Correlation between testicular sperm extraction outcomes and clinical, endocrine and testicular histology parameters in 120 azoospermic men with normal serum FSH levels

[First-line management of infertile couple. Guidelines for clinical practice of the French College of Obstetricians and Gynecologists 2022]

OBJECTIVE

To update the 2010 CNGOF clinical practice guidelines for the first-line management of infertile couples.

MATERIALS AND METHODS

Five major themes (first-line assessment of the infertile woman, first-line assessment of the infertile man, prevention of exposure to environmental factors, initial management using ovulation induction regimens, first-line reproductive surgery) were identified, enabling 28 questions to be formulated using the Patients, Intervention, Comparison, Outcome (PICO) format. Each question was addressed by a working group that had carried out a systematic review of the literature since 2010, and followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) methodology to assess the quality of the scientific data on which the recommendations were based. These recommendations were then validated during a national review by 40 national experts.

RESULTS

The fertility work-up is recommended to be prescribed according to the woman's age: after one year of infertility before the age of 35 and after 6months after the age of 35. A couple's initial infertility work-up includes a single 3D ultrasound scan with antral follicle count, assessment of tubal permeability by hysterography or HyFOSy, anti-Mullerian hormone assay prior to assisted reproduction, and vaginal swabbing for vaginosis. If the 3D ultrasound is normal, hysterosonography and diagnostic hysteroscopy are not recommended as first-line procedures. Chlamydia trachomatis serology does not have the necessary performance to predict tubal patency. Post-coital testing is no longer recommended. In men, spermogram, spermocytogram and spermoculture are recommended as first-line tests. If the spermogram is normal, it is not recommended to check the spermogram. If the spermogram is abnormal, an examination by an andrologist, an ultrasound scan of the testicles and hormonal test are recommended. Based on the data in the literature, we are unable to recommend a BMI threshold for women that would contraindicate medical management of infertility. A well-balanced Mediterranean-style diet, physical activity and the cessation of smoking and cannabis are recommended for infertile couples. For fertility concern, it is recommended to limit alcohol consumption to less than 5 glasses a week. If the infertility work-up reveals no abnormalities, ovulation induction is not recommended for normo-ovulatory women. If intrauterine insemination is indicated based on an abnormal infertility work-up, gonadotropin stimulation and ovulation monitoring are recommended to avoid multiple pregnancies. If the infertility work-up reveals no abnormality, laparoscopy is probably recommended before the age of 30 to increase natural pregnancy rates. In the case of hydrosalpinx, surgical management is recommended prior to ART, with either salpingotomy or salpingectomy depending on the tubal score. It is recommended to operate on polyps>10mm, myomas 0, 1, 2 and synechiae prior to ART. The data in the literature do not allow us to systematically recommend asymptomatic uterine septa and isthmoceles as first-line surgery.

CONCLUSION

Based on strong agreement between experts, we have been able to formulate updated recommendations in 28 areas concerning the initial management of infertile couples.

A Machine Learning Approach for the Prediction of Testicular Sperm Extraction in Nonobstructive Azoospermia: Algorithm Development and Validation Study

BACKGROUND

Testicular sperm extraction (TESE) is an essential therapeutic tool for the management of male infertility. However, it is an invasive procedure with a success rate up to 50%. To date, no model based on clinical and laboratory parameters is sufficiently powerful to accurately predict the success of sperm retrieval in TESE.

OBJECTIVE

The aim of this study is to compare a wide range of predictive models under similar conditions for TESE outcomes in patients with nonobstructive azoospermia (NOA) to identify the correct mathematical approach to apply, most appropriate study size, and relevance of the input biomarkers.

METHODS

We analyzed 201 patients who underwent TESE at Tenon Hospital (Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris), distributed in a retrospective training cohort of 175 patients (January 2012 to April 2021) and a prospective testing cohort (May 2021 to December 2021) of 26 patients. Preoperative data (according to the French standard exploration of male infertility, 16 variables) including urogenital history, hormonal data, genetic data, and TESE outcomes (representing the target variable) were collected. A TESE was considered positive if we obtained sufficient spermatozoa for intracytoplasmic sperm injection. After preprocessing the raw data, 8 machine learning (ML) models were trained and optimized on the retrospective training cohort data set: The hyperparameter tuning was performed by random search. Finally, the prospective testing cohort data set was used for the model evaluation. The metrics used to evaluate and compare the models were the following: sensitivity, specificity, area under the receiver operating characteristic curve (AUC-ROC), and accuracy. The importance of each variable in the model was assessed using the permutation feature importance technique, and the optimal number of patients to include in the study was assessed using the learning curve.

