Efficiency of percutaneous testicular sperm aspiration as a mode of sperm collection for intracytoplasmic sperm injection in nonobstructive azoospermia

PURPOSE: We determined the feasibility of obtaining mature spermatozoa for intracytoplasmic sperm injection (ICSI) by percutaneous testicular sperm aspiration in men with nonobstructive azoospermia. We also compared the results of ICSI using spermatozoa recovered by open excisional biopsy versus percutaneous testicular sperm aspiration. MATERIALS AND METHODS: A total of 84 men with nonobstructive azoospermia underwent percutaneous testicular sperm aspiration to recover testicular spermatozoa for ICSI on the day of ova retrieval from the wife. Percutaneous testicular sperm aspiration was performed with the patient under general anesthesia in the upper and lower poles of each testis. It was followed by immediate microscopic search of the aspirate to confirm the presence of spermatozoa. In the absence of spermatozoa open excisional biopsy was performed in the same setting. RESULTS: Percutaneous testicular sperm aspiration resulted in the recovery of mature spermatozoa in 45 men (53.6%). Of the remaining 39 men (46.4%) requiring open biopsy adequate spermatozoa were recovered in 28 (71.8%). Although the fertilization rate was significantly higher in the sperm aspiration group, the cleavage and pregnancy rates were similar in the 2 groups. CONCLUSIONS: Percutaneous testicular sperm aspiration was a successful initial approach to collect mature spermatozoa in a high proportion of men with nonobstructive azoospermia. It is safe, minimally invasive and well tolerated by all patients.     

无精子症患者睾丸系统针吸检查与组织病理检查的关系

目的探讨将睾丸系统针吸检查(SFNA)与组织病理检查相结合来预测睾丸中精子存在的可能性。方法67例无精子症患者先接受睾丸切开活检术及组织病理学检查,根据活检结果将患者分为梗阻性和非梗阻性无精子症(NOA),然后进行睾丸系统针吸检查及湿片镜检来发现精子的存在。结果67例患者中梗阻性无精子症12例,非梗阻性无精子症55例。所有患者的睾丸组织病理类型分为以下几种:正常精子生成、精子生成低下、生精阻滞、唯支持细胞综合征和混合型损害。行睾丸SFNA后,49％的NOA患者中发现精子,其中组织病理类型为精子生成低下的患者具有最高的精子获取率(95％)。结论对于无精子症患者而言,睾丸系统针吸检查是在睾丸中检测精子存在的有效方法;通过该方法检测到精子的可能性与睾丸组织病理类型有密切关系。     

Beneficial effect of tamoxifen on sperm recovery in infertile men with nonobstructive azoospermia

About 10% of infertile men have azoospermia. After the introduction of microinjection [intracytoplasmic sperm injection (ICSI)], many of these men obtain the chance to be a father. But still in many cases of nonobstructive azoospermia, we are not able to find spermatozoa for ICSI. Medications may be able to increase the chance of finding spermatozoa in testis samples. So in this study, we evaluated the effect of tamoxifen citrate on the results of sperm recovery from testis tissue in infertile men with nonobstructive azoospermia. Thirty-two azoospermic infertile men with proved nonobstructive azoospermia were selected. Tamoxifen was administered for 3 months. Semen samples and in the cases of azoospermia second testis biopsy were taken, and the results were compared with the first samples. According to first testis samples, 13 patients had hypospermatogenesis, 9 had maturation arrest and 10 patients sertoli cell syndrome. After tamoxifen treatment, six patients showed spermatozoa in their ejaculates. From other patients all in hypospermatogenesis group, 75% in maturation arrest group and 20% in sertoli cell group showed spermatozoa in their second testis samples. Our study showed that treatment of patients with nonobstructive azoospermia with anti-oestrogenic drugs like tamoxifen can improve the results of sperm recovery in testis samples and also increase the chance of pregnancy by microinjection.     

