Testicular Biopsy Histopathology as an Indicator of Successful Restoration of Spermatogenesis after Varicocelectomy in Non-obstructive Azoospermia

Testicular arterial blood flow volume in predicting semen improvement following microscopic subinguinal varicocelectomy

Background

Varicocele is a significant but treatable contributor to male infertility. The efficacy of varicocelectomy in improving sperm quality is not consistent, with only 60-80% of patients experiencing improved semen quality. This prospective cohort study aimed to evaluate the effect of microscopic subinguinal varicocelectomy (MSV) on testicular arterial blood flow volume (TABFV) and to determine the value of preoperative TABFV in predicting the outcome of MSV.

Methods

Patients with varicocele who underwent MSV at the same clinical center between July 2020 and April 2023 were enrolled. All patients underwent ultrasound assessment and at least one semen analysis before and after MSV. Both univariate and multivariate logistic regression analyses were performed to assess the association between pre-MSV variables and semen improvement after MSV. Subsequently, a diagnostic model was developed.

Results

This study enrolled 96 patients with varicocele, including 31 who showed semen improvement after MSV and 65 who did not. The postoperative semen-improved group demonstrated a significant increase in TABFV of the right testis (TABFV-R) and left testis (TABFV-L) (P<0.001). Notably, the postoperative TABFV-L was more than twice the preoperative TABFV-L. Preoperative TABFV-R and a combination of subclinical right-sided varicocele were found to be associated with semen improvement after MSV, and a diagnostic model was developed using these two variables. The diagnostic model exhibited satisfactory performance, with an area under the curve (AUC) of 0.824 [95% confidence interval (CI): 0.735-0.913], which was further validated internally yielding an AUC of 0.824 (95% CI: 0.726-0.900). Additionally, calibration analysis confirmed that the diagnostic model was well calibrated, and the Hosmer-Lemeshow test resulted in a P value of 0.794. The decision curve demonstrated that using this proposed nomogram would yield a net benefit if the threshold probability for semen improvement after MSV exceeded 10%.

Conclusions

TABFV-L demonstrated potential utility in clinical practice for assessing outcomes of MSV, and the diagnostic model incorporating TABFV-R and a combination of right-side varicocele performed well in predicting improvements in semen parameters following MSV.

Varicocele and nonobstructive azoospermia

Approximately 15% of men in the general population have varicoceles, and varicoceles are diagnosed in 40% of men presenting for fertility evaluations. One percent of men in the general population are azoospermic, and 15% of men presenting for fertility evaluations are diagnosed with azoospermia. This article aims to review the impact of varicoceles on testicular function in men with azoospermia, the impact of varicocele repair on the semen parameters of azoospermic men, and the impact of varicocele repair on sperm retrieval and pregnancy outcomes when the male partner remains azoospermic after varicocele repair.

Role of varicocele repair in the era of assisted reproductive technologies: Lessons from 2000 cases of microsurgical varicocele repair

Backgrounds

In an era of advanced maternal age, there is less conclusive evidence regarding the treatment outcomes of varicocele repair for assisted reproductive technology (ART). Progress in basic research on varicocele is notable whereas there are many clinically relevant points to discuss.

Methods

Based on our experience with more than 2000 cases of microsurgical varicocele repair, we focused on the effectiveness of varicocele repair, pathophysiology, surgical approaches, contributions to ART, sperm DNA fragmentation, and varicocele-associated azoospermia in this review with the aim of identifying clearer directions for basic and clinical research on varicocele.

Results

Microsurgical low ligation for varicocele repair is expected to remain the gold standard for surgical therapy. Based on the findings from a number of systematic reviews and meta-analyses, negative opinions regarding the efficacy of microsurgical varicocele repair in male infertility treatment have become virtually nonexistent. However, the majority of evidence regarding surgical indications and effectiveness pertains to improvements in semen parameters or non-ART pregnancy rates.

