Efficacy of intracytoplasmic sperm injection using testicular spermatozoa

The management of obstructive azoospermia: a committee opinion

Infertility due to obstructive azoospermia may be treated effectively by surgical reconstruction or by retrieval of sperm from the epididymis or testis, followed by in vitro fertilization with intracytoplasmic sperm injection. This replaces the ASRM documents titled "Sperm retrieval for obstructive azoospermia" and "The management of infertility due to obstructive azoospermia," last published in 2008.

Microscopic varicocelectomy as a treatment option for patients with severe oligospermia

Purpose

Many studies have shown improved semen parameters after varicocele surgery; however, the benefit in terms of improved pregnancy rates and live births is still disputed in cases of severe oligoasthenozoospermia (OAS). The present study evaluated the outcome of microscopic subinguinal varicocelectomy in terms of the spontaneous pregnancy rate in patients with severe OAS.

Materials and Methods

This was a retrospective, observational, analytic study of 56 men with OAS who underwent microscopic varicocelectomy at our center between 2008 and 2015. The subjects were followed for a mean period of 12.4 months. Outcome was compared among groups of men with mild (sperm concentration, 10.2–19 million/mL), moderate (5.7–9.5 million/mL), and severe (<5 million/mL) OAS who were operated on during the same period.

Results

A total of 13 of 35 men (37.1%) with severe OAS achieved spontaneous pregnancy. Mean sperm density increased from 2.29 million/mL preoperatively to 14.09 million/mL postoperatively. The mean time to pregnancy from the date of surgery was 8.5 months. The spontaneous pregnancy rate in men with mild and moderate OAS was 62.5% and 46.2%, respectively.

Conclusions

Although pregnancy rates after varicocele surgery are lower preoperatively in men with severe OAS than in men with mild or moderate OAS, the spontaneous pregnancy rate of 37.1% still compares very favorably with outcomes after a single attempt at in vitro fertilization.

Sperm recovery and IVF after testicular sperm extraction (TESE): effect of male diagnosis and use of off-site surgical centers on sperm recovery and IVF

Objective

Determine whether testicular sperm extractions and pregnancy outcomes are influenced by male and female infertility diagnoses, location of surgical center and time to cryopreservation.

Patients

One hundred and thirty men undergoing testicular sperm extraction and 76 couples undergoing 123 in vitro fertilization cycles with testicular sperm.

Outcome Measures

Successful sperm recovery defined as 1–2 sperm/0.5 mL by diagnosis including obstructive azoospermia (n = 60), non-obstructive azoospermia (n = 39), cancer (n = 14), paralysis (n = 7) and other (n = 10). Obstructive azoospermia was analyzed as congenital absence of the vas deferens (n = 22), vasectomy or failed vasectomy reversal (n = 37) and “other”(n = 1). Sperm recovery was also evaluated by surgical site including infertility clinic (n = 54), hospital operating room (n = 67) and physician’s office (n = 11). Treatment cycles were evaluated for number of oocytes, fertilization, embryo quality, implantation rate and clinical/ongoing pregnancies as related to male diagnosis, female diagnosis, and use of fresh or cryopreserved testicular sperm.

Results

Testicular sperm recovery from azoospermic males with all diagnoses was high (70 to 100%) except non-obstructive azoospermia (31%) and was not influenced by distance from surgical center to laboratory. Following in vitro fertilization, rate of fertilization was significantly lower with non-obstructive azoospermia (43%, p = <0.0001) compared to other male diagnoses (66%, p = <0.0001, 59% p = 0.015). No differences were noted in clinical pregnancy rate by male diagnosis; however, the delivery rate per cycle was significantly higher with obstructive azoospermia (38% p = 0.0371) compared to diagnoses of cancer, paralysis or other (16.7%). Women diagnosed with diminished ovarian reserve had a reduced clinical pregnancy rate (7.4% p = 0.007) compared to those with other diagnoses (44%).

Conclusion

Testicular sperm extraction is a safe and effective option regardless of the etiology of the azoospermia. The type of surgical center and/or its distance from the laboratory was not related to success. Men with non-obstructive azoospermia have a lower chance of successful sperm retrieval and fertilization.