RESULTS

The ensemble models, based on decision trees, showed the best performance, especially the random forest model, which yielded the following results: AUC=0.90, sensitivity=100%, and specificity=69.2%. Furthermore, a study size of 120 patients seemed sufficient to properly exploit the preoperative data in the modeling process, since increasing the number of patients beyond 120 during model training did not bring any performance improvement. Furthermore, inhibin B and a history of varicoceles exhibited the highest predictive capacity.

CONCLUSIONS

An ML algorithm based on an appropriate approach can predict successful sperm retrieval in men with NOA undergoing TESE, with promising performance. However, although this study is consistent with the first step of this process, a subsequent formal prospective multicentric validation study should be undertaken before any clinical applications. As future work, we consider the use of recent and clinically relevant data sets (including seminal plasma biomarkers, especially noncoding RNAs, as markers of residual spermatogenesis in NOA patients) to improve our results even more.

Histological and immunohistochemical outcomes after microdissection TESE in contrast with hormonal profile, testis volume and genetics in patients with azoospermia

A limited number of individuals with non-obstructive azoospermia (NOA) may recover spermatozoa through traditional testicular sperm extraction (TESE) techniques. There is an ongoing debate over the effectiveness of microdissection TESE compared to standard TESE methods. Microdissection TESE (micro-TESE) techniques enable the identification of spermatogenesis foci in non-obstructive forms of azoospermia. Only histological examination can provide an objective and definitive assessment of the testicular phenotype. This study aimed to evaluate the correlation between histopathological findings after microdissection TESE (micro-TESE) and the predictive role of various factors in determining the success of sperm retrieval. We evaluated 24 patients with azoospermia who underwent micro-TESE and considered the patient's hormonal profile, testis ultrasound, genetic evaluation, histology, and immunohistology (PLAP antibody) of collected testis biopsies. The preoperative blood FSH level, in conjunction with other parameters, may aid in the prediction of micro-TESE success. Sensitivity increases, and specificity decreases with higher FSH levels. Furthermore, testicular volume and FSH levels are typically normal in patients with maturation arrest. In conclusion, hormones, ultrasound evaluation of the testicles, testis volume, and available genetic tests have a predictive value in differentiating obstructive azoospermia (OA) from NOA with various sensitivity and specificity rates. Histological and immunohistochemical evaluation establishes the testicular phenotype accurately and guides patient management.

Retinal vessel diameters: Can they predict future risk of infertility in patients with varicocele?

OBJECTIVE

The objective of this study was to assess the relationship between retinal vessel diameters, such as retinal arteriolar diameter, retinal venular diameter, and arteriolar/venular ratio (AVR), as clinical parameters of fertility in varicocele patients.

MATERIALS AND METHODS

Sixty-eight (68) infertile varicocele men with abnormal semen parameters and sixty-one (61) varicocele normozoospermic men were included in the study. Moreover, fifty-eight (58) healthy normozoospermic men without varicocele were enrolled as a control group. For each participant, retinal vascular diameters were measured from the digital retinal photographs as a central retinal arteriolar equivalent (CRAE), central retinal venular equivalent (CRVE), and AVR. In addition, hormones (total testosterone and FSH), and semen parameters were assessed and correlated with retinal vessel diameters.

RESULTS

The mean CRAE, CRVE, and AVR values were 147.8 ± 15.8 μm, 198.3 ± 39.3 μm, and 0.61 ± 0.01 in infertile varicocele patients, respectively. Significant difference of CRAE, CRVE, and AVR were found when comparing infertile varicocele patients with both varicocele and control normozoospermic male groups (p = 0.01, p = 0.006, and p = 0.007; respectively). Larger retinal venular caliber and smaller AVR ratio showed a significant inverse correlation with both sperm parameters and hormones (total testosterone and FSH) (p < 0.05). No significant correlations were found between CRAE with both sperm parameters and hormonal values (total testosterone and FSH) (p > 0.05).

