Conventional versus microdissection testicular sperm extraction for nonobstructive azoospermia

PURPOSE: We established a practical and safe strategy for testicular sperm extraction (TESE) in patients with nonobstructive azoospermia and compared conventional with microdissection TESE. MATERIALS AND METHODS: In a retrospective comparative study 46 patients, including 22 with obstructive and 24 with nonobstructive azoospermia, underwent conventional TESE. Another 100 patients, including 26 with obstructive and 74 with nonobstructive azoospermia, underwent microdissection TESE. Conventional TESE was performed via 3 small 5 mm. incisions in the tunica albuginea. Microdissection TESE was performed by making a 3 to 4 cm. incision in the tunica albuginea under operating microscopy, avoiding the underlying testicular artery. Seminiferous tubules that appeared dilated and opaque were harvested. Sperm recovery rates were compared, as were complication rates assessed by ultrasonographic and endocrinological evaluations. RESULTS: In obstructive azoospermia cases the sperm recovery rate was 100% for each procedure. In nonobstructive azoospermia cases sperm were recovered in 16.7% and 44.6% by conventional and microdissection TESE, respectively (p = 0.0271). In cases of histologically diagnosed maturation arrest the sperm recovery rate was 37.5% and 75%, respectively (p = 0.22585). In cases of the Sertoli-cell-only syndrome the sperm recovery rate was 6.3% and 33.9%, respectively (p = 0.0494). We identified dilated and opaque seminiferous tubules containing spermatozoa under operating microscopy in 22.2% of patients with maturation arrest and in 63.2% with the Sertoli-cell-only syndrome. The complication rate was significantly lower for microdissection than for conventional TESE. CONCLUSIONS: In nonobstructive cases, especially those of the Sertoli-cell-only syndrome, microdissection TESE can effectively retrieve spermatozoa and minimize the risk of complications.     

The efficacy of repeat percutaneous epididymal sperm aspiration procedures

PURPOSE: The development of intracytoplasmic sperm injection spawned new methods of sperm retrieval for men with obstructive azoospermia who did not want to undergo reconstruction of the seminal tract. There is a wide array of different procedures that may be performed in these cases, for instance percutaneous epididymal sperm aspiration (PESA) and microepididymal sperm aspiration. However, concerns regarding the presence of sperm in a second PESA attempt due to possible fibrosis have been suggested by many authors. We evaluate if it is worthwhile to repeat percutaneous epididymal sperm aspiration. MATERIALS AND METHODS: The records of 20 patients (23 attempts) who underwent repeat PESA from January 1996 to September 2000 for assisted reproductive technique purposes were reviewed. In all patients the repeat procedure was performed on the same side as the previous PESA. Data were collected on patient age, presence of motile sperm during PESA, epididymal side, pregnancies and abortion rates. RESULTS: Mean patient age +/- SD was 32.4 +/- 5.6 years. One patient was excluded from our analysis due to lack of information on the chart regarding the side of the procedure. Repeat PESA was performed in the right epididymis in 12 attempts and in the left in 10. Of the remaining 19 patients 14 (73.68%) did not and 5 (26.3%) have sperm in the epididymal fluid. In these 5 patients 8 repeat PESA procedures were performed (3 procedures in 1 and motile sperm was always found (8 of 22 attempts, 36.4%). Three patients achieved pregnancy with the motile sperm retrieved from the repeat PESA (3 of 8 repeat attempts, 37.5%). No abortions were detected. CONCLUSIONS: More than a third of repeat PESA attempts resulted in the presence of motile sperm. Before performing testicular sperm aspiration or extraction in patients who have undergone previous PESA without achieving pregnancy, repeat PESA may be done. Further attempts should be added in the future to confirm these results.     

