Andrology: Percutaneous epididymal sperm aspiration for obstructive azoospermia

We report the use of percutaneous epididymal sperm aspirationas a simpler and more acceptable alternative to microscopicepididymal sperm aspiration for patients with obstructive azoospermiain whom bypass surgery is not feasible or has not been successful.Some contamination of the aspirate with blood is inevitable,but with careful sperm preparation techniques this can be reducedsubstantially in the final aliquot used for assisted conception.Spermatozoa with active forward progression may be used forgamete intra-Fallopian transfer treatment, but when this capacityis absent intracytoplasmic sperm injection is recommended. Threepregnancies were obtained in seven couples and a set of twinshas been delivered.     

Results of percutaneous epididymal sperm aspiration and intracytoplasmic sperm injection in two major groups of patients with obstructive azoospermia

Percutaneous epididymal sperm aspiration (PESA) and intracytoplasmic sperm injection (ICSI) were carried out in patients with congenital bilateral absence of the vas deferens (CBAVD) and men with failed reversal of vasectomy (FRV). PESA was successful in 55 out of 62 patients with CBAVD (89%) and in 57 out of 60 men with FRV (95%). The fertilization rates after ICSI (53 and 55%), cleavage rates (70 and 76%) and pregnancy rates (36 and 32%) did not differ significantly between the two respective groups (CBAVD and FRV). PESA and ICSI are effective both in patients with CBAVD and in those with FRV.      

Testicular needle biopsy, open biopsy, epididymal aspiration and intracytoplasmic sperm injection in obstructive azoospermia

Testicular or epididymal spermatozoa were obtained for in-vitrofertilization and intracytoplasmic sperm injection ICSI) in27 cycles out of 33 (in six men the azoospermia proved to havetesticular causes). Testicular needle biopsy carried out inaddition to surgical open biopsy proved to be an effective methodto obtain spermatozoa for ICSI from patients with obstructiveazoospermia. Thus it might be possible to replace scrotal operationsby simple needle biopsies. Embryos resulting from ICSI withtesticular spermatozoa were used in 19 transfers that resultedin six pregnancies. One pregnancy resulted from six embryo transfersfrom ICSI after microsurgical-epididymal sperm aspiration (MESA).The normal fertilization rates with testicular (37.3%) and MESAspermatozoa (53.7%) did not differ significantly from each other,but with testicular spermatozoa the rate was significantly lowerthan that obtained with ejaculated spermatozoa and ICSI (59.7%)in the matched couples. The abnormal fertilization of oocyteswith one pronucleus was significantly higher with testicularspermatozoa than with ejaculated spermatozoa in the controlcouples.     

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。     

The efficacy of local anaesthesia for percutaneous epididymal sperm aspiration and testicular sperm aspiration

A total of 37 percutaneous epididymal sperm aspiration (PESA) and/or testicular sperm aspiration (TESA) procedures were performed under local anaesthesia (LA) on 34 men between June and November 1996. Local anaesthesia was achieved by injecting 10 ml of 1% lignocaine solution along the sides of the vas deferens near the external inguinal ring (spermatic cord block). Sperm retrieval was successful in 92% of the procedures. Of the 37 procedures, in 29 the patients felt either no pain or mild discomfort while in six they experienced moderate but tolerable pain. Analgesia was incomplete in two procedures and was supplemented with i.v. sedation. Vasovagal reflex in two procedures was reversed by i.v. atropine. In 24 procedures patients felt relaxed, whilst in 13 they felt anxious. In 32 procedures the patients expressed overall satisfaction. If the procedure was to be repeated, after 29 procedures the patients requested LA again, while after four procedures they preferred i.v. sedation and after four were undecided. LA is adequate for PESA and TESA in a large proportion of patients. Prior discussion of LA technique with the patient is necessary. Back-up facilities for i.v. sedation and atropine should be available.      

