Impact of testicular histopathology as a predictor of sperm retrieval and pregnancy outcome in patients with nonobstructive azoospermia: correlation with clinical and hormonal factors

Predictive Value of Varicocele Grade and Histopathology in Simultaneous Varicocelectomy and Sperm Retrieval in Non-Obstructive Azoospermia: A Retrospective Cohort Study

Background and Objectives: Varicocele repair in men with non-obstructive azoospermia (NOA) remains a subject of debate due to inconsistent outcomes. This study aimed to evaluate the impact of microsurgical varicocelectomy on sperm recovery rates in men with NOA and to assess the role of varicocele grade and testicular histopathology in predicting postoperative outcomes. Materials and Methods: A retrospective cohort study was conducted of 78 men diagnosed with NOA and clinical varicocele who underwent microsurgical subinguinal varicocelectomy with simultaneous diagnostic and therapeutic testicular biopsy at the Department of Urology of the University of Ioannina between September 2013 and December 2021. Varicoceles were graded I to III based on physical examination and Doppler ultrasound. Histopathological patterns were classified as hypospermatogenesis (HYPO), early maturation arrest (EMA), late maturation arrest (LMA), or Sertoli cell-only syndrome (SCOS). Patients were followed postoperatively at 3, 6, 9, and 12 months, with semen analyses performed according to World Health Organization guidelines to assess sperm presence. Results: At the 12-month follow-up, spermatozoa were detected in the ejaculate of 26 out of 78 patients, resulting in an overall sperm return to ejaculate rate of 33.3%. Varicocele grade significantly influenced outcomes: patients with Grade II varicoceles had the highest sperm return to ejaculate rate (45.2%, 14/31), followed by Grade III (39.1%, 9/23) and Grade I (12.5%, 3/24) (p-value < 0.05). The sperm retrieval rate (SRR) from testicular biopsies also varied with varicocele grade: Grade II had the highest SRR (54.8%, 17/31), followed by Grade III (47.8%, 11/23) and Grade I (33.3%, 8/24). Histopathological findings were significant predictors of sperm retrieval: patients with HYPO had an SRR of 84.8% (28/33) and a sperm return to ejaculate rate of 66.7% (22/33); those with LMA had an SRR of 47.1% (8/17) and a sperm return rate of 23.5% (4/17). No sperm retrieval was observed in patients with EMA (0%, 0/4) or SCOS (0%, 0/24) (p-value < 0.01). Multivariate logistic regression identified varicocele grade and histopathology as independent predictors of sperm retrieval, with higher grades and favorable histopathology associated with increased likelihood of success. Conclusions: Microsurgical varicocelectomy can induce spermatogenesis in a significant proportion of men with NOA, particularly those with higher-grade varicoceles and favorable histopathological patterns such as HYPO or LMA. Varicocele grade and histopathological findings are important predictors of postoperative outcomes and should inform patient selection and counseling. These findings provide valuable insights for optimizing fertility treatments in men with NOA undergoing varicocele repair.

Predictors of Successful Testicular Sperm Extraction: A New Era for Men with Non-Obstructive Azoospermia

Background/Objectives: Non-obstructive azoospermia (NOA) is a severe form of male infertility characterized by the absence of sperm in the ejaculate due to impaired spermatogenesis. Testicular sperm extraction (TESE) combined with intracytoplasmic sperm injection is the primary treatment, but success rates are unpredictable, causing significant emotional and financial burdens. Traditional clinical and hormonal predictors have shown inconsistent reliability. This review aims to evaluate current and emerging non-invasive preoperative predictors of successful sperm retrieval in men with NOA, highlighting promising biomarkers and their potential clinical applications. Methods: A comprehensive literature review was conducted, examining studies on clinical and hormonal factors, imaging techniques, molecular biology biomarkers, and genetic testing related to TESE outcomes in NOA patients. The potential role of artificial intelligence and machine learning in enhancing predictive models was also explored. Results: Traditional predictors such as patient age, body mass index, infertility duration, testicular volume, and serum hormone levels (follicle-stimulating hormone, luteinizing hormone, inhibin B) have limited predictive value for TESE success. Emerging non-invasive biomarkers-including anti-Müllerian hormone levels, inhibin B to anti-Müllerian hormone ratio, specific microRNAs, long non-coding RNAs, circular RNAs, and germ-cell-specific proteins like TEX101-show promise in predicting successful sperm retrieval. Advanced imaging techniques like high-frequency ultrasound and functional magnetic resonance imaging offer potential but require further validation. Integrating molecular biomarkers with artificial intelligence and machine learning algorithms may enhance predictive accuracy. Conclusions: Predicting TESE outcomes in men with NOA remains challenging using conventional clinical and hormonal parameters. Emerging non-invasive biomarkers offer significant potential to improve predictive models but require validation through large-scale studies. Incorporating artificial intelligence and machine learning could further refine predictive accuracy, aiding clinical decision-making and improving patient counseling and treatment strategies in NOA.

