (CF) disease and a significant portion of men that are CFTR mutation carriers. In the past two decades, assisted reproductive technologies have made the prospect of fathering children a viable possibility in this subset of men, using a combination of sperm extraction techniques and intracystoplasmic sperm injection (ICSI). In order to assess techniques for sperm retrieval, as well as reproductive outcomes, a systemic search of the MEDLINE database was conducted for all articles pertaining to management options for CBAVD, and also all reports describing outcomes of these procedures in the CBAVD population. Both epididymal and testicular sperm extraction (TESE) are viable options for men with CBAVD, and though rigorous data are lacking, live birth rates range from 8% to 50% in most small retrospective series and subset analyses. In addition, there does not appear to be significant differences in the rate of live birth or complications and miscarriages between the various techniques, though further investigation into other factors that limit reproductive potential of men with CFTR mutations and CBAVD is warranted.

Fertility outcome after Intracytoplasmic Sperm Injection with surgically retrieved sperm

BACKGROUND

Surgically retrieved sperm samples and Intra Cytoplasmic Sperm Injection are indicated when we face severe sperm abnormalities such as azoospermia. The objective of this study was to assess the rates of clinical pregnancies and live births with sperm from testicular biopsies.

DESIGN

This was a retrospective descriptive study of all Intra Cytoplasmic Sperm Injection (ICSI) cycles performed with surgically retrieved sperm at the Nîmes University Hospital from January 1st, 2015 to December 31st, 2018. The main outcome was the clinical pregnancy rate. The secondary outcomes were the fertilization rate, the implantation rate and the live birth rate.

RESULTS

In all, 99 couples were treated at our center during this period and 164 ICSI cycles using surgically-collected sperm were performed. The men were 34.7 ± 7.4 years old on average at the time of undergoing testicular biopsy and the women were 32.15 ± 5.07 years at the time of ICSI. Out of 127 fresh embryo transfers, we observed 47 clinical pregnancies (37 %) and 45 live births (35.4 %). The average fertilization rate was 45 % and the implantation rate was 23.7 %. Among these infertile couples, 53 % obtained at least one clinical pregnancy and 42 % at least one live birth.

CONCLUSION

Testicular sperm extraction combined with ICSI is indicated in cases of male infertility linked with azoospermia or severe semen alteration. This technique offers couples a marvelous opportunity to have children with their own gametes.

Superior clinical pregnancy rates after microsurgical epididymal sperm aspiration

Purpose

To assess normal fertilization, clinical pregnancy, and live birth rates after the use of microscopic epididymal sperm aspiration (MESA).

Methods

One-hundred-and-sixty azoospermic participants who underwent MESA were evaluated. The MESA was performed by using a micropuncture method with a micropipette. In cases in which motile sperm were not obtained after the MESA, conventional or micro-testicular sperm extraction (TESE) was completed.

Results

Adequate motile sperm were retrieved in 71 participants by using MESA and in 59 out of 89 participants by using TESE. Of the total number of patients, 123 underwent intracytoplasmic sperm injection. After MESA, the normal fertilization rate was 73.5% and the clinical pregnancy rate per case was 95.7%. Healthy deliveries resulted after MESA in 65 (92.9%) cases and after TESE in 38 (71.7%) cases.

Conclusion

The MESA specimen collection does not have any special requirements, such as mincing tissue disposition. The MESA also can reduce the amount of laboratory work that is needed for cryopreservation. In the authors' experience, MESA is a beneficial procedure and should be given priority over TESE.