CONCLUSIONS

Infertile patients with varicocele showed a significant relationship with the retinal vascular diameter (CRVE and AVR ratio). This finding supports recommendation for regular eye examinations in the varicocele population.

Development a nomogram to predict fertilisation rate of infertile males with borderline semen by using semen parameters combined with AMH and INHB

The sperm quality of some males is in a critical state, making it hard for clinicians to choose the suitable fertilisation methods. This study aimed to develop an intelligent nomogram for predicting fertilisation rate of infertile males with borderline semen. 160 males underwent in vitro fertilisation (IVF), 58 of whom received rescue ICSI (R‐ICSI) due to fertilisation failure (fertilisation rate of IVF ≤30%). A least absolute shrinkage and selection operator (LASSO) regression analysis identified sperm concentration, progressively motile spermatozoa (PMS), seminal plasma anti‐Müllerian hormone (spAMH), seminal plasma inhibin (spINHB), serum AMH (serAMH) and serum INHB (serINHB) as significant predictors. The nomogram was plotted by multivariable logistic regression. This nomogram‐illustrated model showed good discrimination, calibration and clinical value. The area under the receiver operating characteristic curve (AUC) of the nomogram was 0.762 (p < .001). Calibration curve and Hosmer–Lemeshow test (p = .5261) showed good consistency between the predictions of the nomogram and the actual observations, and decision curve analysis showed that the nomogram was clinically useful. This nomogram may be useful in predicting fertilisation rate, mainly focused on new biomarkers, INHB and AMH. It could assist clinicians and laboratory technicians select appropriate fertilisation methods (IVF or ICSI) for male patients with borderline semen.

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.

Bilateral versus unilateral cryptorchidism in nonobstructive azoospermia: Testicular sperm extraction outcomes

Cryptorchidism is one of the most frequent causes of nonobstructive azoospermia (NOA) in adulthood. Although it is well known that spermatogenesis is more impaired in bilateral than in unilateral cryptorchidism, previous studies have only described small cohorts or inhomogeneous population. Consequently, we analyzed a cohort of 225 men with only a history of cryptorchidism as sole etiopathogenetic factor for NOA, and compared testicular sperm extraction (TESE) outcomes between men with bilateral versus unilateral cryptorchidism. Our results show no difference in follicle-stimulating hormone (FSH) levels and testicular volumes between men with a history of bilateral cryptorchidism compared to unilateral cryptorchidism (median: 21.3 IU l⁻¹vs 19.3 IU l⁻¹, P = 0.306; and 7.2 ml vs 7.9 ml, P = 0.543, respectively). In addition, sperm retrieval rates were similar (66.2% vs 60.0%, P = 0.353). Using multivariate analysis, we have found that only a low inhibin B level (above the assay's detection limit) was positively associated with successful sperm retrieval (P < 0.05). Regarding intracytoplasmic sperm injection outcomes, we found that cumulative pregnancy rate and live birth rate per cycle were not statistically different between the two groups (17.4% vs 27.8%, P = 0.070; and 16.1% vs 26.4%, P = 0.067, respectively). Unexpectedly, there was no significant difference in hormonal profiles (FSH, luteinizing hormone [LH], testosterone, and inhibin B levels) and TESE outcomes between unilateral versus bilateral cryptorchidism. This suggests that a history of unilateral cryptorchidism could reflect a bilateral testicular impairment. Interestingly, inhibin B level might be a predictor of successful TESE.

Prediction of sperm extraction in non-obstructive azoospermia patients: a machine-learning perspective

STUDY QUESTION

Can a machine-learning-based model trained in clinical and biological variables support the prediction of the presence or absence of sperm in testicular biopsy in non-obstructive azoospermia (NOA) patients?

SUMMARY ANSWER

Our machine-learning model was able to accurately predict (AUC of 0.8) the presence or absence of spermatozoa in patients with NOA.