Secondary azoospermia after a successful natural pregnancy: a primary prospective study

BACKGROUND

To date, there is a lack of studies conducted on males with secondary azoospermia as a potential cause of male infertility who had previously fathered children through natural conception. The current study aims to investigate the potential causes of secondary azoospermia as a presentation of male infertility as well as the prognostic factors that can impact sperm retrieval rate (SRR) while undergoing microdissection testicular sperm extraction (microTESE).

RESULTS

Thirty two patients were recruited from the andrology outpatient clinic from August 2023 till January 2024. The mean age of the patients was sixty-two years old. All patients had varicoceles. Twenty seven patients (84%) had palpable varicocele grade 2 and 3 on both sides. Further multivariate logistic regression analysis of the significant factors in the univariate regression revealed that younger age (OR 0.7, 95% C.I. 0.7-1.0, p = 0.03) and having a history of coronary artery disease (CAD) were predictable factors for negative TESE outcome (OR 123.1, 95% C.I. 3.2-4748.5, P = 0.01).

CONCLUSION

It appears that the etiopathogenesis of secondary azoospermia are multifactorial. Varicocele and CAD are major factors to be considered. Future studies should be implemented deploying larger pools of patients suffering from the same condition to affirm the findings of this primary study.

Discordant Bilateral Testicular Pathology Does not Affect Sperm Retrieval Rate in Bilateral Microdissection Testicular Sperm Extraction (mTESE)

OBJECTIVE

To assess the incidence of discordant testicular pathology in men undergoing bilateral microdissection testicular sperm extraction (mTESE) and association with sperm retrieval rate.

METHODS

We performed a retrospective single-institutional review of all patients undergoing mTESE from 2007 to 2021 and aggregated clinical history, physical exam, semen analysis, and operative findings. Specimens with discordant pathology were re-reviewed by an experienced genitourinary.ßpathologist and categorized in a standardized fashion. Data were analyzed using SPSS.

RESULTS

One hundred fourteen non-obstructive azoospermia.ßmen undergoing 132 mTESEs were identified within the study period. Eighty-five percent (112/132) of cases had pathology specimens available, and within this specific cohort the success rate was 41.9% (47/112). A total of 206 pathological reports resulted including 52.4% Sertoli cell only, 4.9% Leydig cell hyperplasia, 8.7% fibrosis, 16.5% maturation arrest, and 17.5% hypospermatogenesis. Twelve percent of testicles had more than 1 pathologic diagnosis. Sixty-six men had synchronous bilateral testicular pathology, and 11/66 (16.6%) had at least partially discordant pathology on initial review. Focused re-review by a genitourinary pathologist confirmed exclusively discordant pathology in 7/66 (10.6%) cases, with a sperm retrieval rate of 57% (4/7). The sperm retrieval rate.ßin men with discordant pathology was not significantly different from those with concordant pathology.

CONCLUSION

Over 1 in 10 men undergoing mTESE may have discordant pathology between testicles, though this may not affect sperm retrieval rate.ßat the time of procedure. Clinicians should consider submitting bilateral testicular specimens for pathology to (1) clarify their outcomes data, and (2) assist with clinical decision-making and surgical planning if a repeat mTESE is indicated.

Testicular microlithiasis defines a subgroup of azoospermic men with low rates of sperm retrieval

OBJECTIVE

To investigate the prevalence of testicular microlithiasis and its association with sperm retrieval rates and histopathology in men with non-obstructive azoospermia.

METHODS

A total of 120 men underwent scrotal ultrasonography prior to microsurgical testicular sperm extraction. Sperm retrieval rate, testicular histopathology, testicular size, reproductive hormones, karyotyping, Y chromosome microdeletion analyses, and presence of varicoceles and hydroceles were compared between men with and without testicular microlithiasis.

RESULTS

The total sperm retrieval rate was 40%. Ten men with normal spermatogenesis were excluded. The remaining 110 men with non-obstructive azoospermia were analyzed and testicular microlithiasis was detected in 16 of them (14.5%). The sperm retrieval rate in that subgroup was only 6.2% (1/16) as opposed to 39.4% (37/94) in men with non-obstructive azoospermia and no evidence of microlithiasis (P = 0.009). The mean right and left testicular diameters were significantly lower in the microlithiasis group (P = 0.04). On multivariate logistic regression analysis, the presence of mictolithiasis (odds ratio 7.4, 95% confidence interval 2.3, 12.2; P = 0.01) was the only independent predictor of unsuccessful sperm retrieval. The 15 patients with microlithiasis and without successful sperm extraction were diagnosed by histopathology as having Sertoli cells only. The 16th patient with successful sperm retrieval had a histopathology of mixed atrophy and was diagnosed with Klinefelter syndrome.

CONCLUSION

The presence of testicular microlithiasis is associated with low sperm retrieval rates among our cohort of men with non-obstructive azoospermia undergoing scrotal ultrasonography prior to microsurgical testicular sperm extraction. Larger, prospective studies should be conducted to confirm these findings.