Surgical recovery of sperm in non-obstructive azoospermia

The development of intracytoplasmic sperm injection (ICSI) opened a new era in the field of assisted reproduction and revolutionized the assisted reproductive technology protocols for couples with male factor infertility. Fertilisation and pregnancies can be achieved with spermatozoa recovered not only from the ejaculate but also from the seminiferous tubules. The most common methods for retrieving testicular sperm in non-obstructive azoospermia (NOA) are testicular sperm aspiration (TESA: needle/fine needle aspiration) and open testicular biopsy (testicular sperm extraction: TESE). The optimal technique for sperm extraction should be minimally invasive and avoid destruction of testicular function, without compromising the chance to retrieve adequate numbers of spermatozoa to perform ICSI. Microdissection TESE (micro-TESE), performed with an operative microscope, is widely considered to be the best method for sperm retrieval in NOA, as larger and opaque tubules, presumably with active spermatogenesis, can be directly identified, resulting in higher spermatozoa retrieval rates with minimal tissue loss and low postoperative complications. Micro-TESE, in combination with ICSI, is applicable in all cases of NOA, including Klinefelter syndrome (KS). The outcomes of surgical sperm retrieval, primarily in NOA patients with elevated serum follicle-stimulating hormone (FSH) (NOA including KS patients), are reviewed along with the phenotypic features. The predictive factors for surgical sperm retrieval and outcomes of treatment were analysed. Finally, the short- and long-term complications in micro-TESE in both 46XY males with NOA and KS patients are considered.

Recovery, Preparation, Storage and Utilization of Spermatozoa for Fertility Preservation in Cancer Patients and Sub-Fertile Men

Sperm cryopreservation is an important part of an infertility program for patients undergoing infertility treatments, fertility assurance for vasectomy cases, and for fertility preservation due to cancer or other medical conditions. With recent developments in reproductive technology, even men with severely impaired sperm parameters can benefit from cryopreservation as procedures such as intra-cytoplasmic sperm injection (ICSI) require only a few sperm to achieve fertilization and pregnancy. The increasing success of cancer treatment and concerted efforts to ensure quality of life after successful treatment have placed great emphasis on the need to preserve the reproductive capability of young men. It is a highly effective method of protecting male fertility potential, and involves collection, freezing, and long-term storage of sperm. Based on the etiological condition of the patients, sperm can be collected by ejaculation or by surgical retrieval from epididymis or testes. The option to bank sperm should be offered systematically to all patients who may benefit. However, this is not a standard of practice yet; it may be overlooked due to lack of physician awareness regarding the need for fertility preservation and the effectiveness of this option, and/or overestimating the limitations of poor baseline sperm quality leading physician to view cryopreservation as futile. Failure to offer cryopreservation ignores the only possible reproductive option available to certain patients.

Testicular sperm from patients with obstructive and nonobstructive azoospermia: aneuploidy risk and reproductive prognosis using testicular sperm from fertile donors as control samples

OBJECTIVE

To establish a baseline incidence of chromosomal abnormalities in testicular sperm of fertile men and to determine the best control sample for comparisons with azoospermic males to estimate their reproductive prognosis.

DESIGN

Prospective study.

SETTING

Infertility clinic.

PATIENT(S)

Sixteen obstructive azoospermic (OA) and 19 nonobstructive azoospermic patients (NOA). Control samples were ejaculated sperm from ten fertile donors and testicular sperm from ten other fertile donors.

INTERVENTION(S)

Fluorescence in situ hybridization (FISH) in sperm.

MAIN OUTCOME MEASURE(S)

Sperm numerical abnormalities for chromosomes 13, 18, 21, X, and Y; ongoing implantation and pregnancy rates in intracytoplasmic sperm injection (ICSI) cycles.

RESULT(S)

In control samples, testicular sperm showed higher incidences of diploidy (0.27% vs. 0.10%) and disomy for chromosomes 13 (0.16% vs. 0.07%), 21 (0.25% vs. 0.12%), and sex chromosomes (0.34% vs. 0.21%) than ejaculated sperm. Comparisons with ejaculated control samples showed 12.5% OA and 68.4% NOA patients having significantly higher incidence of sperm chromosomal abnormalities. Compared with testicular control subjects, fewer OA (6.3%) and NOA (42.1%) patients had chromosomally abnormal sperm. NOA patients had lower ongoing implantation and pregnancy rates than OA patients, particularly those with abnormal FISH compared with testicular control samples.

