Sperm retrieval techniques for assisted reproduction

Advances in human In vitro spermatogenesis: A review

Recent advances surrounding in vitro spermatogenesis (IVS) have shown potential in creating a new paradigm of regenerative medicine in the future of fertility treatments for males experiencing non-obstructive azoospermia (NOA). Male infertility is a common condition affecting approximately 15% of couples, with azoospermia being present in 15% of infertile males (Cocuzza et al., 2013; Esteves et al., 2011a). Treatment for patients with NOA has primarily been limited to surgical sperm retrieval combined with in vitro fertilization intracytoplasmic sperm injection (IVF-ICSI); however, sperm retrieval is successful in only half of these patients, and live birth rates typically range between 10 and 25% (Aljubran et al., 2022). Therefore, a significant need exists for regenerative therapies in this patient population. IVS has been considered as a model for further understanding the molecular and cellular processes of spermatogenesis and as a potential regenerative therapeutic approach. While 2D cell cultures using human testicular cells have been attempted in previous research, lack of proper spatial arrangement limits germ cell differentiation and maturation, posing challenges for clinical application. Recent research suggests that 3D technology may have advantages for IVS due to mimicry of the native cytoarchitecture of human testicular tissue along with cell-cell communication directly or indirectly. 3D organotypic cultures, scaffolds, organoids, microfluidics, testis-on-a-chip, and bioprinting techniques have all shown potential to contribute to the technology of regenerative treatment strategies, including in vitro fertilization (IVF). Although promising, further work is needed to develop technology for successful, replicable, and safe IVS for humans. The intersection between tissue engineering, molecular biology, and reproductive medicine in IVS development allows for multidisciplinary involvement, where challenges can be overcome to realize regenerative therapies as a viable option.

Establishment and validation of a 5-factor diagnostic model for obstructive and non-obstructive azoospermia based on routine clinical parameters

Azoospermia is a serious leading male-factor cause of infertility in couples of childbearing age. The two main azoospermia types, obstructive (OA) and non-obstructive (NOA) azoospermia, differ in their treatment approaches. Therefore, their clinical diagnosis is extremely important, requiring an accurate, efficient, and easy-to-use diagnostic model. This retrospective observational study included 707 patients with azoospermia treated between 2017 and 2021, 498 with OA, and 209 with NOA. Hematological and seminal plasma parameters, hormone levels, and testicular volume were used in logistic regression analysis to evaluate and compare their diagnostic performance, results showed that the optimal diagnostic model is constructed by five variables including semen volume, semen pH, seminal plasma neutral α-glucosidase activity, follicle-stimulating hormone in the serum, and testicular volume, compared with follicle-stimulating hormone-based and testicular volume-based models. The 5-factor diagnostic model had an accuracy of 90.4%, sensitivity of 96.4%, positive predictive value of 90.6%, negative predictive value of 89.8%, and area under the curve of 0.931, all higher than in the other two models. However, its specificity (76.1%) was slightly lower than in the other models. Meantime, the internal 5-fold cross-validation results indicated that the 5-factor diagnostic model had a good clinical application value. This study established an accurate, efficient, and relatively accessible 5-factor diagnostic model for OA and NOA, providing a reference for clinical decision-making when selecting an appropriate treatment.

Etiology of Male Infertility: an Update

Spermatogenesis is a complex process of germ cell division and differentiation that involves extensive cross-talk between the developing germ cells and the somatic testicular cells. Defective endocrine signaling and/or intrinsic defects within the testes can adversely affect spermatogenic progression, leading to subfertility/infertility. In recent years, male infertility has been recognized as a global public health concern, and research over the last few decades has elucidated the complex etiology of male infertility. Congenital reproductive abnormalities, genetic mutations, and endocrine/metabolic dysfunction have been demonstrated to be involved in infertility/subfertility in males. Furthermore, acquired factors like exposure to environmental toxicants and lifestyle-related disorders such as illicit use of psychoactive drugs have been shown to adversely affect spermatogenesis. Despite the large body of available scientific literature on the etiology of male infertility, a substantial proportion of infertility cases are idiopathic in nature, with no known cause. The inability to treat such idiopathic cases stems from poor knowledge about the complex regulation of spermatogenesis. Emerging scientific evidence indicates that defective functioning of testicular Sertoli cells (Sc) may be an underlying cause of infertility/subfertility in males. Sc plays an indispensable role in regulating spermatogenesis, and impaired functional maturation of Sc has been shown to affect fertility in animal models as well as humans, suggesting abnormal Sc as a potential underlying cause of reproductive insufficiency/failure in such cases of unexplained infertility. This review summarizes the major causes of infertility/subfertility in males, with an emphasis on infertility due to dysregulated Sc function.

Micromapping testicular sperm extraction: A new technique for microscopic testicular sperm extraction in nonobstructive azoospermia

Purpose

In microscopic testicular sperm extraction (mTESE) for nonobstructive azoospermia (NOA), sperm can be recovered relatively easily in some cases, and mTESE may be retrospectively considered excessive. However, mTESE is routinely performed in the majority of NOA patients because of the difficulty in predicting tissue status. A minimally invasive and comprehensive sperm retrieval method that allows on-the-spot tissue assessment is needed. We have developed and evaluated a novel sperm retrieval technique for NOA called micromapping testicular sperm extraction (MMTSE).

Methods

MMTSE involves dividing the testis into four sections and making multiple small needle holes in the tunica albuginea to extract seminiferous tubules and retrieve sperm. The sperm-positive group by MMTSE (Group I) underwent additional tissue collection (ATC) via a small incision, whereas the sperm-negative group by MMTSE (Group 0) underwent mTESE.

Results

In total, 40 NOA participants underwent MMTSE. Group I included 15 patients and Group 0 included 25 patients. In Group 1, sperm were recovered from all patients by ATC. In Group 0, sperm were recovered in 4 of 25 cases using mTESE.

Conclusions

MMTSE shows promise as a simple method that comprehensively searches testicular tissue and retrieves sperm using an appropriate method while minimizing patient burden.

Clinical management of nonobstructive azoospermia: An update

Approximately 1% of the general male population has azoospermia, and nonobstructive azoospermia accounts for the majority of cases. The causes vary widely, including chromosomal and genetic abnormalities, varicocele, drug-induced causes, and gonadotropin deficiency; however, the cause is often unknown. In azoospermia caused by hypogonadotropic hypogonadism, gonadotropin replacement therapy can be expected to produce sperm in the ejaculate. In some cases, upfront varicocelectomy for nonobstructive azoospermia with varicocele may result in the appearance of ejaculated spermatozoa; however, the appropriate indication should be selected. Each guideline recommends microdissection testicular sperm extraction for nonobstructive azoospermia in terms of successful sperm retrieval and avoidance of complications. Sperm retrieval rates generally ranged from 20% to 70% but vary depending on the causative disease. Various attempts have been made to predict sperm retrieval and improve sperm retrieval rates; however, the evidence is insufficient. Further evidence accumulation is needed for salvage treatment in cases of failed sperm retrieval. In Japan, there is inadequate provision on the right to know the origin of children born from artificial insemination of donated sperm and the rights of sperm donors, as well as information on unrelated family members, and the development of these systems is challenging. In the future, it is hoped that the pathogenesis of nonobstructive azoospermia with an unknown cause will be elucidated and that technology for omics technologies, human spermatogenesis using pluripotent cells, and organ culture methods will be developed.