经皮睾丸精子抽吸术治疗无精子症的研究

目的探讨经皮睾丸精子抽吸术(PTSA)获取睾丸精子结合卵胞浆内单精子注射术(ICSI)治疗梗阻性和非梗阻性无精子症,使之获得亲生子女.方法对121例因男性梗阻性及非梗阻性无精子症患者进行诊断性穿刺,均证实有精子后进行119个周期PTSA ICSI治疗.结果共获卵子1514个,成熟卵985个,胚胎741个,平均每例6.23个胚胎,总受精率74.4%,卵裂率97.6%;共移植114个周期和冷冻胚胎移植5个周期,平均移植2.86个胚胎,B超证实临床妊娠48例,临床妊娠率40.3%.结论采用PTSA技术获取的睾丸精子进行ICSI是治疗梗阻性及非梗阻性无精子症的一种安全、简单、有效的方法.     

Sperm retrieval and fertilization in repeated percutaneous epididymal sperm aspiration

Percutaneous epididymal sperm aspiration (PESA) for retrievalof spermatozoa for intracytoplasmic sperm injection (ICSI) isa new simplified technique in the treatment of men with obstructiveazoospermia. There has been a fear that the PESA procedure,being blind, could cause damage to the epididymal duct systemand make it impossible to retrieve spermatozoa if a repeatedprocedure is required. We report here on repeated PESA proceduresfrom the same unilateral epididymis. Twenty-seven men with obstructiveazoospermia were investigated retrospectively regarding sufficiencyof the number of motile spermatozoa for ICSI, fertilizationrate (FR) and possibility of collecting spermatozoa for cryopreservationin repeated PESA procedures. Sufficient motile spermatozoa forICSI were found in a similar proportion of men at the firsttwo attempts: 91 and 89% respectively. Fertilization rate andthe possibility of collecting spermatozoa for cryo-preservationwere also similar at the first two PESA procedures: 62 versus67% and 33 versus 33% respectively. At the third procedure,motile spermatozoa for ICSI were retrieved in 86% (6/7), FRwas 47% and spermatozoa were cryopreserved in one case. Twomen underwent a fourth PESA. In both cases, a sufficient numberof motile spermatozoa for ICSI was found and FR was 62%. Thisstudy shows that in men with obstructive azoospermia, PESA canbe repeated on the same unilateral epididymis up to three times,with good opportunity of retrieving sufficient motile spermatozoafor ICSI.     

Studies of percutaneous epididymal sperm aspiration (PESA) and intracytoplasmic sperm injection

Four distinct studies were carried out using two data sets ofpercutaneous epididymal sperm aspiration (PESA) and intracytoplasmicsperm injection (ICSI) procedures performed from March 1993to January 1997. In study A, an analysis of 181 ICSI treatmentcycles following PESA revealed a successful epididymal spermretrieval rate of 83%. It confirmed that PESA is an effectivesperm retrieval method and the associated ICSI pregnancy rate(35% per embryo transfer) compared favourably with that of othersperm retrieval methods. In study B, the relevance of a priordiagnostic PESA procedure was ascertained by comparing the spermretrieval rates in two groups of patients having their firstICSI treatment cycle with spermatozoa retrieved through PESA.Group B1 (n=50) had diagnostic PESA prior to the ICSI treatmentcycle PESA procedure, unlike patients in group B2 (n=64) whodid not. The sperm retrieval rate in the treatment cycle procedurewas not different at 90 and 82.8% for groups B1 and B2 respectively.However, the discontinuation of diagnostic PESA is fraught withproblems including liability to medico-legal sanctions. In studyC, analysis of 177 treatment cycles involving PESA and ICSIrevealed a successful sperm retrieval rate by PESA of 82% inthe first cycle, 93% in the second, 96% in the third and 100%in the fourth cycle. The same trend was evident when sperm retrievalwas examined in relation to each of the epididymides. Retrievedspermatozoa were found to be motile in 67-100% of cases andthe frequency of samples containing motile spermatozoa did notdecrease with increase in the number of PESA attempts. Theseresults show that PESA does not jeopardize future epididymalsperm retrieval. In study D, the outcome of treatment with ICSIusing ejaculated spermatozoa (305 cycles) (group D1) was comparedwith that of ICSI using spermatozoa obtained through PESA (54cycles) (group D2). The median age of women in the two groupsof couples was similar (34 years). In group D1, 70% of metaphaseII oocytes were fertilized compared with 61% in group D2 (P<0.01).The cleavage rate and the median numbers of transferred andcryopreserved embryos were similar in both groups. There wasno significant difference between the clinical pregnancy rates(33 and 42% in groups D1 and D2 respectively). Our results showthat the outcome of PESA-ICSI treatment compared favourablywith that of ICSI using ejaculated spermatozoa.     

