Two Decades from the Introduction of Microdissection Testicular Sperm Extraction: How This Surgical Technique Has Improved the Management of NOA

Comparative motility assessment of sperm retrieved from micro-testicular sperm extraction: A single-centre study comparing fresh and frozen-thawed sperm

INTRODUCTION

Microsurgical testicular sperm extraction (microTESE) is crucial for treating non-obstructive azoospermia (NOA), offering both 'fresh' and 'frozen' options. This study evaluates the impact of fresh versus frozen microTESE on the progression to intra-cytoplasmic sperm injection (ICSI) cycles, focusing on sperm motility.

MATERIALS AND METHODS

We conducted a retrospective analysis of microTESE procedures at a major medical centre from 2007 to 2021, excluding cases of obstructive azoospermia and cryptozoospermia. Patients were divided into two groups: fresh microTESE (Group FR) and frozen microTESE (Group FZ). Sperm motility was assessed, and ICSI outcomes were compared between groups.

RESULTS

Out of 128 microTESE procedures on 113 NOA patients, 31 were fresh and 97 were frozen. Sperm was found in 67.7% of fresh cases and 45.3% of frozen cases. In fresh cases, 85.7% had motile sperm for ICSI, whereas in frozen cases, 81.8% had motile sperm initially, but only 52.7% retained motility post-thaw.

CONCLUSIONS

Our findings indicate a significant drop in motile sperm availability for ICSI in frozen microTESE cases compared to fresh ones. This suggests a potential advantage of fresh microTESE for certain couples, despite the logistical challenges, highlighting the need for careful patient selection and counselling.

Non-invasive biomarkers for sperm retrieval in non-obstructive patients: a comprehensive review

Recent advancements in reproductive medicine have guided novel strategies for addressing male infertility, particularly in cases of non-obstructive azoospermia (NOA). Two prominent invasive interventions, namely testicular sperm extraction (TESE) and microdissection TESE (micro-TESE), have emerged as key techniques to retrieve gametes for assisted reproduction technologies (ART). Both heterogeneity and complexity of NOA pose a multifaceted challenge to clinicians, as the invasiveness of these procedures and their unpredictable success underscore the need for more precise guidance. Seminal plasma can be aptly regarded as a liquid biopsy of the male reproductive tract, encompassing secretions from the testes, epididymides, seminal vesicles, bulbourethral glands, and prostate. This fluid harbors a variety of cell-free nucleic acids, microvesicles, proteins, and metabolites intricately linked to gonadal activity. However, despite numerous investigations exploring potential biomarkers from seminal fluid, their widespread inclusion into the clinical practice remains limited. This could be partially due to the complex interplay of diverse clinical and genetic factors inherent to NOA that likely contributes to the absence of definitive biomarkers for residual spermatogenesis. It is conceivable that the integration of clinical data with biomarkers could increase the potential in predicting surgical procedure outcomes and their choice in NOA cases. This comprehensive review addresses the challenge of sperm retrieval in NOA through non-invasive biomarkers. Moreover, we delve into promising perspectives, elucidating innovative approaches grounded in multi-omics methodologies, including genomics, transcriptomics and proteomics. These cutting-edge techniques, combined with the clinical and genetics features of patients, could improve the use of biomarkers in personalized medical approaches, patient counseling, and the decision-making continuum. Finally, Artificial intelligence (AI) holds significant potential in the realm of combining biomarkers and clinical data, also in the context of identifying non-invasive biomarkers for sperm retrieval.

Frequency, morbidity and equity - the case for increased research on male fertility

