Postmortem sperm retrieval: the effect of instituting guidelines

PURPOSE: Postmortem sperm retrieval (PMSR) raises serious medical and ethical concerns. In this study we report the effect of intra-institutional guidelines developed for the permissibility of the procedure on the number of procurement procedures performed. MATERIALS AND METHODS: The family members of 22 men who died suddenly sought PMSR. We performed an institutional review board approved chart review of the requests for PMSR from 1994 to 2002. A set of guidelines addressing PMSR was developed by a panel of experts at our institution. Key elements included 1) evidence of intended paternity for the deceased man, 2) next of kin/legal consent (i.e. only the wife can give consent for PMSR), 3) the death was sudden (permitting retrieval less than 24 hours post mortem) and 4) consent to a 1-year waiting period for bereavement and assessment of recipient. RESULTS: Of the 22 families who sought PMSR 18 were not candidates for retrieval based on the criteria established by the guidelines. Four men 29 to 36 years old underwent PMSR after death and maintained on a respiratory (2) or within the first 24 hours after death (2). Procedures performed included vasal aspiration in 3 patients and epididymal/testicular retrieval in 1. Average specimen volume (including medium) was 2.1 cc, the average number of vials cryopreserved per patient was 3, sperm count was 17.6 million per ml and motility was 8.7%. All specimens demonstrated post-thaw motility. Only 1 wife used retrieved sperm for an in vitro fertilization cycle, and no pregnancy was obtained. CONCLUSIONS: The exclusionary guidelines presented provide a framework utilized at 1 institution for consideration of requests for PMSR and dramatically decreased the number of postmortem sperm retrievals performed.     

Surgical sperm retrieval

The introduction of intracytoplasmic sperm injection (ICSI) into the catalogue of assisted reproductive technologies in the mid-nineties has, for the first time, offered men who suffer from severe disorders of spermatogenesis and azoospermia the possibility of fathering a child. Different surgical techniques can be used to extract spermatozoa from these men from either the epididymis and/or the testis for ICSI. Surgical sperm retrieval offers a treatment for both patients with testicular or obstructive azoospermia in cases where microsurgical refertilization is not an option or has already failed. Among surgical techniques that have been developed over the years, microsurgical epididymial sperm aspiration (MESA) and testicular sperm extraction (TESE) have become the most popular. By utilizing these techniques together with the cryopreservation of extracted spermatozoa, a single surgical intervention is able to provide spermatozoa for several ICSI attempts.     

Updates on sperm retrieval techniques

In the most extreme form of male infertility, the male partner is azoospermic. The advent of in vitro fertilization (IVF)-intracytoplasmic sperm injection (ICSI) has revolutionized our ability to treat azoospermia in both obstructive and non-obstructive cases. In obstructive azoospermia, it allows paternity without microsurgical reproductive tract reconstruction and also in cases where the reproductive tract is unreconstructable. In men with non-obstructive azoospermia, microdissection testicular sperm extraction (mTESE) has allowed us to retrieve sperm in men with exceedingly low sperm production. The introduction of microsurgery in sperm retrieval improves sperm yields and quality while minimizing the chance of surgical morbidity.     