Diagnostic findings from testis fine needle aspiration mapping in obstructed and nonobstructed azoospermic men

PURPOSE: Although helpful for defining extratesticular obstruction, the testis biopsy offers limited information on nonobstructive azoospermic testes. Guided by diagnostic biopsies, testis sperm extraction procedures fail in 25% to 50% of patients with nonobstructive azoospermia, largely because it is clinically difficult to know where sperm are located. To provide a more complete assessment of spermatogenesis in nonobstructive azoospermic patients and to simplify the confirmation of sperm production in men with obstruction, we use a systematic, fine needle aspiration "mapping" procedure. We summarize the diagnostic findings in a series of azoospermic men. MATERIALS AND METHODS: From 118 azoospermic infertile men (22 with obstructed and 96 with nonobstructed azoospermia) fine needle aspiration data were used to generate location specific, sperm frequency maps for obstructed and nonobstructive azoospermic testes to determine if "sperm rich" locations existed. RESULTS: Fine needle aspiration map analysis revealed that all aspiration locations from obstructed cases showed sperm. In men with nonobstructive azoospermia, sperm was identified in the right testis in 134 of 652 (20.5%) and in the left testis in 151 of 716 (21.1%) separate aspirations. Rates of sperm detection among various intratesticular sites were not statistically different. In 27.1% of cases the fine needle aspiration map found sperm in men with sperm negative biopsies. The likelihood of heterogeneity in fine needle aspiration sperm findings was 25% within individual nonobstructive azoospermic testes and 19.2% between testis sides. At post-procedure followup of 88 patients (74%), no clinical or surgical complications were observed. CONCLUSIONS: Testis fine needle aspiration mapping is a simple, reliable and informative diagnostic tool in the evaluation of azoospermic infertile men.     

Role of testicular tissue telomerase assay for the prediction of the presence of testicular spermatozoa in azoospermic men with varicoceles, pre- and post-varicocelectomy

We evaluated the reproductive potential of frozen/thawed testicular spermatozoa of azoospermic men with left varicocele. The role of testicular tissue telomerase assay (TTA) in the prediction of the presence of testicular spermatozoa pre- and post-varicocelectomy was investigated, as well. Therapeutic testicular biopsy and TTA were performed in 82 nonobstructed azoospermic (NOA) men with varicoceles. Testicular spermatozoa were found in 33 men and processed for cryopreservation. Oocytes were later recovered from the spouses of the latter azoospermic men with varicoceles and injected with frozen/thawed testicular spermatozoa. Among the 49 men who were negative for testicular spermatozoa, 22 men underwent subsequently subinguinal microsurgical varicocelectomy. A total of 198 mature oocytes were successfully injected and 101 were normally fertilized and subsequently cleaved. Transfer of these 101 embryos in 26 women resulted in nine full-term pregnancies. Thirteen healthy babies were delivered. A cut-off value of TTA of 39 TPG U microg(-1) protein had an overall diagnostic accuracy equal to 90.2% to predict the presence of testicular spermatozoa pre-varicocelectomy. Within the group of men who were negative for testicular spermatozoa a cut-off value of TTA equal to 28 TPG U microg(-1) protein (pre-varicocelectomy) had a 84.2 % diagnostic accuracy to recognize the men who would become positive for either ejaculated or testicular spermatozoa post-varicocelectomy. Testicular spermatozoa can be found in 40% of NOA men with left varicocele. Ooplasmic injections with frozen/thawed testicular spermatozoa have a role in the therapeutic management of non-obstructive azoospermia associated with varicocele. Pre-varicocelectomy, a TTA cut-off value equal to 39 TPG U microg(-1) protein has a 90.2% diagnostic accuracy to indicate the men positive/negative for testicular spermatozoa. In addition, pre-varicocelectomy, a cut-off value equal to 28 TPG U microg(-1) protein has a 84.2% diagnostic accuracy to identify those men with varicoceles without testicular spermatozoa, who will become positive/negative for spermatozoa (either ejaculated or testicular) post-varicocelectomy.     

Image Analysis Assessment of the Abnormal Testis Biopsy in Male Infertility

Purpose

We previously demonstrated that testis biopsy image analysis is an effective method for quantifying intratubular spermatogenic cells in the obstructed testis with normal spermatogenesis. As an extension of the initial report, we describe using the quantitative ploidy and morphological characteristics of cells counted with image analysis in abnormal testis biopsies obtained for a male infertility evaluation.

Materials and Methods

Image analysis using a specifically designed filter was performed on Feulgen stained 5 micro m. sections of paraffin embedded testicular tissue. Archival testicular tissue had been obtained using standard biopsy techniques from patients with azoospermia or severe oligospermia. Qualitative classification was based on standard evaluation of hematoxylin and eosin processed tissue.