Currently, most men with infertility cannot be given an aetiology, which reflects a lack of knowledge around gamete production and how it is affected by genetics and the environment. A failure to recognize the burden of male infertility and its potential as a biomarker for systemic illness exists. The absence of such knowledge results in patients generally being treated as a uniform group, for whom the strategy is to bypass the causality using medically assisted reproduction (MAR) techniques. In doing so, opportunities to prevent co-morbidity are missed and the burden of MAR is shifted to the woman. To advance understanding of men's reproductive health, longitudinal and multi-national centres for data and sample collection are essential. Such programmes must enable an integrated view of the consequences of genetics, epigenetics and environmental factors on fertility and offspring health. Definition and possible amelioration of the consequences of MAR for conceived children are needed. Inherent in this statement is the necessity to promote fertility restoration and/or use the least invasive MAR strategy available. To achieve this aim, protocols must be rigorously tested and the move towards personalized medicine encouraged. Equally, education of the public, governments and clinicians on the frequency and consequences of infertility is needed. Health options, including male contraceptives, must be expanded, and the opportunities encompassed in such investment understood. The pressing questions related to male reproductive health, spanning the spectrum of andrology are identified in the Expert Recommendation.

Male infertility with muscle weakness: a point of view

Introduction and importance

The most common causes of infertility are idiopathic spermatogenetic disorders, occurring in multiple reproductive or systemic diseases. The underlying genetic disorders influence the treatment and transmission of the disease to the offspring.

Case presentation

A 32-year-old Syrian male, married for 6 years, presented with primary infertility. The patient had a history of muscle dystrophy for 12 years. He had no previous medical or drug addiction or family history. He had gynecomastia. Semen analysis revealed oligospermia in the patient. Follicle-stimulating hormone was elevated. Gene analysis could not be done due to funding issues. The percutaneous testicular biopsy revealed hypospermatogenesis, atrophy, and marked hyalinization of the seminiferous tubules. Electromyography of the upper extremities demonstrated myotonic discharges, with a waxing-waning frequency, amplitude, and a characteristic 'engine revving' sound.

Clinical discussion

Myotonic dystrophy (MD) is an autosomal dominant inheritance disease with adult onset. Muscle weakness is the predominant presenting feature, with early involvement of the distal limbs and neck muscles and a characteristic facial appearance.Systemic clinical manifestations may include cardiac conduction defects, cataracts, insulin resistance and diabetes, testicular atrophy with impaired spermatogenesis, and others. Testicular biopsy findings are specific. To our knowledge, this is the first case of male infertility associated with MD in Syria. However, there are no data on the prevalence of myotonic dystrophy type 1 (MD1) in Syria.

Conclusion

The practicing physician should keep in mind the frequent association between MD and infertility.

A Narrative Review Discussing Vasectomy-Related Impact upon the Status of Oxidative Stress and Inflammation Biomarkers and Semen Microbiota

Background: Male contraceptive approaches besides tubal sterilization involve vasectomy and represent the method of choice among midlife men in developing countries thanks to many advantages. However, the subsidiary consequences of this intervention are insufficiently explored since the involved mechanisms may offer insight into a much more complex picture. Methods: Thus, in this manuscript, we aimed to reunite all available data by searching three separate academic database(s) (PubMed, Web of Knowledge, and Scopus) published in the past two decades by covering the interval 2000–2023 and using a predefined set of keywords and strings involving “oxidative stress” (OS), “inflammation”, and “semen microbiota” in combination with “humans”, “rats”, and “mice”. Results: By following all evidence that fits in the pre-, post-, and vasectomy reversal (VR) stages, we identified a total of n = 210 studies from which only n = 21 were finally included following two procedures of eligibility evaluation. Conclusions: The topic surrounding this intricate landscape has created debate since the current evidence is contradictory, limited, or does not exist. Starting from this consideration, we argue that further research is mandatory to decipher how a vasectomy might disturb homeostasis.

Male Infertility: A Review of Key Papers Appearing in the Reproductive Medicine and Andrology Section of the Journal of Clinical Medicine

Male infertility accounts for 30% of infertility cases and its prevalence in the general population approximately ranges between 9 and 15%, according to the available surveys [...].

The Challenges and Hopes in Treating Patients with NOA

Infertility due to the male factor occurs in no less than 50% of investigated couples [...]

Delaying testicular sperm extraction in 47,XXY Klinefelter patients does not impair the sperm retrieval rate, and AMH levels are higher when TESE is positive

STUDY QUESTION

Should testicular sperm extraction (TESE) in non-mosaic 47,XXY Klinefelter syndrome (KS) patients be performed soon after puberty or could it be delayed until adulthood?

