Diagnostic epididymal and testicular sperm recovery and genetic aspects in azoospermic men.

Various procedures for sperm recovery in azoospermic men have been described, from open testicular biopsy to simple needle aspiration from the epididymis and the testis. Fifty-one obstructive and 86 non-obstructive azoospermic men were treated to compare the recovery of spermatozoa obtained by percutaneous aspiration from the epididymis (PESA) and aspiration/extraction from the testis (TESA, TESE) with histopathology. If TESA failed, the work up proceeded with TESE. All patients were karyotyped. Spermatozoa were recovered by PESA or TESA in all obstructive men (51/51 patients). In 22 out of 86 patients with non-obstructive azoospermia, testicular spermatozoa could be successfully recovered by TESA. In five additional patients TESE was successful in recovering spermatozoa where TESA had failed. In 43 patients, neither TESA nor TESE was successful. Sixteen patients chose not to proceed with TESE. Seven out of 86 patients had an abnormal karyotype in the non-obstructive group (8%), none in the obstructive group. In the non-obstructive patient group testicular histopathology showed hypospermatogenesis, incomplete maturation arrest and germ cell aplasia with focal spermatogenesis in cases where spermatozoa were recovered and complete germ cell aplasia, complete maturation arrest and fibrosis in cases where no spermatozoa were found. Spermatozoa were recovered by PESA or TESA from all patients with obstructive azoospermia and from approximately 40% of patients with non-obstructive azoospermia by TESA or TESE. Retrieval of viable spermatozoa in the infertility work-up was highly predictable for sperm recovery in subsequent ICSI cycles. TESA performed under local anaesthesia seems almost as effective as more invasive procedures in recovering testicular spermatozoa, both in obstructive and non-obstructive azoospermic men.     

Successful testicular sperm extraction (TESE) in spite of high serum follicle stimulating hormone and azoospermia: correlation between testicular morphology, TESE results, semen analysis and serum hormone values in 103 infertile men

Spermatozoa recovered from testicular biopsies can be used through intracytoplasmic sperm injection (ICSI) to achieve a pregnancy. To assess the likelihood of successful testicular sperm extraction (TESE) in men suffering from severe oligo- or azoospermia, bilateral biopsy specimens were obtained. Following semi-thin sectioning, the morphology of testicular samples was graded according to a modified Johnsen score. TESE was performed in parallel to this histological examination. The number of isolated spermatozoa was assessed in a semiquantitative way. From 103 patients investigated, 64 (62.1%) showed azoospermia in a preceding semen analysis and 29 (28.2%) patients had sperm concentrations between 0.1 and 1 x 10(6)/ml. In 10 patients who had higher sperm counts, most spermatozoa were non-motile. Spermatozoa could be detected after TESE in the testicular tissue of 49 (77%) azoospermic men. When follicle stimulating hormone (FSH) concentration was normal, most patients had detectable spermatozoa after TESE. Nearly one-third of patients with mildly elevated FSH had no spermatozoa. Thirty-nine percent of patients in whom FSH was elevated to more than twice normal and 50% of patients with grossly elevated FSH had no detectable spermatozoa. In all, 82.8% of men with sperm concentrations between 0.1 and 1x10(6)/ml in their ejaculate showed spermatozoa in the tissue sample after TESE. Our data demonstrate that, contrary to previous recommendations, infertile men with azoospermia and high FSH values should be reconsidered for testicular biopsy, provided that tissue samples can be cryopreserved for later TESE/ICSI treatment.      

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.      

Testicular fine needle aspiration: the alternative method for sperm retrieval in non-obstructive azoospermia.

