Sperm pellet analysis: a technique to detect the presence of sperm in men considered to have azoospermia by routine semen analysis

Andrology laboratory technique for analysis of semen in men with azoospermia

ABSTRACT

Discovery of spermatozoa during the 17th century led to developing technologies for semen analysis in the early 1900s, and then, standard techniques were implemented during the 20th century. Semen analysis has a pivotal role in the male infertility evaluation, and azoospermia is an important finding. Azoospermia is identified in 15% of infertile men. However, the accurate laboratory assessment of azoospermia poses certain technical challenges. Laboratories currently perform semen assessment with great variability; thus, a standard method should be used. Planning suitable management and determining the cause of infertility require a precise evaluation of azoospermia. This review aims to address the definition of azoospermia and highlight laboratory methods in the assessments of azoospermia. Basic methods such as centrifugation, repeat pellet analysis, and staining and advanced methods such as genetic testing and biomarkers have been discussed. These methods have helped in standardizing the protocol for accurate azoospermia assessments with less variability.

Role of Cytocentrifugation Combined with Nuclear Fast Picroindigocarmine Staining in Detecting Cryptozoospermia in Men Diagnosed with Azoospermia

PURPOSE

Azoospermia is defined as the absence of spermatozoa in the pellet of a centrifuged semen sample. In fact, when a basic semen analysis fails to detect sperm in the ejaculate, there is still the possibility of detecting rare sperm after centrifugation of the sample and examination of the pellet. In this study, we assessed the role of Cytospin centrifugation in combination with the nuclear fast picroindigocarmine (NF-PIC) staining in identifying sperm in azoospermic samples.

MATERIALS AND METHODS

Semen samples of 251 men diagnosed as having azoospermia after standard examination were further analyzed by Cytospin centrifugation in combination with NF-PIC staining.

RESULTS

Sperm were detected in 60 men (23.9%), thus changing their diagnosis to cryptozoospermia.

CONCLUSIONS

By identifying sperm in the semen of men who were thought to have total azoospermia, the Cytospin NF-PIC test can alter the diagnosis and further treatment of these men.

Male factor infertility: A contemporary overview of investigation, diagnosis and management

Infertility, defined as the failure to achieve a clinical pregnancy after 1 year of regular, unprotected sexual intercourse, is a public health issue of global concern. It affects up to 12% of couples worldwide. While traditionally, research and treatment have focused on female causes of infertility, male factors contribute to up to 70% of cases and therefore deserve appropriate recognition. The purpose of this comprehensive review is to detail the diagnostic work-up, investigations and management of male factor infertility. We discuss much-debated pathologies, such as varicocele, and novel investigations, including sperm DNA fragmentation and reactive oxygen species.

Level of evidence: Not applicable

Follicle-stimulating hormone may predict sperm retrieval rate and guide surgical approach in patients with non-obstructive azoospermia

Testicular sperm aspiration- (TESA) or micro-dissection testicular sperm extraction- (MD-TESE) combined intracytoplasmic sperm injection (ICSI) was the only option for non-obstructive azoospermia (NOA) patients to have a biological offspring and they had different success rates in sperm retrieval. Our study aimed to find predictor(s) for predicting the sperm retrieval rate (SRR) in NOAs and guide clinicians in choosing different surgical approaches, TESA or MD-TESE for NOAs. 294 NOAs who had undergone TESA or MD-TESE were divided into TESA group and MD-TESE group. Depending on sperm retrieval, each group was divided into two subgroups: successful subgroups and failure subgroups. They respectively were 24 cases and 131 cases, 53 cases and 86 cases. Clinical data, including body mass index (BMI), testicular volume, and serum hormone levels, were analyzed in a retrospective manner. The results showed that follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels and SRR were lower in TESA group as compared to these in MD-TESE group, while testicular volume was higher (P < 0.05). The surgical approach of sperm retrieval significantly affected the SRR (P < 0.05). In TESA subgroups, testicular volume, FSH and LH differed significantly (P < 0.05). In MD-TESE subgroups, the level of FSH and LH differed significantly between both groups (P < 0.05). Using logistics regression, we found a negative correlation (β=-0.083) between FSH and the SRR in TESA group but a positive correlation (β = 0.064) in MD-TESE group (P < 0.05). In conclusion, serum FSH level can predict the SRR of NOAs and guide the clinicians while selecting the suitable surgery approach for NOAs.