SUMMARY ANSWER

The difference in sperm retrieval rate (SRR) in TESE was not significant between the 'Young' (15-22 years old) cohort and the 'Adult' (23-43 years old) cohort of non-mosaic KS patients recruited prospectively in parallel.

WHAT IS KNOWN ALREADY

Several studies have tried to define predictive factors for TESE outcome in non-mosaic KS patients, with very heterogeneous results. Some authors have found that age was a pejorative factor and recommended performing TESE soon after puberty. To date, no predictive factors have been unanimously recognized to guide clinicians in deciding to perform TESE in azoospermic KS patients.

STUDY DESIGN, SIZE, DURATION

Two cohorts (Young: 15-22 years old; Adult: 23-43 years old) were included prospectively in parallel. A total of 157 non-mosaic 47,XXY KS patients were included between 2010 and 2020 in the reproductive medicine department of the University Hospital of Lyon, France. However 31 patients gave up before TESE, four had cryptozoospermia and three did not have a valid hormone assessment; these were excluded from this study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data for 119 patients (61 Young and 58 Adult) were analyzed. All of these patients had clinical, hormonal and seminal evaluation before conventional TESE (c-TESE).

MAIN RESULTS AND THE ROLE OF CHANCE

The global SRR was 45.4%. SRRs were not significantly different between the two age groups: Young SRR=49.2%, Adult SRR = 41.4%; P = 0.393. Anti-Müllerian hormone (AMH) and inhibin B were significantly higher in the Young group (AMH: P = 0.001, Inhibin B: P < 0.001), and also higher in patients with a positive TESE than in those with a negative TESE (AMH: P = 0.001, Inhibin B: P = 0.036). The other factors did not differ between age groups or according to TESE outcome. AMH had a better predictive value than inhibin B. SRRs were significantly higher in the upper quartile of AMH plasma levels than in the lower quartile (or in cases with AMH plasma level below the quantification limit): 67.7% versus 28.9% in the whole population (P = 0.001), 60% versus 20% in the Young group (P = 0.025) and 71.4% versus 33.3% in the Adult group (P = 0.018).

LIMITATIONS, REASONS FOR CAUTION

c-TESE was performed in the whole study; we cannot rule out the possibility of different results if microsurgical TESE had been performed. Because of the limited sensitivity of inhibin B and AMH assays, a large number of patients had values lower than the quantification limits, preventing the definition a threshold below which negative TESE can be predicted.

WIDER IMPLICATIONS OF THE FINDINGS

In contrast to some studies, age did not appear as a pejorative factor when comparing patients 15-22 and 23-44 years of age. Improved accuracy of inhibin B and AMH assays in the future might still allow discrimination of patients with persistent foci of spermatogenesis and guide clinician decision-making and patient information.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by a grant from the French Ministry of Health D50621 (Programme Hospitalier de Recherche Clinical Régional 2008). The authors have no conflicts of interest to disclose.

TRIAL REGISTRATION NUMBER

NCT01918280.