Temperature controlled centrifugation improves sperm retrieval

Sperm retrieval techniques form an integral part of the assisted reproductive programme. The success of sperm separation is measured by the number of motile sperm retrieved from a given semen sample. The study aimed to evaluate the effect of temperature during sperm preparation events on the number and percentage motile sperm retrieved following a double wash swim-up procedure. Thirty semen samples were obtained from 10 normozoospermic donors. After collection samples were divided into two aliquots, one aliquot was placed in an incubator at 34 °C, while the second aliquot was left at room temperature (25 °C). Sperm motility assessments were recorded with a computer assisted sperm analyser. Motile sperm fractions were retrieved from the semen samples following a double wash swim-up technique. Two tubes were prepared for each experiment. Tubes were placed in two different centrifuges: (i) SpermFuge (Shivani Industries, India) with temperature centrifuge control (34 °C) and (ii) Sigma with no temperature control facilities. Both centrifuges were set at 484 g for 5 min. Following the second wash, sperm pellets were layered with culture medium, and sperm was allowed to swim up. Supernatants were removed and analysed for sperm concentration and motility values. Percentage motile sperm was transformed to ARCSIN values and results of the two centrifugation methods at 34 °C and room temperature were compared with Mann-Whitney test for independent samples. The mean sperm concentration retrieved at 34 °C was 43.8 ± 50 (SpermFuge) and 32.7 ± 21 (Sigma) (P < 0.05), compared to retrieved concentration at room temperature namely, 30.9 ± 33 (SpermFuge) and 30.6 ± 17 (Sigma) (P ≥ 0.05). The mean percentage motile sperm at 34 °C was 64.0 ± 19 (SpermFuge) and 44.2 ± 24 (Sigma) (P = 0.02), while at room temperature the percentage motile sperm was 54.7 ± 17 (SpermFuge) compared to 46.5 ± 14 (Sigma) (P ≥ 0.05). Centrifuge temperature and incubation temperature significantly influenced the percentage retrieved motile sperm. The use of temperature-controlled sperm preparation might have clinical value for men with poor sperm motility values.     

Therapeutic testis biopsy for sperm retrieval

PURPOSE OF REVIEW: The introduction of IVF and intracytoplasmic sperm injection revolutionized the treatment of male infertility by requiring a minimal number of sperm to achieve pregnancy. We describe the various methods for testicular sperm retrieval in different types of azoospermia. RECENT FINDINGS: Different techniques for surgical sperm retrieval are available, including testicular sperm aspiration, single, multisite and microdissection testicular sperm extraction, as well as percutaneous and microsurgical epididymal sperm aspiration. While these methods have similar retrieval outcomes in obstructive azoospermia, testicular sperm extraction procedures appear to be more beneficial in cases of nonobstructive azoospermia. A reliable algorithm for predicting the outcome of microdissection testicular sperm extraction using clinical parameters is still lacking, and may be difficult to develop, given the fact that this method is designed to detect and sample even minute areas of focal spermatogenesis. SUMMARY: A variety of surgical sperm retrieval procedures can be performed for the purpose of subsequent or simultaneous IVF/intracytoplasmic sperm injection. The decision regarding the type of procedure should be based on the type of azoospermia, specific clinical circumstances, as well as on the surgeon's preference and experience.     

Parameters predicting sperm retrieval rates during microscopic testicular sperm extraction in nonobstructive azoospermia

The aim of this study was to investigate the predictive value of the parameters that might have an effect on the success of microscopic testicular sperm extraction (micro‐TESE) in infertile patients with nonobstructive azoospermia (NOA). Between 2003 and 2014, 860 patients with NOA were retrospectively analysed. The effect of age, infertility duration, history of varicocelectomy, herniorrhaphy or orchiopexy, presence of solitary testis, tobacco use, previous testicular biopsy results, history of orchitis, usage of human chorionic gonadotropin in the past three months, presence of undescended or retractile testis, presence of varicocele, testicular volume, levels of serum follicle‐stimulating hormone, luteinising hormone, and testosterone, presence of Klinefelter syndrome and micro‐deletion of Y chromosome on sperm retrieval rates were evaluated. In 45.8% (n = 394) of the patients who underwent micro‐TESE, spermatozoon was adequately obtained. Multiple logistic regression analysis demonstrated that previous successful testicular biopsy (OR = 15.346; GA = 5.45–43.16; p < .001) and higher testicular volumes significantly increase sperm retrieval rate in micro‐TESE. The testicular volume cut‐off as 11 ml was found to be the most significant factor. Although currently testicular biopsy result is not being used as a diagnostic method, it is significantly associated with micro‐TESE result.     

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。     

Microdissection testicular sperm extraction: effect of prior biopsy on success of sperm retrieval

