Testicular fine-needle aspiration versus testicular open biopsy: Comparable sperm retrieval rate in selected patients

Spermatozoa retrieval in azoospermia and expression profile of JMJD1A, TNP2, and PRM2 in a subset of the Karachi population

BACKGROUND

The difficulties encountered in surgical spermatozoa retrieval for intracytoplasmic sperm injection procedure in azoospermic men have stressed the dire need for a robust biomarker for the prediction of spermatozoa retrieval. Data have highlighted the role of JMJD1A (Jumonji domain-containing 1A), a histone H3K9 demethylase, and other nuclear proteins, protamines (PRM) and transition nuclear proteins (TNP), as biomarkers in male infertility.

OBJECTIVE

To access successful spermatozoa retrieval at the time of intracytoplasmic sperm injection by evaluating the mRNA expression profile of JMJD1A, TNP, and PRM in testicular tissue.

MATERIALS/METHODS

About 100 azoospermic patients, who visited the Australian Concept Infertility Medical Center, Karachi for spermatozoa retrieval by testicular sperm extraction or microsurgical testicular sperm extraction participated in the study. mRNA expression of the JMJD1A, TNP1, TNP2, PRM1, and PRM2 genes was determined. Patients were categorized into successful spermatozoa retrieval (n = 42) group and unsuccessful spermatozoa retrieval (n = 58) group.

RESULTS

Azoospermic men in successful spermatozoa retrieval had significantly increased expression of JMJD1A, TNP2, and PRM2. The hormonal parameters - follicle-stimulating hormone, luteinizing hormone, and thyroid-stimulating hormone were significantly higher in unsuccessful spermatozoa retrieval. Multivariate analysis showed a significant association between JMJD1A, TNP2, PRM2, and successful spermatozoa retrieval. The area under the receiver operating characteristics curve showed a significant discriminatory ability to predict the spermatozoa retrieval outcome in azoospermic patients for mRNA expression of JMJD1A, TNP2, and PRM2 was 71, 72, and 73%, respectively. The area under the curve for follicle-stimulating hormone, luteinizing hormone, and thyroid-stimulating hormone was 0.67, 0.81, and 0.65, respectively.

DISCUSSION

Our study demonstrates that the mRNA expression profile of JMJD1A, TNP2, and PRM2 along with hormonal parameters, is a useful marker to assess the probability of spermatozoa retrieval before intracytoplasmic sperm injection intervention.

CONCLUSION

The probability of spermatozoa retrieval in azoospermic patients is increased when the mRNA expression profile of JMJD1A, TNP2, and PRM2 in testicular tissue is increased.

Follicle-stimulating hormone may predict sperm retrieval rate and guide surgical approach in patients with non-obstructive azoospermia

Testicular sperm aspiration- (TESA) or micro-dissection testicular sperm extraction- (MD-TESE) combined intracytoplasmic sperm injection (ICSI) was the only option for non-obstructive azoospermia (NOA) patients to have a biological offspring and they had different success rates in sperm retrieval. Our study aimed to find predictor(s) for predicting the sperm retrieval rate (SRR) in NOAs and guide clinicians in choosing different surgical approaches, TESA or MD-TESE for NOAs. 294 NOAs who had undergone TESA or MD-TESE were divided into TESA group and MD-TESE group. Depending on sperm retrieval, each group was divided into two subgroups: successful subgroups and failure subgroups. They respectively were 24 cases and 131 cases, 53 cases and 86 cases. Clinical data, including body mass index (BMI), testicular volume, and serum hormone levels, were analyzed in a retrospective manner. The results showed that follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels and SRR were lower in TESA group as compared to these in MD-TESE group, while testicular volume was higher (P < 0.05). The surgical approach of sperm retrieval significantly affected the SRR (P < 0.05). In TESA subgroups, testicular volume, FSH and LH differed significantly (P < 0.05). In MD-TESE subgroups, the level of FSH and LH differed significantly between both groups (P < 0.05). Using logistics regression, we found a negative correlation (β=-0.083) between FSH and the SRR in TESA group but a positive correlation (β = 0.064) in MD-TESE group (P < 0.05). In conclusion, serum FSH level can predict the SRR of NOAs and guide the clinicians while selecting the suitable surgery approach for NOAs.

Sperm recovery and ICSI outcomes in men with non-obstructive azoospermia: a systematic review and meta-analysis

BACKGROUND

Factor affecting sperm retrieval rate (SRR) or pregnancy rates (PR) after testicular sperm extraction (TESE) in patients with non-obstructive azoospermia (NOA) have not been systematically evaluated. In addition, although micro-TESE (mTESE) has been advocated as the gold standard for sperm retrieval in men with NOA, its superiority over conventional TESE (cTESE) remains conflicting.

