Intracytoplasmic sperm injection in obstructive and non-obstructive azoospermia

We compared the results of intracytoplasmic sperm injection (ICSI) in: (i) obstructive versus non-obstructive azoospermia, (ii) obstructive azoospermia using epididymal versus testicular spermatozoa and (iii) acquired versus congenital obstructive azoospermia due to congenital absence of the vas deferens (CAVD). A retrospective analysis was done of 241 consecutive ICSI cycles done in 103 patients with non- obstructive azoospermia and 119 patients with obstructive azoospermia. In the obstructive group, 135 ICSI cycles were performed. Epididymal spermatozoa were used in 44 cycles and testicular spermatozoa in 91 cycles. In the non-obstructive group, 106 cycles were performed. The fertilization and pregnancy per cycle rates were 59.5 and 27.3% respectively using epididymal spermatozoa, 54.4 and 31.9% respectively using testicular spermatozoa in obstructive cases, and 39 and 11.3% respectively in non-obstructive cases. The fertilization and pregnancy per cycle rates were 56.6 and 37% respectively in acquired obstructive cases, and 55.2 and 20.4% respectively in CAVD. In conclusion, ICSI using spermatozoa from patients with acquired obstructive azoospermia resulted in significantly higher fertilization and pregnancy rates as compared to CAVD and non-obstructive cases.      

Fertilization, pregnancy and embryo implantation rates after ICSI in cases of obstructive and non-obstructive azoospermia

The aetiology of azoospermia can be grossly divided into obstructive and non-obstructive causes. Although in both cases testicular spermatozoa can be used to treat male fertility, it is not well established whether success rates following intracytoplasmic sperm injection (ICSI) are comparable. Therefore, a retrospective analysis of fertilization, pregnancy and embryo implantation rates was performed following ICSI with testicular spermatozoa in obstructive or non-obstructive azoospermia. In total, 193 ICSI cycles were carried out with freshly retrieved testicular spermatozoa; in 139 cases of obstructive and 54 cases of non-obstructive azoospermia. The fertilization rate after ICSI with testicular spermatozoa in non-obstructive azoospermia was significantly lower than in obstructive azoospermia (67.8% versus 74.5%; P = 0.0167). Within the non-obstructive group, the fertilization rate in the group of maturation arrest (47.0%) was significantly lower than in case of Sertoli cell-only (SCO) syndrome (71.2%) or germ cell hypoplasia (79. 5%). Embryo quality on day 2 after ICSI was similar for all groups. Pregnancy rates per transfer between obstructive (36.8%) and non-obstructive groups (36.7%) were similar. In cases of maturation arrest the pregnancy rate per transfer was lowest (20.0%) although not significantly different from SCO syndrome or hypoplasia groups. Embryo implantation rates were not different between the obstructive (19.6%) and non-obstructive groups (25.8%), and were lowest in cases of germ cell hypoplasia (15.8%). This retrospective analysis shows that although fertilization rate after ICSI with testicular spermatozoa in non-obstructive azoospermia is significantly lower than in obstructive azoospermia, pregnancy and embryo implantation rates are similar.     

The effect of female age and ovarian reserve on pregnancy rate in male infertility: treatment of azoospermia with sperm retrieval and intracytoplasmic sperm injection

