Microsurgical epididymal sperm aspiration versus epididymal micropuncture with perivascular nerve stimulation for intracytoplasmic sperm injection to treat unreconstructable obstructive azoospermia

Superior clinical pregnancy rates after microsurgical epididymal sperm aspiration

Purpose

To assess normal fertilization, clinical pregnancy, and live birth rates after the use of microscopic epididymal sperm aspiration (MESA).

Methods

One-hundred-and-sixty azoospermic participants who underwent MESA were evaluated. The MESA was performed by using a micropuncture method with a micropipette. In cases in which motile sperm were not obtained after the MESA, conventional or micro-testicular sperm extraction (TESE) was completed.

Results

Adequate motile sperm were retrieved in 71 participants by using MESA and in 59 out of 89 participants by using TESE. Of the total number of patients, 123 underwent intracytoplasmic sperm injection. After MESA, the normal fertilization rate was 73.5% and the clinical pregnancy rate per case was 95.7%. Healthy deliveries resulted after MESA in 65 (92.9%) cases and after TESE in 38 (71.7%) cases.

Conclusion

The MESA specimen collection does not have any special requirements, such as mincing tissue disposition. The MESA also can reduce the amount of laboratory work that is needed for cryopreservation. In the authors' experience, MESA is a beneficial procedure and should be given priority over TESE.

Techniques for surgical retrieval of sperm prior to intra-cytoplasmic sperm injection (ICSI) for azoospermia

BACKGROUND

Azoospermia, the absence of sperm in ejaculated semen, is the most severe form of male-factor infertility and is present in approximately 5% of all investigated infertile couples. The advent of intra-cytoplasmic sperm injection (ICSI) has transformed treatment of this type of severe male-factor infertility. Sperm can be retrieved for ICSI from either the epididymis or the testis, depending on the type of azoospermia.

OBJECTIVES

To evaluate the efficacy of the various surgical retrieval techniques for men with obstructive or non-obstructive azoospermia prior to ICSI.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (November 2007), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 4), MEDLINE (1966 to November 2007), EMBASE (1980 to November 2007), Biological Abstracts (1980 to November 2007), and reference lists of identified articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effectiveness of different sperm-retrieval techniques in men with azoospermia prior to ICSI. Due to the lack of RCTs, non-randomised trials that used the participants as their own control were also considered in the review but their results were not included in the meta-analysis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

The search was revised and re-run in November 2007. No new trials were located therefore the results of the updated review remain unchanged from those published in 2006. Two trials involving 98 men were included. The first small RCT had 59 participants and compared two epididymal techniques. The trial gave limited evidence that microsurgical epididymal sperm aspiration (MESA) achieved a significantly lower pregnancy rate (one pregnancy in 29 procedures compared with seven pregnancies in 30 procedures; OR 0.19, 95% CI 0.04 to 0.83) and fertilisation rate (OR 0.16, 95% CI 0.05 to 0.48) than the micropuncture with perivascular nerve stimulation technique. The other RCT comparing two testicular aspiration techniques (TSA) in 39 participants gave no statistically significant evidence for the superiority of the ultrasound-guided technique compared to the aspiration technique without ultrasound. TSA with ultrasound resulted in pregnancy in three out of 16 participants compared with four out of 23 participants (OR 1.10, 95% CI 0.21 to 5.74).

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend any specific sperm retrieval technique for azoospermic men undergoing ICSI. In the absence of evidence to support more invasive or more technically difficult methods, the review authors recommend the least invasive and simplest technique available. Further randomised trials are warranted, preferably multi-centred trials. The classification of azoospermia as obstructive and non-obstructive appears to be relevant to a successful clinical outcome and a distinction according to the cause of azoospermia is important for future clinical trials.

Techniques for surgical retrieval of sperm prior to ICSI for azoospermia

BACKGROUND

Azoospermia, the absence of sperm in ejaculated semen, is the most severe form of male factor infertility and is present in approximately 5% of all investigated infertile couples. The advent of intra-cytoplasmic sperm injection (ICSI), however, has transformed treatment of this type of severe male factor infertility. Sperm can be retrieved for ICSI from either the epididymis or the testis depending on the type of azoospermia.