Comparison and outcomes of nonobstructive azoospermia patients with different etiology undergoing MicroTESE and ICSI treatments

Background

The purpose of the study was to compare clinical, laboratory, histological features, microdissection testicular sperm extraction (MicroTESE) and intracytoplasmic sperm injection (ICSI) treatment outcomes of nonobstructive azoospermia (NOA) patients of various etiologies, and to investigate ICSI outcomes using fresh and frozen thawed sperms from MicroTESE, so to explore an optimal MicroTESE-ICSI procedure for NOA couples.

Methods

A retrospective analysis was made in 595 NOA patients undergoing MicroTESE from January 2013 to December 2017. The men were classified into six groups based on etiology. Patients' age, history, hormone profile, testis volume, testicular histology, sperm retrieval, fertile and pregnancy outcomes of ICSI were included for analysis.

Results

A total of 595 NOA patients were included in this study, with 446 (75.0%) were idiopathic NOA, 66 (11.1%) were Klinefelter syndrome (KS), 34 (5.7%) with microdeletion of the AZFc, 33 (5.5%) cases had the history of cryptorchidism, 13 (2.2%) had a history of mumps orchitis, and 3 (0.5%) cases underwent chemotherapy. The overall sperm retrieval rate (SRR) was 40.3% (240/595), SRR of the cryptorchidism (84.8%, 28/33) and mumps orchitis (84.6%, 11/13) groups were much higher than that of other groups, the SRR of idiopathic group was the lowest (31.8%, 142/446). One hundred and ninety-eight ICSI cycles utilizing MicroTESE sperm were retrospectively analyzed, including 155 fresh MicroTESE ICSI cycles and 43 frozen-thawed MicroTESE ICSI cycles. Fertilization rate, cleavage rate, and clinical pregnancy rate of fresh sperm group were slightly higher than those in frozen thawed MicroTESE sperm group, but high qualified embryo rate of fresh sperm group was lower than frozen thawed group. The differences were of no statistical meaning.

Conclusions

Etiology may be an effective prognostic factor for SRR in NOA patients. NOA of definite etiology, such as cryptorchidism, has high SRR, while idiopathic NOA, the most common type of NOA, has the lowest SRR. Using of frozen thawed sperm from MicroTESE had similar pregnant outcome to that of fresh sperm, so cryopreservation of testicular sperm seems to be more suitable and of great benefit in these cases and good results can also be expected when oocyte retrieval and ICSI are not performed at the same time.

Clinical management of infertile men with nonobstructive azoospermia

The clinical management of men with nonobstructive azoospermia (NOA) seeking fertility has been a challenge for andrologists, urologists, and reproductive medicine specialists alike. This review presents a personal perspective on the clinical management of NOA, including the lessons learned over 15 years dealing with this male infertility condition. A five-consecutive-step algorithm is proposed to manage such patients. First, a differential diagnosis of azoospermia is made to confirm/establish that NOA is due to spermatogenic failure. Second, genetic testing is carried out not only to detect the males in whom NOA is caused by microdeletions of the long arm of the Y chromosome, but also to counsel the affected patients about their chances of having success in sperm retrieval. Third, it is determined whether any intervention prior to a surgical retrieval attempt may be used to increase sperm production. Fourth, the most effective and efficient retrieval method is selected to search for testicular sperm. Lastly, state-of-art laboratory techniques are applied in the handling of retrieved gametes and cultivating the embryos resulting from sperm injections. A coordinated multidisciplinary effort is key to offer the best possible chance of achieving a biological offspring to males with NOA.

Fertility Preservation in Young Men Treated for Malignancies: Options for Precancer Treatment

INTRODUCTION

Fertility preservation (FP) is an essential component of treatment for young men with a new cancer diagnosis.