Cohort study of perinatal outcomes of children born following surgical sperm recovery

There is a relative paucity of data on perinatal outcomes following Intracytoplasmic Sperm Injection using surgically retrieved sperm. In this retrospective cohort study, data were collected on couples who conceived following Intracytoplasmic Sperm Injection using surgically retrieved sperm from 1996 to 2014. Outcome measures included live birth, miscarriage, congenital abnormality, birthweight, gestation at delivery, stillbirth and neonatal death. Outcome measures were compared according to male diagnosis and sperm source. Live birth rates were similar between groups (obstructive azoospermia 90%, non-obstructive azoospermia 83%, p = 0.55). There was a trend towards higher miscarriage rates in the non-obstructive azoospermia group (17% versus 9%, p = 0.45). Other perinatal outcomes were similar between groups. In those with obstructive azoospermia, live birth rates were similar regardless of source of sperm (epididymal 89%, testicular 91%, p = 0.79). Median gestation at delivery was earlier in the epididymal sperm group (39 weeks versus 40 weeks, p = 0.02). Other perinatal outcomes were unaffected by sperm source. Overall these results are reassuring, suggesting high live birth rates regardless of diagnosis or sperm source, although there may be higher miscarriage rates in cases of non-obstructive azoospermia. Other perinatal outcomes were not affected by diagnosis or sperm source.

Congenital bilateral absence of the vas deferens: the impact of spermatogenesis quality on intracytoplasmic sperm injection outcomes in 108 men

In azoospermic men with congenital bilateral absence of the vas deferens (CBAVD), it is not known whether the outcomes of intracytoplasmic sperm injection (ICSI) depend on the quality of testicular spermatogenesis (as determined histopathologically). We retrospectively studied the impact of spermatogenesis quality on ICSI outcomes in 108 azoospermic men with CBAVD consulting in a university hospital's department of andrology and reproductive biology. As part of an ICSI program, sperm samples were obtained from the epididymis [by microsurgical epididymal sperm aspiration (MESA); n = 47] or the testis [by testicular sperm extraction (TESE); n = 14] or both (MESA + TESE, n = 47). In the TESE group (i.e., TESE-only and MESA + TESE), spermatogenesis was normal in 21 of the 108 men (19.4%) and hypospermatogenesis occurred in 33 (30.5%). The fertilization rate was significantly lower in the hypospermatogenic group than in the normospermatogenesis group (65.6 and 72.9%, respectively; p = 0.02); this was also true for the embryo cleavage rate (88.6 and 92.1%, respectively; p = 0.007), and the proportion of embryos with fewer than 30% of enucleate fragments (79.5 and 86.9%, respectively; p = 0.02). Our study results showed that impaired spermatogenesis had a negative impact on certain early-stage biological outcomes of ICSI. In CBAVD, male factors are likely to exert a harmful effect on the early stages of embryo development.

Cryopreservation of testicular and epididymal sperm: techniques and clinical outcomes of assisted conception

The introduction of the technique of intracytoplasmic sperm injection to achieve fertilization, especially using surgically retrieved testicular or epididymal sperm from men with obstructive or non-obstructive azoospermia, has revolutionized the field of assisted reproduction. The techniques for the retrieval of spermatozoa vary from relatively simple percutaneous sperm aspiration to open excision (testicular biopsy) and the more invasive Micro-TESE. The probability of retrieving spermatozoa can be as high as 100% in men with obstructive azoospermia (congenital bilateral absence of the vas deferens, status post-vasectomy). However, in nonobstructive azoospermia, successful sperm retrieval has been reported in 10-100% of cases by various investigators. The surgical retrieval and cryopreservation of sperm, especially in men with non-obstructive azoospermia, to some extent ensures the availability of sperm at the time of intracytoplasmic sperm injection. In addition, this strategy can avoid unnecessary ovarian stimulation in those patients intending to undergo in vitro fertilization-intracytoplasmic sperm injection with freshly retrieved testicular sperm when an absolute absence of sperm in the testis is identified. Several different methods for the cryopreservation of testicular and epididymal sperm are available. The choice of the container or carrier may be an important consideration and should take into account the number or concentration of the sperm in the final preparation. When the number of sperm in a testicular biopsy sample is extremely low (e.g., 1-20 total sperm available), the use of an evacuated zona pellucida to store the cryopreserved sperm has been shown to be an effective approach.

Reproductive potential of men with obstructive azoospermia undergoing percutaneous sperm retrieval and intracytoplasmic sperm injection according to the cause of obstruction

PURPOSE

We evaluated the retrieval rates and reproductive outcomes of percutaneous sperm retrieval according to the cause of obstructive azoospermia.