The objective of this prospective open study was to determine the feasibility of obtaining mature spermatozoa for intracytoplasmic sperm injection (ICSI) by testicular fine needle aspiration (TEFNA) in men diagnosed with non-obstructive azoospermia. TEFNA consisted of a mean of 15 punctures and aspirations in each testis, using 23 gauge butterfly needles, connected to a 20 ml syringe with an aspiration handle. Patients (n = 85) underwent 111 TEFNA cycles. Mature testicular spermatozoa were recovered in 65 (58.5%) cycles from 50 (58.8%) patients. The sperm recovery rate by testicular histology was 14 out of 29 (48.3%) in patients with Sertoli cell-only, 13 out of 28 (46.4%) in patients with maturation arrest, 19 out of 20 (95%) in patients with hypospermatogenesis, four out of six (66.6%) in patients with tubular hyalinization due to non-mosaic Klinefelter's syndrome. No spermatozoa were found in two cases with post-irradiation fibrosis. ICSI was performed in all 65 cycles. In 58 cycles in which only the husbands' spermatozoa were used, 406 mature oocytes were injected, and 154 (37.9%) were normally fertilized. Of the 143 embryos that developed (92.8%), 119 were transferred in 42 cycles resulting in 18 clinical pregnancies (42. 8%), with 31 gestational sacs, providing an implantation rate of 26%. One abortion of a singleton pregnancy occurred (5.6%). No major side-effects, such as haematoma or infection were recorded. In conclusion, we have found TEFNA to be efficient, easy to learn, safe and well tolerated by all patients. In our opinion, TEFNA should be considered the first choice whenever sperm recovery is attempted in patients with non-obstructive azoospermia.     

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.     

Extended sperm preparation: an alternative to testicular sperm extraction in non-obstructive azoospermia

Testicular sperm retrieval for the treatment of non-obstructive azoospermia requires the execution of an invasive procedure, with all its possible attending complications and subsequent long-term effects. This study suggests a new non-invasive approach for collection of spermatozoa in these patients: the extended sperm preparation (ESP). ESP consists of conducting a thorough microscopic search through many droplets of ejaculate sediment. ESP was performed for 49 patients; in 17 patients (35%), spermatozoa were found and subsequently used in intracytoplasmic sperm injection (ICSI). Of these preparations, five yielded fewer motile spermatozoa than the number of corresponding oocytes available, and in one patient only non-motile spermatozoa were recovered. The remaining 32 ESP-negative patients underwent testicular sperm extraction (TESE) from testicular biopsy. Spermatozoa were found in 16 of 32 biopsies (50%) and subsequently used in ICSI. Fertilization and cleavage rates were comparable in both ESP and TESE groups, yielding four clinical pregnancies in each group (27 and 29% respectively). Embryo morphology was defined as excellent in significantly more cases in the ESP group than the TESE group, and implantation rate appeared somewhat higher in the ESP group (16%) than the TESE group (13%). The ESP technique yields results similar to TESE, and can be applied in cases of non-obstructive azoospermia as a prerequisite modality enabling us to avoid testicular biopsy in 35% of cases.      

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.     

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.     

Testicular sperm extraction (TESE) and ICSI in patients with permanent azoospermia after chemotherapy

BACKGROUND: Patients persistently azoospermic after chemotherapy have been considered traditionally as sterile unless sperm was frozen before therapy. Recent advances during the last decade combining testicular sperm extraction (TESE) and ICSI in patients with non-obstructive azoospermia allow these males to father their own genetic offspring. METHODS: A retrospective study was conducted of 12 patients with non-obstructive azoospermia after chemotherapy undergoing TESE between 1995 and 2002. Cancer type and anti-neoplastic treatments were recorded, together with maximum testicular volume, serum FSH levels and testicular histopathology. When TESE was successful, spermatozoa were cryopreserved for performing ICSI later. RESULTS: In five patients (41.6%) motile spermatozoa for cryopreservation and ICSI were retrieved. Four of them had received chemotherapy for testicular cancer, and one had been treated by chemotherapy/radiotherapy for Hodgkin's disease. Clinical and histological parameters were unable to predict with certainty TESE outcome in an individual patient. Eight ICSI cycles were performed on five couples and one pregnancy was obtained which resulted in the delivery of a healthy girl. CONCLUSION: Some patients with permanent azoospermia after chemotherapy can be successfully treated by TESE-ICSI. This procedure, however, may have potential genetic risks. Therefore, freezing semen before starting gonadotoxic therapy is the strategy of choice, and patients should be counselled accordingly.     