OBJECTIVES

To evaluate the efficacy of the various surgical retrieval techniques for men with obstructive or non obstructive azoospermia prior to ICSI.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched 12 Jan 2005), Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2004), MEDLINE (1966 to Nov 2004), EMBASE (1980 to Dec 2004), and Biological Abstracts (1980 to Nov 2004) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effectiveness of sperm retrieval techniques in men with azoospermia prior to ICSI. Due to the lack of RCTs, non-randomised trials that used the participants as their own control, were also considered in the review but not included in the meta-analysis.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Two trials involving 98 men were included. The first small RCT had 59 participants and compared two epididymal techniques. The trial gave limited evidence that microsurgical epididymal sperm aspiration (MESA) achieved significantly lower pregnancy (One pregnancy in 29 procedures compared with seven pregnancies in 30 procedures, OR 0.19, 95% CI 0.04 to 0.83) and fertilisation rates (OR 0.16, 95% CI 0.05 to 0.48) than the micropuncture with perivascular nerve stimulation technique. The other RCT comparing two testicular techniques in 39 participants gave no statistically significant evidence about the superiority of the ultrasound guided aspiration technique compared to the aspiration technique without ultrasound guidance. TSA with ultrasound resulted in pregnancy in 3 out of 16 participants and TSA without ultrasound in four pregnancies with 23 participants (OR 1.10, 95% CI 0.21 to 5.74)

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend any specific sperm retrieval technique for azoospermic men undergoing ICSI. In the absence of evidence to support more invasive or more technically difficult methods the reviewers recommend the least invasive and simplest technique available. Further randomised trials are warranted, preferably multi-centred trials. The classification of azoospermia as obstructive and non-obstructive appears to be relevant to a successful clinical outcome so a distinction according to the cause azoospermia is important for future clinical trials.

Evidence of improving quality of reporting of randomized controlled trials in subfertility

BACKGROUND

The quality of randomized controlled trials (RCTs) in subfertility and their suitability for inclusion in meta-analyses have been assessed in the past and found to be insufficient. Our aim was to assess whether this quality has improved over time, particularly since the publication of the Consolidated Standards of Reporting Trials (CONSORT) statement, and to assess what proportion of trials could be included in the meta-analyses of pregnancy outcomes such as those included in Cochrane Reviews.

METHODS

A selection of subfertility trials published in 1990, 1996 and 2002 was collected from the Cochrane Menstrual Disorder and Subfertility Group (MDSG) database. Only trials published in English as full journal articles, claiming to be randomized and reporting on pregnancy outcomes, were included.

RESULTS

One hundred and sixty-four trials met our inclusion criteria. Twenty-four (15%) were found not to be randomized, despite claims, and only 10 trials (6%) provided adequate details on the methods of randomization and allocation concealment. Of these, only three had sufficient details extractable to allow for an intention-to-treat analysis of the outcome 'live birth'.

CONCLUSIONS

Although an improvement in some subfertility-specific issues was observed, the quality of reporting of RCTs still needs to improve to make them suitable for inclusion in meta-analyses such as those in the Cochrane Library.

Genetic abnormalities and male infertility. A comprehensive review

The development of assisted reproductive technologies, such as intracytoplasmic sperm injection (ICSI) substantially improved the outlook for patients with severe male fertility problems. However this implies that for the first time genetic defects associated with male in- or subfertility might be transmitted to offspring and result in genetic disease [de Kretser DM, The potential of intracytoplasmic sperm injection (ICSI) to transmit genetic defects causing male infertility. Reprod. Fertil. Dev. 1995;7:137-142]. The knowledge of male specific fertility genes on the Y chromosome increased enormously in the last decade. The SRY gene plays a critical role in gonadal differentiation. DAZ, SPGY and related genes on the Y chromosome are very important for spermatogenesis. Interstitial Y-chromosomal microdeletions encompassing the AZFa, b or c region have become an additional class of genetic abnormalities causing male infertility. A review is given of the different genetic aspects of male infertility.