Conclusions

Further understandings regarding to pathophysiology of varicocele will likely be gained through comprehensive genetic, transcriptomic, and epigenetic analyses using blood and testicular samples from humans and we hope to develop new diagnostic methods and pharmacotherapy.

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.

Varicoceles in Men With Non-obstructive Azoospermia: The Dilemma to Operate or Not

The knowledge on male reproduction is constantly expanding, especially in treating infertility due to non-obstructive azoospermia (NOA). Varicocele is occasionally diagnosed in a subpopulation of males with NOA. Varicocele repair in NOA-men may contribute to the reappearance of spermatozoa in semen. However, spontaneous pregnancies are observed in only a small percentage of NOA-men post-varicocelectomy. Additionally, it has been reported that the repair of varicocele in NOA-men (before the performance of sperm retrieval techniques) may increase the testicular sperm recovery rate. In addition, it increases the pregnancy rate in intracytoplasmic sperm injection (ICSI) programs in NOA-men without spermatozoa in the semen post-varicocelectomy. In addition, to the improvement in Sertoli cellular secretory function, varicocelectomy may increase the secretory function of Leydig cells, which subsequently results in improved androgen production, raising the probability to negate the need for testosterone replacement therapy in cases of late-onset hypogonadism. On the other hand, the benefit of varicocelectomy in patients with NOA is still debatable. The current review study aims to provide a critical and extensive review of varicocele repair in males with NOA. This study additionally focuses on the impact of varicocele repair on sperm retrieval rates and its influence on the ICSI outcomes for those couples who remain negative for spermatozoa in their semen samples post-varicocelectomy.

Varicocele treatment in non-obstructive azoospermia: a systematic review

Objective: To review the available literature and identify factors associated with successful outcomes after varicocele repair (VR) in the setting of non-obstructive azoospermia (NOA). Methods: The PubMed and EMBASE databases were searched for relevant articles. Primary outcomes were return of spontaneous spermatogenesis, sperm retrieval rates (SRRs), and unassisted and assisted pregnancy rates. Histopathological subtypes, when available, were used for subgroup analysis. Results: A total of 16 articles were finally included. The average sample size was 43 and average duration of follow-up was 10.5 months. The average rate of primary spermatogenesis after VR was 27.3%. The average SRR, across five studies in men with NOA undergoing microscopic testicular sperm extraction status after varicocelectomy, was 48.9% vs 32.1% for the untreated cohort groups, and the average spontaneous pregnancy rate was 5.24%. Histopathology subtype was a significant contributing factor when analysed. Conclusion: Varicocele repair should be considered in men with NOA, as it may allow some patients to avoid assisted reproductive technologies and improves success rates when utilised.

"Second-look" Micro Testicular Sperm Extraction (MicroTESE) in Patients with Non-obstructive Azoospermia Following Histopathological Analysis

Introduction:

Microdissection testicular sperm extraction (microTESE) is considered the gold standard method for surgical sperm retrieval among patients with non-obstructive azoospermia (NOA).

Aim:

This study aimed to evaluate the correlation between histopathological findings after failed microTESE procedure and outcomes of the „second-look“ procedure and to provide insight into the most common histopathological patterns after testicular biopsy within our population.

Methods:

The retrospective study included 33 selected patients with NOA, who had undergone unsuccessful sperm retrieval. The diagnosis of NOA was made after the assessment of the patient’s history data, a physical examination, semen analysis, the hormonal profile, and genetic studies. After negative sperm retrieval, histopathological report has been analyzed for „second-look“ microTESE attempt.

Results:

Five testicular histopathological patterns were found: hypospermatogenesis (9,1%), Sertoli cell-only syndrome (43%), germ cell maturation arrest (15%), seminiferous tubule hyalinization (15%), mixed pattern (21%). Y-microdeletions were detected in 5 patients, of which 3 patients showed AZFc region deletions. Only 3 patients (9,1%) underwent a „second-look“ procedure after the evaluation of histopathological reports. After the stimulation therapy and „second-look“ procedure, we had a positive outcome in a single patient (33,3%). Mean FSH value in patients with confirmed spermatogenesis was 17.26±3.11IU/l, while mean FSH value in patients without presence or germ cell statistically significantly exceeded and was 24.28±4.71IU/L (p=0.038).