Controversy and Consensus on the Management of Elevated Sperm DNA Fragmentation in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

PURPOSE

Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition.

MATERIALS AND METHODS

An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method.

RESULTS

A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4-6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated.

CONCLUSIONS

This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians.

A realistic model for vasectomy reversal training using swine testicles

PURPOSE

To evaluate the viability of the porcine vas deferens as a realistic microsurgical training model for vasectomy reversal.

METHODS

The model uses swine testicles (vas deferent), which are usually discarded in large street markets since they are not part of Brazilian cuisine. The spermatic cord was carefully dissected, and the vas deferens were isolated, measuring 10 cm in length. A paper quadrilateral with 5 cm2 was built to delimit the surgical training field. The objective of the model is to simulate only the microsurgical step when the vas deferens are already isolated. The parameters analyzed were: feasibility for reproducing the technique, patency before and after performing the vasovasostomy, cost of the model, ease of acquisition, ease of handling, execution time, and model reproducibility.

RESULTS

The simulator presented low cost. All models made were viable with a texture similar to human, with positive patency obtained in 100% of the procedures. The internal and external diameters of the vas deferens varied between 0.2-0.4 mm and 2-3 mm, respectively, with a mean length of 9 ± 1.2 cm. The total procedure time was 43.28 ± 3.22 minutes.

CONCLUSIONS

The realistic model presented proved to be viable for carrying out vasectomy reversal training, due to its low cost, easy acquisition, and easy handling, and providing similar tissue characteristics to humans.

The Renaissance of Male Infertility Management in the Golden Age of Andrology

Infertility affects nearly 186 million people worldwide and the male partner is the cause in about half of the cases. Meta-regression data indicate an unexplained decline in sperm concentration and total sperm count over the last four decades, with an increasing prevalence of male infertility. This suggests an urgent need to implement further basic and clinical research in Andrology. Andrology developed as a branch of urology, gynecology, endocrinology, and, dermatology. The first scientific journal devoted to andrological sciences was founded in 1969. Since then, despite great advancements, andrology has encountered several obstacles in its growth. In fact, for cultural reasons, the male partner has often been neglected in the diagnostic and therapeutic workup of the infertile couple. Furthermore, the development of assisted reproductive techniques (ART) has driven a strong impression that this biotechnology can overcome all forms of infertility, with a common belief that having a spermatozoon from a male partner (a sort of sperm donor) is all that is needed to achieve pregnancy. However, clinical practice has shown that the quality of the male gamete is important for a successful ART outcome. Furthermore, the safety of ART has been questioned because of the high prevalence of comorbidities in the offspring of ART conceptions compared to spontaneous conceptions. These issues have paved the way for more research and a greater understanding of the mechanisms of spermatogenesis and male infertility. Consequently, numerous discoveries have been made in the field of andrology, ranging from genetics to several "omics" technologies, oxidative stress and sperm DNA fragmentation, the sixth edition of the WHO manual, artificial intelligence, management of azoospermia, fertility in cancers survivors, artificial testis, 3D printing, gene engineering, stem cells therapy for spermatogenesis, and reconstructive microsurgery and seminal microbiome. Nevertheless, as many cases of male infertility remain idiopathic, further studies are required to improve the clinical management of infertile males. A multidisciplinary strategy involving both clinicians and scientists in basic, translational, and clinical research is the core principle that will allow andrology to overcome its limits and reach further goals. This state-of-the-art article aims to present a historical review of andrology, and, particularly, male infertility, from its "Middle Ages" to its "Renaissance", a golden age of andrology.

Are testicular sperms superior to ejaculated sperms in couples with previous ART failure due to high rate of fragmented embryos? A retrospective cohort study

Objective

The aim was to clarify whether using testicular sperm reduces embryo fragmentation and improves cycle outcomes.

Methods

Fragmented embryo was defined as an embryo in which fragments account for more than one third of the embryonic surface area. High rate of fragmented embryos was defined by a proportion of fragmented embryos higher than 50%. We recruited infertile couples who had undergone at least one ovarian stimulation cycle using ejaculated sperm but failed to conceive due to high rate of fragmented embryos in each previous cycle. After fully informed consent, the couples agreed to obtain testicular sperm by testicular puncture and use testicular sperm for intracytoplasmic sperm injection (ICSI). The normal fertilization rate, transferable embryo rate, fragmented embryo rate and cycle outcomes were compared between ejaculated sperm group (EJA-sperm group) and testicular sperm group (TESTI-sperm group).

Results

Twenty-two couples who agreed to participate in our study underwent 32 ICSI cycles with ejaculated spermatozoa and 23 ICSI cycles with testicular spermatozoa. Embryo transfers were cancelled in 8 ejaculated cycles and 4 testicular cycles because of no transferable embryos. There were no significant differences in age, normal fertilization rate and high-quality embryo rate between ejaculated and testicular groups. The transferable embryo rate and implantation rate in TESTI-sperm group were significantly higher than those in EJA-sperm group (36.9% vs. 22.0%, p < 0.01; 34.2% vs. 0%, p < 0.001). The fragmented embryo rate in TESTI-sperm group was significantly lower than that in EJA-sperm group (61.2% vs. 75.7%, p < 0.05).

Conclusion

Our small retrospective cohort study suggests that using testicular sperm may be a recommended option for couples with previous ART failure because of high rate of fragmented embryos. Large samples, multicenter studies or randomized controlled trial (RCT) are needed to further confirm the superiority of testicular sperm.

Family Planning and Reproductive Health in Cystic Fibrosis

Family planning in cystic fibrosis (CF) is an increasingly important aspect of care, as improvements in care and outcomes lead to a rise in the number of pregnancies and parenthood in people with CF. This article highlights: (1) Health considerations for people with CF related to pregnancy, contraception, and parenthood. (2) Facets of reproductive planning, fertility, and preconception counseling. (3) Relationship-centered reproductive health discussions.

Is testicular microdissection the only way to retrieve sperm for non-obstructive azoospermic men?