CONCLUSION(S)

Sperm FISH analysis using testicular sperm control samples better identifies NOA patients with a lower likelihood of reproductive success.

Impact of luteinizing hormone administration on gonadotropin-releasing hormone antagonist cycles: an age-adjusted analysis

OBJECTIVE

To analyze the impact of LH administration on cycle outcome in ovarian stimulation with GnRH antagonists.

DESIGN

Randomized, open-label, controlled trial performed in two age subgroups. Recombinant (r) FSH versus rFSH + rLH administration was compared.

SETTING

University-affiliated private infertility clinic.

PATIENT(S)

Up to 35 years old (n = 380) and aged 36 to 39 years (n = 340), undergoing their first or second IVF cycle.

INTERVENTION(S)

Recombinant LH administration since stimulation day 1.

MAIN OUTCOME MEASURE(S)

Implantation rate, ongoing pregnancy rate.

RESULT(S)

In the young population, implantation rates were similar: 27.8% versus 28.6%, odds ratio (OR) 1.03 (95% confidence interval [CI] 0.73-1.47), as was the ongoing pregnancy rate per started cycle: 37.4% versus 37.4%, OR 1.0 (95% CI 0.66-1.52). In older patients, the implantation rate was significantly higher in the rFSH + rLH group: 26.7% versus 18.6%, OR 1.56 (95% CI 1.04-2.33). Ongoing pregnancy rates per started cycle were 33.5% versus 25.3%, OR 1.49 (95% CI 0.93-2.38).

CONCLUSION(S)

Recombinant LH administration significantly increased the implantation rate in patients aged 36 to 39 years. A clinically relevant better ongoing pregnancy rate per started cycle was observed, although the difference was not statistically significant. Patients younger than 36 years do not obtain any benefit from rLH administration.

Which is the best sperm retrieval technique for non-obstructive azoospermia? A systematic review

Our objective was to establish which is the best sperm retrieval technique in non-obstructive azoospermia based on the available evidence. To date, no randomized controlled trial has compared the efficiency of these strategies and thus current recommendations are based on cumulative evidence provided by descriptive, observational and controlled studies. Three outcome measures were assessed for the sperm retrieval techniques: sperm retrieval rate (SRR), complications and live birth rate. Twenty-four descriptive studies reporting on the results of testicular sperm extraction (TESE) were encountered. Seven controlled studies that compared microdissection (MD) TESE with conventional TESE and seven controlled studies comparing fine needle testicular aspiration (FNA) with TESE were identified. The mean SRR for TESE was 49.5% (95% CI 49.0-49.9). TESE with multiple biopsies results in a higher SRR than FNA especially in cases of Sertoli-cell-only (SCO) syndrome and maturation arrest. Current evidence suggests that MD performs better than conventional TESE only in cases of SCO where tubules containing active focus of spermatogenesis can be identified. MD appears to be the safest technique regarding post-operative complications followed by FNA. Only three studies could be identified concerning the influence of the sperm retrieval technique on clinical pregnancy and live birth rate, hence no definitive conclusions can be made. However, so far there appears to be no impact of the technique itself on success rates.

Comparison of two different starting multiple dose gonadotropin-releasing hormone antagonist protocols in a selected group of in vitro fertilization-embryo transfer patients

OBJECTIVE

To compare the efficacy of two starting protocols of multiple dose GnRH antagonists (GnRH-a).

DESIGN

Prospective randomized controlled study.

SETTING

In vitro fertilization-embryo transfer program at the Instituto Valenciano de Infertilidad, Valencia, Spain.

PATIENT(S)

One hundred nine patients undergoing controlled ovarian hyperstimulation (COH) with recombinant gonadotropins and GnRH-a (0.25 mg/d).

INTERVENTION(S)

Patients started GnRH-a administration on stimulation day 6 (group 1) or when the leading follicle reached a mean diameter of 14 mm (group 2).

MAIN OUTCOME MEASURE(S)

Implantation and pregnancy rates; serum E(2) and LH levels during ovarian stimulation; days of stimulation and GnRH-a administration.