Results

There were 62 biopsies performed in 58 men. Significant differences in the intratubular content of haploid (spermatozoa and spermatids), diploid and tetraploid cells were found among the 5 categories of abnormalities: the Sertoli-cell-only syndrome, spermatocyte arrest, spermatid arrest, hypospermatogenesis and normal spermatogenesis. Moderate variability was found in the proportion of cell types in spermatid arrest and hypospermatogenesis.

Conclusions

Testis biopsy image analysis provides a quantitative method for categorizing abnormalities of intratubular cell content present in male infertility states by using deoxyribonucleic acid content and morphology characteristics. The limitations of the present qualitative analysis system are emphasized by the moderate variability evident within the current categories of spermatid arrest and hypo-spermatogenesis states.     

Effects of phosphodiesterase-5 inhibitor vardenafil on testicular androgen-binding protein secretion, the maintenance of foci of advanced spermatogenesis and the sperm fertilising capacity in azoospermic men

We evaluated the effects of vardenafil on testicular androgen-binding protein secretion (ABP). Bilaterally obstructed azoospermic (OA)-men (n = 19) (group A) underwent unilateral testicular biopsy. A group of nonobstructed azoospermic (NOA)-men (n = 68) (group B) underwent bilateral testicular biopsy. ABP secretion in vitro by testicular tissue was assessed in each participant of every group. In addition, intracytoplasmic sperm injection (ICSI) cycles were performed in several couples of group A or group B using frozen/thawed spermatozoa from the biopsy material. Ten OA-men (group A1), 14 NOA-men (group B1), and nine different NOA-men (group B2) had been positive for spermatozoa in the biopsy but pregnancies were not achieved in the respective female partners. Men of groups A1, B1 and B2 were treated with vardenafil, vardenafil and L-carnitine respectively. Then, the men of groups A1, B1 and B2 underwent a second testicular (unilateral) biopsy. Within the group A1 and within the group B1, ABP secretion rate was significantly larger after vardenafil treatment than prior to vardenafil treatment. In addition, fertilisation rates in ICSI cycles within groups A1 or B1 were not affected by vardenafil administration. Vardenafil administration in NOA-men increased ABP secretion and did not affect detrimentally the presence of testicular foci of advanced spermatogenesis.     

Histopathological mapping of open testicular biopsies in patients with unobstructive azoospermia.

OBJECTIVE: To evaluate, in patients with unobstructive azoospermia, the heterogeneity of spermatogenesis within the testes and thus whether there is any region of advanced spermatogenesis. Patients and methods Seventy infertile men (mean age 34 years, SD 5.01) with no varicoceles or testicular atrophy had bilateral open testicular biopsies taken from six different sites. For each biopsy specimen the number of seminiferous tubules and of tubules with sperm maturation were counted (by light microscopy at x 400). The ratio of tubules with active spermatogenesis to the total number was calculated for each biopsy sample. RESULTS: The mean (SD) right and left testicular volumes were 19.82 (7.8) and 18.84 (7.89) mL, respectively; the patients' follicle-stimulating hormone level was 8.34 (1.17) IU/mL. On sextant biopsy spermatozoa were detected in 42 of the 70 patients (60%). The mean (SD) ratio of tubules with spermatozoa was 5.23 (0.8)% for the right and 5.37 (0.76)% for the left testes. There was no statistically significant difference in the ratio of seminiferous tubules positive for spermatozoa at the different biopsy sites in either the right or left testis. Spermatozoa were identified in only one to three biopsy sites in almost half of those with maturation arrest; this ratio increased to 74% in patients diagnosed as having Sertoli-cell-only syndrome with focal spermatogenesis. Conclusion There is no region of the testis that is rich or advanced in spermatogenesis in patients with unobstructive azoospermia. Without multiple testicular biopsy it is possible to miss advanced spermatogenesis in some unobstructed patients. The sextant testis biopsy is a reliable method for detecting the presence and exact location of seminiferous tubules with spermatozoa in patients with unobstructive azoospermia.     