Sperm retrieval by microdissection testicular sperm extraction and intracytoplasmic sperm injection outcomes in nonobstructive azoospermic patients with Klinefelter syndrome

Klinefelter syndrome is the most frequent chromosomal abnormality in patients with nonobstructive azoospermia. The development of advanced assisted reproductive techniques, such as testicular sperm extraction and intracytoplasmic sperm injection, has provided the possibility of biological fathering in nonobstructive azoospermic patients with Klinefelter syndrome. We aimed to evaluate our sperm retrieval rate by microdissection testicular sperm extraction and to analyse the intracytoplasmic sperm injection outcomes in these patients. Medical records of 110 nonobstructive azoospermic patients with Klinefelter syndrome were retrospectively reviewed. We found that the sperm retrieval rate by microdissection testicular sperm extraction is lower than published reports on other types of secretory azoospermia. The statistical analyses yielded that age, FSH and testosterone levels as predictive factors for successful sperm retrieval.     

微创取精术结合ICSI治疗阻塞性无精子症的研究

目的探讨采用微创手术从阻塞性无精子症患者获取精子,再行卵母细胞单精子显微注射(ICSI)及胚胎移植治疗不育症的效果。方法对20例阻塞性无精子症患者先行经皮附睾精子抽吸术(PESA),如果未取到精子,再行睾丸精子穿刺吸取术(TESA),随后行ICSI辅助生育治疗周期共20次。结果20例病人中,采用PESA成功获得精子者共18例,未成功者2例,进一步行TESA后,均获得精子。用取得的精子行MⅡ期卵子ICSI后,受精率达68．09%,在20例胚胎移植后获得临床妊娠9例(45%)。结论对于阻塞性无精子症患者,应用微创取精术可以成功获得精子,行ICSI治疗后可获得满意的受精率和临床妊娠率,微创取精术可以成为阻塞性无精子症患者获得精子的首选方法。     

Outcome of in vitro fertilization and intracytoplasmic injection of epididymal and testicular sperm obtained from patients with obstructive and nonobstructive azoospermia

PURPOSE: We assessed fertilization, pregnancy and miscarriage rates in patients with obstructive and nonobstructive azoospermia who underwent intracytoplasmic sperm injection. MATERIALS AND METHODS: From June 1996 to March 2000, 166 consecutive patients (198 intracytoplasmic sperm injection cycles) with azoospermia were studied. Of these 198 cycles 68 were performed due to nonobstructive azoospermia using testicular spermatozoa and 130 were performed due to obstructive azoospermia using epididymal spermatozoa. RESULTS: The normal (2 pronuclei) and abnormal (1 plus 3 pronuclei) fertilization rates for obstructive and nonobstructive azoospermia were 60.5% and 16.6%, and 54% and 16.4%, respectively (p >0.05). The pregnancy rate per cycle, pregnancy rate per patient and abortion rate were 30%, 39.8% and 28% for obstructive azoospermia, and 22%, 28.3% and 40% for nonobstructive azoospermia (p <0.05). The normal and abnormal fertilization rates were 58.7% and 21.4% for percutaneous epididymal sperm aspiration (PESA), 62.3% and 10.4% for PESA plus testicular sperm aspiration (TESA), and 57.3% and 14.5% for TESA, respectively (p >0.05). The pregnancy rate per cycle, pregnancy rate per patient and abortion rate were 34.6%, 54.5% and 11.1% for PESA, 37.5%, 37.5% and 33.3% for PESA plus TESA, and 26.1%, 31% and 41% for TESA, respectively (PESA versus PESA plus TESA p >0.05, and PESA and PESA plus TESA versus TESA p <0.05). Epididymal or testicular motile sperm resulted in a lower abortion rate than epididymal or testicular immotile sperm (p = 0.03). CONCLUSIONS: No differences were noted in the fertilization and embryo transfer rates irrespective of etiology (obstructive versus nonobstructive) and type of spermatozoa (epididymal versus testicular). Testicular sperm retrieval results in lower fertilization and pregnancy rates as well as higher abortion rates than epididymal sperm retrieval.     