RESULT(S)

Days needed for ovarian stimulation were similar in both groups but there was a significant difference when comparing days of GnRH-a administration. Serum E(2) and LH followed similar curves in both groups. Implantation and pregnancy rates were 23.7% and 44.4 % in group 1 and 28.6% and 50.9 % in group 2 (P=not significant [NS]).

CONCLUSION(S)

The efficacy of the two starting protocols of the multiple dose GnRH-a evaluated in this study is similar; however, this remark can only be drawn for a selected group of patients.

Premature luteinization during gonadotropin-releasing hormone antagonist cycles and its relationship with in vitro fertilization outcome

OBJECTIVE

To determine the prevalence and the effect of premature luteinization in GnRH antagonist IVF-ET cycles.

DESIGN

Prospective observational study.

SETTING

In vitro fertilization-embryo transfer (IVF-ET) program at the Instituto Valenciano de Infertilidad.

PATIENT(S)

Eighty-one infertile patients undergoing controlled ovarian hyperstimulation with gonadotropins and GnRH antagonist for IVF-ET.

INTERVENTION(S)

Gonadotropin-releasing hormone (GnRH) antagonist was administered from stimulation day 6. Serum P, E(2), and LH were determined on the day of hCG administration.

MAIN OUTCOME MEASURE(S)

Cycles were grouped according to serum P level on the day of hCG administration (<1.2 ng/mL or > or =1.2 ng/mL). Clinical pregnancy and implantation rates were determined.

RESULT(S)

The incidence of premature luteinization was 38.3%. Total recombinant FSH dose and stimulation days differed significantly between the groups. Pregnancy rate (25.8% vs. 54.0%) and implantation rate (13.8% vs. 32.0%) were significantly lower in the premature luteinization group.

CONCLUSION(S)

Premature luteinization during GnRH antagonist IVF-ET cycles is a frequent event that is associated with lower pregnancy and implantation rates. Progesterone elevations are not related to serum LH levels and may reflect the mature granulosa cell response to high FSH exposure.

Human ovarian steroid secretion in vivo: effects of GnRH agonist versus antagonist (cetrorelix)

BACKGROUND

In order to investigate whether gonadotrophin-releasing hormone (GnRH) antagonists exert a significant effect on steroid secretion in vivo compared with GnRH agonists, concentrations of sex steroid hormones (oestradiol, progesterone and testosterone) were studied in follicular fluid from women undergoing ovarian stimulation and treated with either GnRH agonist or antagonist. In addition, the correlation between follicular fluid steroid hormone concentrations and variables of follicular and oocyte development was evaluated.

METHODS

Microparticle enzyme immunoassay and radioimmunoassays were used.

RESULTS

The mean (SEM) follicular fluid oestradiol concentration was significantly lower in patients treated with GnRH antagonist than in those treated with GnRH agonist (542.0 +/- 76.9 versus 873.0 +/- 105.1 pg/ml, P = 0.02), which correlates with the mean serum oestradiol concentrations found in these two groups. No significant differences were found between groups in follicular fluid progesterone concentrations. Women undergoing GnRH antagonist treatment showed similar concentrations of follicular fluid testosterone compared with GnRH agonist-treated women (14.8 +/- 1.1 versus 13.3 +/- 2.7 ng/ml). The oestradiol:testosterone ratio was markedly reduced in women treated with GnRH antagonist (49.1 +/- 2.3 versus 60.1 +/- 4.4, P = 0.04). In contrast, no differences were found either in the progesterone:testosterone ratio, or in the oestradiol:progesterone ratio.

CONCLUSIONS

GnRH antagonist therapy in women undergoing ovarian stimulation had a significant effect on ovarian follicular steroidogenesis.

The origin of spermatozoa does not affect intracytoplasmic sperm injection outcome

OBJECTIVE

To assess whether the origin of spermatozoa, ejaculate or testicular, affects intracytoplasmic sperm injection (ICSI) outcome.

STUDY DESIGN

Retrospective study of 890 consecutive first ICSI and embryo transfer cycles done for male infertility. The ICSI outcome of ejaculated spermatozoa (n=780) and testicular spermatozoa retrieved from patients with obstructive azoospermia (n=43), non-obstructive azoospermia (n=53) and severe oligoasthenoteratozoospermia (n=14) were compared by using chi-square test, independent t-test and ANOVA with Bonferroni test.