AIM

To discuss the barriers and recommendations for FP along with the impacts of cancer and cancer treatment on fertility, and to present the various options for FP in young men prior to cancer treatment.

METHODS

Literature Review.

MAIN OUTCOME MEASURE

To evaluate the options for FP in young men, including novel and experimental options for pre-pubertal boys.

RESULTS

With the advent of assisted reproductive technologies, fertility can be successfully preserved in the majority of post-pubertal patients with sperm cryopreservation, neurostimulatory methods of ejaculation, or surgical sperm retrieval procedures.

CONCLUSIONS

All men with a new diagnosis of cancer, including adolescents and children, should be offered FP prior to undergoing treatment. Sperm cryopreservation, the mainstay of FP, should be encouraged regardless of the treatment plan. Even without significant abnormalities on semen analysis, prompt referral to a male fertility specialist is recommended. Coward RM, Kovac JR, Smith RP, and Lipshultz LI. Fertility preservation in young mentreated for malignancies: Options for precancer treatment. Sex Med Rev 2013;1:123-134.

In cryptozoospermia or severe oligozoospermia is sperm freezing useful?

Background

Intracytoplasmic Sperm Injection (ICSI) is an Assisted Reproduction Technique (ART) which offers the chance to conceive to patients presenting very low sperm counts (cryptozoospermia/severe oligozoospermia). Sperm freezing before the oocyte pick-up, can prevent from a lack of spermatozoa on the day of the ICSI. It can avoid the cancellation of the ICSI or the use of TESE (Testicular sperm extraction). The objective of this study was to analyse the practice of sperm freezing for these patients in our center over 8 years and the rate of use of these frozen sperms. We also compared the outcome of ICSIs with frozen versus ejaculated sperm.

Material and methods

We performed a retrospective epidemiological study between 2004 and 2011. We recruited all the patients having a sperm count below 1 Million/mL and who were waiting for their first ICSI attempt.

Results

169 patients were recruited: 84 cryopreserved their sperm before the ICSI (secured ICSI) while 85 did not (non-secured ICSI). Both groups were split in cryptozoospermia (<10³ spermatozoa/ml): 19 and 17 patients respectively, very severe oligozoospermia (10³–10⁵/ml): 37 and 13 patients, and severe oligozoospermia (10⁵–10⁶/ml): 28 and 55 patients. The part of secured ICSI significantly increased from 29% during 2004–2007 to 74% during 2008–2011(p = 0.0029) and the frozen sperm was used in 5.9% of the cases. Median age was significantly higher in the non secured ICSI group (33.57 vs 35.52 for men, p = 0.0069 and 30.45 vs 32.26 for women, p = 0.025) but no significant difference was found in the outcome of the ICSI between frozen-thawed sperm and fresh ejaculated sperm.

Conclusion

Sperm freezing before ICSI for severe oligozoospermic and cryptozoospermic patients significantly increased in our practice but the rate of use remain very low. This encourages to define more accurate criteria leading to sperm freezing.

Electronic supplementary material

The online version of this article (doi:10.1186/2051-4190-24-15) contains supplementary material, which is available to authorized users.

Micro-dissection testicular sperm extraction as an alternative for sperm acquisition in the most difficult cases of Azoospermia: Technique and preliminary results in India

CONTEXT:

Non-obstructive azoospermia (NOA) is an unfavorable prognostic condition for male infertility since spermatogenesis is disrupted. Sperm retrieval (SR) coupled with intracytoplasmic sperm injection (ICSI) is the only option for men with NOA who seek fertility. Among the SR techniques, microdissection testicular sperm extraction (micro-TESE) has been applied with encouraging results.

AIMS:

We describe how we implemented the micro-TESE procedure and present initial micro-TESE experience in a group of men with NOA and poor prognosis for SR.

SETTINGS AND DESIGN:

Case series of men with NOA treated in a tertiary healthcare center.