Controlled comparison of percutaneous and microsurgical sperm retrieval in men with obstructive azoospermia

A controlled comparison of the efficacy and reliability of sperm retrieval by testicular fine needle aspiration (TFNA), percutaneous testicular needle biopsy (PercBiopsy) and microsurgical epididymal sperm aspiration (MESA) was performed in nine patients with obstructive azoospermia. During a planned MESA procedure, sperm retrieval was attempted on the same testis with TFNA and PercBiopsy. Spermatozoa were obtained from all patients using MESA and PercBiopsy. Spermatozoa were retrieved using TFNA from 6/9 (67%) men. The mean number of epididymal spermatozoa retrieved with MESA (15 x 106) was significantly higher (P = 0.003) than that retrieved percutaneously from the testis. The mean number of spermatozoa obtained by PercBiopsy was 0.116 x 10(6) while TFNA recovered 0.014 x 106 spermatozoa (P = 0.025). MESA is the optimal choice to retrieve the greatest number of spermatozoa with highest motility for assisted reproduction and subsequent cryopreservation. However, percutaneous testicular retrieval does not require microsurgical expertise and is less invasive. Our results suggest that the optimal percutaneous procedure for sperm retrieval from the testis involves percutaneous testicular needle biopsy with an automatic biopsy gun.      

Microsurgical epididymal sperm aspiration: aspirate analysis and straws available after cryopreservation in patients with non-reconstructable obstructive azoospermia. MESA/TESE Group Giessen

Microsurgical epididymal sperm aspiration (MESA) combined with intracytoplasmic sperm injection (ICSI) represents a great advance in the therapy of non-reconstructable obstructive azoospermia. For procedure synchronization, a great number of organizational facilities are needed. Intentional cryopreservation of the aspirate may reduce these problems, therefore the aim of this study was to analyse the amount and quality of aspirate fluid obtained by means of MESA and the quality of the vials after thawing. Furthermore, the available cryopreserved straws were calculated. A total of 93 consecutive MESA procedures were performed and epididymal spermatozoa were obtained in 88 patients. Mean sperm concentration was 40.9 x 10(6) spermatozoa/ml. Global and progressive motility were 24.8 and 7.5% respectively. In one-third of the aspirates, no progressive motile spermatozoa were found. The mean number of straws available was 7.6. In 33 ICSI cycles with frozen-thawed epididymal spermatozoa, a pregnancy rate of 42.4% was achieved. In conclusion, these data show that enough spermatozoa are available for various ICSI cycles following a single MESA procedure in men with non-reconstructable obstructive azoospermia. Furthermore, ICSI with cryopreserved spermatozoa leads to excellent pregnancy rates     

Outcome of testicular sperm retrieval procedures in non-obstructive azoospermia: percutaneous aspiration versus open biopsy

The aim of this study was to evaluate whether the extraction of testicular spermatozoa with percutaneous versus open biopsy has an effect on the treatment outcome with intracytoplasmic sperm injection (ICSI) in men with non-obstructive azoospermia. Regardless of testicular size, follicle stimulating hormone concentration, and previous biopsy result, percutaneous testicular sperm aspiration (PTSA) using a 21-gauge butterfly needle was attempted first and if this failed testicular sperm extraction (TESE) was performed. In 63 men spermatozoa were found with PTSA whereas in 228 men TESE had to be undertaken. More men in the PTSA group had previously been diagnosed with hypospermatogenesis (82 versus 50%). Compared with the PTSA group, more men in the TESE group had germ cell aplasia (27 versus 10%) or maturation arrest (22 versus 8%). There was no difference between the groups regarding mean age of men and their partners, duration of stimulation, oestradiol concentration on the day of human chorionic gonadotrophin, number of oocytes retrieved, fertilization rate, and embryo quality between the two groups. The number of embryos transferred (4.38 versus 3.90) was significantly higher in the PTSA group (P < 0.05), reflecting the increased number of embryos available for transfer. Implantation rate per embryo was 20.7% in the PTSA and 13.3% in the TESE group (P < 0.05). Clinical pregnancy rates were 46 and 29% in the PTSA and TESE groups respectively (P < 0.05). Clinical abortion rates were similar (21.2 versus 24%). It is concluded that in men with non-obstructive azoospermia, easier sperm retrieval, which is most likely indicative of a more favourable histopathology, is associated with higher implantation rates per embryo.     