MATERIALS AND METHODS

We retrospectively studied the records of 146 men with obstructive azoospermia who underwent sperm retrieval for intracytoplasmic sperm injection. Patients were grouped by the cause of obstruction, including 32 with congenital bilateral absence of the vas deferens, 59 with vasectomy and 55 with obstruction due to post-infection disease. Sperm were retrieved percutaneously from the epididymis or testis. We compared retrieval rates and intracytoplasmic sperm injection outcomes, including neonatal results, in the groups of men with obstructive azoospermia.

RESULTS

The success of sperm retrieval was similar among the etiology groups, including 100% for congenital bilateral absence of the vas deferens, 96.6% for vasectomy and 96.3% for previous infection. Significantly fewer men in the congenital bilateral absence of the vas deferens group needed testicular aspiration compared to those in the post-infection and vasectomy groups (3.1% vs 23.6% and 30.5%, respectively, p <0.001). Sperm cryopreservation was possible in 26.7% of the cases and did not significantly differ among the groups. Live birth rates after sperm injection were similar in the congenital (34.4%), vasectomy (32.2%) and previous infection (36.4%) groups. Birth parameters, prematurity and low birth weight rates were comparable among the groups.

CONCLUSIONS

Percutaneous sperm retrieval is an effective method to retrieve sperm in men with obstructive azoospermia irrespective of the cause of obstruction. The chance of achieving a live birth and the profile of neonates born after sperm injection do not seem to be related to the cause of obstruction.

Microsurgical epididymal sperm aspiration: indications, techniques and outcomes

Microsurgical epididymal sperm aspiration (MESA) refers to retrieval of sperm-containing fluid from optimal areas of the epididymis that are selected and sampled using high-power optical magnification provided by an operating microscope. Retrieved sperm are subsequently used for intracytoplasmic sperm injection (ICSI) to induce fertilization and pregnancy. MESA is considered by many experts to be the gold standard technique for sperm retrieval in men with obstructive azoospermia given its high yield of quality sperm, excellent reported fertilization and pregnancy rates, and low risk of complications. However, MESA must be performed in an operating room, requires microsurgical skills and is only useful for reproduction using ICSI. Herein we present an overview of the evaluation of candidate patients for MESA, the technical performance of the procedure and the outcomes that have been reported.

Effect of 1,25(OH)2 vitamin D3 on cytokine production by endometrial cells of women with repeated implantation failure

Repeated implantation failure (RIF) is a worldwide health problem that imposes a great deal of cost on patients and health care system. Vitamin D(3) has been proposed to have positive impact on the process of implantation. The present study was performed to compare the effect of 1,25-dihydroxy vitamin D(3) (1,25(OH)(2)D(3)) on cytokine production by endometrial cells of women with RIF and healthy fertile controls. Whole endometrial cells (WECs) and endometrial stromal cells (ESCs) from RIF and normal fertile women were treated with 1,25(OH)(2)D(3). The levels of IL-10, TGF-β, IFNγ, Il-6, IL-8 and IL-17 in culture supernatants were assayed by ELISA. Also, ability of the cells from both groups to produce 1,25(OH)(2)D(3) was evaluated and compared. 1,25(OH)(2)D(3) down-regulated cytokine production in WECs from both groups except for IL-8 which was upraised. Similar trends were also observed in ESCs except up-regulation of TGF-β in RIF group. Endometrial cells of both groups had comparable capacity to produce 1,25(OH)(2)D(3). Based on the minimal differential immunoregulatory effect of vitamin D(3) on endometrial cells from RIF and control women, it may be suggested that circulating levels of maternal vitamin D(3) be the subject of further investigation.