Salvage microdissection testicular sperm extraction after failed conventional testicular sperm extraction in patients with nonobstructive azoospermia

PURPOSE: TESE is considered the best procedure for identifying a tubule for spermatozoa retrieval. This technique improves the SRR to around 50%. However, it has been unclear whether it is useful in patients in whom conventional TESE has failed. We compared the outcome of microdissection TESE in patients in whom conventional TESE failed to that in patients who did not undergo conventional TESE. We also evaluated relations between the outcome of salvage microdissection TESE and the characteristics of previous conventional TESE. MATERIALS AND METHODS: A total of 46 patients with nonobstructive azoospermia in whom salvage microdissection TESE was performed after failed conventional TESE were included. Patient characteristics and the SRR were compared between these patients and 134 in whom conventional TESE had not been performed previously. The previous TESE procedure, testicular histology and interval between TESEs were also evaluated. RESULTS: Patient characteristics did not differ significantly between the groups. The microdissection TESE SRR also did not differ significantly between the groups (45.7% vs 44.0%). The possibility of successful spermatozoa retrieval by salvage microdissection TESE remained regardless of the previous failure of any other TESE procedure and regardless of testicular histology. The salvage microdissection TESE SRR was not related to the interval between TESEs. CONCLUSIONS: Because salvage microdissection TESE is effective in patients in whom conventional TESE has failed, this option should be made available to them with the understanding that extended followup after salvage microdissection TESE is necessary due to the risk of hypogonadism.     

66例男性不育患者采用自然周期IVF/M结合胞浆内单精子注射技术治疗的研究

目的探讨自然周期成熟卵母细胞结合未成熟卵母细胞体外成熟方法(natural cycle in vitro fertilization combined with in vitro maturation of immature oocytes,自然周期IVF/M)用于治疗男性因素引起不育的临床价值。方法66例适应证患者分成3组:少弱精子组、偶见活精子组和无精子症组[行经皮附睾精子抽吸术(PESA)、睾丸精子抽吸术(TESA)或睾丸切开取精术(TESE)],接受72个自然周期IVF/M,比较三组受精率和临床妊娠率。结果64例患者完成70个治疗周期。少弱精子组、偶见活精子组和无精子症组分别占完成周期数的54.3%、38.6%和7.1%,共获得卵母细胞812个,平均(11.3±5.2)个。卵母细胞成熟率为61.2%,正常受精率为82.2%,卵裂率为90.0%(377/419)。共26例患者获得临床妊娠,每取卵周期的妊娠率为36.4%(26/72),每移植周期的妊娠率为37.1%(26/70)。三组受精率分别为84.5%、78.9%和80.0%,三组间差异无统计学意义(P>0.05),临床妊娠率分别为39.5%,29.6%和60.0%,PESA/PESE和TESE组的临床妊娠率(60%)显著高于精液中偶见活精子组(29.6%,P<0.05)。结论自然周期IVF/ M技术对于治疗由于男性因素引起的不育如少弱精子症以及无精子症是一种简便有效的方法。     

Genetic and epigenetic risks of intracytoplasmic sperm injection method

Pregnancies achieved by assisted reproduction technologies,particularly by intracytoplasmic sperm injection(ICSI)procedures,are susceptible to genetic risks inherent to the male population treated with ICSI and additionalrisks inherent to this innovative procedure.The documented,as well as the theoretical,risks are discussed in thepresent review study.These risks mainly represent thatconsequences of the genetic abnormalities underlying malesubfertility(or infertility)and might become stimulators for the development of novel approaches and applications inthe treatment of infertility.In addition,risks with a polygenic background appearing at birth as congenital anomaliesand other theoretical or stochastic risks are discussed.Recent data suggest that assisted reproductive technologymight also affect epigenetic characteristics of the male gamete,the female gamete,or might have an impact on earlyembryogenesis.It might be also associated with an increased risk for genomic imprinting abnormalities.(Asian JAndrol 2006 Nov;8:643-673)     