Men presenting with non-obstructive azoospermia are the most challenging clinical scenario for an infertile couple. Intracytoplasmic Sperm Injection (ICSI) with testicular sperm retrieval gave a chance for biological fatherhood once sperm can be found, but unfortunately sperm recovery rate (SSR) is something near 50%, leading to a discussion about what surgical retrieval technique is the best. Historically sperm have been retrieved using conventional Testicular Sperm Extraction (c-TESE), Testicular Sperm Aspiration (TESA), a combination of Testicular Fine Needle Aspiration (TfNA)/c-TESE, Testicular Microdissection (TM) and Open Testicular Mapping (OTEM). c-TESE published in 1995 by Devroey and cols. consists of testis delivery, a large unique albuginea incision and extraction of a portion from the majority of testicular tubules. TESA published in 1996 by Lewin and cols. is done percutaneously using a 21–23 gauge needle and a syringe to aspire testicular tubules. TfNA was published in 1965 by Obrant and Persson as an aspiration biopsy and cytological exam to verify sperm production. In 1999 Turek and cols. published the use of TfNA combined with c-TESE for sperm retrieval. In 1999, Peter Schlegel published a technique using a microsurgical approach to identify more probable sperm production areas inside the testicle that could be excised with better precision and less tissue. OTEM is a multiple biopsy approach, published in 2020 by Vieira and cols., based on TfNA principles but done at the same time without albuginea opening or surgical microscope need. Since Testicular Microdissection publication, the method became the gold standard for sperm retrieval, allowing superior SSR with minimal tissue removal, but the amount of testicular dissection to find more probable spermatogenesis areas, difficulties in comparative design studies, diversity TM results among doctors and other methods that can achieve very similar results we question TM superiority. The objective is review existing literature and discuss advantages and disadvantages of all the methods for sperm retrieval in non-obstructive azoospermia.

Clinical outcome of microsurgical vasoepididymostomy versus epididymal or testicular sperm retrieval combined with intracytoplasmic sperm injection in obstructive azoospermia males

This purpose of the retrospective study was to compare the clinical outcome of microsurgical vasoepididymostomy (MVE) and sperm retrieval combined with intracytoplasmic sperm injection (ICSI) in the treatment of males with obstructive azoospermia. From February 2018 to December 2019, a total of 69 males with obstructive azoospermia underwent MVE while 351 males with obstructive azoospermia in their first ICSI cycles were enrolled. Patients in the MVE group achieved higher pregnancy rate and births delivered rate than those in ICSI group (pregnancy rate, 44.6% vs. 27.6% for MVE and ICSI, respectively; delivery rate, 38.5% versus 25.8% for MVE and ICSI, respectively). Besides, lower female age (<35 vs. ≥35 years old, OR 1.15, 95% CI = 1.08-1.21), higher sperm concentration and forward motility after MVE((sperm concentration, OR (95% CI) = 1.12 (1.08-1.23), sperm forward motility, OR (95% CI) = 1.10 (1.06-1.20)) were associated with higher probability of pregnancy. Based on these data, it has been found that MVE is the prior option for males with obstructive azoospermia suitable for the surgery, other than direct subjected to ICSI. More high quality studies are needed in the future due to the non-randomized design and the relative small size of this study.

Recombinant gonadotropin therapy to improve spermatogenesis in nonobstructive azoospermic patients – A proof of concept study

Purpose:

Nonobstructive azoospermia (NOA) associated with primary spermatogenic failure is a common cause of male infertility usually considered untreatable; however, some reports have suggested that hormonal stimulation to boost the intra-testicular testosterone level and spermatogenesis might increase the chance of achieving pregnancy using homologous sperm.

Materials and Methods:

We report a series of eight NOA males who received long-term treatment with recombinant human chorionic gonadotropin twice a week for spermatogenesis stimulation. Six males received additional recombinant follicle-stimulating hormone (FSH) supplementation 150-225 IU twice weekly.

Results:

After recombinant gonadotropin therapy, viable spermatozoa were retrieved from the ejaculate in two patients and by testicular sperm aspiration (TESA) in another two subjects. Singleton spermatozoon retrieved from testes were frozen by vitrification on Cell-Sleeper devices. Two live births were obtained after intracytoplasmic sperm injection with ejaculated spermatozoa and one live birth and an ongoing pregnancy using thawed spermatozoa from TESA.

Conclusion:

Our proof-of-concept study indicates that hormonal therapy with recombinant gonadotropins could be considered in infertile men with NOA as an alternative to sperm donation. Large-scale studies are needed to substantiate hormone stimulation therapy with recombinant gonadotropins in routine clinical practice for this severe form of male infertility.

Recombinant gonadotropin therapy to improve spermatogenesis in nonobstructive azoospermic patients - A proof of concept study

PURPOSE

Nonobstructive azoospermia (NOA) associated with primary spermatogenic failure is a common cause of male infertility usually considered untreatable; however, some reports have suggested that hormonal stimulation to boost the intra-testicular testosterone level and spermatogenesis might increase the chance of achieving pregnancy using homologous sperm.

MATERIALS AND METHODS

We report a series of eight NOA males who received long-term treatment with recombinant human chorionic gonadotropin twice a week for spermatogenesis stimulation. Six males received additional recombinant follicle-stimulating hormone (FSH) supplementation 150-225 IU twice weekly.

RESULTS

After recombinant gonadotropin therapy, viable spermatozoa were retrieved from the ejaculate in two patients and by testicular sperm aspiration (TESA) in another two subjects. Singleton spermatozoon retrieved from testes were frozen by vitrification on Cell-Sleeper devices. Two live births were obtained after intracytoplasmic sperm injection with ejaculated spermatozoa and one live birth and an ongoing pregnancy using thawed spermatozoa from TESA.

CONCLUSION

Our proof-of-concept study indicates that hormonal therapy with recombinant gonadotropins could be considered in infertile men with NOA as an alternative to sperm donation. Large-scale studies are needed to substantiate hormone stimulation therapy with recombinant gonadotropins in routine clinical practice for this severe form of male infertility.

Success rate and ART outcome of microsurgical sperm extraction in non obstructive azoospermia: A retrospective study

Background

The management of non-obstructive azoospermia (NOA) disease relies on microdissection testicular sperm extraction (micro-TESE). Few studies have assessed the role of micro-TESE in men with NOA in our country.

Objective

The aim of the current study was to investigate the success rate of micro-TESE.

Materials and Methods

This retrospective descriptive-analytical study was conducted on 463 men with NOA in Yazd Reproductive Sciences Institute during September 2017 through September 2019. Sperm were retrieved and frozen according to the rapid sperm freezing protocol. After preparing the oocyte of the male partner's spouse, sperms were thawed and then entered the intracytoplasmic sperm injection process. The clinical pregnancy of individuals was confirmed via ultrasound. Demographic data were extracted from medical records.

Results

The success rate of micro-TESE was 38% and successful fertilization, biochemical pregnancy, clinical pregnancy, and live birth were observed in 111 (85.4%), 29 (22.3%), 29 (22.3%) and 14 (10.7%) men, respectively. A significant difference was seen between the two groups, regarding age (p = 0.01). In addition, the mean follicle-stimulating hormone in men with positive micro-TESE was significantly lower than in men with negative micro-TESE (p = 0.02).

Conclusion

The success of pregnancy in couples with NOA managed via micro-TESE was significant. The study found that the success rate of micro-TESE was higher in older men and in those with lower follicle-stimulating hormone levels.

ISAR Consensus Guidelines on Add-Ons Treatment in In vitro Fertilization

STUDY QUESTION

What are the good practices for the use of ADD-ON Treatments in IVF cycles in INDIA?