Intérêt de la ponction épididymaire et de la biopsie testiculaire systématique dans la prise en charge de l’azoospermie obstructive

Introduction

Dans l’azoospermie obstructive (AO), les taux d’extraction chirurgicale de spermatozoïdes sont élevés. Cependant, en ce qui concerne les issues des ICSI (Intra cytoplasmic Sperm Injection) chirurgicales, les données de la littérature divergent. Quels sont, dans notre équipe, les taux d’extraction de spermatozoïdes après aspiration épidydimaire (MESA) et après extraction testiculaire (TESE) dans l’AO ? Les taux de grossesses, les taux de fausses couches spontanées et d’accouchements diffèrent-ils en fonction de l’origine du sperme ?

Matériels et méthodes

L’étude a rétrospectivement inclus 48 couples dont l’homme présente une azoospermie obstructive pure et ayant bénéficié d’un prélèvement chirurgical de spermatozoïdes associant systématiquement MESA et TESE. Les ICSI ont été réalisées de manière asynchrone. À chaque fois que cela était possible, la première ICSI a été réalisée avec des spermatozoïdes épididymaires.

Résultats

Pour les 48 couples, 99 ICSI ont été réalisées. Quinze couples ont réalisé 24 ICSI-TESE car l’aspiration épididymaire était négative. Onze couples ont réalisé 20 ICSI-TESE car la qualité du prélèvement épididymaire n’était pas satisfaisante (vitalité spermatique réduite le plus souvent). Vingt-deux couples ont réalisé 22 ICSI-MESA en première intention puis en cas d’échec, 11 couples ont réalisé 12 ICSI-MESA et dix couples ont réalisé 20 ICSI-TESE. Alors que les nombres d’ovocytes injectés (7,1±4,1 vs 6,9 ±3,6 P: 0,8) et d’embryons obtenus (4,5±3,0 vs 4,7±2,7; P: 0,7) ne sont pas significativement différents dans les deux groupes d’ICSI, les nombres d’embryons de top qualité (2,4±1,9 vs 3,6±2,0 P: 0,005) et d’embryons congelés (0,9±1,8 vs 1,7±1,9 P: 0,04) sont significativement supérieurs dans le groupe TESE. Le nombre de grossesse par ponction est supérieur dans le groupe TESE (58,5 % vs 26,5 %, P: 0,002).

Conclusion

L’approche de notre centre a la particularité d’associer systématiquement un prélèvement testiculaire au prélèvement épididymaire chez tout homme présentant une azoospermie obstructive alors que la plupart des autres études rapportées se limitent à l’exploration épididymaire si cette dernière est positive lors de l’examen extemporané. Alors que classiquement, on rapporte 100% de positivité lors du prélèvement épididymaire chez l’homme atteint d’une azoospermie obstructive, dans notre étude, plus de la moitié des explorations épididymaires s’est avérée inexploitable. La qualité embryonnaire et les taux de grossesses sont meilleurs avec des spermatozoïdes testiculaires. L’association de ces 2 sites de prélèvement (MESA et TESE) peut être complémentaire et utile pour le couple et l’issue de sa prise en charge en AMP sans pour autant entraîner un sur-risque pour l’homme dans les suites de la chirurgie.

Outcomes for offspring of men having ICSI for male factor infertility

Since the introduction of intracytoplasmic sperm injection (ICSI) using single sperm isolated from testicular tissue in men with obstructive and non-obstructive azoospermia, or using ejaculated sperm in those with poor semen quality, there have been concerns that this might have adverse effects on the offspring compared to conventional in vitro fertilisation (IVF) and natural conceptions. ICSI is done for reasons other than male factor infertility, and on the whole has not been shown to have any more negative effects than those seen with IVF. There have however, been very few studies of ICSI with a focus on, or large enough numbers to examine, the specific outcomes associated with male factor infertility. From the limited information available in relation to the source of the sperm and aetiology of infertility in the presence of ICSI, there appears to be no increased risk of congenital malformations. There is, however, a small increase in both de novo and inherited chromosome abnormalities. In terms of growth and neurodevelopment, there are very few studies, and so far, no adverse outcomes have been found in young children whose fathers have a sperm defect. The origin of the sperm used in ICSI does not have a major influence on the early life outcomes for the offspring, but transgenerational and epigenetic effects remain unknown. When the male factor infertility is known or thought to be due to a Y-chromosome deletion, this information should be given to the young male offspring at a time that will ensure his own reproductive health and plans are optimized.

