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

Genetic profiling of azoospermic men to identify the etiology and predict reproductive potential

PURPOSE

To identify germline mutations related to azoospermia etiology and reproductive potential of surgically retrieved spermatozoa, and to investigate the feasibility of predicting seminiferous tubule function of nonobstructive azoospermic men by transcriptomic profiling of ejaculates.

MATERIALS AND METHODS

Sperm specimens were obtained from 30 men (38.4 ± 6 years) undergoing epididymal sperm aspiration for obstructive azoospermia (OA, n = 19) acquired by vasectomy, or testicular biopsy for nonobstructive azoospermia (NOA, n = 11). To evaluate for a correlation with azoospermia etiology, DNAseq was performed on surgically retrieved spermatozoa, and cell-free RNAseq on seminal fluid (n = 23) was performed to predict spermatogenesis in the seminiferous tubule.

RESULTS

Overall, surgically retrieved sperm aneuploidy rates were 1.7% and 1.8% among OA and NOA cohorts, respectively. OA men carried housekeeping-related gene mutations, while NOA men displayed mutations on genes involved in crucial spermiogenic functions (AP1S2, AP1G2, APOE). We categorized couples within each cohort according to ICSI clinical outcomes to investigate genetic causes that may affect reproductive potential. All OA-fertile men (n = 9) carried mutations in ZNF749 (sperm production), whereas OA-infertile men (n = 10) harbored mutations in PRB1, which is essential for DNA replication. NOA-fertile men (n = 8) carried mutations in MPIG6B (stem cell lineage differentiation), whereas NOA-infertile individuals (n = 3) harbored mutations in genes involved in spermato/spermio-genesis (ADAM29, SPATA31E1, MAK, POLG, IFT43, ATG9B) and early embryonic development (MBD5, CCAR1, PMEPA1, POLK, REC8, REPIN1, MAPRE3, ARL4C). Transcriptomic assessment of cell-free RNAs in seminal fluid from NOA men allowed the prediction of residual spermatogenic foci.

CONCLUSIONS

Sperm genome profiling provides invaluable information on azoospermia etiology and identifies gene-related mechanistic links to reproductive performance. Moreover, RNAseq assessment of seminal fluid from NOA men can help predict sperm retrieval during testicular biopsies.

A Prediction Model of Sperm Retrieval in Males with Idiopathic Non-obstructive Azoospermia for Microdissection Testicular Sperm Extraction

Patients with Idiopathic non-obstructive azoospermia (iNOA) can achieve fertility by extracting testicular sperm through microdissection testicular sperm extraction (mTESE). But more than half of iNOA patients still cannot benefit from mTESE. In recent years, some studies had reported that serum hormones may be related to the outcome of sperm retrieval, but few had been verified. We hope to obtain a predictive method that is convenient for clinical application and can help judge the outcome of sperm extraction before implementing mTESE. We performed a retrospective analysis of NOA patients who underwent mTESE in the same andrology center from June 2020 to November 2022. A total of 261 patients with complete data were collected, logistic regression analysis was performed and a predictive model was constructed. Then, from December 2022 to May 2023, one prospective cohort of 48 NOA patients who met the inclusion criteria from the same center was recruited to validate the risk prediction model. We successfully constructed a logistic regression model to predict the outcome of iNOA patients undergoing mTESE and found that higher serum anti-Müllerian hormone (AMH) levels were associated with failure sperm retrieval, resulting in an AMH cut-off of 2.60 ng/ml. The area under the receiver operating curve was 0.811, the sensitivity was 0.870, and the specificity was 0.705. Decision curve analysis demonstrated that the threshold probability was above 4%, and unnecessary mTESE could be reduced using this model. In a prospective cohort at the same center, 85.42% (41/48) of iNOA patients correctly identified the mTESE outcome using this model. A logistic regression model with AMH as an independent predictor can predict mTESE outcomes in iNOA patients. Preoperative selection of mTESE in patients with iNOA using this model had clinical benefit in reducing unnecessary surgery. The model demonstrated good accuracy in a small prospective cohort validation.