RESULTS

All azoospermic males had a diagnostic testicular biopsy at least 6 months before the ICSI procedure. Spermatozoa were successfully retrieved in all 43 patients with obstructive azoospermia and in 72.6% of 73 non-obstructive cases. The cycle characteristics of the four groups were similar apart from a younger mean female age in the non-obstructive azoospermia group when compared with the ejaculated spermatozoa group. The fertilization, implantation and clinical pregnancy rates were comparable among the four groups.

CONCLUSION

Testicular spermatozoa recovered from patients with obstructive and all types of non-obstructive azoospermia were as much as effective as ejaculated spermatozoa in ICSI.

Use of frozen-thawed testicular sperm for intracytoplasmic sperm injection

OBJECTIVE

To determine the feasibility of using frozen-thawed testicular spermatozoa for intracytoplasmic sperm injection.

DESIGN

Prospective clinical study.

SETTING

A university hospital.

PATIENT(S)

One hundred seventy-five azoospermic men participating in a routine intracytoplasmic sperm injection program.

INTERVENTION(S)

The men underwent testicular biopsy for cryopreservation of tissue to be used in consecutive intracytoplasmic sperm injection treatment cycles. Their female partners underwent controlled ovarian hyperstimulation for conventional IVF treatment.

MAIN OUTCOME MEASURE(S)

Fertilization and pregnancy rates.

RESULT(S)

In 77% of the patients, spermatozoa could be harvested from the testis by an open testicular biopsy technique and used for intracytoplasmic sperm injection after freezing and thawing of testicular tissue. Histopathologic evaluation revealed a Sertoli cell-only pattern in 21%, maturation arrest in 60%, and hypospermatogenesis in 19% of the patients. In 2. 9% of the patients, carcinoma in situ or a germ cell tumor was detected. In all patients, viable spermatozoa could be visualized after the tissue samples were thawed. One hundred thirty-five intracytoplasmic sperm injection treatment cycles were performed, with a fertilization rate of 45% and a clinical pregnancy rate of 30% per oocyte retrieved.

CONCLUSION(S)

The use of frozen-thawed testicular tissue allows ovarian stimulation of the female partner to be timed and avoids cancellation of ovum pick-up when spermatozoa cannot be retrieved.

Extraction of testicular sperm from previously cryopreserved tissue in couples with or without transport of oocytes and testicular tissue

OBJECTIVE

To evaluate results of IVF and intracytoplasmic sperm injection (ICSI) with extraction of sperm from frozen-thawed testicular tissue.

DESIGN

Retrospective follow-up study.

SETTING

Fertility center.

PATIENT(S)

Thirty-five couples with transport of testicular tissue from a transport clinic and 125 local couples.

INTERVENTION(S)

Extraction of testicular sperm by maceration and enzymatic digestion from frozen-thawed testicular tissue before ICSI.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate (PR) and implantation rate in couples with obstructive or nonobstructive azoospermia, motile or immotile sperm, and differing male serum FSH values.

RESULT(S)

The clinical PR per ET and implantation rate per embryo in couples with transport of testicular tissue were 40% and 18%, respectively, in cases of obstructive azoospermia and 37% and 26%, respectively, in cases of nonobstructive azoospermia. In the local couples, these rates were 42% and 19%, respectively, in cases of obstructive azoospermia and 18% and 10%, respectively, in cases of nonobstructive azoospermia. The implantation rates for ICSI were 26% with motile sperm and 11% with immotile sperm in the transport group and 16% and 8%, respectively, in the local group. Male serum FSH level did not clearly correlate with implantation rate.

CONCLUSION(S)

Clinical PR and implantation rate are not affected by transport of testicular tissue but are significantly affected by nonobstructive azoospermia and the use of immotile sperm. No major increase in chromosomal aberration or congenital malformation was noted in the offspring of this limited group.

Approaches for obtaining sperm in patients with male factor infertility

OBJECTIVE

To describe methods of sperm retrieval for intracytoplasmic sperm injection (ICSI) in patients with male factor infertility and to review the clinical results using sperm from the different sources.