Surgical techniques for the management of male infertility

Evaluation and surgical treatment of male infertility has evolved and expanded, now leading to more precise diagnoses and tailored treatments with diminished morbidity and greater success. Surgeries for male infertility are divided into four major categories: (i) diagnostic surgery; (ii) surgery to improve sperm production; (iii) surgery to improve sperm delivery; and (iv) surgery to retrieve sperm for use with in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI). While today we are more successful than ever in treating male infertility, pregnancy is still not always achieved likely due to factors that remain poorly understood. Clinicians treating infertility should advocate for couple-based therapy, and require that both partners have a thorough evaluation and an informed discussion before undergoing specific surgical therapies.

[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.

Spermatogenesis affects the outcome of ICSI for azoospermic patients rather than sperm retrieval method

The study investigated the clinical outcome of intracytoplasmic sperm injection (ICSI) with epididymal and testicular sperm of azoospermic patients exhibiting various disturbances in spermatogenesis, in order to understand the possible factors that might affect ICSI outcome. Of the 134 patients, 92 were diagnosed as being obstructive azoospermic (OA group) with normal spermatogenesis and the remaining 42 patients were diagnosed as being non-obstructive azoospermic (NOA group) with hypospermatogenesis. The 92 OA patients underwent 112 ICSI cycles, which were divided into two subgroups according to their sperm retrieval methods: 1) OA-PESA group (n=51) with sperm obtained by percutaneous sperm aspiration (PESA) cycles and 2) OA-TEFNA group (n=61) with sperm obtained by testicular fine needle sperm aspiration (TEFNA) cycles. The NOA patients diagnosed with hypospermatogenesis according to histopathological analysis and hormone analysis, underwent 42 ICSI cycles with TEFNA. The results showed that the fertilization, cleavage, and clinical pregnancy rates portrayed a significant difference (44.9% vs. 64.1%, P<0.001, 79.8% vs. 89.0%, P<0.001, and 21.4% vs. 40.2%, P=0.047, respectively) between NOA and OA groups. Moreover, the miscarriage rate in the NOA group was visibly higher even though it did not reach a statistical difference (33.3% vs. 15.6%, P=0.433) compared with the miscarriage rate of the OA group. The same statistical differences were observed between the subgroup OA-TEFNA and the NOA group. No statistical difference was observed between OA-PESA and OA-TEFNA groups for the fertilization, cleavage, clinical pregnancy, and miscarriage rates. This study indicates that defective spermatogenesis affects the ICSI clinical outcome of azoospermic patients rather than the sperm retrieval methods.

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.

Russell-Silver syndrome due to paternal H19/IGF2 hypomethylation in a patient conceived using intracytoplasmic sperm injection

Epigenetic alterations at several maternal loci have been associated with imprinting disorders in children conceived using assisted reproductive technologies. To date, epimutations at paternal loci have been observed in the spermatozoa of infertile men, but there is little evidence of paternal epimutations in babies conceived using assisted reproductive treatment. This is a report of a female infant with classic Russell-Silver Syndrome (RSS) who was conceived using intracytoplasmic injection of spermatozoa obtained from testicular aspiration. Methylation studies revealed hypomethylation of the paternally derived H19/IGF2 locus. As far as is known, this is the second assisted reproduction treatment-conceived patient with classic RSS and this epigenotype. This case provides further evidence that epimutations affecting paternal alleles might be associated with assisted reproductive treatment.