Azoospermic men with isolated elevation of follicle-stimulating hormone represent a specific subpopulation of patients with poor reproductive outcomes

Objective

This study aimed to describe a distinct subpopulation of azoospermic patients with isolated elevation of follicle-stimulating hormone (iFSH) and poor outcomes of microdissection testicular sperm extraction (microTESE).

Methods

A retrospective analysis of microTESE outcomes was conducted among 565 patients with non-obstructive azoospermia (NOA). Testicular pathology was assessed by the dominant histological pattern and Bergmann-Kliesch score (BKS). Descriptive statistics were presented for the iFSH subgroup. Inhibin B levels, the sperm retrieval rate (SRR), and BKS were compared in iFSH patients and other NOA patients.

Results

The overall SRR was 33.3% per microTESE attempt. The median BKS was 0.6 (interquartile range, 0–2). Of all NOA patients, 132 had iFSH, and microTESE was successful only in 11 of those cases, with an SRR of 8.3%, while the total SRR in other NOA patients was 38.1% (p<0.001). iFSH had a sensitivity of 32.1% (95% confidence interval [CI], 27.4%–36.8%) and specificity of 94.1% (95% CI, 90.8–97.5%) as a predictor of negative microTESE outcomes.

Conclusion

Patients with iFSH may harbor a distinct testicular phenotype with total loss of the germ cell population and poor outcomes of surgical sperm retrieval.

European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2021 Update on Male Infertility

CONTEXT

The European Association of Urology (EAU) has updated its guidelines on sexual and reproductive health for 2021.

OBJECTIVE

To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health, including advances and areas of controversy in male infertility.

EVIDENCE ACQUISITION

The panel performed a comprehensive literature review of novel data up to January 2021. The guidelines were updated and a strength rating for each recommendation was included that was based either on a systematic review of the literature or consensus opinion from the expert panel, where applicable.

EVIDENCE SYNTHESIS

The male partner in infertile couples should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors causing fertility impairment. Infertile men are at a higher risk of harbouring and developing other diseases including malignancy and cardiovascular disease and should be screened for potential modifiable risk factors, such as hypogonadism. Sperm DNA fragmentation testing has emerged as a novel biomarker that can identify infertile men and provide information on the outcomes from assisted reproductive techniques. The role of hormone stimulation therapy in hypergonadotropic hypogonadal or eugonadal patients is controversial and is not recommended outside of clinical trials. Furthermore, there is insufficient evidence to support the widespread use of other empirical treatments and surgical interventions in clinical practice (such as antioxidants and surgical sperm retrieval in men without azoospermia). There is low-quality evidence to support the routine use of testicular fine-needle mapping as an alternative diagnostic and predictive tool before testicular sperm extraction (TESE) in men with nonobstructive azoospermia (NOA), and either conventional or microdissection TESE remains the surgical modality of choice for men with NOA.

CONCLUSIONS

All infertile men should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors. Increasing data indicate that infertile men are at higher risk of cardiovascular mortality and of developing cancers and should be screened and counselled accordingly. There is low-quality evidence supporting the use of empirical treatments and interventions currently used in clinical practice; the efficacy of these therapies needs to be validated in large-scale randomised controlled trials.

PATIENT SUMMARY

Approximately 50% of infertility will be due to problems with the male partner. Therefore, all infertile men should be assessed by a specialist with the expertise to not only help optimise their fertility but also because they are at higher risk of developing cardiovascular disease and cancer long term and therefore require appropriate counselling and management. There are many treatments and interventions for male infertility that have not been validated in high-quality studies and caution should be applied to their use in routine clinical practice.