OBJECTIVE AND RATIONALE

The objective was to perform a meta-analysis of the currently available studies comparing the techniques of sperm retrieval and to identify clinical and biochemical factors predicting SRR in men with NOA. In addition, PRs and live birth rates (LBRs), as derived from subjects with NOA post-ICSI, were also analysed as secondary outcomes.

SEARCH METHODS

An extensive Medline, Embase and Cochrane search was performed. All trials reporting SRR derived from cTESE or mTESE in patients with NOA and their specific determinants were included. Data derived from genetic causes of NOA or testicular sperm aspiration were excluded.

OUTCOMES

Out of 1236 studies, 117 studies met the inclusion criteria for this study, enrolling 21 404 patients with a mean age (± SD) of 35.0 ± 2.7 years. cTESE and mTESE were used in 56 and 43 studies, respectively. In addition, 10 studies used a mixed approach and 8 studies compared cTESE with mTESE approach. Overall, a SRR per TESE procedure of 47[45;49]% (mean percentage [95% CI]) was found. No differences were observed when mTESE was compared to cTESE (46[43;49]% for cTESE versus 46[42;49]% for mTESE). Meta-regression analysis demonstrated that SRR per cycle was independent of age and hormonal parameters at enrolment. However, the SRR increased as a function of testis volume. In particular, by applying ROC curve analysis, a mean testis volume higher than 12.5 ml predicted SRR >60% with an accuracy of 86.2% ± 0.01. In addition, SRR decreased as a function of the number of Klinefelter's syndrome cases included (S = -0.02[-0.04;-0.01]; P < 0.01. I = 0.12[-0.05;0.29]; P = 0.16). Information on fertility outcomes after ICSI was available in 42 studies. Overall, a total of 1096 biochemical pregnancies were reported (cumulative PR = 29[25;32]% per ICSI cycle). A similar rate was observed when LBR was analysed (569 live births with a cumulative LBR = 24[20;28]% per ICSI cycle). No influence of male and female age, mean testis volume or hormonal parameters on both PR and LBR per ICSI cycle was observed. Finally, a higher PR per ICSI cycle was observed when the use of fresh sperm was compared to cryopreserved sperm (PR = 35[30;40]%, versus 20[13;29]% respectively): however, this result was not confirmed when cumulative LBR per ICSI cycle was analysed (LBR = 30[20;41]% for fresh versus 20[12;31]% for cryopreserved sperm).

WIDER IMPLICATIONS

This analysis shows that cTESE/mTESE in subjects with NOA results in SRRs of up to 50%, with no differences when cTESE was compared to mTESE. Retrieved sperms resulted in a LBR of up to 28% ICSI cycle. Although no difference between techniques was found, to conclusively clarify if one technique is superior to the other, there is a need for a sufficiently powered and well-designed randomized controlled trial to compare mTESE to cTESE in men with NOA.

Testicular Fine-Needle Aspiration for Sperm Retrieval in Azoospermia: A Small Step toward the Technical Standardization

PURPOSE

The aim was to describe our preliminary experience performing testicular fine-needle aspiration (TEFNA) with a larger needle in infertile patients with obstructive azoospermia, and to provide a systematic literature review of the different testicular sperm aspiration techniques, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations.

MATERIALS AND METHODS

We prospectively collected data between March 2017 and June 2018. All men underwent bilateral TEFNA under analgo-sedation, using a larger disposable 18-gauge butterfly needle with 60 mL Luer-Lock syringe attached to it.

RESULTS

Thirty consecutive patients were enrolled. Median operative time was 16 minutes (interquartile range [IQR]: 12-30 minutes). No intraoperative complications occurred. Two/thirty patients (6.7%) reported postoperative adverse events: 1 patient had prolonged orchialgia, 1 patient presented scrotal hematoma. Successful sperm retrieval was found in 28/30 cases (93.3%). Median sperm concentration was 0.05 ×10⁶/mL (IQR: 0.001-0.1 ×10⁶/mL). Median total sperm motility was 10% (IQR: 0%-15%). In 20/30 men (66.7%) sperm retrieved was used for fresh intracytoplasmic sperm injection cycle, in 8/30 (26.7%) sperm cryopreservation was necessary, because on the day of sperm retrieval the female resulted not responder to ovarian stimulation. In this cases mean number of 3 (IQR: 1-4) bio system straws was cryopreserved.