MATERIALS AND METHODS:

An Assisted Reproductive Technology (ART) facility was setup to perform SR using microsurgery. Fourteen men with NOA and previous failed retrievals or unfavorable histologic results underwent micro-TESE while their female partners received ovarian stimulation for oocyte pickup (OCP). Micro-TESE was performed the day prior to OCP and testicular sperm were used for sperm injections. We assessed retrieval rates and ICSI outcomes.

STATISTICAL ANALYSIS:

Outcomes of SR and ICSI were analyzed descriptively. Mann-Whitney and Fisher exact test were used to compare characteristics of men with successful and failed SR.

RESULTS:

The success of micro-TESE was 50.0% with no major complications. A clear microscopic distinction between enlarged and collapsed seminiferous tubules was seen in 35.7% of the cases, and sperm were retrieved in all but one of these cases. Patients with successful and failed retrieval did not differ with respect to baseline characteristics, use of medical therapy, presence of varicocele, and testicular histology. Sperm injections resulted in normal fertilization and embryo cleavage of 64% and 75%, respectively. A total of five transfers with an average of 1.5 embryos resulted in a cumulative clinical pregnancy rate per ICSI cycle of 28.6%, with an implantation rate of 33.3%.

CONCLUSIONS:

We were successful in integrating the micro-TESE procedures to the in vitro fertilization (IVF) laboratory. Our initial experience with micro-TESE applied to the most difficult cases of azoospermia is reassuring.

Predictive factors for sperm retrieval and sperm injection outcomes in obstructive azoospermia: do etiology, retrieval techniques and gamete source play a role?

Obstructive azoospermia is a relatively common male infertility condition. The main etiologies of obstructive azoospermia include congenital, surgical-derived, traumatic and post-infectious cases. Although seminal tract reconstruction is a cost-effective treatment in most cases, this approach may not be feasible or desired in some cases. In such cases, assisted reproduction techniques offer a method for achieving pregnancy, notably via sperm retrieval and intracytoplasmic sperm injection. This process requires several considerations and decisions to be made, including the cause and duration of obstruction, which sperm retrieval technique to use, and whether to use fresh or frozen-thawed sperm. We present a review of obstructive azoospermia and assisted reproduction techniques, highlighting the most relevant aspects of the decision-making process for use in clinical practice.

The importance of semen analysis in the context of azoospermia

Azoospermia is a descriptive term referring to ejaculates that lack spermatozoa without implying a specific underlying cause. The traditional definition of azoospermia is ambiguous, which has ramifications on the diagnostic criteria. This issue is further compounded by the apparent overlap between the definitions of oligospermia and azoospermia. The reliable diagnosis of the absence of spermatozoa in a semen sample is an important criterion not only for diagnosing male infertility but also for ascertaining the success of a vasectomy and for determining the efficacy of hormonal contraception. There appears to be different levels of rigor in diagnosing azoospermia in different clinical situations, which highlights the conflict between scientific research and clinical practice in defining azoospermia.

Evaluation of the azoospermic male

When presented with an azoospermic patient, a thorough history and careful, considered physical examination often leads to a definite or presumptive diagnosis. An algorithmic, logical thought process is important to have in mind when embarking on the evaluation. Adjunctive laboratory tests, such as hormonal assays or genetic studies, are often complementary and/or additive and allow a very precise determination to be made as to the etiologies, either genetic or acquired. It is only with this information that a therapeutic plan can be made for the patient. As will be discussed, a targeted approach to testing is far more satisfying and cost-effective than a blind, shotgun approach.

Effectiveness of vasectomy techniques

The effectiveness of various vasectomy techniques is reviewed, with a focus on methods used for vas occlusion. Spontaneous recanalization of the vas is more common than generally recognized and is often transient. Simple ligation and excision has an unacceptably high risk for failure. Techniques that include cautery seem to have a lower risk for failure than techniques that do not include cautery. There is insufficient evidence to recommend a particular standardized cautery technique, but adding fascial interposition to cautery seems to be associated with the lowest risk for failure.

The outcome of intracytoplasmic sperm injection using occasional spermatozoa in the ejaculate of men with spermatogenic failure

PURPOSE

Men with spermatogenic failure so profound that they are considered as having nonobstructive azoospermia occasionally have spermatozoa in the ejaculate. We compared intracytoplasmic sperm injection outcomes following the injection of ejaculated or surgically retrieved spermatozoa from these men.