Untoward Azoospermia by absurd testosterone therapy

The established role of the male partner in overall infertility is almost 50%.1 The most significant cause is degraded number as well as the quality of sperms.2 Spermatogenesis is governed by gonadotropin-releasing hormone (GnRH) then follicle-stimulating hormone (FSH) and finally by testosterone, which is linked with puberty, and essentially required well controlled hypothalamic-pituitary axis leading the Leydig cells along with Sertoli cells.3 In Pakistan incidence of azoospermia is 12.32%, and another study reported it to be 16%, this incidence is comparable to infertility in the USA at 10% while 11.35% in Kenya.4The non-obstructive azoospermia (NOA) is mostly treated with testicular sperm extraction and then intracytoplasmic sperm injection (ICSI), but only a small percentage can afford it, and mostly it requires multiple attempts. So, most couples end up with adaptation or sperm donation.5,6 One percent of all men and 10% of infertile are azoospermic. In non-obstructive azoospermia primary testicular failure occur, testosterone therapy (TTh) negative feedback mechanism can cause suppression of luteinizing hormone (LH).7 In 30% of infertile men, the cause cannot be established, but genetics, chronic infection, prostatitis, anti-sperm antibodies, and persistent obesity can lead to it.8Unfortunately, in Pakistan, most of our physicians are fond of prescribing a high dosage of testosterone for the long term, to infertile male patients. Patients become satisfied due to the positive characteristics of testosterone, but the most painful aspect is that high TTh leads to complete azoospermia. Moreover, in most such cases, it is permanent due to damage to the germinal layer. More than six-month high TTh is contraceptive.9 In 2018 the Endocrine Society and the American Urological Association recommend testosterone therapy to treat infertility and preserve fertility.10 The first management of such cases is the cessation of TTh. An integrated analysis of 1549 men on high TTh was reported as the median time to recover was 3.4 months, to a sperm concentration of 20 million/ mL and the median time to recover to baseline sperm concentration was 5.4 months.10 According to this analysis, 90% of men recovered in 12-month time after stopping TTh with 20 million/ml sperms, and 100% recovered after 24 months, all of them were on average 31.8 years of age. They were on TTh for 9.5 months.11 Hypothalamic-pituitary-gonadal (HPG) axis is almost terminated by testosterone replacement therapy (TRT) and anabolic androgenic steroids (AAS) resulting in very much suppressed or even the complete arrest of the spermatogenesis. Spontaneous cessation of such overwhelming male infertility treatments can recover spermatogenesis depending upon the length and strength of such treatments.12,13 The Prime concern is the weightage of the decision by a physician to start such therapies, which have an abusive role in treating infertility. Most physicians are unfortunately causing such azoospermia.Many very reputed international guidelines and recommendations are against such TTh, TRT, and even AAS for the treatment of male infertility. Clomiphene citrate (CC) and human chorionic gonadotropin (HCG) along with the revival of the hypothalamic-pituitary-gonadal axis can help to restore spermatogenesis in these men, after 1-2 years of the cessation of the TTh.14

Predictive factors of successful testicular sperm extraction for non-obstructive azoospermia with a history of bilateral cryptorchidism and normal testosterone

This study aimed to assess the predictive factors of successful sperm retrieval in non-obstructive azoospermia with a history of bilateral cryptorchidism. This retrospective study included 103 patients with azoospermia who had micro-dissection testicular sperm extraction between January 2010 and January 2020. The median (range) age of the patients and their wives in the study group was 33 (21-44) and 24 (19-33) years, respectively. The patients with low testosterone level (<3 ng/dl) were prescribed with human chorionic gonadotropin 5,000 IU injection every 3 days for 3 months. Those with persistent low testosterone even after hormonal stimulation were excluded. Sperms were retrieved from 64 (62%) patients, whilst failed in 39 (38%) patients. On univariate analysis, the median testicular volume was significantly larger in the successful group versus the failed group (p < .001), serum FSH and serum LH were significantly lower in the successful group (p = .001), serum testosterone was significantly higher in the successful group compared to the failed group (p < .001) and the age of orchidopexy was lower in the successful group versus the failed group (p = .016). On multivariate analysis, the average testicular volume and the serum testosterone levels were independent factors for successful sperm retrieval.

Technological Advancements in Male Infertility Microsurgery

There have been significant advancements in male infertility microsurgery over time, and there continues to be significant promise for new and emerging techniques, technologies, and methodologies. In this review, we discuss the history of male infertility and the evolution of microsurgery, the essential role of education and training in male infertility microsurgery, and new technologies in this space. We also review the potentially important role of artificial intelligence (AI) in male infertility and microsurgery.

Microdissection testicular sperm extraction (micro-TESE) in men with infertility due to nonobstructive azoospermia: summary of current literature

PURPOSE

Nonobstructive azoospermia (NOA) is associated with intrinsic testicular defects that severely impair sperm production. Although NOA invariably leads to infertility, focal sperm production may exist in the testicles of affected patients, which can be retrieved and used for intracytoplasmic sperm injection (ICSI) to generate healthy offspring. However, geographic locations of testicular sperm producing-areas are uncertain, making microsurgical-guided sperm retrieval (microdissection testicular sperm extraction; micro-TESE) an attractive method to identify and retrieve sperm in patients with NOA due to spermatogenic failure. Given the widespread use of micro-TESE, its effectiveness in harvesting sperm and related potential complications need to be clarified.