CONCLUSIONS

TEFNA with 18-gauge needle proved to be a feasible, safe and effective treatment, even if future prospective studies will be addressed to clarify what type of azoospermia benefits from this procedure, and if a larger needle permits to improve Assisted Reproductive Technologies (ART) outcomes.

DNA Flow cytometric analysis of the human testicular tissues to investigate the status of spermatogenesis in azoospermic patients

A single, rapid and reproducible diagnostic test to predict the type of azoospermia and outcome of sperm retrieval is not yet available. So the feasibility of employing DNA flow cytometry for rapid investigation of the status of spermatogenesis in the patients with azoospermia was investigated. Testicular biopsies of 44 patients with azoospermia undergoing sperm-retrieval surgery and 4 controls were analyzed by flow cytometry to ascertain their testicular germ-cell patterns. The observed germ-cell pattern was further confirmed by RT-PCR analysis of the cell-specific markers and histology for some patients. The patients with Obstructive Azoospermia (OA) exhibited normal spermatogenesis similar to the control fertile patients showing the presence of diploid, double-diploid and haploid cells. The non-obstructive azoospermia (NOA) patients exhibited disrupted spermatogenesis with arrest at the pre-meiotic (only diploid cells present) or meiotic (diploid and double-diploid cells present) stages. The germ-cell pattern, as ascertained by flow cytometry, provided a clear picture of the intra-testicular spermatogenesis and the presence of spermatozoa in the patients’ testes, which was prognostic of their sperm-retrieval. DNA flow cytometry test to ascertain the testicular germ-cell pattern is simple in execution, analysis and interpretation, requires small amount of tissue and provides quantitative data about the status of spermatogenesis in patients. This test would allow comparable analysis of the status of spermatogenesis in patients across clinics and may form the basis for deciding future treatment and intervention strategies.

Scrotal hemorrhage after testicular sperm aspiration may be associated with phosphodiesterase-5 inhibitor administration: a retrospective study

Background

Scrotal hemorrhage after testicular sperm aspiration (TESA) is uncommon in clinical operation. Phosphodiesterase-5 inhibitors (PDE5i) are commonly given to men who have difficulty providing a sperm sample for assisted reproductive technique such as in vitro fertilization. In this study, we examine the incidence of scrotal hemorrhage after TESA in men who received a PDE5i.

Methods

In this retrospective study, 504 men with TESA operation in Center for Reproductive Medicine, Nanfang Hospital, Southern Medical University were collected. Men in the drug group had taken orally PDE5i before TESA. Men in the control group only operated TESA. The testis volume, coagulation function were measured. Sonographic examination with Doppler imaging was performed when scrotal hemorrhage appeared.

Results

A total of 504 men with a mean age of 28.63 ± 4.22 years were included in the analysis. Of these, 428 did not receive a PDE5i prior to TESA and 76 received a PDE5i prior to TESA. Measures of coagulation function were not different between the groups. The incidence of hemorrhage was 0.0% in the control group and the drug group was 5.3%. The incidence of hemorrhage between two groups was different significantly (P = 0.000).

Conclusion

In summary, the results of this study suggest that a PDE5i administration increases the risk of scrotal hemorrhage in men undergoing TESA, although the study design does not allow drawing a conclusion of cause and effect. Given the potential risk of scrotal hemorrhage after the ingestion of PDE5i, it may be wise not to administer it to men in whom a TESA may be performed.

Treatment for Vas Deferens Obstruction Following Childhood Herniorrhaphy

OBJECTIVE

To enhance the management of inguinal obstruction, and to present the procedures and results of our surgical strategy for vas deferens obstruction following childhood herniorrhaphy.

METHODS

We treated a total of 56 patients diagnosed with obstructive azoospermia following bilateral inguinal herniorrhaphy. First, conventional inguinal open surgery was performed. If the abdominal vas was not identified in the inguinal region, laparoscopy was used to retrieve the deeper abdominal vas deferens, which was obstructed above the internal inguinal ring. Then, microsurgical vasovasostomy (VV) was performed. Overall patency and natural pregnancy rates were determined.