A prospective study of multiple needle biopsies versus a single open biopsy for testicular sperm extraction in men with non-obstructive azoospermia

Little is known about the efficacy and the factors affecting the outcome of fine needle aspiration biopsy of the testis for sperm retrieval in azoospermic men with defective spermatogenesis. A prospective study was designed to compare the efficacy of needle and open (window) testicular biopsies for testicular epididymal sperm extraction (TESE) in 35 consecutive men with azoospermia due to defective spermatogenesis undergoing testicular biopsy for intracytoplasmic injection of oocytes. Each of the consecutive 35 patients underwent TESE using a 19 gauge butterfly needle followed by a window (1-1.5 cm-sized incision) testicular biopsy in the same procedure. The extraction of spermatozoa into culture medium was compared with the assessment of testicular biopsies by histology, the mode of biopsy (needle or open biopsy) and the amount of tissue retrieved by either method. Testicular spermatozoa were retrieved in 22 (63%) who had an open testicular biopsy compared with five (14%) patients who had multiple needle biopsies, respectively; the difference was statistically significant. Open testicular biopsy retrieves more testicular tissue than needle biopsy. Needle testicular biopsy retrieved testicular spermatozoa in 50% of those with hypospermatogenesis, 10% with focal spermatogenesis and in no patients with maturation arrest or Sertoli cell-only pattern. In contrast, sperm retrieval was successful in 100%, 90% and 66% of those with respective histologies using open testicular biopsy. Other than bruising, for which they required no analgesia, none of the patients suffered any obvious complications associated with traditional testicular biopsy. We conclude that open testicular biopsy is more effective than needle biopsy for the retrieval of testicular spermatozoa in azoospermic men with defective spermatogenesis. The difference observed may be related to the amount of testicular tissue retrieved and to the influence of testicular histology.      

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.     

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.     

Fertility with testicular sperm extraction and intracytoplasmic sperm injection in non-obstructive azoospermic men

In non-obstructive azoospermia spermatozoa can usually onlybe isolated from the testicles, and thus the most promisingtreatment model is testicular sperm extraction (TESE). Hormoneconcentrations, testicular volume determinations and testicularbiopsy results are not uniform enough to select potential candidatesfor successful TESE and intracytoplasmic sperm injection (ICSI)approaches in advance. The aim of this study was to assess theefficacy of using ICSI with testicular spermatozoa in casesof non-obstructive azoospermia and to compare the inclusioncriteria and sperm existence in the testicles in sperm obtainableand non-obtainable groups. All men showed either complete orincomplete (n = 14) maturation arrest in spermatogenesis, severehypospermatogenesis (n = 10) or Sertoli cell-only syndrome (n= 5) in their testicular biopsies. Only 14 out of a total of29 men provided enough spermatozoa for the ICSI procedure, whileno spermatozoa were found in the testicular samples of the remaining15 men. Out of 123 oocytes obtained from 14 females, 101 wereinjected with the husbands' testicular sperm cells. Total fertilizationfailure was observed in three cases. Of 39 oocytes fertilized,38 cleaved. The fertilization and cleavage rates were 38.6 and97.4% respectively. The pregnancy rate was 20.7% per initiatedcycle. In the group from whom spermatozoa were obtainable, thepregnancy rate was 42.9% per initiated cycle and 54.5% per embryotransfer. A total of six pregnancies were achieved, of whichtwo Were twins and four were singletons. One singleton pregnancyresulted in abortion in the first trimester. There was no statisticaldifference concerning the serum follicle stimulating hormoneconcentration, testicular volume and biopsy results in groupsin which spermatozoa were obtainable or not. In conclusion,although the association of TESE with ICSI obtained pregnanciesfor some patients with non-obstructive azoospermia, furtherstudies are needed to determine the inclusion criteria for successfulTESE.     

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.     