METHODS

We queried PubMed/MEDLINE for studies published in English, from inception to May 2021, concerning the effect of micro-TESE on sperm retrieval rate (SRR), complication rate and ICSI pregnancy rate-using retrieved testicular sperm in subfertile couples where the male had NOA.

RESULTS

We found 116 articles, including 70 original papers, 32 review articles, and 14 systematic reviews. The evidence accounted for 4895 patients. Micro-TESE retrieved sperm in 46.6% of men with NOA, but SRRs varied considerably (18.4-70.8%) and were mainly related to the treated population characteristics. Concerning the general population of NOA patients who have not undergone previous sperm retrieval (naïve population), the SRR by micro-TESE was 46.8% (1833 of 3914 patients; range 20-70.8%; 28 studies). In studies reporting SR by micro-TESE for men who had failed percutaneous testicular sperm aspiration or non-microsurgical testicular sperm extraction, the SRR was 39.1% (127 of 325 patients; range 18.4-57.1%; 4 studies). Data on adverse events indicated that micro-TESE was associated with low (~ 3%) short-term postoperative complication rates. The fertilizing ability of testicular sperm retrieved by micro-TESE and used for ICSI was adequate (~ 57%), whereas clinical pregnancy and live birth were obtained in 39% and 24% of couples who had an embryo transfer, respectively. The health of the resulting children seems reassuring, but the evidence is limited. The procedure increases sperm retrieval success compared to non-microsurgical retrieval methods, particularly in men with Sertoli cell-only testicular histopathology.

CONCLUSION

We concluded that micro-TESE is an effective and safe method to retrieve sperm from men with NOA-related infertility, with potential advantages over non-microsurgical methods. Nevertheless, high-quality, head-to-head comparative randomized controlled trials by sperm retrieval method, focusing on SRR, live birth rate and assessing long-term adverse events and health of children conceived using testicular sperm from NOA patients are lacking. Therefore, further research is required to determine the full clinical implications of micro-TESE in male infertility treatment.

Is a contralateral testicular exploration required at microdissection testicular sperm extraction for men with nonobstructive azoospermia, cryptozoospermia or severe oligozoospermia?

OBJECTIVES

Men with nonobstructive azoospermia (NOA), cryptozoospermia and severe oligozoospermia are candidates for microdissection testicular sperm extraction (micro-TESE) and intracytoplasmic sperm injection (ICSI). We sought to evaluate micro-TESE outcomes and the need for bilateral testicular exploration in the three groups of men.

METHODS

We conducted a retrospective study of 233 consecutive micro-TESEs in men with nonobstructive azoospermia (n = 173), cryptozoospermia (n = 43) and severe oligozoospermia (n = 17). The decision to terminate the micro-TESE after a unilateral or bilateral testicular exploration was determined at the time of surgery and was based on the presence or absence of mature spermatozoa in the harvested micro-biopsies. Final assessment of sperm recovery, on the day of ICSI, was reported as successful (available spermatozoon for ICSI) or unsuccessful (no spermatozoon for ICSI).

RESULTS

Unilateral testicular exploration resulted in successful sperm retrieval in 43% (75/173), 79% (34/43) and 100% (17/17) of men with NOA, cryptozoospermia and severe oligozoospermia respectively. Therefore, 57%, 21% and none of the men with NOA, cryptozoospermia and severe oligozoospermia, respectively, required a bilateral micro-TESE. Overall, micro-TESE resulted in successful sperm retrieval in 52% (90/173), 91% (39/43) and 100% (17/17) of men with NOA, cryptozoospermia and severe oligozoospermia respectively.

CONCLUSION

Our data indicate that men with severe oligozoospermia are unlikely to require a bilateral testicular exploration at micro-TESE. Moreover, most cryptozoospermic men will have a successful sperm retrieval by micro-TESE with the majority of these patients requiring a unilateral exploration. In contrast, over 50% of the men with nonobstructive azoospermia will require a bilateral micro-TESE.