睾丸穿刺活检在卵浆内单精子注射辅助生育中的价值

目的 评价单、双侧睾丸穿刺活检在无精症的病理诊断和卵浆内单精子注射生育中的价值。方法 随机对65例无精症患者进行单侧或双侧活检；测量患者睾丸体积，计算手术时间，评估术后并发症，记录病理结果。结果 65例无精症患者睾丸穿刺病理结果显示：唯支持细胞综合征41例（63％），生精功能低下10例（15．4％），精子成熟阻滞9例（13．8％），正常生精功能5例（7．8％）。双侧睾丸活检术后出现腰腹疼痛10例、恶心8例，单侧睾丸活检仅2例出现腰腹疼痛。双侧睾丸活检中，病理显示生精状态不同者占50％（15／30）。结论 睾丸钳穿活检是一种简单、损伤少的活检方法。单点、单侧睾丸活检可以对无精症进行诊断，但不能反映双侧睾丸的不同生精状态，对欲行卵浆内单精子注射的患者应行双侧睾丸活检，切开获取精子可能是最好的办法。     

不同生精功能和取精方式对无精子症ICSI妊娠结局的影响

目的 分析采用经皮附睾精子抽吸术(PESA)或经皮睾丸精子抽吸术(TESA)获得精子对不同生精功能无精子症进行卵泡浆内单精子注射(ICSI)治疗的妊娠结局.方法 经PESA获得附睾精子,经TESA获得睾丸精子,女方进行常规超排卵.两种取精方法获得的精子进行ICSI,比较其妊娠率.结果 216次采用PESA获得附睾精子,87次采用TESA获得睾丸精子,PESA和TESA组的妊娠率分别为41.7%和43.7%,(P>0.05).随着生精功能状态从正常到重度生精功能障碍的变化,其妊娠率依次为:46.8%,41.6%,36.7%和16.7%.其中生精功能正常组与轻度和中度生精功能障碍组差异无统计学意义,但与重度生精功能障碍组差异均有统计学意义.结论 采用PESA或TESA结合ICSI是治疗男性无精子症的有效方法,而且认为生精功能正常组和轻度及中度生精功能障碍三组无精子症患者均可试行ICSI.     

睾丸组织Johnsen评分对非梗阻性无精子症患者取精成功率的预测

目的探讨睾丸组织病理学Johnsen评分是否可以作为非梗阻性无精子症患者取精成功的预测因素.方法选取2008年6月至2011年6月来院就诊的非梗阻性无精子症患者513例.所有患者均行详细的病史采集、体格检查、实验室检查、睾丸活检及活检组织病理学检查等.患者随访1~3年,其主要包括患者是否进一步行睾丸取精术以及取精的结果.结果总计有399例患者接受了活检同侧的睾丸取精术,其中睾丸穿刺取精成功112例,而穿刺取精失败的患者通过进一步接受睾丸显微取精术,成功取精44例.通过分析睾丸取精成功的预测因素后发现,当Johnsen评分≥7时,非梗阻性无精子症患者睾丸取精的成功率将显著提升.结论睾丸组织病理学Johnsen评分≥7可能是睾丸取精成功的预测因素.     

Ideal culture time for improvement in sperm motility from testicular sperm aspirates of men with azoospermia

PURPOSE: The motility of testicular derived spermatozoa reflects viability and predicts success during intracytoplasmic sperm injection. Although improvements in sperm motility are seen after incubation for extended periods, no guidelines suggest duration or media use for optimal improvement in motility. MATERIALS AND METHODS: Between July 1999 and February 2005 testicular aspirations were performed on 95 men with azoospermia, including 51 with obstructive azoospermia and 44 with nonobstructive azoospermia. Sperm motility was determined at initial collection and following incubation for 24 or 48 hours in processing media or Ham's F10 + protein. A mixed regression model controlling for testis side, media and baseline motility was created to analyze the change in motility between 24 and 48 hours. RESULTS: Mean motility improved from 3% to 20% at 24 hours and 25% at 48 hours for OA cases and from 0% to 5% at 24 hours and 11% at 48 hours for nonobstructive azoospermia cases. The improvement in motility from 24 to 48 hours was significant for obstructive azoospermia cases (p = 0.001). While media was a nonsignificant factor in regression models, when patients were grouped into categories of motility change there was a significantly better response to F10 compared to processing media (p = 0.03). CONCLUSIONS: Incubation in processing media or Ham's F10 + albumin media improves sperm motility with significant improvement noted between 24 and 48 hours for obstructive azoospermia cases. Ham's F10 + albumin media may provide extra benefit for cases of nonobstructive azoospermia or nerve injury. These results suggest the ideal timing of oocyte retrieval for intracytoplasmic sperm injection correlates with 48-hour sperm incubation for obstructive azoospermia cases, and 24 hours for nonobstructive azoospermia and nerve injury cases.     