WHAT IS KNOWN ALREADY

Patients with NOA can conceive with their own biological gametes using ICSI in combination with successful testicular sperm extraction (TESE). Testicular sperm retrieval is successful in up to 50% of men with NOA. However, to the best of our knowledge, there is no existing model that can accurately predict the success of sperm retrieval in TESE. Moreover, machine-learning has never been used for this purpose.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study of 119 patients who underwent TESE in a single IVF unit between 1995 and 2017 was conducted. All patients with NOA who underwent TESE during their fertility treatments were included. The development of gradient-boosted trees (GBTs) aimed to predict the presence or absence of spermatozoa in patients with NOA. The accuracy of these GBTs was then compared to a similar multivariate logistic regression model (MvLRM).

PARTICIPANTS/MATERIALS, SETTING, METHODS

We employed univariate and multivariate binary logistic regression models to predict the probability of successful TESE using a dataset from a retrospective cohort. In addition, we examined various ensemble machine-learning models (GBT and random forest) and evaluated their predictive performance using the leave-one-out cross-validation procedure. A cutoff value for successful/unsuccessful TESE was calculated with receiver operating characteristic (ROC) curve analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

ROC analysis resulted in an AUC of 0.807 ± 0.032 (95% CI 0.743–0.871) for the proposed GBTs and 0.75 ± 0.052 (95% CI 0.65–0.85) for the MvLRM for the prediction of presence or absence of spermatozoa in patients with NOA. The GBT approach and the MvLRM yielded a sensitivity of 91% vs. 97%, respectively, but the GBT approach has a specificity of 51% compared with 25% for the MvLRM. A total of 78 (65.3%) men with NOA experienced successful TESE. FSH, LH, testosterone, semen volume, age, BMI, ethnicity and testicular size on clinical evaluation were included in these models.

LIMITATIONS, REASONS FOR CAUTION

This study is a retrospective cohort study, with all the associated inherent biases of such studies. This model was used only for TESE, since micro-TESE is not performed at our center.

WIDER IMPLICATIONS OF THE FINDINGS

Machine-learning models may lay the foundation for a decision support system for clinicians together with their NOA patients concerning TESE. The findings of this study should be confirmed with further larger and prospective studies.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Division of Obstetrics and Gynecology, Soroka University Medical Center, there are no potential conflicts of interest for all authors.

Reference range and cutoff value of serum inhibin B to predict successful sperm retrieval: A cross-sectional study of 30 613 Chinese men

BACKGROUND

The power of inhibin B to predict competent spermatogenesis is not fully understood. The aims of this study were to identify the reliable reference range of inhibin B among normozoospermic men in China and to evaluate the diagnostic accuracy of serum inhibin B level as a complementary predictor of successful sperm retrieval in patients with azoospermia.

METHODS

This was a cross-sectional study. The male partners of 30 613 infertile couples who visited our hospital were investigated between March 2017 and March 2019. We analysed semen parameters, serum levels of reproductive hormones (inhibin B, FSH and testosterone) and sperm retrieval results from PESA/TESE in Chinese men.

RESULTS

The normal reference range of inhibin B was 87.42-299.93 pg/mL among men with normozoospermia in China. Inhibin B levels were negatively correlated with age (r = -.111; P < .001) but positively correlated with total sperm counts in the overall population, reference group and case group (r = .311, r = .208 and r = .444, respectively; P < .001). Stepwise multiple regression analyses revealed that compared with the FSH and testosterone levels, the inhibin B level had the closest relationship with the total sperm count. The best cutoff value of inhibin B for predicting the retrieval outcome of testicular/epididymal sperm was >77.72 pg/mL (sensitivity = 59.14%, specificity = 92.00% and AUC = 0.801). The inhibin B:FSH ratio (cutoff value > 6.98, sensitivity = 56.99%, specificity = 96.00% and AUC = 0.814) performed better than either the inhibin B level or the FSH level alone.

CONCLUSION

A new reference range for serum inhibin B was established in China. However, neither serum inhibin B, FSH nor their ratio is adequate for men to decide whether to undergo PESA/TESE to determine the adequacy of spermatogenesis.

Comparison of Serum Inhibin B and Follicle-Stimulating Hormone (FSH) Level between Normal and Infertile Men in Yaoundé

Objective

Hormones play a vital role in initiating and maintaining male reproductive function. The present study explores the influence and predictive ability of two reproductive hormones on semen quality among men who were partners in an infertile couple.