Conclusion:

Histopathological reports following the microTESE procedure are obligatory for the proper selection of patients who are candidates for the „second-look“ microTESE attempt. Patients with Sertoli cell-only syndrome and hypospermatogenesis particularly can benefit from the “second-look” procedure.

Effect of varicocele repair on sperm retrieval rate and testicular histopathological patterns in men with nonobstructive azoospermia

Varicocele adversely affects semen parameters. However, the effect of varicocele repair on the sperm retrieval rate and testicular histopathological patterns in men with nonobstructive azoospermia has not been widely reported. We retrospectively assessed the sperm retrieval rates and testicular histopathological patterns in men with nonobstructive azoospermia who were referred to the Urology Clinic in Dr. Cipto Mangunkusumo Hospital (Jakarta, Indonesia) and Bunda General Hospital (Jakarta, Indonesia) between January 2009 and December 2019. We compared patients who had undergone a surgical sperm retrieval procedure for assisted reproductive technology no earlier than three months after varicocele repair and those who had not undergone varicocele repair. The study included 104 patients (age range: 26-54 years), 42 of whom had undergone varicocele repair before the sperm retrieval procedure and 62 who had not. Motile spermatozoa were found in 29 (69.1%) and 17 (27.4%) patients who had undergone varicocele repair before the sperm retrieval procedure and those who had not undergone the repair, respectively (relative risk: 2.51; 95% confidence interval: 1.60-3.96; P < 0.001). A predicted probabilities graph showed consistently higher sperm retrieval rates for patients with varicocele repair, regardless of their follicle-stimulating hormone levels. Patients who underwent varicocele repair showed higher testicular histopathological patterns (P = 0.001). In conclusion, men with nonobstructive azoospermia and clinical varicocele who underwent varicocele repair before the sperm retrieval procedure had higher sperm retrieval rates compared to those who did not undergo varicocele repair.

Does varicocelectomy improve semen in men with azoospermia and clinically palpable varicocele?

The effectiveness of varicocelectomy in nonobstructive azoospermia is controversial. The current study assessed the efficacy of microsurgical subinguinal varicocelectomy in nonobstructive azoospermic men with palpable varicocele and to evaluate predictive parameters of outcome. We reviewed the records of 723 patients who had microsurgical varicocelectomy and diagnostic testicular biopsy between 2012 and 2016 at a tertiary medical centre. Data pertaining to the physical, laboratory (semen analysis and hormonal profile) and histopathology features were examined, exploring the predictors of improvement in semen analysis post-varicocelectomy. In total, 42 patients with mean age 35.71 ± 6.35 years were included. After a mean varicocelectomy follow-up of 6.7 months, motile spermatozoa in the ejaculate could be observed in 11 patients (26.2). Out of all the factors examined, only testicular histopathology significantly predicted post-varicocelectomy outcome, where 8/11 patients exhibited hypospermatogenesis, and 3/11 Sertoli cell-only regained spermatozoa in semen. Microsurgical varicocelectomy in nonobstructive azoospermic men with clinically palpable varicocele can result in sperm appearance in the ejaculate with the highest success expected in hypospermatogenesis.