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.      

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.      

Epididymal sperm aspiration in conjunction with in-vitro fertilization and embryo transfer in cases of obstructive azoospermia.

Epididymal sperm aspiration is a new treatment for vasal agenesis. In previous reports, epididymal spermatozoa resulted in pregnancy by utilizing in-vitro fertilization (IVF) or gamete intra-Fallopian transfer (GIFT). We sought to investigate the efficacy of epididymal sperm aspiration in conjunction with IVF in patients with congenital absence of the vas deferens or with secondary extended obstruction of spermatic ducts. Fifty-eight attempts were performed in 23 patients (25-50 years). Eight patients (34.7%) had vasal agenesis and 14 (60.8%) presented with vasal secondary extended obstruction. The sperm count was adequate (greater than or equal 20 x 10(6)/ml) in 13.8% of sperm retrievals and sperm motility of 20% was obtained in 15.5% of sperm retrievals. Fourteen attempts at IVF were performed with epididymal sperm counts of 2-44 x 10(6)/ml and motilities of 0-45%. A mean of six mature oocytes (0-13) were inseminated in each case. Five embryo transfers were performed in five patients' wives (35.7%) and two couples had an early pregnancy loss (14.2%). Epididymal sperm aspiration is an advance in treating such patients, as an adequate number of mature spermatozoa can be obtained and used for IVF. However, spermatozoa directly aspirated from the proximal epididymis and with fertilizing capacity in vitro, gave a high rate of embryo degeneration (greater than 50%) after embryo transfer.     

Surgical sperm retrieval and intracytoplasmic sperm injection as treatment of obstructive azoospermia

Male genital tract obstructions may result from infections, previous inguinal and scrotal surgery (vasectomy) and congenital bilateral absence of the vas deferens (CBAVD). Microsurgery can sometimes be successful in treating the obstruction. In other cases and in cases of failed surgical intervention, the patient can be treated by microsurgical or percutaneous epididymal sperm aspiration (MESA, PESA) or testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI). We present the results of 39 ICSI procedures for obstructive azoospermia in 24 couples. The aetiology of the obstruction was failed microsurgery in 11 patients, CBAVD in nine and genital infections in four. Sperm retrieval was accomplished via MESA in four cases, PESA in 18 cases and via TESE in 11 cases. TESE was only applied when PESA failed to produce enough spermatozoa for simultaneous ICSI. In six patients, the ICSI procedure was performed with cryopreserved spermatozoa after an initial PESA procedure. Fertilization occurred in 47% of the metaphase II oocytes; embryo transfer was performed in 92% of procedures and resulted in a clinical pregnancy in 13/39 procedures. Ongoing pregnancy was achieved in 10/39 procedures. One pregnancy was terminated early after prenatal investigation showed a cytogenetic abnormality (47,XX+18, Edwards syndrome). The other nine pregnancies resulted in the live birth of 10 children, without any congenital abnormalities. Epididymal and testicular retrieved spermatozoa were successfully used for ICSI to treat obstructive azoospermia, and resulted in an ongoing pregnancy in 10 of 24 couples (41.6%) after 39 ICSI procedures, a success rate of 25.6% per treatment cycle and of 27.7% per embryo transfer.      