Treatment of infertility due to anejaculation in the male with electroejaculation and intracytoplasmic sperm injection

PURPOSE: We tested the hypothesis that spinal cord injury and/or anejaculation affects the outcome of intracytoplasmic sperm injection (ICSI). MATERIALS AND METHODS: From November 1993 to October 1998 we obtained and prospectively reviewed data on 34 ICSI cycles using electroejaculated sperm, 620 male factor infertility ICSI cycles using normal ejaculated sperm and 120 cases of obstructive azoospermia, in which microsurgical epididymal aspiration and testicular sperm extraction-ICSI were done in 93 and 27, respectively. RESULTS: A total of 34 ICSI cycles were performed in 17 couples with male infertility due to anejaculation secondary to spinal cord injury in 10 patients and retroperitoneal lymph node dissection in 5, and idiopathic in 2. In all 17 couples at least 3 previous intrauterine insemination cycles had failed. After electroejaculation 11 men had oligozoospermia and 6 normal sperm density. Median sperm retrieval volume plus or minus standard deviation was 1.9 +/- 1.9 ml., median sperm concentration 70.7 +/- 60.2 x 106 sperm per ml., median motility 10.7% +/- 10.8% and median forward progression 2.3 +/- 0.5 (scale 1 to 4). In the anejaculation group ICSI resulted in a median fertilization of 60% +/- 28%, 15% pregnancies per cycle and 29% pregnancies per couple. In the control group of 620 ICSI cycles from ejaculated specimens obtained from male patients with infertility median fertilization was 58% +/- 26%, and there were 39% pregnancies per cycle and 47% pregnancies per couple. The rate of pregnancies per embryo transfer and per couple was higher in the control than in the electroejaculation-ICSI group (p <0.05). However, there was no statistically significant difference in the fertilization rate. CONCLUSIONS: ICSI or in vitro fertilization is a viable alternative for patients with anejaculation in whom intrauterine insemination failed. While the fertilization rate is similar in these couples, the pregnancy rate is significantly lower than that achieved with ejaculated specimens from patients with severe male factor infertility. ICSI is a viable alternative for a patient with anejaculation in whom intrauterine insemination or in vitro fertilization failed.     

Imprinting analysis in spermatozoa prepared for intracytoplasmic sperm injection (ICSI)

Genetic imprinting is a mechanism of gene regulation by which only one of the parental copies of a gene is expressed. This process is mediated by the methylation of DNA. As spermatozoa represent exclusively the paternal contribution to a future individual, they are expected to carry the paternal imprint only. For intracytoplasmic sperm injection (ICSI), spermatozoa mostly have to be selected from samples with pathological semen parameters. Correct establishment of the paternal imprint in these spermatozoa has not yet been demonstrated. In the present study, imprinting analysis was undertaken using DNA extracted from spermatozoa from men with normal semen analysis (group A: n=30 patients) and from men with an abnormal sperm count (B: n=30 patients with 5--20 million spermatozoa/mL and C: n=30 patients with < or =5 million spermatozoa/mL) from the ICSI program. It was performed using firstly a conventional methylation-specific polymerase-chain-reaction (M-PCR) and secondly a more sensitive modified hemi-nested M-PCR technique. In addition, a single cell PCR was performed on a total of 88 single spermatozoa (collected from nine males) and on 25 leucocytes (control group). With the conventional M-PCR, exclusively paternal imprints were found in all groups. Using the more sensitive hemi-nested M-PCR, additional maternal imprints were found in 63% of the samples in A, 57% in B and 60% in C. In the single cell PCR, exclusively paternal imprints were detected. Because of the very small amount of DNA (3 pg), a complete amplification failure occurred in 43% of spermatozoa. The correct paternal and maternal imprints were found in 56% of the analysed leucocytes (complete amplification failure in the other 44%). In conclusion, ejaculated spermatozoa from males with medium or high-grade semen pathology proved to have the same imprinting status as those from males with normal semen parameters. As the additional maternal imprints were never found at the single cell level, they were classified as contamination by diploid cells such as leucocytes or immature germ cells in the processed and purified semen samples, which can be detected by a more sensitive PCR method in contrast to the conventional standard PCR.     