Sensitivity and specificity of serum FSH and testis size in predicting the existence of spermatogenesis in azoospermic infertile men

The objective of research was to determine the sensitivity, specificity and positive predictive value of serum follicle stimulating hormone and testis size in predicting spermatogenesis in infertile men with azoospermia. In a prospective study, azoospermic men were studied. Serum follicle stimulating hormone measurement and scrotal sac ultrasonography were performed. Bilateral testis biopsy was performed for all of these patients. The sensitivity and specificity of follicle stimulating hormone and testis size were determined to predict the existence of different cellular steps of spermatogenesis. Of eighty infertile men who recruited into the study, 53 patients did not represent any different cellular steps of spermatogenesis, while 27 of them had various steps of such differentiation. Among the 53 patients without cellular steps of spermatogenesis in the biopsy, 41 were predicted to be azoospermic based on their serum follicle stimulating hormone levels (77.3% sensitivity), and of 27 patients with various cellular steps of spermatogenesis in the biopsy, 23 were predicted to have spermatozoa according to the follicle stimulating hormone level (85.2%) specificity. It is suggested that combination of these two indicators can substitute the invasive testis biopsy for predicting the existence of spermatozoa in infertile men with azoospermia.     

Testicular sperm extraction with intracytoplasmic sperm injection for nonobstructive azoospermia: testicular histology can predict success of sperm retrieval

PURPOSE: We present treatment results of testicular sperm extraction with intracytoplasmic sperm injection for men with nonobstructive azoospermia and reevaluate the role of testicular histology on open diagnostic testicular biopsy as a predictor of sperm retrieval success. MATERIALS AND METHODS: We evaluated 75 men diagnosed with nonobstructive azoospermia. Cases were categorized into 3 groups of hypospermatogenesis, maturation arrest or Sertoli-cell-only based on the most advanced pattern of spermatogenesis seen on histology. A total of 81 testicular sperm extractions with intracytoplasmic sperm injection were performed for these 75 men. The main outcome measures reviewed included sperm retrieval, fertilization and pregnancy rates with intracytoplasmic sperm injection. Sperm retrieval success rates for men in the 3 histological categories were compared. RESULTS: Spermatozoa were successfully retrieved during 47 of 81 (58%) testicular sperm extraction attempts, with subsequent fertilization of 268 of 439 (61%) injected metaphase II oocytes using intracytoplasmic sperm injection. Clinical pregnancies were obtained in 26 of 47 (55%) cycles when sperm were retrieved, with ongoing pregnancies or live deliveries for 20 of 47 (43%). Of 39 men with hypospermatogenesis on diagnostic biopsy 31 (79%) had successful sperm retrieval, compared to 9 of 19 (47%) with maturation arrest and 5 of 21 (24%) with a pure Sertolicell-only pattern. CONCLUSIONS: Critical examination of the most advanced pattern of spermatogenesis from open diagnostic testis biopsy allows prediction of sperm retrieval success with testicular sperm extraction. In this study population spermatozoa were retrieved in 58% of attempts. When this testicular sperm was used with intracytoplasmic sperm injection, clinical pregnancy rate was 55% for men with nonobstructive azoospermia.     

Percutaneous Testis Biopsy: An Alternative to Open Testicular Biopsy in the Evaluation of the Subfertile Man

Purpose

We evaluated the safety and efficacy of percutaneous testis biopsy by comparing the ultrasound appearance and histological status of testicular parenchyma obtained to those noted after open testis biopsy.

Materials and Methods

A total of 51 consecutive infertile men with azoospermia or severely impaired semen quality, in whom ductal obstruction was suspected, underwent percutaneous (31) or open (20) testis biopsy, with 58 and 34 procedures performed, respectively. Scrotal ultrasound was performed preoperatively, and at 2 weeks and 1, 3 and 6 months after biopsy. In addition, immunoglobulins G and A antisperm antibody assays were obtained preoperatively and postoperatively. Two biopsy specimens were obtained from each testis for formal histological evaluation. A touch preparation was also performed and examined immediately for mature spermatozoa using phase contrast microscopy.

Results

All biopsies yielded adequate tissue for diagnosis and morphometric analysis. Of 58 percutaneous biopsies 4 (7 percent) demonstrated sonographic evidence of intratesticular bleeding, characterized by a hypoechoic region within the testicular parenchyma, which resolved by 6 months postoperatively. In contrast, 10 of 34 open biopsies (29 percent) showed evidence of intratesticular bleeding or a new area of increased echogenicity at 1 month after the procedure (intraparenchymatous scar). All intraparenchymatous scars persisted to 6 months postoperatively. No patient undergoing percutaneous or open testis biopsy had antisperm antibodies in the seminal fluid or serum (azoospermia cases) or on sperm postoperatively. Of the 32 and 20 patients undergoing percutaneous and open testis biopsy 3 (9 percent) and 14 (70 percent), respectively, required narcotic analgesia. All patients returned to routine activities within 24 hours after percutaneous testis biopsy. No postoperative infections or extratesticular hematomas were noted. Pathological study was diagnostic in all specimens.