Factors other than spermatozoa could be the major determinant of the success of assisted reproduction treatment in cases of male infertility. Our aim was to evaluate the effect of the wife's age and ovarian reserve on assisted reproduction success rates in the most severe type of male infertility, i.e. azoospermia. A total of 249 consecutive couples suffering from male infertility caused by azoospermia underwent microsurgical epididymal sperm aspiration (MESA) or testicular sperm extraction (TESE) with intracytoplasmic sperm injection (ICSI). Of these men, 186 had irreparable obstructive azoospermia, and 63 had non-obstructive azoospermia due to testicular failure. Neither the pathology, the source, the quantity, nor the quality of spermatozoa had any effect on fertilization or pregnancy rates. Maternal age and ovarian reserve (number of eggs) had no effect on fertilization or embryo cleavage, but did dramatically affect the embryo implantation, pregnancy and delivery rates. Wives of azoospermic men who were in their 20s had a 46% live delivery rate per cycle, wives aged 30-36 years had a 34% live delivery rate per cycle, wives aged 37- 39 years had a 13% live delivery rate per cycle, and wives > or = 40 years had only a 4% live delivery rate per cycle. The number of eggs retrieved also affected pregnancy and delivery rate, but to a lesser extent than age. In virtually all cases of obstructive azoospermia, and in 62% of cases with non-obstructive azoospermia caused by germinal failure, sufficient spermatozoa could be retrieved to perform ICSI, with normal fertilization and embryo cleavage. However, the pregnancy rate and the live delivery rate were dependent strictly on the age of the wife, and on her ovarian reserve. Unfortunately, exaggerated claims of high pregnancy rates can thus easily be made by manipulating, in a very simple way, selection for female factors.      

Fertilization and pregnancy outcome with intracytoplasmic sperm injection for azoospermic men

The evident ability of the intracytoplasmic sperm injection (ICSI) procedure to achieve high fertilization and pregnancy rates regardless of semen characteristics has induced its application with spermatozoa surgically retrieved from azoospermic men. Here, ICSI outcome was analysed in 308 cases according to the cause of azoospermia; four additional cycles were with cases of necrozoospermia. All couples were genetically counselled and appropriately screened. Spermatozoa were retrieved by microsurgical epididymal aspiration or from testicular biopsies. Epididymal obstructions were considered congenital (n = 138) or acquired (n = 103), based on the aetiology. Testicular sperm cases were assessed according to the presence (n = 14) or absence (n = 53) of reproductive tract obstruction. The fertilization rate using fresh or cryopreserved epididymal spermatozoa was 72.4% of 911 eggs for acquired obstructions, and 73.1% of 1524 eggs for congenital cases; with clinical pregnancy rates of 48.5% (50/103) and 61.6% (85/138) respectively. Spermatozoa from testicular biopsies fertilized 57.0% of 533 eggs in non-obstructive cases compared to 80.5% of 118 eggs (P = 0.0001) in obstructive azoospermia. The clinical pregnancy rate was 49.1% (26/53) for non-obstructive cases and 57.1% (8/14) for testicular spermatozoa obtained in obstructive azoospermia, including three established with frozen-thawed testicular spermatozoa. In cases of obstructive azoospermia, fertilization and pregnancy rates with epididymal spermatozoa were higher than those achieved using spermatozoa obtained from the testes of men with non-obstructive azoospermia.     

Outcome of in-vitro culture of fresh and frozen-thawed human testicular spermatozoa

The effect of in-vitro culture on the motility and morphology of fresh and frozen-thawed human testicular spermatozoa obtained from obstructive azoospermic patients and on the motility of testicular spermatozoa obtained from non-obstructive azoospermic patients was evaluated. The outcome of intracytoplasmic sperm injection (ICSI) with fresh and frozen-thawed human testicular spermatozoa was studied. The results showed that significant improvement of sperm morphology and motility was observed in culture of fresh (n = 17) and frozen-thawed (n = 15) testicular sperm samples obtained from patients with obstructive azoospermia. The motility of cultured testicular spermatozoa reached a peak at 72 h without the need for special media. In six of 20 samples obtained from patients with non-obstructive azoospermia, improvement of sperm motility was observed. When only non-motile testicular spermatozoa were cultured, they all remained non-motile (n = 9). In patients with obstructive azoospermia, fertilization rates of 80 and 81% were obtained using ICSI with fresh and frozen-thawed testicular spermatozoa respectively. Clinical pregnancies were observed in four out of nine patients with fresh testicular spermatozoa and two out of five patients after using frozen-thawed spermatozoa. When fresh testicular spermatozoa obtained from patients with non-obstructive azoospermia were used for ICSI, the fertilization rate was 68% and two out of seven patients achieved clinical pregnancies. In conclusion, the morphology and motility of fresh and frozen-thawed testicular spermatozoa in patients with obstructive azoospermia can be significantly improved after in-vitro culture. The outcome of in-vitro culture of testicular spermatozoa in patients with non-obstructive azoospermia is unpredictable. In-vitro culture of non-motile testicular spermatozoa is not successful so far. The outcome of ICSI with fresh and with frozen-thawed testicular spermatozoa was similar.      