MATERIALS AND METHODS

A study was performed of intracytoplasmic sperm injection cycles with no spermatozoa on initial semen analysis and 100 or fewer following centrifugation (cryptozoospermia). Only 16 couples that underwent intracytoplasmic sperm injection cycles with ejaculated spermatozoa and cycles with testicular spermatozoa were included.

RESULTS

Initial analysis was done to compare outcomes between the 2 semen origins. There was no difference in the rate of normal or abnormal fertilization between the 2 groups. The rate of clinical pregnancies seemed to favor testicular spermatozoa (47.4% vs 20.8%), although results were not significant. When a comparison was performed between the first testicular cycle and the ejaculated cycle closest in time to the cycle with testicular spermatozoa, a higher rate of normal fertilization with testicular spermatozoa was observed (60.9% vs 48.5%, p <0.05). Also, in this comparison a clear trend toward a higher percent of clinical pregnancies and deliveries in the testicular group was observed (50.0% vs 14.3%).

CONCLUSIONS

Transit through the male genital tract did not enhance the ability of ejaculated spermatozoa to achieve fertilization with intracytoplasmic sperm injection compared to that of testicular spermatozoa in men with severely impaired production. In ejaculated samples a lower number of spermatozoa available resulted in an impaired chance of achieving pregnancy. Using testicular spermatozoa may be a reasonable alternative for couples in whom multiple attempts at intracytoplasmic sperm injection have failed using ejaculated sperm from men with cryptozoospermia.

Persistent Motile Sperm After Ligation Band Vasectomy

PURPOSE

We evaluated the efficacy and mechanism of failure in a small case series of VasClip vasectomies.

MATERIALS AND METHODS

Between September 2003 and March 2004, 8 patients underwent elective vasectomy using the VasClip ligation band. Microscopic semen analysis was done a minimum of 4 weeks postoperatively and after at least 15 ejaculations. The number of sperm and motility were quantified in 15 or more high power fields. Successful vasectomy was defined as 2 consecutive postoperative unspun semen analyses containing no sperm. Patients with failed vasectomy underwent bilateral surgical removal of the vas deferens segments containing the ligation band for gross and histological analysis.

RESULTS

Six of 8 patients (75%) were deemed azoospermic after 2 semen analyses at a mean followup of 7 and 11 weeks postoperatively, respectively. Two of 8 patients (25%) had semen analyses containing multiple motile sperm after vasectomy. In the 2 failed cases 1 side was patent, as demonstrated by vasal cannulation and irrigation with dilute methylene blue despite a well positioned, intact and secure ligation band. Histological analysis showed extravasation and sperm granuloma on the patent side.

CONCLUSIONS

The VasClip was found to fail at an unexpectedly high rate. Pathological analysis suggests sperm extravasation and fistula tract formation as the mechanism. One failure resulted in an unwanted pregnancy, which demonstrates the need for patient counseling regarding postoperative followup.

Practical approaches to the diagnosis and management of male infertility

Male infertility affects 10% of couples of reproductive age worldwide, and is treatable in many cases. In addition to well-established etiologies, genetic causes of male infertility are now diagnosed more commonly, as our knowledge of genomic medicine advances. Using principles of evidence-based medicine, this review outlines diagnostic and treatment algorithms that guide clinical management. In order of importance, randomized controlled clinical trials, basic scientific studies, meta-analyses, case-controlled cohort studies, best-practice policy recommendations and reviews from peer-reviewed literature were incorporated into algorithms that provide organized and timely guidelines to the current management of male infertility. The strength of the evidence for treatment recommendations is also classified when appropriate.

The diagnosis of azoospermia depends on the force of centrifugation

OBJECTIVE

To determine the centrifugal force required to pellet sperm.

DESIGN

Prospective, in vitro study.

SETTING

Tertiary referral center.

PATIENT(S)

Men undergoing semen processing or postvasectomy semen analyses.