RESULTS

We terminated the surgery in 16 patients with pasty vasal fluid and no sperm. When bilateral remnants of the vas deferens were found, laparoscopic mobilization was not required, and 22 (55.0%) patients underwent bilateral VV with patency and natural pregnancy rates of 90.9% (20 of 22) and 50.0% (11 of 22), respectively. When a unilateral end could not be found, 7 (17.5%) patients underwent unilateral laparoscopy-assisted VV plus unilateral VV, with patency and natural pregnancy rates of 85.7% (6 of 7) and 42.9% (3 of 7), respectively. When bilateral ends were not found, 11 (27.5%) patients underwent bilateral laparoscopy-assisted VV, with patency and natural pregnancy rates of 81.8% (9 of 11) and 27.3% (3 of 11), respectively. Overall, our surgery yielded a patency rate of 87.5% (35 of 40) and a natural pregnancy rate of 42.5% (17 of 40).

CONCLUSION

Our treatment for vas deferens obstruction following childhood herniorrhaphy yielded good postoperative outcomes in terms of sperm concentration and motility, vas patency, and natural pregnancy, with no complications.

Comparison of microdissection testicular sperm extraction, conventional testicular sperm extraction, and testicular sperm aspiration for nonobstructive azoospermia: a systematic review and meta-analysis

OBJECTIVE

To investigate the relative differences in outcomes among microdissection testicular sperm extraction (micro-TESE), conventional testicular sperm extraction (cTESE), and testicular sperm aspiration (TESA) in men with nonobstructive azoospermia.

DESIGN

Systematic review and meta-analysis.

SETTING

Outpatient academic and private urology clinics.

PATIENTS(S)

Men with nonobstructive azoospermia.

INTERVENTION(S)

Micro-TESE, cTESE, or TESA.

MAIN OUTCOME MEASURE(S)

Sperm retrieval (SR).

RESULT(S)

Fifteen studies with a total of 1,890 patients were identified. The weighted average age of the patients was 34.4 years, the follicular stimulating hormone level was 20.5 mIU/mL, the T was 373 ng/dL, and the testicular volume was 13.5 mL. In a direct comparison, performance of micro-TESE was 1.5 times more likely (95% confidence interval 1.4-1.6) to result in successful SR as compared with cTESE. Similarly, in a direct comparison, performance of cTESE was 2.0 times more likely (95% confidence interval 1.8-2.2) to result in successful SR as compared with TESA. Because of inconsistent reporting, evaluation of other procedural characteristics and pregnancy outcomes was not possible.

CONCLUSION(S)

Sperm retrieval was higher for micro-TESE compared with cTESE and for cTESE compared with TESA. Standardization of reported outcomes as well as combining all available SR data would help to further elucidate the SRs of these procedures.

Salvage micro-dissection testicular sperm extraction; outcome in men with non-obstructive azoospermia with previous failed sperm retrievals

OBJECTIVE

To assess the outcome of micro-dissection testicular exploration sperm extraction (m-TESE) as a salvage treatment in men with non-obstructive azoospermia (NOA) in whom no sperm was previously found on single/multiple TESE or testicular sperm aspiration (TESA).

PATIENTS AND METHODS

In all, 58 men with NOA underwent m-TESE. All the patients had previously undergone either single/multiple TESE or TESA with no sperm found. All the patients underwent an m-TESE using a standard technique. Serum follicle-stimulating hormone (FSH), testosterone and histopathological diagnosis were examined as predictive factors for sperm recovery. All patients underwent preoperative genetic screening. One patient was found to have an azoospermic factor c (AZFc) micro-deletion and five were diagnosed with Kleinfelter's syndrome.

RESULTS

The mean (range) patient age was 39.0 (26-57) years. Spermatozoa were successfully retrieved in 27 men by m-TESE (46.5%). The mean (range) FSH level was 19.4 (1.6-58.5) IU/L. There was no correlation in age (mean age retrieved 38.1 years, not retrieved 39.7 years, P = 0.38), FSH levels (mean FSH retrieved 21.4 IU/L, not retrieved 17.7 IU/L, P = 0.3) and the ability to find sperm by m-TESE. However, there was a significant difference in testosterone levels and sperm retrieval (mean testosterone retrieved 14.99 nmol/L, not retrieved 11.39 nmol/L, P < 0.05). Patients with a diagnosis of Sertoli-cell-only (SCO) syndrome [14/35 (40%)] and maturation arrest [four of 11 (36%)] had lower sperm retrieval rates than those in the hypospermatogenesis group [nine of 12 (75.0%)] (P < 0.05). There were no significant complications after m-TESE.

CONCLUSIONS

In men with NOA who have undergone previous attempts at sperm retrieval with negative results, a salvage m-TESE offers a significant chance of finding sperm even in SCO syndrome. There does seem to be a correlation between preoperative testosterone levels and the ability to successfully find sperm.