The outcome of intracytoplasmic injection of fresh and cryopreserved epididymal spermatozoa from patients with obstructive azoospermia--a comparative study

The aim of our study was to compare the outcome of intracytoplasmic sperm injection (ICSI) with fresh and frozen-thawed epididymal spermatozoa retrieved by percutaneous epididymal sperm aspiration (PESA) or microepididymal sperm aspiration (MESA) from patients with obstructive azoospermia. A retrospective analysis of consecutive ICSI cycles was performed, comparing the outcome in 24 patients with obstructive azoospermia undergoing surgical sperm aspiration by MESA (7 cycles) or PESA (17 cycles). In 23 of 24 patients, excess spermatozoa were cryopreserved. Following thawing, 21 ICSI cycles were performed (11 cycles after MESA, 10 after PESA). No statistically significant differences were noted in all parameters examined in ICSI cycles with fresh or cryopreserved spermatozoa from the same patients. Comparing all ICSI cycles with fresh and frozen-thawed epididymal spermatozoa, the rates of two-pronuclear fertilization (56% versus 53%), embryo cleavage (90% versus 86%), implantation (10% versus 14%), clinical pregnancy per embryo transfer (32% versus 37%) and delivery/ongoing pregnancy rate (27% versus 26%) were not statistically different. The cumulative ongoing pregnancy rate per sperm retrieval procedure was 46%, respectively. We conclude that the clinical outcome of ICSI with fresh and frozen-thawed spermatozoa after retrieval by PESA was similar to that by MESA. Epididymal sperm cryopreservation in patients with obstructive azoospermia is feasible and efficient using a simple freezing protocol and should be offered to optimize the yield of pregnancies achieved following such procedures.      

Testicular sperm retrieval and cryopreservation prior to initiating ovarian stimulation as the first line approach in patients with non-obstructive azoospermia.

The potency for fertilization and successful implantation was compared between fresh and cryopreserved testicular spermatozoa obtained from the same patient with non-obstructive azoospermia. Spermatozoa cryopreserved at the outset were also evaluated. Non-obstructive azoospermic men (n = 55) underwent testicular sperm extraction (TESE); mature spermatozoa were found in 33 (60%) of them. Of 57 intracytoplasmic sperm injection (ICSI) cycles in 25 patients, 15 used fresh spermatozoa (14 patients, group 1), 24 used the excess spermatozoa cryopreserved after 'fresh' ICSI (11 couples who did not conceive in the 'fresh' cycle, group 2) and 18 cycles used cryopreserved spermatozoa at the outset (11 other patients, group 3). Fertilization, cleavage, embryo quality, implantation and take home baby rates were not significantly different in groups 1 and 2, and 6/14 couples ultimately had healthy babies (42.8% cumulative take home baby rate per TESE). In group 3, neither the fertilization rate, embryo development, pregnancy nor implantation rates per embryo transfer were significantly different from groups 1 and 2. The cumulative delivery and ongoing pregnancy rate in this group was 36. 4%. Cryopreservation did not impair the availability of motile spermatozoa for ICSI. When immotile spermatozoa were injected, however, fertilization rate decreased dramatically. Since criteria for predicting the presence of spermatozoa in the testicular tissue of patients with non-obstructive azoospermia are inadequate, it is suggested that TESE be performed prior to initiating ovarian stimulation.     