Fresh vs frozen testicular sperm for assisted reproductive technology in patients with non-obstructive azoospermia: A systematic review

Objective

: To review the debate about the routine use of cryopreserved testicular sperm for intracytoplasmic sperm injection (ICSI) from patients with non-obstructive azoospermia (NOA), as some authors suggest repeating sperm retrieval in such cases due to poorer ICSI results when frozen–thawed testicular sperm is used compared with fresh sperm.

Methods

: A systematic literature review was performed in August 2020 using the Medical Literature Analysis and Retrieval System Online (MEDLINE), Web of Science databases and the Excerpta Medica dataBASE (EMBASE), and we included 26 studies that were considered eligible for this systematic review.

Results

: In all, 1189 publications were screened and 26 articles were included in the systematic review. Three meta-analysis reviews were included and they all concluded that the use of fresh and frozen sperms for ICSI from patients with NOA showed comparable fertilisation and pregnancy rates.

Conclusion

: The use of frozen testicular sperm from men with NOA results in fertilisation and clinical pregnancy rates similar to those of fresh sperm. This may encourage fertility centres to use frozen testicular sperm samples, as this policy has certain advantages that would help with organising their workflow.

Abbreviations: CPR: clinical pregnancy rate; 2PN%: two pronuclei % fertilisation rate; ICSI: intracytoplasmic sperm injection; NOA: non-obstructive azoospermia; OA, obstructive azoospermia; SCO: Sertoli cell-only syndrome; (micro-)TESE: (microsurgical) testicular sperm extraction

The expression of Beclin-1 in testicular tissues of non-obstructive azoospermia patients and its predictive value in sperm retrieval rate

Background

Beclin-1 is an autophagy gene and higher levels suggest mammalian testicular damage. Our study aims at exploring the role of Beclin-1 in non-obstructive azoospermia (NOA) patients and clarifying the predictive value of Beclin-1for sperm retrieval in microdissection testicular sperm extraction (micro-TESE).

Methods

In the present study, 62 NOA patients were finally recruited. Serum hormone including luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol II (E2), testosterone (T) and prolactin (PRL), as well as testicular volume were measured. Testicular histopathology was diagnosed by two independent pathologists. The expression of Beclin-1 was detected by real-time PCR in testicular tissue.

Results

Our study illustrated that Beclin-1 was differently expressed in three pathological types of NOA. Compared with hypospermatogenesis (HS, P=0.002) or maturation arrest (MA, P=0.049), Beclin-1 showed significantly up-regulated in Sertoli cell-only syndrome (SCOS) group. Moreover, Beclin-1 expression was obviously positive related with serum LH (rho =0.269, P=0.036), meanwhile significantly negative correlation with testicular volume (rho =-0.370, P=0.003), serum T (rho =-0.326, P=0.010), Johnsen score (rho =-0.318, P=0.012), and pathologic type (rho =-0.452, P<0.001). Furthermore, a logistic regression model demonstrated that Beclin-1 is an important predictor of failed sperm retrieval (OR =0.001, P=0.007), which exhibited a pretty AUC =78.6 (P=0.001).

Conclusions

Beclin-1 may play a critical role in spermatogenesis. Elevated Beclin-1 may be obviously associated with lower chances of positive sperm retrieval.

European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2021 Update on Male Infertility

CONTEXT

The European Association of Urology (EAU) has updated its guidelines on sexual and reproductive health for 2021.

OBJECTIVE

To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health, including advances and areas of controversy in male infertility.

EVIDENCE ACQUISITION

The panel performed a comprehensive literature review of novel data up to January 2021. The guidelines were updated and a strength rating for each recommendation was included that was based either on a systematic review of the literature or consensus opinion from the expert panel, where applicable.

EVIDENCE SYNTHESIS

The male partner in infertile couples should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors causing fertility impairment. Infertile men are at a higher risk of harbouring and developing other diseases including malignancy and cardiovascular disease and should be screened for potential modifiable risk factors, such as hypogonadism. Sperm DNA fragmentation testing has emerged as a novel biomarker that can identify infertile men and provide information on the outcomes from assisted reproductive techniques. The role of hormone stimulation therapy in hypergonadotropic hypogonadal or eugonadal patients is controversial and is not recommended outside of clinical trials. Furthermore, there is insufficient evidence to support the widespread use of other empirical treatments and surgical interventions in clinical practice (such as antioxidants and surgical sperm retrieval in men without azoospermia). There is low-quality evidence to support the routine use of testicular fine-needle mapping as an alternative diagnostic and predictive tool before testicular sperm extraction (TESE) in men with nonobstructive azoospermia (NOA), and either conventional or microdissection TESE remains the surgical modality of choice for men with NOA.

CONCLUSIONS

All infertile men should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors. Increasing data indicate that infertile men are at higher risk of cardiovascular mortality and of developing cancers and should be screened and counselled accordingly. There is low-quality evidence supporting the use of empirical treatments and interventions currently used in clinical practice; the efficacy of these therapies needs to be validated in large-scale randomised controlled trials.

PATIENT SUMMARY

Approximately 50% of infertility will be due to problems with the male partner. Therefore, all infertile men should be assessed by a specialist with the expertise to not only help optimise their fertility but also because they are at higher risk of developing cardiovascular disease and cancer long term and therefore require appropriate counselling and management. There are many treatments and interventions for male infertility that have not been validated in high-quality studies and caution should be applied to their use in routine clinical practice.