WHAT IS ALREADY KNOWN

Add on treatments in IVF are procedures and technologies which are offered to patients in hope of improving the success rates. A lot of add on treatments exist; most of them have limited evidence and data for the Indian patient population is miniscule. These interventions may have limited effects, so it is imperative that any new technology that is offered is evaluated properly and has enough evidence to suggest that it is safe and effective.

STUDY DESIGN SIZE DURATION

This is the report of a 2-day consensus meeting where two moderators were assigned to a group of experts to collate information on Add on treatments in IVF in INDIA. This meeting utilised surveys, available scientific evidence and personal laboratory experience into various presentations by experts on pre-decided specific topics.

PARTICIPANTS/MATERIALS SETTING METHODS

Expert professionals from ISAR representing clinical and embryology fields.

MAIN RESULTS AND THE ROLE OF CHANCE

The report is divided in various components including the health of the Offspring, the various ADD ons available to an ART center, consensus points for each technology & qualifications and trainings for embryologists, the report and recommendations of the expert panel reflect the discussion on each of the topics and try to lay down good practice points for labs to follow.

LIMITATIONS REASONS FOR CAUTION

The recommendations are solely based on expert opinion. Future availability of data may warrant an update of the same.

WIDER IMPLICATIONS OF THE FINDINGS

These guidelines can help labs across the country to standardise their ART services and improve clinical outcomes, it will also motivate clinics to collect data and report the use of Add ons to the national registry.

STUDY FUNDING/COMPETING INTERESTS

The consensus meeting and writing of the paper was supported by funds from CooperSurgical India.

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

Tissue and sperm handling before assisted reproductive technology (ART): A systematic review

Objective

: To explore the medical literature on techniques of tissue and sperm handling after surgical retrieval for intracytoplasmic sperm injection (ICSI).

Methods

: A search was performed in PubMed and Google Scholar databases, according to a modified Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guideline, considering the studies investigating tissue handling and sperm selection techniques for ICSI.

Results

: Overall, 42 articles were included in this study, investigating sample handling, methods for sperm selection, and the use of chemical compounds to improve sperm motility and fertilisation rates.

Conclusion

: The ideal sperm handling method should provide a high sperm count, high vitality and appropriate sperm function, without side-effects. In this review the most common and useful techniques are described and the best combination strategies discussed in clinical scenarios.

Perinatal Outcomes Using Ejaculate versus Surgical Sperm Retrieval in Patients Undergoing Intracytoplasmic Sperm Injection for Male Infertility - A Retrospective Analysis of 628 Cycles

Background:

Men with azoospermia undergoing a surgical sperm retrieval are anxious about the well-being of the baby. It is therefore important to study the perinatal outcomes in this group compared to the ejaculate sample group.

Aim:

The aim of the study was to compare the perinatal outcomes between ejaculate and surgical sperm retrieval (SSR) groups in couples undergoing intracytoplasmic sperm injection for male factor.

Study Setting and Design:

This was a retrospective cohort study conducted in a university-level infertility unit.

Materials and Methods:

It is a retrospective cohort study analysis of 628 assisted reproductive technique (ART) cycles with male factor and combined (male and female) factor infertility over a period of 5 years (January 2011–December 2015). All women who underwent a fresh embryo ART cycle were followed up. The study population included the ejaculate and SSR groups. The perinatal outcomes of these two groups were compared. The congenital anomaly risks among the two groups were also analyzed.

Statistical Analysis:

Chi-square test, Fisher's exact test and Logistic regression

Results:

A total of 628 ART cycles were included in the current study, of which 478 cycles used ejaculate sperm, while SSR was done in 150 cycles. The analysis was restricted to singletons, and the risk of preterm birth was 22.9% in the ejaculate group, 5.9% in the epididymal group, and 12% in the testicular group (epididymal vs. ejaculate odds ratio [OR], 0.21; 95% confidence interval [CI]: 0.02–1.66) (testicular vs. ejaculate OR, 0.46; 95% CI: 0.12–1.65). The risk of low birth weight was 23.7% in the ejaculate group, 11.8% in the epididymal group, and 20.0% in the testicular group (epididymal vs. ejaculate OR, 0.42; 95% CI: 0.09–1.9) (testicular vs. ejaculate OR, 0.80; 95% CI: 0.27–2.3). The incidence of congenital anomalies was 7.3% in the ejaculate group, 0 in the epididymal group, and 3.5% in the testicular group (epididymal vs. ejaculate OR, 0.28; 95% CI: 0.01–5.2) (testicular vs. ejaculate OR, 0.63; 95% CI: 0.10–3.7) which was not significantly different.

Conclusion:

The current study showed no significant differences in the risk of adverse perinatal outcomes in the ejaculate group versus the surgically retrieved sperm groups.

TESE-ICSI outcomes per couple in vasectomized males are negatively affected by time since the intervention, but not other comorbidities

RESEARCH QUESTION

Does time since vasectomy (as obstructive interval) and the presence of different male comorbidities adversely affect the likelihood of achieving a newborn for vasectomized males undergoing testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI)?

DESIGN

This retrospective study included 364 couples with vasectomized males undergoing TESE-ICSI cycles with autologous oocytes at IVI Valencia. The main outcome was live birth rate (LBR). Subjects were divided according to the male risk factor evaluated into quartiles (obstructive interval, body mass index [BMI]) or groups (hypertension, diabetes mellitus, dyslipidaemia). The reproductive outcomes were calculated per embryo transfer, per ovarian stimulation completed, and per couple.

RESULTS

The average obstructive interval was 11.3 years. The LBR was 34.4% (95% CI 30.1-38.6) per embryo transfer, 27.8% (95% CI 24.1-31.5) per ovarian stimulation and 46.2% (95% CI 41.8-51.3) per couple. When considering obstructive interval, a significantly lower LBR per couple (P = 0.04) was found in the group with the longest obstruction time: Q1 42.1% (95% CI 33.5-50.7), Q2 49.1% (95% CI 36.1-62.1), Q3 56.3% (95% CI 46.7-65.9) and Q4 37.2% (95% CI 26.5-47.9) but the cumulative live birth rate (CLBR) was not affected (P = 0.63). LBR per ovarian stimulation of males with hypertension was significantly lower (P = 0.04) than healthy males: 13.5% (95% CI 2.5-24.5) and 28.6% (95% CI 24.7-32.5), respectively. The group of diabetic vasectomized males had a significantly higher CLBR (P = 0.02). The remaining risk factors assessed (smoking, dyslipidaemia and a high BMI) did not affect LBR compared with their healthy counterparts.

CONCLUSION

Time since vasectomy appears to negatively influence the LBR when assessed per couple. The CLBR was not affected by the obstructive interval or the presence of other male comorbidities apart from diabetes, which had a significant effect.