INTERVENTION(S)

In Phase I, postvasectomy semen samples were centrifuged at 600 x g, and the pellets were examined. Supernatants from samples with no visible sperm underwent repeat centrifugation at 1,000 x g; the supernatants were removed and centrifuged at 3,000 x g. Pellets from both centrifugations were examined. Phase II examined nonazoospermic semen that was divided into 3 aliquots and centrifuged at 500, 1,000, and 3,000 x g. The supernatants were examined for the presence of sperm.

MAIN OUTCOME MEASURE(S)

Sperm presence in centrifuged pellets or seminal supernatant.

RESULT(S)

Phase I: After centrifugation at 1,000 x g and 3,000 x g, sperm were noted in 12% and 0% of samples, respectively. Phase II: Sperm were noted in the supernatant in 100% of samples subjected to 500 x g and 1,000 x g, and in 92% of samples subjected to 3,000 x g centrifugation.

CONCLUSION(S)

If sperm are in the seminal plasma, they will also be present in the pellet following centrifugation at a force of 1,000 x g or greater. Semen samples that appear azoospermic upon initial wet mount microscopy should be centrifuged at a minimum of 1,000 x g for 15 minutes.

Clinical Laboratory Evaluation of Male Subfertility

Male subfertility is a common problem with a complex etiology, requiring a complete andrological work-up for proper diagnosis. The male reproductive tract is controlled by a well-balanced hormonal system, in which hypothalamic (GnRH), pituitary (LH, FSH) and testicular hormones (androgens, inhibin B) participate. Any disturbance of this hormonal system may therefore lead to testicular dysfunction and interfere with the spermatogenesis process. In addition, also other components along the ductal system, such as epididymis, prostate and seminal vesicles, that improve sperm fertility by contributing their secretions to the semen, might function inadequately and thus fail to enhance the fertilizing capacity of the sperm cells. External factors (heat, chemicals, life style) and anatomical abnormalities (varicocele) were shown to have a negative influence on male fertility. In a number of patients genetic defects can be identified as the cause of their infertility. Laboratory tests are available to assess hormone concentrations, semen composition, accessory gland function and sperm cell function. Conventional semen analysis includes the determination of sperm concentration, semen volume, sperm motility (qualitative and quantitative), sperm morphology, sperm cell vitality, pH, leucocytes and antibodies. The usefulness of the determination of these parameters as predictor of fertility appears to be rather limited, however. Therefore, alternative tests, some based on more functional aspects (sperm penetration, capacitation, acrosome reaction), have been developed. Furthermore, there is an increasing attention for the assessment of DNA integrity, for instance by the flowcytometer-based Sperm Chromation Structure Assay (SCSA), as an additional or alternative parameter of sperm quality. It is likely and desirable that further assays with better predictive value are being developed in the near future.

Role of varicocelectomy in men with nonobstructive azoospermia

OBJECTIVE

To evaluate the benefits of varicocelectomy in men with nonobstructive azoospermia.

DESIGN

Retrospective review of effect of prior varicocelectomy on sperm retrieval rates in men with nonobstructive azoospermia. Chart review of men with nonobstructive azoospermia who underwent microsurgical varicocelectomy to determine the effect of the procedure on the need for testicular sperm extraction (TESE).

SETTING

Tertiary, university-based referral center.

PATIENT(S)

Men with clinical varicoceles and nonobstructive azoospermia.

INTERVENTION(S)

Microsurgical varicocelectomy, TESE.

MAIN OUTCOME MEASURE(S)

Return of sperm to the ejaculate and need for TESE after varicocele repair, ability to find sperm using microdissection TESE.

RESULT(S)

Of 31 men who underwent varicocele repair at one institution for documented nonobstructive azoospermia, 7/31 (22%) had sperm reported on at least one semen analysis postoperatively. However, only 3/31 (9.6%) men after varicocele repair had adequate motile sperm in the ejaculate for ICSI, without TESE. Sperm retrieval rates for men with varicoceles were not affected by a history of prior varicocelectomy.