Distribution of spermatogenesis in the testicles of azoospermic men: the presence or absence of spermatids in the testes of men with germinal failure [published erratum appears in Hum Reprod 1998 Mar;13(3):780]

The aim of the study was to determine whether a prior diagnostic testicle biopsy can predict success or failure of testicular sperm extraction (TESE) with intracytoplasmic sperm injection (ICSI) in patients with non-obstructive azoospermia caused by testicular failure, and what is the minimum threshold of sperm production in the testis which must be surpassed for spermatozoa to reach the ejaculate. Forty- five patients with non-obstructive azoospermia caused by testicular failure underwent diagnostic testicle biopsy prior to a planned future TESE-ICSI procedure. The diagnostic testicle biopsy was analysed quantitatively, and correlated with the quantitative findings of spermatogenesis in patients with normal spermatogenesis, as well as with the results of subsequent attempts at TESE-ICSI. Men with non- obstructive azoospermia caused by germinal failure had a mean of 0-6 mature spermatids/seminiferous tubule seen on a diagnostic testicle biopsy, compared to 17-35 mature spermatids/tubule in men with normal spermatogenesis and obstructive azoospermia. These findings were the same for all types of testicular failure whether Sertoli cell only, maturation arrest, cryptorchidism, or post-chemotherapy azoospermia. Twenty-two of 26 men with mature spermatids found in the prior testis biopsy had successful retrieval of spermatozoa for ICSI, 12 of their partners became pregnant, and are either ongoing or delivered. The study suggests that 4-6 mature spermatids/tubule must be present in the testis biopsy for any spermatozoa to reach the ejaculate. More than half of azoospermic patients with germinal failure have minute foci of spermatogenesis which are insufficient to produce spermatozoa in the ejaculate. Prior diagnostic testicle biopsy analysed quantitatively (for the presence of mature spermatids) can predict subsequent success or failure with TESE-ICSI. Incomplete testicular failure may involve a sparse multi-focal distribution of spermatogenesis throughout the entire testicle, rather than a regional distribution. Therefore, it is possible that massive testicular sampling from many different regions of the testes may not be necessary for successful TESE-ICSI.      

Testicular sperm extraction: comprehensive analysis with simultaneously performed histology in 1418 biopsies from 766 subfertile men

The introduction of intracytoplasmic sperm injection (ICSI) has revolutionized treatment of male-factor infertility. Even with a single spermatozoon a pregnancy can be achieved. In cases of azoospermia due to obstruction or highly impaired spermatogenesis, spermatozoa can be retrieved directly from testicular tissue recovered by testicular biopsy followed by sperm extraction. The predictive value of histology from semi-thin sections of testicular biopsies was assessed in relation to testicular sperm extraction (TESE) results, using 1418 biopsy samples from 766 subfertile men which were evaluated simultaneously using a modified Johnsen score and an ordinal classification system for spermatozoa in TESE samples. In 655 men bilateral samples were available. Based on histological findings and TESE results, the quality of spermatogenesis in the right testes was significantly better than that in the left testes. There was a difference between the two sides in 35.7% of all patients for histology and 32.7% for TESE results. When best results from either testis were used for analysis, 76.9% of all men revealed spermatozoa in TESE preparations, although during histological evaluation of semi-thin sections only 64% of all men had shown mature spermatids. In a core group of 250 azoospermic men without anamnestic hints to obstruction and most likely to benefit from ICSI, TESE was successful in 62.8% men. Subdivision of this group dependent on follicle stimulating hormone (FSH) serum concentrations revealed that even in cases of increased FSH concentration, between 39.1 and 64.7% of men showed mature spermatids in their TESE samples. A subset of 70 azoospermic men from the main sample with symptoms and history suggestive of an obstruction and considered as positive controls showed a positive TESE result in all patients. The histology had failed to predict this in 2.9% of all cases. Nevertheless, in five men an early stage of testicular tumour (carcinoma in situ = CIS) was detected. Two of these males suffered from bilateral CIS. This reflects a prevalence of 0.7% testicular malignancy in the group of patients without a history of excurrent duct obstruction. The data demonstrate that a trial TESE with histology based on the semi-thin sectioning technique is a powerful diagnostic and therapeutic procedure, which justifies the invasive nature of sperm retrieval for ICSI. In addition, the results stress the importance of bilateral biopsies to gain optimal diagnostic and therapeutic results.     

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.     