Assisted reproductive technology outcomes in azoospermic men: 10 years of experience with surgical sperm retrieval

An azoospermic man suffers from an absence of sperm in the ejaculate and this condition is present in about 10% of infertile men. Obstructive azoospermia (OA) is characterized by an occlusion or partial absence of the reproductive tract with the presence of normal spermatogenesis. On the other hand, non-obstructive azoospermia (NOA) is characterized by impaired spermatogenesis. In these cases, spermatozoa can be obtained by percutaneous epididymal or testicular sperm aspiration (PESA and TESA, respectively) and used for intracytoplasmic injection (ICSI). To compare ICSI outcomes using spermatozoa that were surgically retrieved by PESA and TESA, azoospermic patients were divided into the following categories: (i) TESA-NOA (n = 102), (ii) TESA-OA (n = 103), and (iii) PESA-OA (n = 171). Fertilization, pregnancy, and implantation rates were compared between the groups. We noted a lower normal fertilization rate (p = 0.0017) and a higher abortion rate (p = 0.0387) among men in the TESA group who had OA when compared with men in the PESA group who had OA. On the other hand, a lower normal fertilization rate (p = 0.05) and a lower rate of non-cleaved embryos (p = 0.034) was found in the TESA group of NOA patients as compared to the TESA group of OA patients. No statistically significant differences were detected between the TESA and PESA groups and the OA and NOA groups, respectively. The clinical outcomes of embryos arising from ICSI cycles using spermatozoa harvested via PESA and TESA were similar, regardless of whether the patient had obstructive or non-obstructive azoospermia.

Does the outcome of ICSI in cases of obstructive azoospermia depend on the origin of the retrieved spermatozoa or the cause of obstruction? A comparative analysis

OBJECTIVE

To compare the outcomes of intracytoplasmic sperm injection (ICSI) for men with obstructive azoospermia and normal spermatogenesis, according to the use of epididymal or testicular spermatozoa and the cause of obstruction.

DESIGN

Retrospective study.

SETTING

Private infertility center.

PATIENT(S)

A detailed chart review of a cohort of 1,121 men with obstructive azoospermia who underwent intracytoplamic sperm injection (ICSI) was performed.

INTERVENTION(S)

Patients were grouped according to the origin of spermatozoa: epididymal (n=331) or testicular (n=790). They were further classified into two subgroups according to the cause of obstruction: congenital bilateral absence of vas deferens (CBAVD; n=434), and other causes of obstruction (n=687).

MAIN OUTCOME MEASURE(S)

Fertilization, clinical pregnancy, and miscarriage rates.

RESULT(S)

Fertilization (64.2% vs. 68.0%), clinical pregnancy (42.3% vs. 43.2%), and miscarriage (17.6% vs. 18.4%) rates did not differ between epididymal spermatozoa and testicular spermatozoa, respectively. Fertilization, clinical pregnancy, and miscarriage rates were also similar in the patients with CBAVD or due to other causes of obstruction.

CONCLUSION(S)

The source of sperm used for ICSI in cases of obstructive azoospermia and the etiology of the obstruction do not affect the outcome in terms of fertilization, pregnancy, or miscarriage rates.

[ICSI with non-ejaculated sperm: what about children?]

For men presenting azoospermia, the development of ICSI with epidydimal (MESA) or testicular (TESE) sperm, allowed them to father their own progeny. Little is known about the issue of these ICSI, in terms of efficiency and quality of the conceptus, and many controversies remain. Some studies emphasized that children born after Assisted Reproductive Technology (ART) with surgically sperm retrieved were at increased risk of birth defects. In this context, we proposed a retrospective analysis of pregnancy issues with non-ejaculated sperm.

Sperm defect severity rather than sperm Source is associated with lower fertilization rates after intracytoplasmic sperm injection

OBJECTIVE

To evaluate the impact of sperm defect severity and the type of azoospermia on the outcomes of intracytoplasmic sperm injection (ICSI).

MATERIALS AND METHODS

This study included 313 ICSI cycles that were divided into two major groups according to the source of spermatozoa used for ICSI: 1) Ejaculated (group 1; n = 220) and 2) Testicular/Epididymal (group 2; n = 93). Group 1 was subdivided into four subgroups according to the results of the semen analysis: 1) single defect (oligo-[O] or astheno-[A] or teratozoospermia-[T], n = 41), 2) double defect (a combination of two single defects, n = 45), 3) triple defect (OAT, n = 48), and 4) control (no sperm defects; n = 86). Group 2 was subdivided according to the type of azoospermia: 1) obstructive (OA: n = 39) and 2) non-obstructive (NOA: n = 54). Fertilization (2PN), cleavage, embryo quality, clinical pregnancy and miscarriage rates were statistically compared using one-way ANOVA and Chi-square analyses.