"Second-look" Micro Testicular Sperm Extraction (MicroTESE) in Patients with Non-obstructive Azoospermia Following Histopathological Analysis

Introduction:

Microdissection testicular sperm extraction (microTESE) is considered the gold standard method for surgical sperm retrieval among patients with non-obstructive azoospermia (NOA).

Aim:

This study aimed to evaluate the correlation between histopathological findings after failed microTESE procedure and outcomes of the „second-look“ procedure and to provide insight into the most common histopathological patterns after testicular biopsy within our population.

Methods:

The retrospective study included 33 selected patients with NOA, who had undergone unsuccessful sperm retrieval. The diagnosis of NOA was made after the assessment of the patient’s history data, a physical examination, semen analysis, the hormonal profile, and genetic studies. After negative sperm retrieval, histopathological report has been analyzed for „second-look“ microTESE attempt.

Results:

Five testicular histopathological patterns were found: hypospermatogenesis (9,1%), Sertoli cell-only syndrome (43%), germ cell maturation arrest (15%), seminiferous tubule hyalinization (15%), mixed pattern (21%). Y-microdeletions were detected in 5 patients, of which 3 patients showed AZFc region deletions. Only 3 patients (9,1%) underwent a „second-look“ procedure after the evaluation of histopathological reports. After the stimulation therapy and „second-look“ procedure, we had a positive outcome in a single patient (33,3%). Mean FSH value in patients with confirmed spermatogenesis was 17.26±3.11IU/l, while mean FSH value in patients without presence or germ cell statistically significantly exceeded and was 24.28±4.71IU/L (p=0.038).

Conclusion:

Histopathological reports following the microTESE procedure are obligatory for the proper selection of patients who are candidates for the „second-look“ microTESE attempt. Patients with Sertoli cell-only syndrome and hypospermatogenesis particularly can benefit from the “second-look” procedure.

Effect of vas ligation on testicular sperm extraction results in nonobstructive azoospermic rats: Shaeer's lock-in technique

This study evaluates the efficacy of vas ligation in enhancing sperm retrieval in nonobstructive azoospermia cases, by accumulating intratesticular spermatozoa. Fifty-six mature male rats with equally sized testes were included in this study. Forty-six were in the study group, and 10 were in the control group. Bilateral testicular fine needle aspiration was performed for all, to confirm presence of spermatozoa in all testes. Nonobstructive azoospermia was induced in all 56 rats, using Dienogest (40 mg/kg) + Testosterone Undecanoate (25 mg/kg) every month for three months. Monthly aspirations confirmed nonobstructive azoospermia from all rats, within the three months treatment. This was followed by unilateral vas ligation and was performed for 46 rats of the study group, with no ligation performed in the control group. After a further period of 90 days (2 spermatogenic cycles) with the same medical treatment maintained, bilateral testicular sperm extraction was performed. Sperm retrieval was evaluated, comparing the outcome of vas-ligated testicles to the nonligated. Upon evaluation, spermatozoa were found in 14/46 of the vas-ligated testes (30.4%), compared to none of the nonligated (0/66), p = .0005. Ligation of the vas deferens in rats with nonobstructive azoospermia may enhance the results of sperm retrieval via sperm accumulation.

Predictors of testicular sperm retrieval in patients with non-obstructive azoospermia: a review

Azoospermia is divided into two categories of obstructive azoospermia and non-obstructive azoospermia. Before 1995, couples with a male partner diagnosed with non-obstructive azoospermia had to choose sperm donation or adoption to have a child. Currently, testicular sperm aspiration or micro-dissection testicular sperm extraction combined with intracytoplasmic sperm injection allows patients with non-obstructive azoospermia to have biological offspring. The sperm retrieval rate is significantly higher in micro-dissection testicular sperm extraction compared with testicular sperm aspiration. Additionally, micro-dissection testicular sperm extraction has the advantages of minimal invasion, safety, limited disruption of testicular function, a low risk of postoperative intratesticular bleeding, and low serum testosterone concentrations. Failed micro-dissection testicular sperm extraction has significant emotional and financial implications on the involved couples. Testicular sperm aspiration and micro-dissection testicular sperm extraction have the possibility of failure. Therefore, predicting the sperm retrieval rate before surgery is important. This narrative review summarizes the existing data on testicular sperm aspiration and micro-dissection testicular sperm extraction to identify the possible factor(s) that can predict the presence of sperm to guide clinical practice. The predictors of surgical sperm retrieval in patients with non-obstructive azoospermia have been widely studied, but there is no consensus.