Design

During our cross sectional study, men were recruited from private and public hospital and laboratories for clinical evaluation of fertility status.

Methods

Fresh semen samples were assessed for quality (concentration, motility and morphology) according to the 2010 World Health Organization manual and the serum levels of hormones, including follicle-stimulating hormone (FSH), Inhibin B was measured (ELISA).

Results

We found a significant difference in the two groups regarding sperm concentration (p < 0.0001), total sperm count (p < 0.0001), total sperm count (p < 0.0001), total sperm count (p < 0.0001), total sperm count (p < 0.0001), total sperm count (

Conclusion

Consistent with other studies, our results show strong association between semen quality and FSH and Inhibin B.

Effect of Wuzi Yanzong on Reproductive Hormones and TGF-β1/Smads Signal Pathway in Rats with Oligoasthenozoospermia

Introduction

Wuzi Yanzong (WZYZ) formula, a famous traditional Chinese medicinal prescription, has been widely used to treat kidney essence insufficiency-induced oligoasthenozoospermia in ancient and modern clinical practice. Previous studies have demonstrated that WZYZ formula exhibits significantly therapeutic activity. The aim of this study was to evaluate the effect of WZYZ formula on the reproductive hormone levels and the TGF-β1/Smads signal pathway in the testis, to explore the underlying mechanisms of WZYZ formula to improve spermatogenic function of testis in rats with oligoasthenozoospermia.

Materials and Methods

In order to control the quality of the drug, the main components of the WZYZ formula were analyzed by HPLC. A rat model of oligoasthenozoospermia was established, by daily administration of tripterygium glucosides for 4 weeks, and treated with 1.62g/kg of WZYZ formula. The testes were histopathologically examined and serum levels of gonadotropin release hormone (GnRH), estradiol (E2), follicle-stimulating hormone (FSH), testosterone (T), and luteinizing hormone (LH) were measured by ELISA. TGf-β1, Smad2, and Smad4 mRNA and protein levels in the testis were evaluated by immunohistochemistry (IHC), quantitative real-time RT-PCR (qRT-PCR), and Western blotting (WB).

Result

Oral administration of WZYZ formula restored testicular structure and significantly increased the histology score in the oligoasthenozoospermic rats. In addition, WZYZ also significantly increased the serum levels of GnRH, LH, E2, and T and decreased that of FSH. Meanwhile, TGf-β1, Smad2, and Sma4 expression levels were significantly decreased.

Conclusions

WZYZ alleviates oligoasthenozoospermia by restoring the reproductive hormones and targeting the TGf-β1/Smads pathway.

Predictive significance of serum inhibin B on testicular haploid gamete retrieval outcomes in nonobstructive azoospermic men

The purpose of this study was to determine the diagnostic accuracy of serum inhibin B (INHB) as a predictor of the retrieval outcome of testicular haploid gametes (spermatids and testicular spermatozoa) in nonobstructive azoospermic men. Serum hormone levels, testicular volume, and histological evaluation were performed in 403 Chinese nonobstructive azoospermic men. Testicular haploid gamete was successfully retrieved in 213 of 403 patients (52.85%). The haploid gamete group always had higher INHB levels than the non-haploid gamete group. According to the receiver operating characteristic (ROC) curve analysis, INHB was a good predictor of testicular haploid gamete retrieval outcome in all patients (sensitivity: 77.93% and specificity: 91.58%) and patients with normal follicle-stimulating hormone (FSH; sensitivity: 88.52% and specificity: 70.83%). The area under the ROC curve (AUC) of INHB was similar to that of FSH in all patients or patients with normal FSH. In patients with elevated FSH, INHB was superior to FSH in predicting the presence of haploid gamete (AUC: 0.73 vs 0.55, P < 0.05), with a sensitivity of 60.00% and a specificity of 80.28%. It concluded that serum INHB as an effective marker for spermatogenesis was a significant predictor of testicular haploid gamete retrieval outcomes in nonobstructive azoospermic men. Especially, INHB is superior to FSH in predicting the presence of haploid gamete in the patients with elevated FSH.