Reproductive capacity of round spermatids compared with mature spermatozoa in a population of azoospermic men

The present study aims to evaluate the injection of testicular round spermatids from patients with complete failure of spermiogenesis compared with that of mature epididymal and testicular spermatozoa. Over a period of 8 months, 188 azoospermic patients were evaluated with a view to their inclusion in our intracytoplasmic sperm injection (ICSI) programme. All patients had had a previous testicular biopsy; 38 had pure obstructive azoospermia, while 150 had non-obstructive azoospermia. Mature spermatozoa were found in 93 patients, whereas spermatozoa were entirely absent, with a predominance of round spermatids in 87. In eight patients, spermatids could not be found and therefore their cycles were cancelled. There was an early appearance of the two pronuclei stage in the round spermatid group compared with the mature spermatozoa group of patients (10.2 and 16 h respectively). The fertilization rate was also significantly lower (P = 0.00001) in the round spermatid group. The numbers of embryos developed and of embryo transfers in the round spermatid injection group were significantly lower compared with the mature spermatozoa injection group (P = 0.05 and 0.0001 respectively). No pregnancies resulted from round spermatid injection, while 18 pregnancies were achieved from the injection of mature spermatozoa. In conclusion, injection of round spermatids from patients with complete failure of spermiogenesis resulted in a significantly lower fertilization rate and a higher developmental arrest compared with injection of mature spermatozoa. With no pregnancies achieved, one may question the unusual variability of reported success rates and stress the need for further research in order to improve the outcome of this novel technique.     

附睾穿刺取精行ICSI治疗梗阻性无精子症

目的探讨附睾穿刺取精术(PESA)结合单精子卵胞浆内注射(ICSI)治疗梗阻性无精子症男性不育的可行性,并观察其临床效果。方法 7对夫妇为研究对象,男方均确诊为梗阻性无精子症,女方超促排卵获得卵细胞,男方于取卵日在局麻下通过细针穿刺附睾头部吸取少量精子,行ICSI,受精成功后24-48h,选择优质胚胎移植入子宫腔。因男性少弱精子症行ICSI治疗的20个治疗周期为对照组。结果附睾取精7例共11个治疗周期全部获得活动精子,ICSI后受精率65．9％,卵裂率98．3％,优质胚胎率71．9％,临床妊娠5例,周期临床妊娠率45．5％,与对照组比较,各项指标均无显著差异。结论附睾穿刺取得的精子与排出体外的精子具有相同的受精和获得优质胚胎的能力,PESA是治疗梗阻性无精子症男性不育的安全有效的方法。     

Testicular biopty gun needle biopsy in collecting spermatozoa for intracytoplasmic injection, cryopreservation and histology.

Using testicular spermatozoa from either open biopsy (29 cycles) or biopty gun needle biopsy (49 cycles), a total of 81 intracytoplasmic sperm injection (ICSI) cycles among 57 couples were carried out from January, 1994 to September, 1997. In six cycles, no spermatozoa were obtained, and in three cycles spermatozoa from both needle and open biopsies were used. The fertilization (37% after open and 41% after needle biopsy) and pregnancy rates (29% per embryo transfer compared with 16% per embryo transfer) were similar after both open and needle biopsies. Five pregnancies were achieved among the 14 couples with non-obstructive azoospermia of the male partner, four of these after needle biopsy. It was possible to use cryopreserved testicular spermatozoa after both needle and open biopsies, and one pregnancy started after using cryopreserved testicular spermatozoa in both groups. Histological needle biopsy was carried out in 62 cases, and they were all diagnostic, giving 15-20 cross-sections of seminiferous tubuli per biopsy. Testicular needle biopsy using a 14 gauge biopsy needle gave a sufficient amount of tissue and spermatozoa for ICSI, cryopreservation and histology, even in non-obstructive azoospermia. This technique is simpler and cheaper than open biopsy and, hence, it can be regarded as the optimal method for the retrieval of testicular spermatozoa.     

Pregnancies after intracytoplasmic sperm injection with cryopreserved testicular spermatozoa