DESIGN

The literature on sperm-obtaining methods and ICSI was reviewed. Studies related to this topic were identified through MEDLINE.

RESULTS(S)

This review describes the evolution of sperm retrieval methods. Sperm can be obtained by microepididymal sperm aspiration (MESA), percutaneous sperm aspiration (PESA), and testicular sperm extraction (TESE), from patients with congenital absence of the vas deferens or acquired vas obstruction. When ICSI is performed with ejaculated, epididymal, or testicular sperm, good fertilization and pregnancy rates are achieved without significant differences among the various sperm sources. The original percutaneous sperm aspiration method has been modified slightly and yields successful results.

CONCLUSION(S)

Viable pregnancies can be achieved with ICSI by using not only ejaculated sperm, but also epididymal and testicular sperm. Microepididymal sperm aspiration, percutaneous sperm aspiration, modified percutaneous sperm aspiration, and testicular sperm extraction can be considered standard procedures to treat male factor infertility.

Fertility options after vasectomy: a cost-effectiveness analysis

OBJECTIVE

To evaluate cost per delivery using two different initial approaches to the treatment of postvasectomy infertility.

DESIGN

Model of expected costs and results in the United States in 1994.

SETTING

Men with postvasectomy infertility, evaluated and treated at centers with experience in vasectomy reversal or sperm retrieval and ICSI.

PATIENT(S)

Men with postvasectomy infertility, with a female partner < or = 39 years of age.

INTERVENTION(S)

Initial microsurgical vasectomy reversal was compared with retrieved epididymal or testicular sperm. Actual treatment charges, complication rates, and pregnancy and delivery rates obtained in the United States were used for cost per delivery analysis.

MAIN OUTCOME MEASURE(S)

Cost per delivery, delivery rates.

RESULT(S)

Cost per delivery with an initial approach of vasectomy reversal was only $25,475. (95% confidence interval $19,609 to $31,339), with a delivery rate of 47%. However, the cost per delivery after sperm retrieval and ICSI was $72,521. (95% confidence interval $63,357 to $81,685), with an average of $73,146 for percutaneous or testicular sperm retrieval and $71,896 for surgical epididymal sperm retrieval. The delivery rate after one cycle of sperm retrieval and ICSI was 33%.

CONCLUSION(S)

The most cost-effective approach to treatment of postvasectomy infertility is microsurgical vasectomy reversal. This treatment also has the highest chance of resulting in delivery of a child for a single intervention.

Quality of frozen-thawed testicular sperm and its preclinical use for intracytoplasmic sperm injection into in vitro-matured germinal-vesicle stage oocytes

OBJECTIVE

To study the effects of cryopreservation on the quality of human testicular spermatozoa and the efficiency of intracytoplasmic sperm injection (ICSI) with frozen-thawed testicular sperm into metaphase II oocytes in vitro-matured from the germinal-vesicle stage oocyte.

DESIGN

Preclinical freezing study on supernumarary testicular spermatozoa after ICSI.

SETTING

Tertiary IVF center coupled with an institutional research environment.

PATIENT(S)

Twenty-nine patients undergoing excisional testicular biopsy for ICSI.

INTERVENTION(S)

Isolated testicular spermatozoa were cryopreserved and thawed; frozen-thawed motile testicular spermatozoa were microinjected.

MAIN OUTCOME MEASURE(S)

Prefreezing and post-thawing motility and viability, survival rate, fertilization rate, cleavage rate, and embryo quality after ICSI.

RESULT(S)

Mean percentage motility decreased from 21% before freezing to 6% after thawing. Vitality was impaired to a similar extent, decreasing from 68% to 22% (32% recovery rate). Injection of frozen-thawed testicular spermatozoa into in vitro-matured oocytes resulted in a fertilization rate of 50.9%. Cleavage rate was severely impaired. Half of the fertilized oocytes became arrested in the one-cell stage.

CONCLUSION(S)

Despite the low quality of the fresh testicular spermatozoa, a high percentage of prepared testicular sperm fractions showed survival and motility after the freezing and thawing process. Injection of frozen-thawed testicular sperm into matured oocytes resulted in fertilization rates comparable with these with fresh testicular sperm, but cleavage rates were severely impaired, which might be due to source of oocytes used for ICSI.