Comparison of the Effects of Different Testicular Sperm Extraction Methods on the Embryonic Development of Azoospermic Men in Intracytoplasmic Sperm Injection (ICSI) Cycles: A Retrospective Cohort Study

Background

The effects of different testicular sperm extraction methods on the embryonic development and clinical outcome of azoospermic men in intracytoplasmic sperm injection (ICSI) cycles have not been researched. Our goal was to evaluate the effect of different sperm retrieval methods used for patients with OA or NOA on the embryonic development and clinical outcomes during the ICSI cycles.

Methods

This was a retrospective cohort study. A total of 530 azoospermic patients who underwent 570 ICSI cycles met the study criteria. ICSI was performed using testicular sperm by TESA in 282 cycles (TESA group); ICSI with testicular sperm by mTESE was performed due to NOA in 90 cycles (mTESE group); ICSI with testicular sperm by MESA was performed in 198 cycles (MESA group). The embryonic development and clinical outcomes of the three groups were counted.

Results

The general characteristics of the three groups were comparable. Our findings showed that the three groups were matched in terms of infertility durations and age. The mean age and the mean BMI of the female partners were similar in the three groups. Also, our findings showed there were no significant differences in the three groups regarding day 3 of the menstrual cycle FSH and days of stimulation. The research results showed that the total dose of FSH and E2 on the HCG administration day was also not statistically different in the three groups. The number of oocytes retrieved had no significant differences in the three groups. However, the number of 2PNs per cycle and the number of cleavages per cycle were higher in the MESA group than in the other two groups; the TESA group and mTESE group were similar. The number of good quality D3 embryos and the number of good quality D5 embryos were significantly decreased in the mTESE group as compared to the other two groups. Good quality D3 embryos and the rate of good quality D5 embryos in the mTESE group were lower than those in the other two groups. Moreover, the clinical pregnancy rates of the TESA group (50.71%) and the MESA group (51.52%) were similar, but both were much higher than that of the mTESE group (32.22%).

Conclusions

The mTESE provides a good clinical outcome for NOA patients with severe spermatogenic impairment, including the rate of good quality D3 embryos, the rate of good quality D5 embryos, and the clinical pregnancy rate. However, our data suggested that both the TESA and MESA groups had better embryonic development and clinical outcomes than the mTESE group.

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

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

Vasectomy re-reversal: effectiveness and parameters associated with its success

Introduction:

When the vasectomy reversal (VR) fails, and the patient desires natural conception with his sperm, vasectomy re-reversal (VRR) is the only alternative.

Purpose:

To determine the VRR effectiveness and whether specific parameters can be associated with its success.

Materials and Methods:

We retrospectively evaluated 18 consecutive vasectomized patients, who had failed their VR through bilateral vasovasostomy, and posteriorly were submitted to VRR. The parameters of the study were: age of the patients, elapsed time between vasectomy and VRR (V-VRRt), elapsed time between VR and VRR (VR-VRRt), presence of spermatozoa in the proximal vas deferens fluid (SptzVDF) in the VRR and results of semen analysis after VRR (SA-VRR).

Results:

The mean of the age of the patients was 44.11±6.55 years (32.0-57.0), the mean of V-VRRt was 11.76±6.46 years (1.5-25.0) and the mean of VR-VRRt was 2.13±2.27 years (0.5-10.0). SptzVDF in the VRR were found bilaterally in 8 patients, unilaterally in 4 and absent in 6. SA-VRR demonstrated normozoospermia in 9 patients, oligozoospermia in 3 and azoospermia in 6, with patency rate of 66.67%. SA-VRR showed statistically significant dependence only with SptzVDF in the VRR (p <0.01).

Conclusions:

VRR was effective in restoring the obstruction in more than half of the patients. Furthermore, the presence of spermatozoa in the vas deferens fluid was the parameter associated with the VRR success.

Intra-Cytosplamic sperm injection outcomes with fresh and cryopreserved human epidydimal sperm from patients with obstructive azoospermia

Techniques for the cryopreservation of epididymal sperm was are widely used in clinical practice. However, given the unique characteristics of sperm from patients with obstructive azoospermia, epididymal sperm cryopreservation is more difficult because of low count and weak motility; therefore, conventional methods of sperm cryopreservation may not result in the best outcomes. We used the micro-straw method to store small quantities of sperm obtained from patients with severe oligozoospermia or azoospermia and achieved successful deliveries in the previous study. This retrospective study of ICSI cycles included the first ICSI cycles of fresh or frozen/thawed epididymal sperm that were performed in patients suffering from obstructive azoospermia who were admitted to the CITIC-Xiangya Hospital of Reproduction and Genetics of China from June 1, 2015 to June 31, 2019. A total of 2441 patients with obstructive azoospermia were divided according to the use of fresh (n = 2342) or frozen/thawed (n = 99) epididymal sperm. The results showed that the fertilisation rate was higher with fresh epididymal sperm than that with frozen/thawed epididymal sperm (85.14% vs. 79.26%, respectively; p = 0.000). However, the rates of embryo cleavage, high-quality embryos, clinical pregnancy, miscarriage, singletons and birth defect were similar between fresh and frozen/thawed epididymal sperm (98.28% vs. 99.13%, 60.34% vs. 57.29%, 67.90% vs. 70.51%, 8.12% vs. 10.91%, 57.76% vs. 49.09%, 1.59% vs. 1.45%respectively; p = 0.088, 0.109, 0.628, 0.462,0.203 and 0.686). In addition, the short-term cryostorage of small quantities of epididymal sperm did not affect clinical outcomes. The results indicated that in cases of obstructive azoospermia, cryostorage of small quantities epididymal sperm is a reliable option.

Endocrine Tests and/or Testicular Volume are Not Predictive of Successful Sperm Retrieval by Conventional Multiple Testicular Sperm Extraction in Nonobstructive Azoospermia

Objectives: This study aimed to determine the role of presurgical markers in the prediction of sperm retrieval by conventional Multiple Testicular Sperm Extraction in infertile Vietnamese men with nonobstructive azoospermia (NOA).

Patients and Methods: Retrospective descriptive analysis of 136 infertile men with azoospermia, examined from August 2014 to July 2018. Patients underwent stepwise surgical sperm retrieval via percutaneous epididymal sperm aspiration, testicular sperm aspiration, then conventional multiple testicular sperm extraction in up to three locations, and procedures stopped as soon as sperm were detected. Factors were analyzed to determine the prediction of the likelihood of successful sperm retrieval, in men with NOA.

Results: The overall success rate of sperm retrieval in men with azoospermia was 49.3%, but it was only 18.4% in NOA group. The difference in testicular volume between men with successful sperm retrieval and unsuccessful sperm retrieval was not statistically significant in NOA group (5.68 ± 2.37 vs. 4.46 ± 2.83, p = 0.138). The differences in the endocrine tests between the two groups were also not significant in terms of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone (p [Formula: see text] 0.05). Multivariable analysis of predictive factors of sperm retrieval in NOA groups found no significant difference, except testicular density (p = 0.015).

Conclusions: In infertile men with NOA, neither an endocrine test nor testicular volume should be used for predicting the results of surgical sperm retrieval by conventional multiple testicular sperm extraction.