RESULTS

Significantly lower fertilization rates were obtained when either ejaculated sperm with triple defect or testicular sperm from NOA patients (63.4 +/- 25.9% and 52.2 +/- 29.3%, respectively) were used for ICSI as compared to other groups ( approximately 73%; P < 0.05). Epididymal and testicular spermatozoa from OA patients fertilized as well as normal or mild/moderate deficient ejaculated sperm. Cleavage, embryo quality, pregnancy and miscarriage rates did not differ statistically between ejaculated and obstructive azoospermia groups. However, fertilization, cleavage and pregnancy rates were significantly lower for NOA patients.

CONCLUSION

Lower fertilization rates are achieved when ICSI is performed with sperm from men with oligoasthenoteratozoospermic and non-obstructive azoospermic, and embryo development and pregnancy rates are significantly lower when testicular spermatozoa from NOA men are used.

Clinical data and parenthood of 63 infertile and Y-microdeleted men

OBJECTIVE

To collect follow-up data for infertile men with Y microdeletion.

DESIGN

Retrospective, observational survey.

SETTING

Multicenter IVF units associated with genetics laboratories.

PATIENT(S)

Sixty-three patients with Y microdeletion.

INTERVENTION(S)

Karyotype analysis, Y microdeletion screening, and assisted reproductive technology.

MAIN OUTCOME MEASURES

Medical history, karyotype, nature of the AZF deletion, semen parameters, testis biopsy results, choice of assisted reproductive technology, and results of intracytoplasmic sperm injection (ICSI).

RESULTS

Abnormal karyotypes were found in 8 men (12.7%), who were azoospermic except 1. Of these 8 men, 5 presented a combined AZFb+c deletion, and 3 had a deletion in AZFc only. Most men (39 of 63) were azoospermic, 3 were cryptoazoospermic, and 19 had extreme oligozoospermia (sperm concentration </=1.10(6)/mL). Sperm concentration above 1.10(6)/mL was found for 2 men (3.1%). A testis biopsy was performed in 27 azoospermic men, resulting in positive sperm extraction in 6 cases. To date, 42 ICSI cycles with either testicular (n = 5) or ejaculated spermatozoa (n = 37) have been carried out in 23 couples with male partners with AZFc deletion. Eighteen clinical pregnancies were obtained, leading to the birth of 14 babies. Donor insemination had been chosen by 28 couples, leading to the birth of 9 children.

CONCLUSION

Karyotype analysis should be systematically performed in Y microdeleted men. Intracytoplasmic sperm injection can be offered to half of AZFc-deleted patients, providing real opportunities to have a child.

Artificial oocyte activation with calcium ionophore A23187 in intracytoplasmic sperm injection cycles using surgically retrieved spermatozoa

OBJECTIVE

To evaluate the effect of artificial oocyte activation (AOA) on intracytoplasmic sperm injection (ICSI) cycles using surgically retrieved sperm.

DESIGN

Laboratory study.

SETTING

Fertility/assisted fertilization center.

PATIENT(S)

Couples undergoing surgical sperm retrieval for ICSI (n = 204).

INTERVENTION(S)

Application of calcium ionophore A23187 for AOA.

MAIN OUTCOME MEASURE(S)

Cycles were divided into experimental groups according to the origin of the sperm used for injection and the type of azoospermia: [1] testicular sperm aspiration in nonobstructive-azoospermic patients (TESA-NOA group, n = 58), [2] TESA in obstructive-azoospermic patients (TESA-OA group, n = 48), [3] and percutaneous epididymal sperm aspiration in obstructive-azoospermic patients (PESA-OA, n = 98). For each experimental group, cycles where AOA was applied (subgroup: activation) were compared with cycles in which AOA was not applied (subgroup: control). The fertilization, high-quality embryo, implantation, and pregnancy rates were compared among the subgroups.