CONCLUSION(S)

Men with clinical varicoceles that are associated with nonobstructive azoospermia will rarely have adequate sperm in the ejaculate after varicocele repair to avoid TESE. A history of prior varicocele repair does not appear to affect the chance of sperm retrieval by TESE for men with clinical varicoceles and nonobstructive azoospermia. The benefits of varicocelectomy in men with nonobstructive azoospermia may be less than previously reported.

Male factor infertility: evaluation and management

There is a male factor involved in up to half of all infertile couples. Potential etiologies in male factor infertility are many and require thorough evaluation for their accurate identification. A complete medical history in conjunction with a focused examination can allow for an appropriate choice of laboratory and imaging studies. The semen analysis is a crucial first step, but by no means is it sufficient to determine a specific etiology or dictate therapy. A systematic approach is necessary to help guide the work-up and rule out less likely causes. The etiologies discussed within this article are tremendously broad, and the prognosis for any given couple depends, in large part, on the etiology. Without a firm understanding of the genetics, anatomy, physiology, and complex interplay of the male reproductive system, the evaluation becomes an inefficient exercise that often fails to define the precise etiology. Couples with male factor infertility need a systematic approach with the efficiency of ultimate treatment determined largely by the physician's ability to identify the specific cause of the man's reproductive failure.

Male factor infertility

There is a male factor involved in up to half of all infertile couples. Potential causes of male factor infertility are many and require thorough evaluation for their accurate elucidation. A complete medical history in conjunction with a focused examination can allow for an appropriate choice of laboratory and imaging studies. The semen analysis is a crucial first step, but it is by no means sufficient to determine cause or dictate therapy. A systematic approach is necessary to help guide the evaluation and exclude less likely causes. The causes discussed within this article are broad, and the prognosis for any given couple depends, in large part, on the cause of the infertility. Without a firm understanding of the genetics, anatomy, physiology, and their interactions necessary to permit full functioning of the male reproductive system, the evaluation becomes an inefficient exercise that often fails to elucidate the precise cause of infertility. Treatment success relies not just on a clinical diagnosis but on a determination of the cause of the male factor infertility. Therefore, couples with a component of male factor infertility need a systematic evaluation directed at the male partner to maximize their reproductive potential.

British Andrology Society guidelines for the assessment of post vasectomy semen samples (2002)

The British Andrology Society guidelines for the assessment of post vasectomy semen samples recommend that initial assessment is undertaken 16 weeks post vasectomy and after the patient has produced at least 24 ejaculates. The laboratory should examine a freshly produced seminal fluid specimen by direct microscopy and if no sperm are seen the centrifugate should be examined for the presence of motile and non-motile spermatozoa. It is recommended that the clinician should give clearance after the production of two consecutive sperm free ejaculates. In cases of persistent identification of non-motile spermatozoa the referring clinician should advise the patient regarding the cessation of other contraceptive precautions. Surgeons are responsible both preoperatively and postoperatively for the counselling of couples regarding complications and the possibility of late recanalisation after clearance.

Microsurgical inguinal varicocele repair in azoospermic men

OBJECTIVES

To evaluate the efficacy of microsurgical inguinal varicocele repair in nonobstructive azoospermic men with palpable varicocele and to determine predictive parameters of outcome.

METHODS

After standard diagnostic evaluation, 24 pellet (-) completely azoospermic men and 14 pellet (+) virtually azoospermic men underwent microsurgical inguinal varicocele repair. Testicular core biopsy was also performed perioperatively in all patients. The outcome was assessed in terms of improvement in semen parameters and spontaneous pregnancy.

RESULTS

After a mean follow-up of 13.4 +/- 4.7 months, motile sperm in the ejaculate could be identified in 5 (21%) of the completely azoospermic patients, and these patients were rescued from invasive sperm extraction techniques when referred to intracytoplasmic sperm injection. Testicular histopathology of these patients with postoperative improvement revealed maturation arrest at spermatid stage (n = 3), Sertoli-cell-only (SCO) pattern with focal spermatogenesis (n = 1), and hypospermatogenesis (n = 1). None of the patients with pure SCO pattern or maturation arrest at spermatocyte stage had improvement after varicocele repair. However, improvement in semen parameters was observed in 12 (85.7%) patients with virtual azoospermia, 4 (28.6%) achieved a total motile sperm count greater than 5 million, and spontaneous pregnancy occurred with 3 (21.4%) of them.