Reproductive Chances of Men with Azoospermia Due to Spermatogenic Dysfunction

Non-obstructive azoospermia (NOA), or lack of sperm in the ejaculate due to spermatogenic dysfunction, is the most severe form of infertility. Men with this form of infertility should be evaluated prior to treatment, as there are various underlying etiologies for NOA. While a significant proportion of NOA men have idiopathic spermatogenic dysfunction, known etiologies including genetic disorders, hormonal anomalies, structural abnormalities, chemotherapy or radiation treatment, infection and inflammation may substantively affect the prognosis for successful treatment. Despite the underlying etiology for NOA, most of these infertile men are candidates for surgical sperm retrieval and subsequent use in intracytoplasmic sperm injection (ICSI). In this review, we describe common etiologies of NOA and clinical outcomes following surgical sperm retrieval and ICSI.

Can preoperative parameters predict successful sperm retrieval and live birth in couples undergoing testicular sperm extraction and intracytoplasmic sperm injection for azoospermia?

Background

We aimed to determine if the success of TESE and live-birth following TESE-ICSI can be predicted from readily available preoperative parameters for couples with azoospermia. Our methodology was as follows, this was a cohort study of couples who attended the fertility service (from 2009-2019) at an NHS hospital in whom the male partner was diagnosed with azoospermia and required conventional TESE with multiple biopsies to obtain sperm. Of 414 men included, 223 had successful TESE and of those 178 have used sperm in ICSI cycle(s). Predictive models were developed using logistic regression. We assessed model performance by internally validated concordance statistics and calibration plots. Successful sperm retrieval was defined as the presence of motile sperm which survived the freeze-thaw process and live-birth defined as delivery after 34 weeks of gestation.

Results

Successful TESE was associated with higher male age and lower FSH. The TESE model discriminated well with a c statistic of 0.81 (0.77-0.85). Live-birth was associated with lower maternal age, earlier ICSI cycle, and lower testicular volume. The live-birth model also discriminated well with a c statistic of 0.70 (0.64-0.76).

Conclusions

These results support the pragmatic counselling of couples diagnosed with azoospermia about the chances of success of the TESE procedure and of biological parenthood prior to surgical intervention. The models help to discriminate between men who have a high or low chance of successful TESE and couples who have a higher chance of achieving a live-birth after successful TESE. This will allow couples to make a better assessment of the balance of risk versus benefit prior to commitment to surgical interventions.

The Germ Cell-Specific Markers ZPBP2 and PGK2 in Testicular Biopsies Can Predict the Presence as well as the Quality of Sperm in Non-obstructive Azoospermia Patients

To assess the role of three testis-specific genes including ZPBP2, PGK2, and ACRV1 in the prediction of sperm retrieval result and quality of retrieved sperm by microdissection testicular sperm extraction (micro-TESE) in non-obstructive azoospermia (NOA) patients. This was a case-control study including 57 testicular samples of NOA patients including 32 patients with successful sperm retrieval (NOA+) and 25 patients with failed sperm retrieval (NOA-), and 9 samples of men with normal spermatogenesis in the testes as the positive control (OA). We investigated the expression of candidate genes by RT-qPCR and germ cell population patterns by DNA flow cytometry in testicular biopsy samples. The association between PGK2 expressions with the quality of retrieved spermatozoa was also evaluated. The RT-qPCR data revealed a significantly higher expression of ZPBP2 and PGK2 in the NOA+ in comparison to NOA- group (P = 0.002, and P = 0.002, respectively). Flow cytometry results revealed that the haploid cell percentage was significantly higher in NOA+ vs. NOA- group (P = 0.0001). In samples with a higher percentage of haploid cells, expression levels of ZPBP2 and PGK2 were higher (P = 0.001). The PGK2 expression was significantly associated with retrieved sperm quality (P = 0.01). Our results contribute to the search for the biomarkers for predicting the presence of testicular sperm and would be useful to avoid unnecessary multiple micro-TESE. Overall, the expression pattern of the ZPBP2 and PGK2 may be useful in predicting sperm recovery success and quality of retrieved sperm in NOA patients.

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.

Over-expression of hsa_circ_0000116 in patients with non-obstructive azoospermia and its predictive value in testicular sperm retrieval

BACKGROUND

Non-obstructive azoospermia (NOA), identified in approximately 10% of infertile males, is a multifactorial disease whose molecular mechanisms remain unknown.

OBJECTIVES

The aim of this study was to identify the role of hsa_circ_0000116 in NOA and illustrate its predictive value in testicular sperm retrieval.

MATERIALS AND METHODS

The study included 78 individuals, 58 with NOA and 20 with obstructive azoospermia (OA). Serum hormones including testosterone (T), follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), and estradiol II (E2) were measured. Testicular histopathology was analyzed by at least two pathologists. The expression of hsa_circ_0000116 in testicular tissue samples was detected using real-time PCR, and the circRNA-miRNA-mRNA networks were predicted using bioinformatics analysis.

RESULTS

Our study illustrated that the expression of hsa_circ_0000116 was significantly higher in testicular tissue samples of NOA patients than in that of OA patients. Moreover, hsa_circ_0000116 was aberrantly expressed in three different pathological types of NOA: It was significantly up-regulated in patients with Sertoli cell-only syndrome (SCOS) when compared to patients with hypospermatogenesis (HS). In addition, the expression of hsa_circ_0000116 was negatively correlated with Johnsen score, while it was positively correlated with serum FSH level. A multivariate logistic regression model demonstrated that a high level of hsa_circ_0000116 was associated with a low rate of successful testicular sperm retrieval. Bioinformatics analysis and verification experiments showed that one of the most probable potential target miRNA for hsa_circ_0000116 was hsa-miR-449a. Further analysis indicated that hsa_circ_0000116 may be affecting the fertility function through a hsa_circ_0000116-miR-449-autophagy-related competing endogenous RNA (ceRNA) network.