Conclusions

Percutaneous testis biopsy is well tolerated by the patient, with fewer apparent complications than and diagnostic value equal to open testis biopsy. Percutaneous testis biopsy should be considered an alternative to open biopsy.     

Testicular biopsy: clinical practice and interpretation

Testicular biopsy was considered the cornerstone of male infertility diagnosis for many years in men with unexplained infertility and azoospermia. Recent guidelines for male infertility have limited the indications for a diagnostic testicular biopsy to the confirmation of obstructive azoospermia in men with normal size testes and normal reproductive hormones. Nowadays, testicular biopsies are mainly performed for sperm harvesting in men with non-obstructive azoospermia, to be used for intracytoplasmic sperm injection. Testicular biopsy is also performed in men with risk factors for testicular malignancy. In a subgroup of infertile men, there is an increased risk for carcinoma in situ of the testis, especially in men with a history of cryptorchidism and testicular malignancy and in men with testicular atrophy. Ultrasonographic abnormalities, such as testicular microlithiasis, inhomogeneous parenchyma and lesions of the testes, further increase the risk of carcinoma in situ (CIS) in these men. For an accurate histological classification, proper tissue handling, fixation, preparation of the specimen and evaluation are needed. A standardized approach to testicular biopsy is recommended. In addition, approaches to the detection of CIS of the testis testicular immunohistochemistry are mandatory. In this mini-review, we describe the current indications for testicular biopsies in the diagnosis and management of male infertility.     

Unilateral or bilateral testicular biopsy in the era of intracytoplasmic sperm injection

PURPOSE: Intracytoplasmic sperm injection has significantly improved the treatment of male infertility. Since only single vital spermatozoa are required for successful fertilization, the value of unilateral or bilateral diagnostic testicular biopsies in patients with azoospermia is controversial. We evaluated differences in bilateral testicular biopsies in azoospermic patients with regard to testicular histology and focal spermatogenesis. MATERIALS AND METHODS: Histopathological results of 100 testicular biopsies from 50 patients (mean age 33.3 years) were reviewed. In all cases azoospermia was the indication for diagnostic testicular biopsy. Intra-individual differences of bilateral testicular biopsies were retrospectively reviewed by determining the latest stage of spermatogenesis. RESULTS: After bilateral biopsy a difference in testicular histology was found in 28% and identical histopathology was noted in 70% of patients. An unsuspected burned out seminoma with maturation arrest in the contralateral testis was seen in 2% of cases. Testicular symmetry determined by a Prader orchidometer was noted in 54.8% of patients whereas 45.2% had asymmetrical testis. The frequency of divergent histopathologies in relation to testicular symmetry was 21.7 and 26.3%, respectively. Spermatozoa were found in 42% of right and 44% of left testes (p >0.05), and spermatids as the latest stage of differentiation were detected in 14 and 16%, respectively (p >0.05). Differentiation of testicular histologies according to the side of biopsy revealed spermatozoa and/or spermatids in 56% of right and 58% of left testes (p >0.05). Bilateral biopsies increased the detection of focal spermatogenesis to 68%. If only unilateral diagnostic testicular biopsies had been performed, in 20% of patients focal spermatogenesis in the contralateral testis would have been missed. CONCLUSIONS: Bilateral testicular biopsies are superior to unilateral biopsies in the evaluation of patients with azoospermia. A 28% intra-individual difference in testicular pathology was seen after bilateral biopsies, and in 20% of patients focal spermatogenesis would have been missed after unilateral biopsy only. Due to the prognostic relevance of testicular biopsies for successful sperm retrieval before assisted reproduction, bilateral diagnostic testicular biopsies are recommended in the evaluation of patients with azoospermia.     