New insights into the morphological and hormonal characteristics of spermatogenic arrest

The reported sperm retrieval rate (SRR) in patients with nonobstructive azoospermia (NOA) due to spermatogenic arrest (SA) is highly variable in the literature. This discrepancy could be explained by the heterogeneity of testicular tissues. Surprisingly, even though inhibin B levels reflect directly Sertoli cell function; no studies have evaluated this parameter in SA. We aimed to clarify the morphological and biological profile in 158 men with SA. From the total population, patients whose seminiferous tubules diameter was below 165 µm have higher SRR (46.9% vs. 27.4%, p < 0.05), lower inhibin levels and a higher frequency of nonuniform SA (71.9% vs. 38.7%, p < 0.001). On multivariate analysis, patients with late SA and a history of cryptorchidism were positively associated with successful sperm extraction. Patients with successful SRR and uniform SA exhibited inhibin levels twofold lower than those with failed TESE (45 pg/ml vs. 95 pg/ml, p < 0.05), whereas FSH levels were similar in the two groups. In this study, we showed for the first time that the mean diameter of the seminiferous tubules may be of value in the diagnosis of SA. Our results suggest that inhibin levels could be useful in the management of NOA with SA, along with FSH levels and testicular volume.

Prospective evaluation of scrotal ultrasound and intratesticular perfusion by color-coded duplex sonography (CCDS) in TESE patients with azoospermia

PURPOSE

The objective of this study was to assess whether CCDS might improve the outcome of testicular sperm retrieval in patients with azoospermia. Furthermore, we evaluated potential sonographic alterations of the testis before and after trifocal and Micro-TESE.

METHODS

78 patients were enrolled prospectively: 24 with obstructive azoospermia (OA) and 54 with non-obstructive azoospermia (NOA). 31 of 54 patients in the NOA group had negative surgical sperm retrieval. Testicular volume, hormonal parameters and sonographical findings were compared before and after TESE. The spermatogenetic score was determined for all retrieval sites. CCDS was performed at the upper, middle and lower segment of the testis. Ultrasound parameters and peak systolic velocity (PSV) were measured pre- and post-operatively.

RESULTS

Testicular volume and epididymal head size were significantly increased in OA patients compared to NOA patients. Ultrasound parameters were comparable between NOA patients with and without successful sperm retrieval. A higher intratesticular PSV was significantly correlated with a better spermatogenic score in the corresponding sonographic position. However, after adjustment for other clinical confounders, PSV does not show a significant influence on the spermatogenic score. Testicular volume decreased significantly in all patients post-operatively after 6 weeks (p < 0.001). Finally, the PSV significantly increased in all patients 24 h after surgery and nearly returned to baseline levels after 6 weeks (p < 0.001).

CONCLUSIONS

A higher intratesticular PSV may be helpful as a pre-operative diagnostic parameter in mapping for better sperm retrieval, but CCDS does not help to predict successful testicular sperm retrieval after adjustment for other clinical confounders.

Extreme spermatogenesis failure: andrological phenotype and intracytoplasmic sperm injection outcomes

Patients with very low sperm count through direct sperm examination can exhibit extreme oligozoospermia or cryptozoospermia (after centrifugation). The management of these patients is a real challenge for both clinicians and biologists. In this retrospective and comparative cohort study, we compared the andrological phenotype of patients with extreme alterations of spermatogenesis and assessed whether the origin of spermatozoa (testicular or ejaculate) had any influence on intracytoplasmic sperm injection (ICSI) outcomes. A total of 161 ICSI cycles were performed using ejaculated spermatozoa from 75 patients with extreme oligozoospermia (EOS) or cryptozoospermia (CS) and 150 ICSI cycles using extracted testicular spermatozoa from 74 patients with non-obstructive azoospermia (NOA). Physical, hormonal, ultrasound assessments, and ICSI outcomes were performed in each group. Cryptorchidism was significantly more frequent in the NOA group (60.8% vs. 22.6%, p = 0.001). FSH levels were significantly higher [18.9 IU/L (5.9-27.0) vs. 15.3 IU/L (9.0-46.5), p = 0.001] and the majority of inhibin B levels measured were found mostly undetectable in the NOA group as compared to EOS/CS group (31.1% vs. 10.7%, p = 0.0004). Moreover, we found no significant differences in the respect to the fertilization rates (48.9% and 43.3%, p = 0.43), implantation rates (17.4% and 15.9%, p = 0.77), and percentage of top quality embryo (22.4% and 20.4%, p = 0.73) between the two groups. The clinical pregnancy rates per embryo transferred were comparable in both groups (28.3% and 27.4%, p = 0.89). In this study, we showed for the first time a different andrological phenotype between EOS/CS and NOA groups. Indeed, cryptorchidism was significantly more frequent with more severe endocrine parameters found in the NOA group. These results reflect a more profound alteration in spermatogenesis in NOA patients. However, there was no difference in ICSI outcomes between NOA and EOS/CS groups.