CONCLUSIONS

Microsurgical inguinal varicocele repair offers completely azoospermic men the chance to provide motile sperm via ejaculate in 21%. Moreover, 28.6% of virtually azoospermic men are rescued from ICSI procedures as an initial treatment modality. Results of varicocele repair in azoospermic men also reveal that a certain threshold of spermatogenesis, requiring the presence of at least spermatids, is necessary for effective varicocele repair.

Varicocele repair improves semen parameters in azoospermic men with spermatogenic failure

PURPOSE

We analyzed the efficacy of varicocele repair in improving semen parameters in azoospermic men with spermatogenic failure.

MATERIALS AND METHODS

After routine clinical evaluation with confirmatory pellet analysis testicular biopsy and varicocele repair were simultaneously performed in 28 azoospermic men with a primary diagnosis of unilateral or bilateral varicocele and spermatogenic failure. Semen analyses were obtained starting 4 months after varicocelectomy.

RESULTS

Repair was bilateral repair in 20 men and unilateral in 8. Of the 28 men 12 (43%) had sperm in the ejaculate with a mean postoperative sperm count plus or minus standard deviation of 1.2+/-3.6x10(6)/ml. and an average followup of 24 months. Mean sperm motility was 19+/-24% (range 0 to 80). Testicular biopsy was predictive of outcome. Only 9 men with severe hypospermatogenesis and 5 with maturation arrest spermatid stage had improvement in sperm density. No improvement was seen in 3 men with the Sertoli-cell-only pattern or 3 with maturation arrest spermatocyte stage. No pregnancies by natural intercourse resulted. One couple used fresh ejaculate for intracytoplasmic sperm injection and 1 underwent testicular sperm extraction with intracytoplasmic sperm injection. Both pregnancies resulted in live births. No other predictive factors were identified.

CONCLUSIONS

Varicocele repair can result in sperm in the ejaculate of azoospermic men when severe hypospermatogenesis or maturation arrest spermatid stage is present. Select men with spermatogenic failure and varicoceles may be candidates for varicocele repair, rather than resorting to testis biopsy for sperm extraction in preparation for intracytoplasmic sperm injection. However, the couple should be counseled that assisted reproductive technologies will most likely be required to initiate pregnancy.

Pathological epididymal obstruction unrelated to vasectomy: results with microsurgical reconstruction

PURPOSE

We determine the success of end-to-side epididymovasostomy in patients presenting with obstructive azoospermia from primary epididymal obstruction and identify prognostic factors that could predict a successful outcome.

MATERIALS AND METHODS

Of 256 consecutive patients undergoing end-to-side epididymovasostomy 49 had primary epididymal obstruction unrelated to prior vasectomy. Patients were excluded from study if they had a history of vasectomy, microsurgical reconstruction or ejaculatory duct obstruction.

RESULTS

Followup was available in 43 of the 49 patients (88%). Patency rates were 87% in the bilateral epididymovasostomy group, 69% in the unilateral group and 81% overall. Pregnancy rates were 43% in the bilateral and 23% in the unilateral group. While higher patency rates were observed for proximal anastomoses, higher pregnancy rates were observed for distal anastomoses. Intraoperative epididymal fluid quality correlated with patency, that is motile sperm in the epididymal aspirate correlated with postoperative patency (p <0.05). There was no correlation between fluid quality and pregnancy rates. Postoperative semen analyses demonstrated higher sperm density and higher motility in the pregnant versus nonpregnant groups.

CONCLUSIONS

Epididymovasostomy may be performed in patients with obstructive azoospermia unrelated to vasectomy with high patency and good pregnancy rates. Intraoperative epididymal fluid quality can be predictive of patency. There was a trend towards higher pregnancy rates for distal anastomosis. There were no pregnancies when anastomosis was at the caput epididymis on both sides.