In 25 patients (14 suffering from obstructive azoospermia, sixfrom non-obstructive azoospermia, three from astheno-azoospermiaand two from absence of ejaculation) spermatozoa were extractedfrom testicular biopsies. Intracytoplasmic sperm injection (ICSI)with fresh testicular spermatozoa was performed in 18 cases;spermatozoa in excess were cryopreserved in pills. No pregnancieswere achieved. In the remaining seven patients, testicular spermatozoawere retrieved and cryopreserved during a diagnostic testicularbiopsy. After thawing, sperm motility was assessed in 17 cases(68%), and 18 ICSI with cryopreserved testicular spermatozoawere performed. The mean two-pronuclear (2PN) fertilizationrate was 59%, the mean cleavage rate was 92%, and six clinicalpregnancies were achieved, all of them still ongoing (pregnancyrate 33%). A comparison of the results of ICSI carried out withfresh or cryopreserved testicular spermatozoa showed that themean 2PN fertilization rates per cycle (53 compared with 55%),mean cleavage rates per cycle (99 compared with 96%) and embryoquality were not significantly different In conclusion, cryopreservationof testicular spermatozoa is feasible, even in patients withnon-obstructive azoospermia, and the results of ICSI with frozen-thawedtesticular spermatozoa are similar to those obtained using freshtesticular spermatozoa. Cryopreservation of testicular spermatozoamay avoid repetition of testicular biopsies to retrieve spermatozoafor successive ICSI cycles in patients in whom the only sourceof motile spermatozoa is the testicle.     

Reproductive capacity of spermatozoa from men with testicular failure.

Controversial reports have been published about the influence of sperm source and of the underlying testicular pathology on success rates of intracytoplasmic sperm injection (ICSI). In this controlled study, ICSI treatment cycles with testicular spermatozoa from men with obstructive and non-obstructive azoospermia were compared with ICSI ejaculated sperm cycles with semen parameters < or = 5 x 10(6)/ml and < or = 10% progressive motility. The control cases were matched for female age, rank of trial, female basal follicle-stimulating hormone serum concentrations and close proximity to the study group's procedure. The fertilization, cleavage, pregnancy and abortion rates were similar in matched groups irrespective of the type of azoospermia. However, the implantation rate in the non-obstructive azoospermic patient group was significantly lower than that in the matched ejaculated sperm group (13.4% versus 26%, P = 0.05). On the other hand, no impairment of the implantation rate was observed in the obstructive azoospermic patient group. These data show that testicular pathology has a negative impact on reproductive performance of testicular spermatozoa, resulting in a decreased implantation potential without any apparent effect on fertilization and early preimplantation development.     

Surgical sperm recovery for intracytoplasmic sperm injection: which method is to be preferred?

Different methods for recovering epididymal or testicular spermatozoa have been described and each has its drawbacks and advantages. Percutaneous aspiration of the testis may be the method of choice in cases of irreparable obstructive azoospermia. Using a 21-gauge needle, spermatozoa may be recovered in 96 % of patients. More patients undergoing fine-needle aspiration experienced less pain than expected as compared with those undergoing open biopsy. Microsurgical epididymal sperm aspiration (MESA) is the preferred method in patients with an incomplete work-up because, if indicated, a vasoepididymostomy can be performed concomitantly with a full scrotal exploration. In azoospermic patients with testicular failure, the sperm recovery rate, i.e. the chance of finding at least one spermatozoon, is around 50% after multiple open biopsies. However, the fertilization rates after intracytoplasmic sperm injection (ICSI) are significantly lower than in men with normal spermatogenesis, and complete fertilization failure may occur more frequently. Although the combination of testicular sperm extraction (TESE) and ICSI may be the sole treatment available for infertility because of non-obstructive azoospermia, the overall success rate is limited and ongoing pregnancies are obtained in < or =20% of ICSI cycles. In patients with incomplete Sertoli cell-only syndrome, testicular damage may be limited by use of a selective microsurgical approach; less invasive methods such as fine-needle aspiration are not useful in these patients. Of 14 patients with primary testicular failure as proven by histopathology, only in one case (7.1%) were spermatozoa recovered by multiple aspirations, while in nine cases (64.3%) spermatozoa were recovered by open biopsy. Although the pregnancy rates reported after ICSI with frozen-thawed testicular spermatozoa from patients with primary testicular failure are relatively low, the recovery of testicular spermatozoa by open biopsy followed by cryopreservation may be the method of choice by which to prevent repeat surgery and pointless ovarian stimulation in the female partner.     