Predictive factors of successful sperm retrieval on microdissection testicular sperm extraction in Japanese men

Purpose

To evaluate retrospectively the outcomes of microdissection testicular sperm extraction (micro-TESE) in men with nonobstructive azoospermia (NOA) and to identify the parameters predicting successful sperm retrieval in this cohort of patients.

Methods

After excluding patients with normal testicular volume and serum follicle-stimulating hormone (FSH) level who received conventional TESE, this study included 329 consecutive NOA patients undergoing micro-TESE at our institution. The significance of several factors, including age, testicular volume, etiology and serum levels of FSH, luteinizing hormone (LH) and serum testosterone (T), as predictors of successful sperm retrieval, was evaluated.

Results

Of the 329 men included in this series, 246 (74.8 %), 40 (12.2 %), and 43 (13.1 %) were pathologically diagnosed with Sertoli cell only, maturation arrest, and hypospermatogenesis, respectively. Spermatozoa were retrieved in 97 (29.5 %) of these 329 men by micro-TESE. Older age and non-idiopathic etiology were significantly associated with the probability of successful sperm retrieval; however, there were no significant effects of testicular volume as well as serum levels of FSH, LH, and T on sperm retrieval outcome. Furthermore, Johnsen score of the micro-TESE specimen showed a significant association with whether spermatozoa were successfully retrieved. Univariate analysis of preoperative parameters identified older age and non-idiopathic etiology as significant predictors of successful sperm retrieval, of which only etiology appeared to be independently related to successful sperm retrieval on multivariate analysis.

Conclusions

Spermatozoa are significantly less likely to be successfully retrieved by micro-TESE in men with idiopathic azoospermia.

The serum inhibin B concentration and reference ranges in normozoospermia

OBJECTIVE

Although an inhibin B assay may be useful in the assessment of testicular function in a number of genital conditions, reliable reference ranges are still lacking. The present study sought to establish the reference range for serum inhibin B by applying the updated Gen II assay.

DESIGN

This prospective study included 818 men referred for semen analysis: 377 were normozoospermic (reference group) and 441 presented at least one abnormal semen parameter (case group).

METHODS

Semen parameters were interpreted according to the 2010 World Health Organization manual and David's modified classification for normal morphology. The inhibin B concentration was determined with the current ELISA.

RESULTS

In the reference group, the 2.5th percentile for inhibin B was 92 pg/ml and the 97.5th percentile for FSH was 7.8 IU/l. In the overall population, an inhibin B level <92 pg/ml was associated with increased odds ratio (OR; 95% CI) for oligozoospermia (16.93 (9.82-29.18), P<0.0001), asthenozoospermia (4.87 (2.88-8.10), P<0.0001), and teratozoospermia (2.20 (1.31-3.68), P=0.0026). The combination of a FSH >7.8 IU/l and an inhibin B <92 pg/ml was associated with greater OR for oligozoospermia (98.74 (23.99-406.35), P<0.0001) than for each hormone considered separately.

CONCLUSIONS

A new reference range for serum inhibin B was established by the use of updated immunoassay. The correlations between hormone levels and semen parameters highlighted the importance of establishing these values with respect to the spermogram. When combined with FSH assay, the inhibin B range may be of value in the evaluation of spermatogenesis in a number of male genital conditions.

[48,XXYY men with azoospermia: how to manage infertility?]

48,XXYY syndrome is a rare form of sex chromosomal aneuploidy. Usually considered as a variant of Klinefelter syndrome because of shared features (azoospermia, tall stature, hypergonadotropic hypogonadism), it is a separate entity because diagnostic is currently made in prepubertal boy with neuro-psychological disorders. We here report the case of a 48,XXYY patient consulting for adult infertility and the indication to perform testicular sperm extraction is discussed.