DISCUSSION AND CONCLUSION

We report for the first time that hsa_circ_0000116 may play pivotal roles in regulating spermatogenesis and may also be a potential biomarker for the diagnosis and treatment of NOA, while acting as a predictive tool for the rate of successful testicular sperm retrieval in NOA patients.

Effects of obesity on sperm retrieval, early embryo quality and clinical outcomes in men with nonobstructive azoospermia undergoing testicular sperm aspiration-intracytoplasmic sperm injection cycles

The objective of this study was to assess the effects of body mass index (BMI) on sperm retrieval, early embryo quality and clinical outcomes in patients with nonobstructive azoospermia (NOA) undergoing testicular sperm aspiration-intracytoplasmic sperm injection (TESA-ICSI). A total of 3,005 infertile couples were evaluated between January 2010 and June 2017, including 1585 normal-weight (BMI < 25 kg/m² ), 847 overweight (BMI 25-29.99 kg/m² ) and 573 obese (BMI ≥ 30 kg/m² ) patients. We found no significant relationship between BMI and sperm retrieval rate (22.4%, 24.3% and 25.1%, p = 0.327) or sperm motility. Among the 705 patients with NOA who underwent TESA-ICSI cycles, obese individuals had lower T levels and higher E2 levels than normal-weight and overweight individuals. However, there were no significant differences in other male hormones (follicle stimulating hormone [FSH], luteinizing hormone [LH], or prolactin [PRL]) among the groups. We also found that the sperm parameters, embryo quality and clinical outcomes of patients with NOA undergoing TESA-ICSI were not influenced by high BMI levels. In conclusion, this study demonstrated a lack of obvious effects of obesity on sperm retrieval, early embryo quality and clinical outcomes in infertile men undergoing TESA-ICSI cycles, although T and E2 levels were affected.

Pregnancy and Neonatal Outcomes in Azoospermic Men After Intracytoplasmic Sperm Injection Using Testicular Sperm and Donor Sperm

Background

The safety of intracytoplasmic sperm injection (ICSI) with testicular sperm in azoospermic men has been a concern. We evaluated ICSI outcomes, including neonatal outcomes, in children born using testicular sperm or donor sperm.

Material/Methods

Ninety-nine males with nonobstructive azoospermia (NOA) who underwent microdissection testicular sperm extraction (micro-TESE) and 126 males with obstructive azoospermia (OA) were included in this study. Sixty-one patients with NOA used donor sperm for ICSI on the day of oocyte retrieval when no spermatozoa were identified by micro-TESE on the day before oocyte retrieval. ICSI outcomes were compared among OA, donor, and NOA groups.

Results

There was no statistical difference in terms of female partner characteristics among OA, donor, and NOA groups. The normal fertilization rate (P=0.005), high quality embryo rate (P=0.014), implantation rate (P<0.001), clinical pregnancy rate (P=0.015), live birth rate (P=0.043) were significant lower in the NOA group, compared with the donor sperm group. The normal fertilization rate was significant lower in the NOA group than the OA group (P<0.001), but the live birth rate was not significantly lower (P=0.058). The high-quality embryo rate (P=0.014) and implantation rate (P=0.009) were lower in the OA group than the donor group. No differences between groups were observed in our study regarding neonatal parameters of the infants born.

Conclusions

The fertilization and pregnancy outcomes were negatively affected by using testicular sperm from males with NOA. Once a live birth was achieved, there was no difference in neonatal outcomes.

Testicular histopathology, semen analysis and FSH, predictive value of sperm retrieval: supportive counseling in case of reoperation after testicular sperm extraction (TESE)

Background

To provide indicators for the likelihood of sperm retrieval in patients undergoing testicular sperm extraction is a major issue in the management of male infertility by TESE. The aim of our study was to determine the impact of different parameters, including testicular histopathology, on sperm retrieval in case of reoperation in patients undergoing testicular sperm extraction.

Methods

We retrospectively analyzed 486 patients who underwent sperm extraction for intracytoplasmic sperm injection and testicular biopsy. Histology was classified into: normal spermatogenesis; hypospermatogenesis (reduction in the number of normal spermatogenetic cells); maturation arrest (absence of the later stages of spermatogenesis); and Sertoli cell only (absence of germ cells). Semen analysis and serum FSH, LH and testosterone were measured.