Outcome of testicular sperm recovery and ICSI in patients with non-obstructive azoospermia with a history of orchidopexy

BACKGROUND: Little is known about sperm recovery and ICSI using testicular sperm from men with non-obstructive azoospermia who had a previous orchidopexy. We therefore studied the sperm recovery in this subgroup and evaluated clinical parameters predicting successful sperm retrieval and the outcome of ICSI. METHODS: A total of 79 non-obstructive azoospermic men with a history of orchidopexy underwent a sperm recovery procedure. The predictive value of clinical parameters such as age at sperm retrieval, age at orchidopexy, testicular volume, FSH, FSH/LH ratio, testosterone and androgen sensitivity index (LH x testosterone) for successful testicular sperm retrieval was evaluated using receiver operating characteristics (ROC) curve analysis. A comparison between 64 ICSI cycles performed in these couples and 92 cycles performed in couples in which the men had an unexplained non-obstructive azoospermia was carried out. RESULTS: Testicular spermatozoa were recovered in 41 patients (52%). The mean age at orchidopexy of the patients with a positive sperm recovery was 10.6 years [95% confidence interval (CI) 7.3-13.8] versus 15.5 years (95% CI 11.3-19.8) for those where no spermatozoa were found. The mean testicular volume of the largest testis of patients with spermatozoa found was 10 ml (95% CI 8.3-11.9) versus 8.5 ml (95% CI 5.8-11.1) in patients with no spermatozoa found. The mean FSH and testosterone value for patients with successful and unsuccessful sperm recovery, respectively, was 24.1 IU/l (95% CI 17.9-30.3) and 4.4 ng/ml (95% CI 3.7-5.1) versus 28.8 IU/l (95% CI 19.4-38.2) and 3.4 ng/ml (95% CI 2.2-4.5). All clinical and biological parameters examined failed to predict the outcome of the testicular sperm extraction. No differences were observed between the orchidopexy and unexplained group for the number of oocytes retrieved, fertilization rate, embryo quality, pregnancy rate and implantation rate. CONCLUSIONS: As in the population of men with non-obstructive azoospermia, the sperm recovery rate for patients with a history of orchidopexy is approximately 50% and there are currently no clinical parameters predicting successful sperm retrieval in this subpopulation of patients. The outcome of the ICSI cycles is comparable with that in the population of men with non-obstructive azoospermia.     

Genetics: The use of epididymal and testicular spermatozoa for intracytoplasmic sperm injection: the genetic implications for male infertility

The results and rationale of using testicular and epididymalspermatozoa with intracytoplasmic sperm injection (ICSI) forsevere cases of male infertility are reviewed. A total of 72consecutive microsurgical epididymal sperm aspiration (MESA)cases were performed for congenital absence of the vas (CAV)and for irreparable obstructive azoospermia. ICSI was used toobtain normal embryos for transfer and fertilization in 90%of the cases. The overall fertilization rate was 46% with anormal cleavage rate of 68%. The pregnancy and delivery ratesper transfer were 58 and 37% respectively. The delivery rateper cycle was 33%. In many cases, no epididymal spermatozoawere available and so testicular sperm extraction (TESE) wasused for sperm retrieval. The transfer rate was lower with TESE(84 versus 96%) and the spermatozoa could not be frozen andsaved for use in future cycles. However, there was little differencein pregnancy rates using epidiymal or testicular spermatozoa.The results were not affected by whether the obstruction wascaused by CAV or failed vasoepididymostomy. Both fresh and frozenspermatozoa gave similar results; the only significant factorappeared to be the age of the female. Because of the consistentlygood results obtained using epididymal sperm with ICSI whencompared with conventional IVF, and the similarly good resultswith testicular tissue spermatozoa, ICSI is mandatory for allfuture MESA patients. All CAV patients and their partners shouldbe offered genetic screening for cystic fibrosis; hence pre-implantationembryo diagnosis should be available in any full service MESAprogramme. It is now clear that even with non-obstructive azoospermia,e.g. Sertoli-cell only, or maturation arrest, there are usuallysome small foci of spermatogenesis which allow TESE with ICSIto be carried out. This means that even in men with azoospermiadue to absence of spermatogenesis or to a block in meiosis,there are usually a few spermatozoa available in the testesthat are adequate for successful ICSI. Finally, it is likelythat some forms of severe male factor infertility are geneticallytransmitted and although ICSI offspring have been shown to becompletely normal, it is possible that the sons of these infertilecouples will also require ICSI when they grow up and wish tohave a family.     