Testicular Sperm Retrieval in Azoospermic Men

ContextSperm retrieval in combination with IVF/ICSI is the only medical procedure for an azoospermic man to father a child. Different techniques, especially testicular sperm extraction (TESE), have evolved over time and have dramatically improved the outlook for men with testicular azoospermia. However sperm retrieval rates are associated not only with the operation proposed but especially with a distinct pattern of prognostic factors that must be effectively managed for all these infertile patients for their best benefit.ObjectivesTo review the etiology, clinical work-up including operative techniques, and prognostic factors for testicular sperm retrieval in azoospermic men to maximin clinical benefit by these procedures.Evidence AcquisitionData from basic and clinical studies with a defined, standardized approach pre- and postoperatively were analyzed.Evidence SynthesisDifferent standardized surgical techniques can be offered to extract spermatozoa of azoospermic men from either the epididymis and/or the testis for ICSI. Sperm retrieval offers a treatment for both patients with testicular azoospermia and men with obstructive azoospermia in cases where microsurgical refertilization is not an option or has already failed. Among surgical techniques testicular sperm extraction (TESE) and microsurgical epididymial sperm aspiration (MESA) have become the most popular techniques. However, also percutaneous techniques are employed due their easy feasibility and low costs. By utilizing these techniques together with kryopreservation of extracted spermatozoa a single surgical intervention is able to provide spermatozoa for several ICSI attempts. Extensive surgical interventions in the testis of azoospermic patients have raised concerns about the potential influence on the endocrine compartment of the testis, particularly in patients with small testes and low levels of testosterone.ConclusionsTesticular sperm retrieval is a feasible and successful procedure. Testicular spermatozoa can be retrieved from the testis in up to 70% of patients, even in cases with testicular azoospermia and severe disorders of spermatogenesis. However, surgical damage of the testis might also compromise the interstitial compartment of the testis with testosterone deficiency as a consequence. Conclusively, endocrine follow-up can be considered mandatory.     

Testicular obstruction: clinicopathological studies.

Genital tract reconstruction has been attempted in subfertile men with obstructive azoospermia (370 patients) or unilateral testicular obstruction (80 patients), and in vasectomised men undergoing reversal for the first (130 patients) or subsequent (32 patients) time. Histopathological changes in the obstructed testes and epididymes, and immunological responses to the sequestered spermatozoa have been studied to gain insight into possible causes of failure of surgical treatment. The results of surgery have been assessed by follow-up sperm counts and occurrence of pregnancies in the female partners. The best results were obtained with vasectomy reversal (patency 90%, pregnancy 45%), even after failed previous attempts (patency 87%, pregnancy 37%). Epididymovasostomy gave good results with postinfective caudal blocks (patency 52%, pregnancy 38%), while postinfective vasal blocks were better corrected by total anatomical reconstruction (patency 73%, pregnancy 27%) than by transvasovasostomy (patency 9%, no pregnancies). Poor results were obtained with capital blocks (patency 12%, pregnancy 3%), in which substantial lipid accumulation was demonstrated in the ductuli efferentes; three-quarters of these patients had sinusitis, bronchitis or bronchiectasis (Young's syndrome). There is circumstantial evidence to suggest that this syndrome may be a late complication of mercury intoxication in childhood. After successful reconstruction, fertility was relatively reduced in those men who had antibodies to spermatozoa, particularly amongst the postinfective cases. Similarly, impaired fertility was found in men with unilateral testicular obstruction and antibodies to spermatozoa. Mononuclear cell infiltration of seminiferous tubules and rete testis was noted occasionally, supporting a diagnosis of autoimmune orchitis; although rare, this was an important observation as the sperm output became normal with adjuvant prednisolone therapy.     

Obstruction of the tubuli recti and ductuli efferentes by dilated veins in the testes of men with varicocele and its possible role in causing atrophy of the seminiferous tubules

Hormone measurements, spermiograms and testicular biopsies studies were performed in young with varicocele. In addition, the testes and epididymides of 27 adults with varicocele were obtained from autopsies. Light and electron microscopic examination of biopsy and autopsy specimens revealed two types of lesions in testes with varicocele: 1) a diffuse lesion consisting of abnormal spermatozoa and spermatid morphology and sloughing of immature spermatozoa and spermatid; 2) focal lesion, distributed irregularly throughout the testicular parenchyma, affecting several small groups of seminiferous tubules. Each of these groups corresponded to a testicular lobule and showed different degrees of tubular atrophy, so that the focal lesions were distributed in a mosaic pattern. The testicular interstitium showed dilated veins and venules, and progressive collagenization. Some testes showed dilated veins in the rete testis, which compressed several tubuli recti and caused tubular atrophy in the seminiferous tubules opening into these tubuli recti. Other testes showed dilated young veins among the ductuli efferentes, and the rete testis channels appeared to be dilated. Among the different etiological mechanisms which have been suggested to for testicular lesions in varicocele, tubular obstruction at the level of either the tubuli recti or the ductuli efferentes might be responsible for lesions leading to testicular atrophy.     