RESULT(S)

For patients undergoing TESA, AOA did not improve ICSI outcomes for either type of azoospermia. However, for cases in which the injected sperm were retrieved from the epididymis, a statistically significantly increased rate of high-quality embryos was observed with AOA.

CONCLUSION(S)

Artificial oocyte activation may improve ICSI outcomes in azoospermic patients when epididymal, but not testicular spermatozoa, are injected.

Paternal effects on early embryogenesis

Historically, less attention has been paid to paternal effects on early embryogenesis than maternal effects. However, it is now apparent that certain male factor infertility phenotypes are associated with increased DNA fragmentation and/or chromosome aneuploidies that may compromise early embryonic development. In addition, there is a growing body of evidence that the fertilizing sperm has more function than just carrying an intact, haploid genome. The paternally inherited centrosome is essential for normal fertilization, and the success of higher order chromatin packaging may impact embryogenesis. Epigenetic modifications of sperm chromatin may contribute to the reprogramming of the genome, and sperm delivered mRNA has also been hythesized to be necessary for embryogenesis. There is less information about the epigenetic factors affecting embryogenesis than genetic factors, but the epigenetics of gamete and early embryogenesis is a rapidly advancing field.

A comparison of post-thaw results between embryos arising from intracytoplasmic sperm injection using surgically retrieved or ejaculated spermatozoa

OBJECTIVE

To study the effect of freeze-thaw on embryos derived from intracytoplasmic sperm injection (ICSI) using surgically retrieved and ejaculated spermatozoa.

DESIGN

Retrospective study.

SETTING

Private IVF center.

PATIENT(S)

Three hundred eighty-three patients undergoing frozen-thawed ET cycles.

INTERVENTION(S)

Testicular sperm aspiration (TESA) or percutaneous epididymal sperm aspiration (PESA) were the sperm surgical retrieval methods used for ICSI. Embryos resulting from ICSI using surgically retrieved and ejaculated spermatozoa were frozen, thawed, and transferred.

MAIN OUTCOME MEASURE(S)

Post-thaw survival, implantation, and pregnancy rates.

RESULT(S)

No differences were found between the ejaculated sperm and TESA/PESA groups in terms of post-thaw survival rate (68.4% vs. 66.1%, respectively), pregnancy rate (20.1% vs. 16.1%), and implantation rate (10.6% vs. 12.7%). Similar results were found for those variables when comparing TESA and PESA groups.

CONCLUSION(S)

Cleavage embryos arising from ICSI cycles using testicular and epididymal spermatozoa can be frozen with survival, pregnancy, and implantation rates comparable to those obtained with ejaculated spermatozoa.

[Management of azoospermias]

An oral assessment and thorough clinical examination are an essential prerequisite in the presence of azoospermia (varicocele? absence of vas deferens?). Examination of the volume and pH of the ejaculate must also be included in the assessment, together with measurement of the FSH and testosterone required and a scrotal and prostatic endorectal ultrasound (particularly helpful in the diagnosis of obstructions, testicular nodules etc.). In terms of second-line treatment, the assessment can be completed by prescription of plasma inhibin B, seminal biochemistry and genetic assessment (blood karyotype, diagnosis of microdeletion of the Y chromosome and diagnosis of mutation of the CFTR gene in the case of bilateral absence of the vas deferens). On completion of this assessment, the azoospermia is either obstructive or non-obstructive, even if it is not always this simple. Obstructive azoospermia can be overcome by reconstructive surgery (vasovasostomy, vasoepididymostomy and transurethral resection of the ejaculatory ducts), thus avoiding the need for ICSI. In the case of azoospermia with varicocele, treatment of the varicocele can achieve certain results. Finally, in the case of non-obstructive azoospermia, it is difficult to draw a conclusion between the use of fresh or frozen spermatozoa although many teams favour frozen spermatozoa.