The results of 154 ICSI cycles using surgically retrieved sperm from azoospermic men

BACKGROUND: The effects of source of sperm, aetiology and sperm cryopreservation on ICSI cycles in azoospermic men were evaluated. The effect of aetiology of azoospermia on embryo development was also assessed. METHODS: This study was a retrospective analysis of 154 cycles (91 couples) using surgically retrieved sperm. Outcome measures were fertilization rate (FR), implantation rate (IR), and clinical pregnancy rate (CPR) and livebirth rate (LBR) per transfer. RESULTS: Our data demonstrated similar outcome between the use of epididymal or testicular sperm in men with obstructive azoospermic (OA). FR and IR were significantly lower (P < 0.05) using sperm from men with non-obstructive azoospermic (NOA), but although pregnancy outcome appeared lower, this did not reach statistical significance (P = 0.08). Cryopreservation of epididiymal sperm did not alter outcome, but the use of frozen-thawed testicular sperm did demonstrate a lower FR, with no statistical difference in IR or pregnancy outcome. Embryos derived from NOA sperm had impaired development beyond day 2 post-oocyte retrieval (OA, 44% <5 cell; NOA, 71% <5 cell; P = 0.002). CONCLUSIONS: The use of sperm from men with NOA significantly affects fertilization and implantation in ICSI cycles. The use of frozen-thawed testicular sperm affects fertilization rate without significantly altering pregnancy outcome. The use of such data on which to base clinical decisions needs to be supported by the meta-analyses of previous reports.     

Testicular sperm retrieval by percutaneous fine needle sperm aspiration compared with testicular sperm extraction by open biopsy in men with non-obstructive azoospermia

The efficiency of testicular sperm retrieval by testicular fine needle aspiration (TEFNA) was compared with open biopsy and testicular sperm extraction (TESE), in 37 rigorously selected patients with non- obstructive azoospermia. All patients underwent TEFNA and TESE consecutively. Thus, each patient served as his own control. The case was regarded as successful if at least one testicular spermatozoon was found allowing intracytoplasmic sperm injection (ICSI) of at least one oocyte. The mean age of the male patients was 32.7 years (range 24-47). Whereas by TEFNA spermatozoa enabling performance of ICSI were found in only four patients out of 37 (11%), open biopsy and TESE yielded spermatozoa in 16 cases (43%). The negative predictive value of high serum follicle stimulating hormone (FSH) concentrations (> or =10 IU/l) (predicting failure to find spermatozoa for ICSI) was low (38.4%). The positive predictive value (predicting the chance to find spermatozoa for ICSI) of normal-sized testicle was not different from that of small- sized (<15 ml) testicle (50%). Complications included one case of testicular bleeding following fine needle aspiration, treated locally, and two cases of extratunical haematomata following TESE requiring no intervention. In patients with non-obstructive azoospermia, TEFNA has a significantly lower yield compared to TESE. Performance of ICSI with testicular sperm in these cases resulted in satisfactory fertilization and high embryo transfer rates. The implantation and pregnancy rates per embryo transfer were 13 and 29% respectively. Neither serum FSH values nor testicular size were predictive of the chances to find spermatozoa for ICSI. Some complications may occur even following TEFNA.      