附睾精子和睾丸精子妊娠结局比较

目的比较经皮附睾穿刺抽吸术和经皮睾丸精子抽吸术两种方法获得的精子妊娠结局。方法83例无精子症患者经皮附睾穿刺抽吸术取得附睾精子；35例无精子症患者经皮睾丸精子抽吸术（TESA）获得睾丸精子。女方进行常规超排卵。采用卵胞浆内单精子注射技术获得妊娠，比较两者的受精率、种植率和临床妊娠率。结果附睾精子组和睾丸精子组的受精率分别为75．20％和74．61％，比较其差异无显著性（P〉0．05）；两者的种植率和临床妊娠率分别为29．18％VS23．89％和52．43％VS40．21％，差异具有显著性（P〈0．05）。结论附睾是精子获能、成熟的重要部位，附睾精子优于睾丸精子，对无精子症患者行ICSI之前尽可能首先选取附睾精子。     

Andrology: Epididymal sperm aspiration with assisted reproductive techniques: difference between congenital and acquired obstructive azoospermia?

From July 1992 to May 1994, 31 cases of obstructive azoospermia-inducedinfertility underwent 35 epididymal sperm aspiration proceduresand assisted reproductive techniques. These included in-vitrofertilization (IVF), zygote intra-Fallopian transfer (ZIFT),subzonal insemination (SUZI) and intracytoplasmic sperm injection(ICSI) with embryo transfer or tubal embryo transfer. The motilespermatozoa were retrieved using a gauge 24 Medicut cannulaand flush medium. Total oocyte fertilization rate was 23.4%and the clinical pregnancy rate was 12.5% (four out of 32 treatmentcycles). Congenital absence of the vas deferens was found in16 cases (51.6%) and secondary genital duct obstruction waspresent in 15 cases (48.4%). In all, 29 aspirations were retrievedfrom the caput of the epididymis and six from the epididymalbody or tail. The fertilization rate for the caput spermatozoawas much less than that for other areas of the epididymis (P< 0.05). Though there were no predictable differences infertilization rates between the congenital and acquired groups,by using epididymal spermatozoa for assisted reproduction, thecongenital group seemed to have a stronger tendency to achievepregnancy (20 versus 5.9%).     

A comparison of DNA damage in testicular and proximal epididymal spermatozoa in obstructive azoospermia.

Testicular and epididymal spermatozoa are used routinely for intracytoplasmic sperm injection (ICSI) to treat men with obstructive azoospermia. Little is known of the effects of obstruction and stasis on the DNA of these spermatozoa, particularly in the epididymis where spermatozoa have been retained for long periods. Surgical epididymal aspiration for ICSI could provide spermatozoa that are senescent or dying. Using the Comet assay, the percentage of undamaged DNA of testicular spermatozoa from 20 men with obstructive azoospermia was significantly better (83.0 +/- 1. 2%) than from proximal epididymal spermatozoa (75.4 +/- 2.3%; P < 0. 05). There was no difference between the percentage of undamaged DNA of testicular spermatozoa from 39 men with obstructive azoospermia (84.0 +/- 0.9) or from 10 fertile men at vasectomy (86.8 +/- 1.8) or from ejaculated spermatozoa from five of the controls (78.9 +/- 3.9; P > 0.05). In nine subjects, a second biopsy was carried out 6 months later. There was no significant difference in undamaged DNA on these two occasions (83.5 +/- 5.6 and 84.1 +/- 4.2; P > 0.05). This confirms the reproducibility of the Comet assay for non-ejaculated spermatozoa. Our data suggest that testicular sperm DNA appears to be significantly less damaged than epididymal sperm DNA, and so testicular spermatozoa should be used in preference for ICSI to treat men with obstructive azoospermia.     

Microsurgical epididymal sperm aspiration with motile trophozoite cells but no spermatozoa

This paper reports on a patient in whom the clinical diagnosis of obstructive azoospermia was made according to clinical observations, i.e. azoospermia, normal andrological examination, normal follicle stimulating hormone and a misleading histopathological report of a testicular biopsy. Microsurgical vasoepididymostomy failed to restore fertility, and as a last resort, microsurgical sperm aspiration was performed. Although flagellated cells were observed in the epididymal aspiration, no spermatozoa were observed and wet preparation of multiple testicular biopsies failed to demonstrate any spermatozoon. This patient was diagnosed to have a non-obstructive azoospermia, resulting from maturation arrest associated with trichomonas infection at the level of the epididymis.