Results

Four hundred thirty patients had non obstructive azoospermia, 53 severe oligozoospermia and 3 necrozoospermia. There were 307 (63%) successful sperm retrieval. Higher testicular volume, lower levels of FSH, and better histological features were predictive for sperm retrieval. The same parameters and younger age were predictive factors for shorter time for sperm recovery. After multivariable analysis, younger age, better semen parameters, better histological features and lower values of FSH remained predictive for shorter time for sperm retrieval while better semen and histology remained predictive factors for successful sperm retrieval. The predictive capacity of a score obtained by summing the points assigned for selected predictors (1 point for Sertoli cell only, 0.33 points for azoospermia, 0.004 points for each FSH mIU/ml) gave an area under the ROC curve of 0.843.

Conclusions

This model can help the practitioner with counseling infertile men by reliably predicting the chance of obtaining spermatozoa with testicular sperm extraction when a repeat attempt is planned.

A clinical trial on the consistency of bilateral testicular tissue histopathology and Johnsen score: single side or bilateral side biopsy?

To evaluate and compare left and right testicular tissue histopathology and Johnsen score, and to investigate the necessity for bilateral testicular biopsy. We recruited180 patients with non-obstructiveazoospermia (NOA) on testicular biopsy who had undergonetesticular sperm aspiration (TESA). Pathological sections of testicular tissue were diagnosed by specially-assigned doctors, who evaluated pathological findings, determined the Johnsen score and confirmed for the presence or absence of sperm. Sperm positive rates for left and right testicular histopathology were 55.0% and 51.7% respectively, and the proportion of Johnsen scores≥8 for left and right testes were 53.3% and 50.0%, respectively. Cohen kappa values revealed that the identification of sperm in bilateral testicular samples was not consistent and was related to random effects; Optimized cut-off value for bilateral testicular volume was 11ml (Johnsen score ≥8), and optimized cut-off values of E₂ on left and right testes were 144.5pmol/L and 133.5 pmol/L (Johnsen score≤7). However, age, serum prolactin (PRL), follicle stimulating hormone (FSH), luteinizing hormone (LH) and total testosterone (TT) levels were not accurate predictors for the existence of testicular sperm. There was nostatistical significance between left and right testicular histopathology in terms of sperm positive rates or Johnsen score; the Johnsen score were caused entirely by random effects and a score from one side could not represent the other side. Therefore, we recommend that both testes need to undergo surgery when NOA patients undergo testicular biopsy or sperm retrieval.

Relevance of testicular histopathology on prediction of sperm retrieval rates in case of non-obstructive and obstructive azoospermia

Introduction:

The aim of our research was to establish the relevance of testicular histopathology on sperm retrieval after testicular sperm extraction in patients with non-obstructive azoospermia and in patients with obstructive azoospermia, who already underwent a previous failure testicular fine needle aspiration.

Methods:

We evaluated a total of 82 azoospermic men, underwent testicular sperm extraction, referring to the Assisted Reproductive Technology Centre of the University of Florence, Italy between January 2008 and March 2017. A general and genital physical examination, scrotal and trans-rectal ultrasound, semen analysis, hormone measurements, including follicle-stimulating hormone, luteinizing hormone and total testosterone, were collected.

Results:

Successful sperm retrieval was obtained in 36 men of total (43.9%). Successful sperm retrieval was 29.5% in non-obstructive azoospermia patients, while men with obstructive azoospermia, who, underwent a previous failure testicular fine needle aspiration, had sperm retrieval in 86% of cases. Mean luteinizing hormone was 6.55 IU/L, total testosterone 4.70 ng/mL, right testicular volume 13.7 mL and left testicular volume 13.6 mL. Mean Follicle-stimulating hormone was 13.45 IU/L in patients with negative sperm retrieval and 8.18 IU/L in men with successful sperm retrieval. According to histology, 20.7% had normal spermatogenesis, 35.3% hypospermatogenesis, 35.3% maturation arrest and 8.5% Sertoli cell-only syndrome. Successful sperm retrieval was 88.2% in patients with normal spermatogenesis, 24.1% in the maturation arrest group and 48.27% in patients with hypospermatogenesis, while negative sperm retrieval was reported in Sertoli cell-only syndrome patients. Seven cases with maturation arrest showed a successful sperm retrieval.

Conclusion:

Testicular histopathology after testicular sperm extraction offers important information on prediction of sperm retrieval and can guide the surgeon in choosing the more suitable therapeutic practice.

Long-term clinical outcomes of testicular sperm extraction and intracytoplasmic sperm injection for infertile men

Purpose

To find the best methods to achieve the highest pregnancy and birth rates for couples needing testicular sperm extraction (TESE)‐intracytoplasmic sperm injection (ICSI).

Methods

Retrospectively studied were 801 patients with male factor infertility who had undergone TESE‐ICSI between April, 1996 and July, 2016 and who had been categorized into four groups: obstructive azoospermia (OA); non‐obstructive azoospermia (NOA); Klinefelter syndrome (KS); and cryptozoospermia (Crypt). The sperm retrieval rate, hormone levels, fertilization rate (FR), pregnancy rate (PR), and birth rate (BR) after ICSI among three groups were compared: fresh testicular sperm (FS)‐fresh oocytes (FO) (Group I); frozen‐thawed testicular sperm‐FO (Group II); and FS‐vitrified‐warmed oocytes (Group III).