High fertilization and pregnancy rate after intracytoplasmic sperm injection with spermatozoa obtained from testicle biopsy

In cases requiring microsurgical epididymal sperm aspiration(MESA) for congenital absence of the vas deferens (CAVD) orirreparable obstructive azoospermia, often no spermatozoa canbe retrieved from the epididymis, or there may even be no epididymispresent. We wished to see whether testicular biopsy with testicularsperm extraction (TESE) in such cases could yield spermatozoathat would result in successful fertilization and pregnancy(despite the absence of epididymal spermatozoa) using intracytoplasmicsperm injection (ICSI). In the same setting during the same2-week period, 28 patients with CAVD or irreparable obstructionwere treated; 16 consecutive fresh MESA—ICSI cycles and12 cycles which required testicular biopsy with testicular spermextraction (TESE—ICSI) were performed. Normal two-pronuclearfertilization rates were similar in both groups: 45% for epididymalspermatozoa and 46% for testicular biopsy-extracted spermatozoa.Cleavage rates were also similar (68% for epididymal and 65%for testicular spermatozoa). The ongoing pregnancy rates inthis series were 50 and 43% respectively. We conclude that epididymalspermatozoa and testicular spermatozoa yield similar fertilization,cleavage and ongoing pregnancy rates using ICSI. When epididymalspermatozoa cannot be retrieved, a testicular biopsy can beperformed and the few barely motile spermatozoa thus obtainedcan be used for ICSI. It appears that all cases of obstructiveazoospermia can now be successfully treated.     

Pregnancies achieved after frozen-thawed pronuclear oocytes obtained by intracytoplasmic sperm injection with spermatozoa extracted from frozen-thawed testicular tissues from non-obstructive azoospermic men.

The use of frozen-thawed testicular tissue as a source of spermatozoa for intracytoplasmic sperm injection (ICSI) in non-obstructive azoospermia yields favourable fertilization and pregnancy rates while avoiding both repetitive biopsies and unexpected cycle cancellations. Spermatozoa were obtained from frozen-thawed testicular biopsy specimens from 67 non-obstructive azoospermic men. Following fertilization, supernumerary two pronuclear (2PN) oocytes were frozen. After thawing, 17 cycles of embryo transfer were carried out with a mean number of 2.7 embryos and a mean cumulative embryo score (CES) of 18.3 per transfer. The clinical pregnancy and implantation rates per transfer in these cycles (23.5 and 8.3% respectively) were comparable to those of fresh embryo transfers (35.7 and 12.7% respectively) with a mean number of 2.7 embryos and a mean CES of 28.7 per transfer. Abortion rates, although higher with cryopreserved 2PN oocytes were not significantly different. With this approach, cryopreservation of supernumerary 2PN oocytes can be used to improve the cumulative pregnancy rates in a severely defective spermatogenetic population. To our knowledge, these are the first pregnancies reported which have been obtained by the transfer of cryopreserved pronuclear oocytes obtained from ICSI using cryopreserved testicular spermatozoa.     

A comparison of ICSI outcomes with fresh and cryopreserved epididymal spermatozoa from the same couples

The published experience with frozen-thawed epididymal spermatozoa and intracytoplasmic sperm injection (ICSI) suggests that fertilization and pregnancy success rates are comparable to those achieved with freshly retrieved spermatozoa. However, no study has exactly compared clinical outcomes between the two IVF/ICSI cycles in the same couples. To formally address this issue, we assessed ICSI outcomes in couples each of whom had had two IVF/ICSI cycles: one using fresh and the second using frozen-thawed epididymal spermatozoa obtained from a single aspiration procedure. From a pool of 101 consecutive patients undergoing IVF/ICSI with epididymal spermatozoa, 19 couples initially used fresh epididymal spermatozoa and subsequently underwent a second IVF/ICSI procedure with frozen-thawed spermatozoa from the same aspiration. Normal (2PN) oocyte fertilization rates, embryo quality and pregnancy rates were compared between the two IVF/ICSI cycles for each couple. In the fresh epididymal sperm group, 58.4% of the injected oocytes fertilized normally compared with 62.0% of the injected oocytes in the frozen-thawed epididymal sperm group, revealing no statistically significant difference. Graded embryo quality also did not differ significantly between the paired IVF/ICSI cycles. The clinical pregnancy rates were 31.6% (6/19) and 36.8% (7/19) in the first and second cycles respectively. All but one pregnancy were singletons. In summary, this study provides strong evidence to support the notion that motile, cryopreserved and thawed epididymal spermatozoa are equal to freshly retrieved spermatozoa for ICSI in couples with obstructive azoospermia.