Sertoli cell only syndrome induced by a varicocele

A case is reported which describes the severity of testicular histological damage that can be induced by a high-grade varicocele in a male with secondary infertility. A chart review of a patient's case was performed. A 34-year-old male with a three-and-a-half-year-old son who was conceived spontaneously with timed intercourse, with a grade three left varicocele, who's semen parameters progressed to non-obstructive azoospermia (NOA). He did not regain sperm in the ejaculate three or six months post left subinguinal microsurgical varicocele repair. He underwent bilateral microdissection testicular sperm extraction (microTESE) without identification of sperm in the testicular samples. A testicular biopsy from the time of microTESE revealed a Sertoli cell only pattern. A high-grade varicocele has the potential to induce sufficient testicular damage to result in the most severe testicular histological architecture associated with non-obstructive azoospermia (NOA), Sertoli cell only syndrome (SCOS).

Microdissection testicular sperm extraction: preoperative patient optimization, surgical technique, and tissue processing

Infertility due to nonobstructive azoospermia is treatable with the use of testicular sperm extraction and IVF. The optimal approach for sperm retrieval is microdissection testicular sperm extraction (mTESE). This systematic review summarizes and evaluates the literature pertaining to patient optimization before mTESE, mTESE technique, and post-mTESE testicular tissue processing. Preoperative patient optimization has been assessed in terms of adjuvant hormone therapy and varicocele repair. Limited data are available for adjuvant medical therapy, and although also limited, data for varicocele repair support increased sperm retrieval, pregnancy, and return of sperm to the ejaculate. Post-mTESE tissue processing has few comparative studies; however, most studies support the combination of mechanical mincing and use of type 4 collagenase for tissue disintegration along with pentoxifylline to assist in identifying motile and viable spermatozoa for intracytoplasmic sperm injection.

Should the current guidelines for the treatment of varicoceles in infertile men be re-evaluated?

Male infertility is a major health burden worldwide. In the United Kingdom, the diagnostic and treatment pathway for male factor fertility is fragmented with wide variance in management and funding protocols. There is now a focus on potential overtreatment of couples with IVF and failure to treat male factors before considering assisted reproductive technology (ART). Despite this, contemporary Urological guidelines are not definitive in the indications for varicocele treatment, whilst the current National Institute for Health and Care Excellence (NICE) guidelines do not advocate surgical intervention. While controversy exists concerning the effects of varicocele treatment on natural pregnancy rates, there is growing evidence that varicocele treatment can have additional positive effects on fertility by reducing their impact on sperm DNA fragmentation and improving ART outcomes. Studies have demonstrated that azoospermic men may become oligospermic following varicocele intervention, obviating the need for surgical sperm retrieval. Sperm retrieval rates also increase following varicocele treatment in men with non-obstructive azoospermia. The contemporary literature demonstrates a clear clinical benefit for treating varicoceles in infertile men, which may be more cost-effective than proceeding to immediate ART. This review comprehensively evaluates the current indications for varicocele treatment, and it is proposed that these should be redefined in contemporary guidelines to reflect current advances in male fertility research.

Analysis of CDK2 mutations in Chinese men with non-obstructive azoospermia who underwent testis biopsy

To examine whether mutations of the CDK2 gene exist in Chinese men with non-obstructive azoospermia (NOA) with different histopathology, we recruited 175 Chinese men with idiopathic NOA who underwent testis biopsy, including hypospermatogenesis, germ cell maturation arrest and Sertoli cell only syndrome. Genomic DNA was extracted from peripheral blood samples. Subsequently, the seven exons of the CDK2 gene were amplified using polymerase chain reaction with specific primers, respectively. The polymerase chain reaction products were sequenced on an automated sequencer. We identified four known single nucleotide polymorphisms: c.324G>A in exon 1; c.363T>C in exon 2; c.*570G>A; and c.*1160G>C in the 3' UTR of the CDK2 gene. Comparison of the genotype and allele frequencies showed no significant differences between NOA cases and controls for the four single nucleotide polymorphisms. Furthermore, no significant differences were found between each pathological group and control group, respectively. The results indicate that mutations in the coding sequence of the CDK2 gene may not be responsible for idiopathic NOA in Chinese men. Future studies in large cohorts of different ethnic populations are warranted to establish whether associations exist between the CDK2 gene and NOA.