Non-obstructive azoospermia: current and future perspectives

Infertility affects 1 in 6 couples, and male factor infertility has been implicated as a cause in 50% of cases. Azoospermia is defined as the absence of spermatozoa in the ejaculate and is considered the most extreme form of male factor infertility. Historically, these men were considered sterile but, with the advent of testicular sperm extraction and assisted reproductive technologies, men with azoospermia are able to biologically father their own children. Non-obstructive azoospermia (NOA) occurs when there is an impairment to spermatogenesis. This review describes the contemporary management of NOA and discusses the role of hormone stimulation therapy, surgical and embryological factors, and novel technologies such as proteomics, genomics, and artificial intelligence systems in the diagnosis and treatment of men with NOA. Moreover, we highlight that men with NOA represent a vulnerable population with an increased risk of developing cancer and cardiovascular comorbodities.

[Peculiarity of recovery of the hypothalamic-pituitary-gonadal (hpg) axis, in men after using androgenic anabolic steroids]

BACKGROUND

Spontaneous recovery of the hypothalamic&ndash;pituitary&ndash;gonadal (HPG) axis after cessation of testosterone replacement therapy or after male contraception may take up to 24 months. There is insufficient data on the duration of recovery of HPG axis after abuse of androgenic anabolic steroids (AAS). AAS users use post-cycle therapy (PCT) to restore HPG axis, the effectiveness of which is unknown and needs further investigation.

AIMS

To evaluate the recovery of HPG axis in men, AAS users, after a 3-month of cessation of their use and after PCT.

METHODS

An observational, single-center, prospective, sampling, open, uncontrolled study was conducted among male AAS users. While using of AAS and 3 months after the refusal of their administration and PCT, the clinical symptoms of hypogonadism were evaluated, luteinizing hormone (LH), follicle-stimulating hormone (FSH), total testosterone (Tt), prolactin, estradiol, inhibin B, thyroid-stimulating hormone (TSH) were determined. The scheme of rehabilitation therapy was the same and did not change throughout the study. Recovery criteria: Tt &gt;3.4 ng/ml and LH &gt;1.24 mIU/ml. The study was conducted from January to August 2019. Fisher&rsquo;s exact test, Mann-Whitney U-test, and Spearman&rsquo;s rank correlation coefficient were used. The differences were considered statistically significant at p&lt;0.05.

RESULTS

The study included 44 men, their age 29 years [27.75; 34], the duration of the use of AAS is 6 months [3.52; 7]. During the use of AAS: LH 0.2 mIU/ml [0.04; 0.47], Tt &mdash; 4.34 ng/ml [1.05; 8.81]. In this group, the number of men with a LH level &lt;1.24 mIU / ml was 84% (n=37) and Tt &lt;3.4 ng/ml was 47.7% (n=21). After 3 months, the LH level reached 4.12 mIU/ml [2.58; 5.84], Tt &mdash; 4.55 ng/ml [3.76; 6.24]. At the same time, the level of Tt &lt;3.4 ng/ml remained in 20.5% (n=9), and LH &lt;1.24 mIU/ml in 4.5% (n=2) men. According to the level of recovery of LH and Tt, patients were divided into two groups: with satisfying (n=35; 79.5%) and poor (n=9; 20.5%) recovery. A clear correlation was established between the duration of use (-0.857; p&lt;0.0001), the amount (-0.443; p=0.003), the dose (-0.7825; p&lt;0.0001), the type of AAS (-0.698; p&lt;0.0001) and testosterone level recovery. A correlation between inhibin B and Tt (0.418; p=0.005) was revealed.

CONCLUSIONS

A three-month refusal to use AAS with PCT led to the restoration of HPG axis a in 79.5% of the volunteers. In 20.5% of cases, recovery did not occur. The negative effect of the duration of use, the number of simultaneously administered drugs, their dose and type of AAS on the restoration of HPG axis was established. The level of inhibin B may serve as a marker for the restoration of spermatogenic epithelium.