Beneficial effects of varicocele embolization on semen parameters

BACKGROUND

The value of varicocele repair and the latter's impact on semen parameters are still subject to debate.

METHODS

We analyse changes over time in initially abnormal sperm parameters and serum concentrations of testosterone, FSH and inhibin B after embolization treatment of males with high-grade varicocele. From 2007 to 2012, we recruited 47 male infertile patients with clinically visible left varicocele in the resting patient and at least one abnormal semen parameter. Sperm parameters and serum levels of total testosterone, FSH and inhibin B were measured prior to retrograde embolization (M0) and then 3 (M3) and 6 (M6) months afterwards.

RESULTS

At M0, the median sperm concentration was 5.78 [0.84-37.70] × 10(6)/ejaculate. The mean ± SD sperm progressive motility, vitality and percentage of normal sperm were respectively, 21.83 ± 16.48%, 61.88 ± 15.98% and 12.88 ± 7.15%. The corresponding values at M3 were significantly higher (38.75 [3.96-95] × 10(6)/ejaculate, 29.32 ± 14.21%, 69.14 ± 14.86% and 19.03 ± 11.02%, respectively). The mean percentage of spermatozoa with a thin head was significantly lower at M6 (6.35 ± 5.29%) than at M0 (14.03 ± 13.09%). The mean serum testosterone, FSH and inhibin B levels did not change significantly over time.

CONCLUSIONS

Embolization treatment in men with clinically visible left varicocele, abnormal sperm parameters and documented infertility is associated with a significant improvement in semen parameters including sperm head morphology.

Predictive factors of successful microdissection testicular sperm extraction

Azoospermia in men requires microsurgical reconstruction or a procedure for sperm retrieval with assisted reproduction to allow fertility. While the chance of successful retrieval of sperm in men with obstructive azoospermia approaches >90%, the chances of sperm retrieval in men with non-obstructive azoospermia (NOA) are not as high. Conventional procedures such as fine needle aspiration of the testis, testicular biopsy and testicular sperm extraction are successful in 20-45% of men with NOA. With microdissection testicular sperm extraction (micro-TESE), the chance of successful retrieval can be up to 60%. Despite this increased success, the ability to counsel patients preoperatively on their probability of successful sperm retrieval has remained challenging. A combination of variables such as age, serum FSH and inhibin B levels, testicular size, genetic analysis, history of Klinefelter syndrome, history of cryptorchidism or varicocele and histopathology on diagnostic biopsy have provided some insight into the chance of successful sperm retrieval in men with NOA. The goal of this review was to evaluate the preoperative factors that are currently available to predict the outcome for success with micro-TESE.

Sperm retrieval and live birth rates in presumed Sertoli-cell-only syndrome in testis biopsy: a single centre experience

We aimed to investigate sperm retrieval rates (SRR) by testicular sperm extraction (TESE), factors affecting SRR, and fertilization rate (FR), implantation rate (IR), clinical pregnancy rate (CPR) and live birth rate (LBR) in patients with presumed Sertoli-cell-only syndrome in testis biopsy (SCOS). We retrospectively evaluated files of 134 patients with SCOS who underwent TESE. Group I were patients in whom spermatozoa were retrieved and Group II were patients in whom no spermatozoa could be retrieved. SRR, Follicle stimulating hormone (FSH), Luteinizing hormone (LH), and testosterone levels, and the volume of testicles were compared between groups. In addition, FR, IR, CPR and LBR were determined. Sperm retrieval was achieved in 37 (27.6%) patients (Group I), and the remaining 97 (72.4%) patients made Group II. There were no significant differences in age, infertility time, testicular volume, serum FSH, LH and testosterone levels between Groups I and II (p > 0.05). Intracytoplasmic sperm injection (ICSI) was performed in 36 patients. FR, IR, and CPR were 60.86 ± 23.03, 36.53 ± 41.78 and 51.3% respectively. Cycle and patient based LBRs were 37.8 and 45.1% respectively. SRR in SCOS is lower than patients with non-obstructive azoospermia (NOA) in general. No parameters to predict spermatozoa retrieval were determined. In patients with SCOS, ICSI achieves similar live birth rate to other patients with NOA.