Are specialized sperm function tests clinically useful in planning assisted reproductive technology?

40-year-old male patient and 32-year-old female partner, with a history of primary infertility of two years duration. The workup revealed idiopathic mild oligoasthenotheratozoospermia, and no apparent female infertility factors. The couple has failed three intrauterine insemination (IUI) cycles, planning more IUI cycles but also considering in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI).

Intracytoplasmic sperm injection for male infertility and consequences for offspring

Intracytoplasmic sperm injection (ICSI) has become the most commonly used method of fertilization in assisted reproductive technology. The primary reasons for its popularity stem from its effectiveness, the standardization of the procedure, which means that it can easily be incorporated into the routine practice of fertility centres worldwide, and the fact that it can be used to treat virtually all forms of infertility. ICSI is the clear method of choice for overcoming untreatable severe male factor infertility, but its (over)use in other male and non-male factor infertility scenarios is not evidence-based. Despite all efforts to increase ICSI efficacy and safety through the application of advanced sperm retrieval and cryopreservation techniques, as well as methods for selecting sperm with better chromatin integrity, the overall pregnancy rates from infertile men remain suboptimal. Treating the underlying male infertility factor before ICSI seems to be a promising way to improve ICSI outcomes, but data remain limited. Information regarding the health of ICSI offspring has accumulated over the past 25 years, and there are reasons for concern as risks of congenital malformations, epigenetic disorders, chromosomal abnormalities, subfertility, cancer, delayed psychological and neurological development, and impaired cardiometabolic profile have been observed to be greater in infants born as a result of ICSI than in naturally conceived children. However, as subfertility probably influences the risk estimates, it remains to be determined to what extent the observed adverse outcomes are related to parental factors or associated with ICSI.

Use of testicular sperm for intracytoplasmic sperm injection in men with high sperm DNA fragmentation: a SWOT analysis

Spermatozoa retrieved from the testis of men with high levels of sperm DNA fragmentation (SDF) in the neat semen tend to have better DNA quality. Given the negative impact of SDF on the outcomes of Assisted Reproductive Technology (ART), an increased interest has emerged about the use of testicular sperm for intracytoplasmic sperm injection (Testi-ICSI). In this article, we used a SWOT (strengths, weaknesses, opportunities, and threats) analysis to summarize the advantages and drawbacks of this intervention. The rationale of Testi-ICSI is bypass posttesticular DNA fragmentation caused by oxidative stress during sperm transit through the epididymis. Hence, oocyte fertilization by genomically intact testicular spermatozoa may be optimized, thus increasing the chances of creating a normal embryonic genome and the likelihood of achieving a live birth, as recently demonstrated in men with high SDF. However, there is still limited evidence as regards the clinical efficacy of Testi-ICSI, thus creating opportunities for further confirmatory clinical research as well as investigation of Testi-ICSI in clinical scenarios other than high SDF. Furthermore, Testi-ICSI can be compared to other laboratory preparation methods for deselecting sperm with damaged DNA. At present, the available literature supports the use of testicular sperm when performing ICSI in infertile couples whose male partners have posttesticular SDF. Due to inherent risks of sperm retrieval, Testi-ICSI should be offered when less invasive treatments for alleviating DNA damage have failed. A call for continuous monitoring is nonetheless required concerning the health of generated offspring and the potential complications of sperm retrieval.

Ninety babies born after round spermatid injection into oocytes: survey of their development from fertilization to 2 years of age

OBJECTIVE

To compare physical and cognitive development of babies born after round spermatid injection (ROSI) with those born after natural conception.

DESIGN

Comparison of efficiencies of ROSI and ICSI using testicular spermatozoa, performed in the St. Mother Clinic. Physical and cognitive development of ROSI babies recorded by parents in the government-issued Mother-Child Handbook was checked and verified by attending pediatricians. Data included baby's weight gain and response to parents' voice/gesture.

SETTING

Assisted reproduction technology practice.

PATIENT(S)

A total of 721 men participated in ROSI; 90 ROSI babies were followed for 2 years for their physical and cognitive development. Control subjects were 1,818 naturally born babies.

INTERVENTION(S)

Surgical retrieval of spermatogenic cells from testes; selection and injection of round spermatids into oocytes; oocyte activation, in vitro culture of fertilized eggs, and embryo transfer to mothers.

MAIN OUTCOME MEASURE(S)

Physical and cognitive development of ROSI babies (e.g., body weight increase, response to parents, and understanding and speaking simple language) compared with naturally born babies.

RESULT(S)

Of 90 ROSI babies, three had congenital aberrations at birth, which corrected spontaneously (ventricular septa) or after surgery (cleft lip and omphalocele). Physical and cognitive development of ROSI babies was similar to those of naturally born babies.

CONCLUSION(S)

There were no significant differences between ROSI and naturally conceived babies in either physical or cognitive development during the first 2 years after birth.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN Clinical Trials Registry UMIN000006117.

Microdissection testicular sperm extraction: Overall results and impact of preoperative testosterone level on sperm retrieval rate in patients with nonobstructive azoospermia

Objective:

The main objective is to review the overall result and impact of preoperative testosterone level on sperm retrieval rate (SRR) by microdissection testicular sperm extraction (micro-TESE) in patients with nonobstructive azoospermia (NOA).

Materials and Methods:

We retrospectively reviewed the files of patients who underwent micro-TESE for NOA from August 2013 to December 2014. All patients were evaluated with history, physical examination, and hormonal assessment. Patients who had previous micro-TESE, obstructive azoospermia, or who took hormone therapy were excluded from the study. Patients were classified into two groups. Group A included patients who had low testosterone (<10 nmol/L), and Group B included patients with normal testosterone (>10 nmol/L). The primary endpoint was to review the overall results of the procedure and the impact of preoperative testosterone level on sperm retrieval.

Results:

A total of 264 patients with NOA underwent micro-TESE. Group A included 133 patients with low testosterone (<10 nmol/l) with a median age of 36 ± 6.59 years, and Group B included 131 patients with normal testosterone (>10 nmol/L) with a median age of 33 ± 7.88 years (P = 0.1350). There was no significant difference in follicle-stimulating hormone (P = 0.2467), luteinizing hormone (P = 0.1078), prolactin (P = 0.5619), and testicular volume (P = 0.4052), whereas a significant difference was found in testosterone level (P = 0.0001) in both groups. Overall, sperm were successfully retrieved in 48.8% of men. SRR in Group B was significantly higher (57.25%) than that in Group A (40.60%) (P = 0.0068). SRR in patients with Sertoli-cell-only pathology was 30.35%, hypospermatogenesis was 89.74%, and maturation arrest was 32.43%.

Conclusion:

Micro-TESE is a successful and safe procedure in NOA patients with a poor prognosis. Preoperative testosterone level has a significant impact in the SRR by micro-TESE.