Results

The testicular sperm recovery rate was 57.8% (463/801): 89.6% in the Crypt, 97.1% in the OA, 28.9% in the NOA, and 42.2% in the KS groups. The follicle‐stimulating hormone levels were significantly higher in the NOA and KS groups and the testosterone levels were significantly lower in the KS group. The FR, PR, and BR were: 65.2%, 43.2%, and 28.5% in group I; 59.2%, 33.4%, and 18.7% in group II; and 56.4%, 33.8%, and 22.1% in group III.

Conclusion

Intracytoplasmic sperm injection with FS‐FO achieved the best PR and BR. It should be considered what to do in cases with no testicular sperm by TESE. The authors hope that ICSI with donor sperm will be allowed in Japan in the near future.

Microdissection testicular sperm extraction

Microdissection testicular sperm extraction (microTESE) is considered the gold standard method for surgical sperm retrieval among patients with non-obstructive azoospermia (NOA). In this review, we will discuss the optimal evaluation of NOA patients and strategies to medically optimize NOA patients prior to microTESE. In addition, we will also discuss technical principles and pearls to maximize the chances of successful sperm retrieval, sperm retrieval rates (SRR) based upon testicular histology, predictors of successful sperm retrieval, gonadal recovery following microTESE, and potential complications.

Preclinical evaluation of a TEX101 protein ELISA test for the differential diagnosis of male infertility

BACKGROUND

TEX101 is a cell membrane protein exclusively expressed by testicular germ cells and shed into seminal plasma. We previously verified human TEX101 as a biomarker for the differential diagnosis of azoospermia, and developed a first-of-its-kind TEX101 ELISA. To demonstrate the clinical utility of TEX101, in this work we aimed at evaluating ELISA performance in a large population of fertile, subfertile, and infertile men.

METHODS

Mass spectrometry, size-exclusion chromatography, ultracentrifugation, and immunohistochemistry were used to characterize TEX101 protein as an analyte in seminal plasma. Using the optimized protocol for seminal plasma pretreatment, TEX101 was measured by ELISA in 805 seminal plasma samples.

RESULTS

We demonstrated that TEX101 was present in seminal plasma mostly in a free soluble form and that its small fraction was associated with seminal microvesicles. TEX101 median values were estimated in healthy, fertile pre-vasectomy men (5436 ng/mL, N = 64) and in patients with unexplained infertility (4967 ng/mL, N = 277), oligospermia (450 ng/mL, N = 270), and azoospermia (0.5 ng/mL, N = 137). Fertile post-vasectomy men (N = 57) and patients with Sertoli cell-only syndrome (N = 13) and obstructive azoospermia (N = 36) had undetectable levels of TEX101 (≤0.5 ng/mL). A cut-off value of 0.9 ng/mL provided 100% sensitivity at 100% specificity for distinguishing pre- and post-vasectomy men. The combination of a concentration of TEX101 > 0.9 ng/mL and epididymis-specific protein ECM1 > 2.3 μg/mL provided 81% sensitivity at 100% specificity for differentiating between non-obstructive and obstructive azoospermia, thus eliminating the majority of diagnostic testicular biopsies. In addition, a cut-off value of ≥0.6 ng/mL provided 73% sensitivity at 64% specificity for predicting sperm or spermatid retrieval in patients with non-obstructive azoospermia.

CONCLUSIONS

We demonstrated the clinical utility of TEX101 ELISA as a test to evaluate vasectomy success, to stratify azoospermia forms, and to better select patients for sperm retrieval.

Correlation of genetic results with testicular histology, hormones and sperm retrieval in nonobstructive azoospermia patients with testis biopsy

To investigate the frequency and types of genetic results in different testicular histology of patients with nonobstructive azoospermia (NOA), and correlated with hormones and sperm retrieval (SR), a retrospective study was conducted in 286 Chinese NOA patients who underwent testis biopsy and 100 age-matched fertile men as the control group. Chromosome karyotype analyses were performed by the peripheral blood chromosome G-band detection method. Screening of Y chromosome microdeletions of azoospermia factor (AZF) region was performed by polymerase chain reaction (PCR) amplification of 11 sequence-tagged sites (STS). The serum levels of follicle-stimulating hormone, luteinising hormone and testosterone (T) and the appearance of scrotal ultrasound were also obtained. In 286 cases of NOA, 14.3% were found to have chromosomal alterations. The incidence of chromosomal abnormality was 2.8%. Sex chromosomal abnormalities were seen in six cases (four cases of Klinefelter's syndrome (47, XXY) and two cases of mosaics). The incidence of polymorphic chromosomal variants was 3% in the normal group and 11.5% in the NOA group. In total, 15.7% of NOA patients were found to have AZF microdeletions and AZF (c + d) was the most frequent one. The results of hormone and SR were found to be significantly different among all testicular histological types, whereas no significant differences were found when it comes to genetic alterations. It is concluded that the rate of cytogenetic alterations was high in NOA patients. So screening for chromosomal alterations and AZF microdeletions would add useful information for genetic counselling in NOA patients with testis biopsy and avoid vertical transmission of genetic defects by assisted reproductive technology.