Fertilization and pregnancy using intentionally cryopreserved testicular tissue as the sperm source for intracytoplasmic sperm injection in 10 men with non-obstructive azoospermia

Testicular tissue extraction (TESE) to obtain spermatozoa for use with intracytoplasmic sperm injection (ICSI) has recently been employed in patients with non-obstructive azoospermia. Standard protocol is to retrieve a new sample of testis tissue on the day of oocyte recovery. Unfortunately, approximately 30% of men will possess no spermatozoa in their tissue, making ICSI an impossibility. We investigated whether testicular tissue that was intentionally obtained well before any planned ICSI cycle and cryopreserved could then serve as an efficacious sperm source in a subsequent ICSI cycle. This study reports on 10 men with non-obstructive azoospermia who did have spermatozoa found within their testis tissue at the time of TESE and who chose to use their frozen samples as the source of spermatozoa for a later cycle of ICSI. In 19 cycles the overall fertilization rate was 48%. Embryo transfer occurred in 89% of cycles. Two couples have achieved pregnancy (one ongoing, one delivered). All patients except one had multiple vials of frozen tissue remaining following their first cycle. This approach is offered as an alternative to repeated testicular tissue sampling, as the availability of spermatozoa is assured prior to the initiation of ovulation induction. This tissue can be harvested at the same time as diagnostic biopsy, thereby minimizing the number of surgical procedures.      

Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision.

Testicular sperm extraction (TESE) is often an effective method for sperm retrieval from men with non-obstructive azoospermia. However, TESE has been a blind procedure that does not identify the focal sperm-producing areas of the testicle until after tissue has been excised from the patient. Experience with a new technique of microdissection of testicular tubules is presented here that identifies sperm-containing regions before their removal. Identification of spermatogenically active regions of the testicle is possible by direct examination of the individual seminiferous tubules. The underlying concept for this technique is simple: seminiferous tubules containing many developing germ cells, rather than Sertoli cells alone, are likely to be larger and more opaque than tubules without sperm production. In a sequential series of TESE cases for men with non-obstructive azoospermia, the ability to find spermatozoa increased from 45% (10/22) to 63% (17/27) after introduction of the microdissection technique. Microdissected samples yielded an average of 160,000 spermatozoa per sample in only 9.4 mg of tissue, whereas only 64,000 spermatozoa were found in standard biopsy samples that averaged 720 mg in weight (P < 0.05 for all comparisons). For men where microdissection was attempted, successful identification of enlarged tubules was possible in 56% (15/27) of cases. However, spermatozoa were retrieved with microdissection TESE for six men in whom sperm retrieval was unsuccessful with standard TESE approaches (35% of all men with spermatozoa retrieved). These findings suggest that microdissection TESE can improve sperm retrieval for men with non-obstructive azoospermia over that achieved with previously described biopsy techniques.     

May-Grünwald-Giemsa stain for detection of spermatogenic cells in the ejaculate: a simple predictive parameter for successful testicular sperm retrieval.

BACKGROUND: Testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI) have become standard treatments for patients with non-obstructive azoospermia. A diagnostic testicular biopsy for histopathological examination is not always predictive of TESE outcome. Moreover, it is not without potential complications. The aim of this study was to determine the value of various clinical and laboratory parameters, particularly identification of seminal spermatids using May-Grünwald-Giemsa (MGG) stain in predicting TESE results. METHODS: A total of 100 patients with non-obstructive azoospermia was subjected to clinical examination, serum FSH measurement, identification of seminal spermatids and spermatocytes using MGG staining and TESE with multiple testicular sampling. Spermatozoa were retrieved from 49% of patients. Results of TESE were compared with previous parameters in addition to histopathology. RESULTS: Testicular histopathology was, in general, an inaccurate parameter, and identification of testicular spermatids by histology predicted successful TESE in only 74% of cases. Testicular volume and serum FSH concentration also had poor predictive values. Round spermatids were identified in the ejaculate of 83.7% of TESE-positive cases, and in 22% of TESE-negative cases. CONCLUSIONS: The detection of round spermatids in semen by MGG staining provides the greatest predictive value for successful testicular sperm retrieval, and also has the advantages of simplicity, low cost and availability.