Role of testicular fine needle aspiration in the diagnosis of azoospermia

Fine needle aspiration (FNA) of the testis is gaining recognition as an important step in the diagnosis of azoospermia. In 1000 azoospermic men receiving a short-acting anaesthetic, each testis was subject to FNA from three standard sites – lower, middle and upper zones – using 26-gauge needles. Azoospermia was graded in the following way: adequate spermatozoa (A1), low, scanty or rare spermatozoa (A2), spermatid arrest (B1), spermatocyte arrest (B2), Sertoli cell-only pattern (C) and sclerosis (D). The FNA grade showed a strong correlation with cell yield, testicular volume and serum follicle stimulating hormone (FSH) levels (all p  < 0.0001). Excretory and secretory azoospermia corresponded strongly with FNA grades A1 and A2, respectively. FNA grading was predictive of clinical outcome in terms of sperm yield at testicular sperm extraction, fertilization and pregnancy. In our series, FNA of the testis was relatively free of complications; we recommend its use in the routine diagnosis of azoospermia.     

The Effect of Epididymal and Testicular Fluids on the Fertilising Capacity of Testicular and Epididymal Spermatozoa

It is possible that the fertilising capacity of spermatozoa in the epididymis is influenced by the epididymal secretion. We have studied this problem by obtaining spermatozoa before entry into the epididymis and after passage through it, incubating both types of spermatozoa in fluids from the rete testis and cauda epididymidis and then checking their fertilising capacity. While spermatozoa from the rete testis were infertile, rete testis fluid did not decrease the fertilising capacity of epididymal sperm from the cauda epididymidis. Fluid from the cauda epididymidis did not promote the fertilising capacity of testicular spermatozoa. These results are discussed in the light of the current understanding of epididymal physiology.     

Male factors determining the outcome of intracytoplasmic sperm injection with epididymal and testicular spermatozoa

During a period of 8 years, 1,079 intracytoplasmic sperm injection (ICSI) procedures with aspirated epididymal or testicular spermatozoa were performed. Epididymal spermatozoa were used in 172 cycles and testicular spermatozoa or spermatids in 907 cycles. Multiple biopsies were obtained from at least two different locations in the testes. Retrieved spermatozoa were used after cryopreservation (frozen) or immediately after aspiration (fresh). Three hundred patients had obstructive azoospermia (OA) or ejaculation failure. In 414 cases, azoospermia was caused by impaired spermatogenesis resulting from maldescended testes, chemotherapy/radiotherapy, or by Sertoli-cell-only syndrome, genetic disorders or unknown aetiology. Transfer rates, pregnancy rates and birth rates per ICSI cycle showed no statistically significant differences between testicular and epididymal spermatozoa in men with OA (28% average birth rates in both cases). However, birth rates differed significantly with regard to the status of spermatogenesis. Treatment of men with nonobstructive azoospermia (NOA) resulted in a birth rate of 19% per cycle. In all patient groups, there was no difference in the birth rates achieved with fresh and cryopreserved spermatozoa. While testicular volume, follicle-stimulating hormone level and age of the male patient are no statistically significant prognostic factors, the underlying cause of azoospermia is the most important factor determining the outcome of ICSI with epididymal and testicular spermatozoa. The pregnancy rate is lower in NOA patients than in those with OA.     

The Occurrence of Sperm Agglutinating Antibodies Before and After Testicular Biopsy

Bilateral testicular biopsy was performed in 30 infertile men with azoospermia or with less than 30 mill. spermatozoa per ml. Blood serum was analysed for sperm-agglutinating antibodies prior to the operation and during six months post-operatively. Out of 26 subjects, with no sperm-agglutinating antibodies in the blood, only one had a weak and transitory agglutinating activity post-operatively.