附睾、睾丸精子卵浆内单精子注射治疗阻塞性无精症引起不育

为评价附睾或睾丸精子卵浆内单精子注射（ＩＣＳＩ）治疗阻塞性无精症引起不育的疗效，对３１例无精子男性不育患者配偶进行超排卵治疗３７个周期，获卵当日从患者附睾取精，其中２４例获得活动精子，７例失败，改用钳取睾丸曲细精管从中分离精子以供ＩＣＳＩ。结果：共获卵４５３个，附睾、睾丸精子ＩＣＳＩ受精率分别为５５７％、６１７％，平均每周期移植胚胎３７个，总妊娠率每周期２９７％。结论：只要获得活动精子ＩＣＳＩ，阻塞性无精症患者也有机会生育     

声触诊组织成像定量技术用于非梗阻性无精子症睾丸精子抽吸术

目的 观察声触诊组织成像定量(VTIQ)技术用于非梗阻性无精子症(NOA)睾丸精子抽吸术(TESA)的价值。 方法 前瞻性纳入60例NOA患者,随机分为VTIQ组和常规组,每组30例;选择于VTIQ组VTIQ示睾丸剪切波速度(SWV)最小处和常规组睾丸中部最厚处行TESA,观察组间获精率差异,分析VTIQ用于TESA的价值。结果 组间患者年龄、不育年限、睾丸体积、促卵泡激素(FSH)、促黄体生成激素(LH)、睾酮(T)、雌二醇(E₂)及抗米勒管激素(AMH)差异均无统计学意义(P均＞0.05);VTIQ组总获精率显著高于常规组(χ²=6.79,P＜0.05)。VTIQ组获精处睾丸穿刺点的SWV为(1.44±0.31)m/s;以SWV=1.63 m/s为截断值,选择睾丸最优穿刺点行TESA的约登指数为0.75,敏感度和特异度分别为91.70%和83.30%。结论 VTIQ有助于TESA前评估NOA患者睾丸组织弹性及选择最优穿刺点。     

Outcome of microsurgical testicular sperm extraction in familial idiopathic nonobstructive azoospermia

The aim of the study was to evaluate the sperm retrieval rate by microsurgical testicular sperm extraction (TESE) in familial idiopathic nonobstructive azoospermia (NOA). One hundred and nineteen patients with idiopathic NOA who underwent microsurgical TESE over the past 5 years were included. Patients were then divided into two groups; Group ‘A’ with familial idiopathic NOA (11 families with two brothers in each family, 22 patients) and Group ‘B’ with nonfamilial idiopathic NOA (97 patients). Clinical data as well as data of microsurgical TESE were recorded. In Group ‘A’, the sperm retrieval rate was 9.1% (2/22 patients) compared to 45.4% in Group ‘B’ (44/97 patients) (P ≤ 0.05). The two patients in Group ‘A’ with successful sperm retrieval belonged to one family. The histopathological diagnosis was the same in the brothers in each family. It can be concluded that the testicular sperm retrieval rate in familial idiopathic NOA is significantly lower than in nonfamilial idiopathic NOA.