Testicular spermatozoon is superior to ejaculated spermatozoon for intracytoplasmic sperm injection to achieve pregnancy in infertile males with high sperm DNA damage

The purpose of this study was to compare the clinical outcome of testicular spermatozoon versus ejaculated spermatozoon in the treatment of infertile males with high sperm DNA damage, referred as sperm DNA fragmentation index (DFI), that attending intracytoplasmic sperm injection (ICSI) programme in terms of clinical pregnancy, births delivered as the primary and pregnancy loss and embryo fertilisation as the secondary outcome. A total of 102 males fulfilling the inclusion criteria were enrolled in the present study. Of the 102 males, 61 infertile males underwent testicular spermatozoon combined with ICSI while the remaining 41 males applied ejaculated spermatozoa in their first ICSI cycles, and the data of them were collected and analysed. In a 18-month follow-up, testicular spermatozoon achieved higher pregnancy rate and deliver rate than those in ejaculated sperm group (pregnancy rate, 36% vs. 14.6%, p = 0.017; deliver rate, 38.5% vs. 9.8%, p = 0.001). Nevertheless, there were no significant differences in the number of oocytes aspirated and number of embryos transferred between the two groups. Additionally, the fertilisation rate in the testicular sperm study cohort (70.4%) was also similar to that in the ejaculated sperm group (75.0%). Based on the current data, we conclude that testicular spermatozoon is the prior option in the treatment of infertile males with high sperm DFI in ICSI programme. More high-quality studies with larger samples size are needed in the future due to the relative small size and the nonrandomized design of the present study.

An adapted carrier for the cryopreservation of human testicular spermatozoa

RESEARCH QUESTION

Does the adapted carrier Cryoplus improve the quality of cryopreserved spermatozoa compared with the use of conventional containers, and what is the effect of the adapted carrier on clinical outcomes?

DESIGN

Semen samples from 27 cases of oligozoospermia were used to investigate whether the adapted carrier improved cryopreserved sperm quality compared with the use of 0.25-ml straws and 2-ml cryogenic vials. Thirty testicular sperm samples were used to study the quality of testicular spermatozoa cryopreserved in the adapted carrier. The retrospective study included a further 104 men with azoospermia to investigate the clinical outcomes of testicular spermatozoa cryopreserved with the adapted carriers. Men with mostly obstructive azoospermia were included in this study.

RESULTS

The adapted carrier improved cryopreserved spermatozoa motility of semen samples compared with 2-ml cryogenic vials but not compared with 0.25-ml straws. No differences were found in cryopreserved sperm DNA fragmentation among the three carriers. Fertilization and good-quality embryo rates were similar in ICSI cycles using fresh or cryopreserved testicular spermatozoa. Additionally, no difference was evident between frozen-thawed embryo transfer cycles using fresh or cryopreserved testicular spermatozoa in clinical pregnancy, implantation, miscarriage, live birth rates or birth weight.

CONCLUSIONS

The adapted carrier improved the cryopreserved sperm motility compared with the effects of 2-ml cryogenic vials. The outcomes of intracytoplasmic sperm injection and frozen-thawed embryo transfer outcomes indicate that testicular spermatozoa cryopreserved using the adapted carrier is not inferior to fresh testicular spermatozoa. The use of the adapted carrier for cryopreserving human testicular spermatozoa especially from obstructive azoospermia is simple and effective.

A novel micro-straw for cryopreservation of small number of human spermatozoon

Cryopreservation of few spermatozoa is still a major challenge for male fertility preservation. This study reports use a new micro-straw (LSL straw) for freezing few spermatozoa for intracytoplasmic sperm injection (ICSI). Semen samples from 22 fertile donors were collected, and each semen sample was diluted and mixed with cryoprotectant in a ratio of 1:1, and then frozen using three different straws such as LSL straw (50–100 μl), traditional 0.25 ml and 0.5 ml straws. For freezing, all straws were fumigated with liquid nitrogen, with temperature directly reducing to −130–−140°C. Sperm concentration, progressive motility, morphology, acrosome integrity, and DNA fragmentation index were evaluated before and after freezing. After freezing-thawing, LSL straw group had significantly higher percentage of sperm motility than traditional 0.25 ml and 0.5 ml straw groups (38.5% vs 27.4% and 25.6%, P < 0.003). Sperm motility and acrosomal integrity after freezing-thawing were significantly lower than that of before freezing. However, there was no significant difference in morphology, acrosome, and DNA integrity between the three types of straws (P > 0.05). As LSL straws were thinner and hold very small volume, the freezing rate of LSL straw was obviously faster than 0.25 ml straw and 0.5 ml straws. In conclusion, LSL micro-straws may be useful to store few motile spermatozoa with good recovery of motility for patients undergoing ICSI treatment.

Should we expand the indications for varicocele treatment?

Current guidelines suggest that treatment of varicocele should be considered in patients with clinically palpable disease and abnormal semen parameters. However, the clinicians are often challenged with the decision whether to treat varicocele in patients with testicular pain or low testosterone levels. Moreover, varicocele is highly associated with DNA fragmentation due to the oxidative stress and it has been demonstrated that surgical repair of varicocele ameliorates oxidative stress markers and consequently the sperm DNA integrity. These new markers could have an adjunctive role to standard semen parameters especially when normal semen analysis is found in adult men with conventional methods. This review presents a contemporary overview of the rationale for varicocele treatment, as well as of the relationship between varicocele and other novel parameters such as DNA fragmentation index and reactive oxygen species. We will also discuss data from several recent series demonstrating that surgical treatment and especially microsurgical approach could resolve testicular pain, increase testosterone levels and fertility rate both in patients with non-obstructive azoospermia as well as in normozoospermia men. The correlation with progressive testicular failure will be also examined. We hope that this overview will provide clinicians with an evidence-based approach to managing these unanswered and conflicting topics.

Reproductive outcomes of testicular versus ejaculated sperm for intracytoplasmic sperm injection among men with high levels of DNA fragmentation in semen: systematic review and meta-analysis

OBJECTIVE

To compare sperm DNA fragmentation (SDF) levels between testicular and ejaculated sperm and to evaluate outcomes of intracytoplasmic sperm injection (ICSI) with the use of testicular (Testi-ICSI) versus ejaculated (Ejac-ICSI) sperm in nonazoospermic men with high SDF.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Normo- and oligozoospermic men with high levels of SDF in semen subjected to Testi-ICSI or Ejac-ICSI.

INTERVENTION(S)

Summary mean difference (MD) and odds ratio (OR) were calculated with the use of an inverse variance model and fixed- or random-effects models, respectively.

MAIN OUTCOME MEASURE(S)

Primary outcomes were SDF levels, clinical pregnancy rates (CPRs), and live birth rates (LBRs). Secondary outcomes were fertilization and miscarriage rates.

RESULT(S)

Five studies involving 143 patients provided paired SDF rates for testicular and ejaculated sperm, revealing lower SDF in testicular sperm (MD -24.58%). Four studies involving 507 cycles and 3,840 oocytes reported clinical outcomes of Testi-ICSI and Ejac-ICSI. Fertilization rates were not different between sperm sources, but a trend to lower rates was observed with Testi-ICSI. CPRs were higher for Testi-ICSI than for Ejac-ICSI, as were LBRs, whereas miscarriage rates were reduced with Testi-ICSI.