Microdissection testicular sperm extraction

Microdissection testicular sperm extraction (microTESE) is considered the gold standard method for surgical sperm retrieval among patients with non-obstructive azoospermia (NOA). In this review, we will discuss the optimal evaluation of NOA patients and strategies to medically optimize NOA patients prior to microTESE. In addition, we will also discuss technical principles and pearls to maximize the chances of successful sperm retrieval, sperm retrieval rates (SRR) based upon testicular histology, predictors of successful sperm retrieval, gonadal recovery following microTESE, and potential complications.

Testicular Biopsy in Males With Infertility: A Longitudinal Study

BACKGROUND & OBJECTIVE

Regarding the importance of histologic examination of testicular biopsy for clinical planning of infertility, the current study was conducted to compare 2 separate histologic examination of testicular biopsy. Also, some cases with known fertility outcome were followed and their histological patterns were also compared with those of the outcome.

METHODS

The current study was conducted on testicular biopsies of 924 males evaluated for infertility from 1990 to 2013, retrieved from the archive of pathology department of Shahid Beheshti Hospital, Babol, Northern Iran. All slides were reviewed by a pathologist unaware of the original results. Data including age, histological pattern of spermatogenesis (pure and mixed), smoking, and the history of ejaculatory duct obstruction were retrieved from the pathology archive. In some cases, the outcome was also compared with that of the histological pattern. All analyses were executed using SPSS version 22 statistical software. To analyze the data, t test, Chi-square test, one-way ANOVA, and the least significant difference (LSD) test were used.

RESULTS AND CONCLUSION

Out of the 924 testicular biopsies, 34 (3.7%) cases had different reports from original reading. LSD analysis indicated Sertoli cell only syndrome (SCO) as the most common histological pattern. There was a significant difference between the mean age of cases with SCO and that of the ones with hypospermatogenesis (HYPO) (P =0.03). Obstruction was higher in pure pattern (P=0.04). The pregnancy rate was higher in the wives of males with obstructive infertility than the ones with non-obstructive infertility. SCO was the most common histological pattern of testicular biopsy during 23 years. Pure patterns were more than mixed patterns, and the mean age was lower in mixed patterns. Also, pure patterns were the most common findings in the cases with obstructive infertility.

Correlation of genetic results with testicular histology, hormones and sperm retrieval in nonobstructive azoospermia patients with testis biopsy

To investigate the frequency and types of genetic results in different testicular histology of patients with nonobstructive azoospermia (NOA), and correlated with hormones and sperm retrieval (SR), a retrospective study was conducted in 286 Chinese NOA patients who underwent testis biopsy and 100 age-matched fertile men as the control group. Chromosome karyotype analyses were performed by the peripheral blood chromosome G-band detection method. Screening of Y chromosome microdeletions of azoospermia factor (AZF) region was performed by polymerase chain reaction (PCR) amplification of 11 sequence-tagged sites (STS). The serum levels of follicle-stimulating hormone, luteinising hormone and testosterone (T) and the appearance of scrotal ultrasound were also obtained. In 286 cases of NOA, 14.3% were found to have chromosomal alterations. The incidence of chromosomal abnormality was 2.8%. Sex chromosomal abnormalities were seen in six cases (four cases of Klinefelter's syndrome (47, XXY) and two cases of mosaics). The incidence of polymorphic chromosomal variants was 3% in the normal group and 11.5% in the NOA group. In total, 15.7% of NOA patients were found to have AZF microdeletions and AZF (c + d) was the most frequent one. The results of hormone and SR were found to be significantly different among all testicular histological types, whereas no significant differences were found when it comes to genetic alterations. It is concluded that the rate of cytogenetic alterations was high in NOA patients. So screening for chromosomal alterations and AZF microdeletions would add useful information for genetic counselling in NOA patients with testis biopsy and avoid vertical transmission of genetic defects by assisted reproductive technology.

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.