CONCLUSION(S)

Testicular sperm have lower levels of SDF than ejaculated sperm, with Testi-ICSI for high post-testicular SDF men improving reproductive outcomes compared with Ejac-ICSI. Infertile couples may benefit from Testi-ICSI if male partners have confirmed high SDF in the ejaculate.

Outcome of varicocele repair in men with nonobstructive azoospermia: systematic review and meta-analysis

The objective of this systemic review was to evaluate the benefit of repairing clinical varicocele in infertile men with nonobstructive azoospermia (NOA). The surgically obtained sperm retrieval rate (SRR) and pregnancy rates following assisted reproductive technology (ART) with the use of retrieved testicular sperm were the primary outcomes. The secondary outcomes included the presence of viable sperm in postoperative ejaculate to avoid the testicular sperm retrieval and pregnancy rates (both assisted and unassisted) using postoperative ejaculated sperm. An electronic search to collect the data was performed using the MEDLINE and EMBASE databases until April 2015. Eighteen studies were included in this systematic review and accounted for 468 patients who were diagnosed with NOA and varicocele. These patients were subjected to either surgical varicocele repair or percutaneous embolization. Three controlled studies evaluating sperm retrieval outcomes indicated that in patients who underwent varicocelectomy, SRR increased compared to those without varicocele repair (OR: 2.65; 95% CI: 1.69–4.14; P < 0.001). Although pregnancy rates with the use of testicular sperm favored the varicocelectomy group, results were not statistically significant (clinical pregnancy rate OR: 2.07; 95% CI: 0.92–4.65; P = 0.08; live birth rate OR: 2.19; 95% CI: 0.99–4.83; P = 0.05). The remaining fifteen studies reported postoperative semen analysis results. In 43.9% of the patients (range: 20.8%–55.0%), sperm were found in postoperative ejaculates. Pregnancy rates for unassisted and assisted (after IVF/ICSI) were 13.6% and 18.9% in the group of men with sperm in postoperative ejaculates, respectively. Our findings indicate that varicocelectomy in patients with NOA and clinical varicocele is associated with improved SRR. In addition, approximately 44% of the treated men will have enough sperm in the ejaculate to avoid sperm retrieval. Limited data on pregnancy outcomes with both postoperative ejaculated sperm and harvested testicular sperm preclude any firm conclusion with regard to the possible increased fertility potential in treated individuals. In conclusion, the results of our study indicate that infertile men with NOA and clinical varicocele benefit from varicocelectomy. Given the low/moderate quality of evidence available, it is advisable that doctors discuss with their patients with NOA the risks and benefits of varicocele repair.

Novel concepts in male factor infertility: clinical and laboratory perspectives

In recent years, the management of male factor infertility has undergone important changes with the introduction of novel concepts, advanced testing, and therapeutic interventions. This review highlights some of these changes and discusses their impact to routine clinical practice. First, we discuss the recent changes in the World Health Organization (WHO) laboratory methods and reference values for the examination of human semen. Second, we examine the role of sperm chromatin integrity tests in light of increasing evidence of the detrimental effect of sperm DNA fragmentation on reproductive outcomes. Third, we summarize the main findings of varicocele-related infertility and the outcomes of microsurgical varicocele repair to different case scenarios. Lastly, we critically discuss the current management of men with nonobstructive azoospermia seeking fertility and the new opportunities that emerged to help these men achieve biological fatherhood.

Transcriptome research on spermatogenic molecular drive in mammals

It is known that spermatogenic disorders are associated with genetic deficiency, although the primary mechanism is still unclear. It is difficult to demonstrate the molecular events occurring in testis, which contains germ cells at different developmental stages. However, transcriptomic methods can help us reveal the molecular drive of male gamete generation. Many transcriptomic studies have been performed on rodents by utilizing the timing of the first wave of spermatogenesis, which is not a suitable strategy for research in fertile men. With the development of separation methods for male germ cells, transcriptome research on the molecular drive of spermatogenesis in fertile men has seen great progress, and the results could be ultimately applied to improve the diagnosis and treatment for male infertility.

The safety of intracytoplasmic sperm injection in men with hepatitis B

INTRODUCTION

In this study, we aimed to evaluate the safety of using different sources of sperm when male partners were infected with hepatitis B virus (HBV).

MATERIAL AND METHODS

A total of 338 couples receiving their first intracytoplasmic sperm injection (ICSI) cycle at the Department of Reproduction, Ren Ji Hospital, between 2007 and 2012 were enrolled if the female partner tested negative for HBV DNA, HBsAg, HBeAg, HBeAb and HBcAb. Couples were divided into HBV active infection (group B), convalescent infection (group C) and controls (group A). Subgroups were divided by source of sperm: ejaculated sperm and testicular sperm aspiration/percutaneous epididymal sperm aspiration (TESA/PESA) sperm.

RESULTS

When using ejaculated sperm for ICSI, two pronuclear (2PN) fertilization rate, implantation rate, clinical pregnant rate, early miscarriage rate and live birth rate showed no significant difference between the three groups. However, in the three TESA/PESA groups, the early miscarriage rate was highest in men with active HBV infection (B2) (23.1%, p = 0.035). The 2PN fertilization rate and CPR were also lower in the active infection group (76.7%, 26.3%) than the convalescent infection (82.9%, 36.2%) and control group (78.2%, 50%), but the difference was not statistically significant. No malformed infant was found in any of these groups.

CONCLUSIONS

When men have an active HBV infection, using TESA/PESA sperm may cause lower fertilization, a high miscarriage rate and a lower live birth rate, which indicates that HBV active infection may cause adverse effects on ICSI reproductive performance when using testicular or epididymal aspirated sperm.

Pregnancy and birth after intracytoplasmic sperm injection with normal testicular spermatozoa in a patient with azoospermia and tail stump epididymal sperm

MAIN FINDINGS

An intriguing yet perplexing case report of a successful pregnancy and live birth with intracytoplasmic sperm injection using normal testicular sperm, after the finding of azoospermia in the semen analysis and discovering only tail stump abnormal sperm in the epididymis. Case hypothesis: A tail stump sperm defect of genetic origin was suspected. However, after obtaining normal testicular sperm we concluded that obstructive azoospermia, either idiopathic or secondary to multiple minor genital trauma was the plausible scenario. This has rendered the search of previous reports on a similar condition, but none was found. However, it has raised scientific thoughts for future research. Promising future implications: The importance of reporting this case is to alert urologists performing sperm retrieval that healthy and morphologically normal sperm may be found in the testis of azoospermic men with 100% tail stump epididymal sperm. Retrieval of normal testicular sperm obviates the need of a more complex investigation, including sperm electron microscopy. It also offers the possibility of utilizing such gametes for sperm injections rather than abnormal tail stump sperm that may be associated with a poor reproductive outcome.

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.