PURPOSE: We determined the effect of prior biopsies with no sperm seen on the chance of sperm retrieval with microdissection testicular sperm extraction in men with nonobstructive azoospermia. MATERIALS AND METHODS: A total of 311 men with NOA underwent microdissection testicular sperm extraction. Of these patients 135 underwent no prior biopsies, 159 underwent 1 or 2 diagnostic testicular biopsies per testis and 17 underwent 3 or 4. The outcome measure studied was the success of sperm retrieval with microdissection testicular sperm extraction. Serum follicle-stimulating hormone and histopathological diagnosis were examined as predictive factors for sperm recovery. RESULTS: Spermatozoa were retrieved in 150 men by microdissection testicular sperm extraction (48%). The success of sperm retrieval in patients who underwent 3 to 4 biopsies (23%) was lower than the retrieval rate in patients who underwent no prior biopsies (56%) and 1 to 2 biopsies per testis (51%) (p = 0.04). When histopathology was considered, patients with Sertoli-cell-only diagnosis on prior diagnostic biopsy had lower retrieval rates compared to the group with no biopsies (p = 0.02). Men with maturation arrest and hypospermatogenesis had similar microdissection testicular sperm extraction sperm retrieval rates regardless of the number of prior biopsies. Spermatozoa recovery was independent of serum follicle-stimulating hormone. CONCLUSIONS: There is no threshold of prior negative biopsies that precludes the success of sperm retrieval using microdissection testicular sperm extraction. A limited number of testicular biopsies provide limited or no prognostic value for sperm retrieval with microdissection testicular sperm extraction.     

Need for sperm retrieval and cryopreservation at vasectomy reversal

PURPOSE: Controversy exists on whether to obtain sperm for cryopreservation routinely at vasectomy reversal. With recent improvements in in vitro fertilization with intracytoplasmic sperm injection, it is now possible to obtain a small amount of testicular tissue for cryopreservation in the event of reversal failure. However, to our knowledge no studies exist of who is most likely to benefit from this procedure. MATERIALS AND METHODS: We reviewed 84 consecutive vasectomy reversals performed by 1 surgeon (J. I. S.) between July 1996 and March 2000 with followup available for 77. We grouped cases by procedure as vasovasostomy, vasoepididymostomy and vasovasostomy with vasoepididymostomy as well as bilateral or unilateral. Sperm was retrieved at reversal in 15 of 46 vasovasostomy (none used), 11 of 18 vasoepididymostomy (3 used) and 13 of 20 vasovasostomy with vasoepididymostomy (none used) cases. RESULTS: The overall anastomotic patency rate after unilateral or bilateral vasovasostomy, unilateral vasovasostomy with contralateral vasoepididymostomy and unilateral or bilateral vasoepididymostomy was 96%, 83% and 57%, respectively. The natural pregnancy rate without in vitro fertilization was 57%, 50% and 14%, respectively. The most recent vasoepididymal anastomoses were performed by the Berger triangulation technique with a 78% patency and 25% pregnancy rate. Only 8% of men with banked sperm eventually used it for assisted reproductive techniques, in whom unilateral or bilateral vasoepididymostomy failed in all. CONCLUSIONS: We currently do not recommend routine sperm retrieval for cryopreservation in men who undergoing vasovasostomy. We encourage men who require bilateral vasoepididymostomy to bank sperm at reversal. In men who undergo vasovasostomy with vasoepididymostomy we base the decision on preoperative counseling and intraoperative findings.     

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.     

睾丸精子细针抽吸结合ICSI治疗非阻塞性无精子症

目的探讨应用睾丸细针穿刺(TEFNA)在非阻塞性无精子症患者获取成熟精子,结合ICSI治疗男性不育。方法用23号蝶型针与20ml注射器相连,注射器固定于保持其负压的手柄上,平均每个睾丸穿刺15针。结果57%(69/121)的患者,56.3%(99/176)个周期获得成熟精子,经睾丸组织学检查不同类型患者的精子获取率分别为:唯支持细胞46.7%(21/45),精子成熟障碍45.7%(16/35),精子发生低下96.1%(25/26),非嵌合型Klinefelter综合征63.6%(7/11),3例放疗后睾丸纤维化及1例单侧睾丸癌切除化疗后未获得精子。在仅注射了丈夫精子的87个周期中,591个卵细胞行精子注射,其中36.9%(218/591)受精,得到202个胚胎,其62个周期移值了178个胚胎(每个周期平均为2.831.7个胚胎),得到26例临床妊娠(共有44个妊娠囊),妊娠率为41.9%,种植率为24.7%,结论TEFNA结合ICIS是一种简易、安全、有效、易被患者接受的治疗非阻塞性无精子症的方法。     

Testicular fine needle aspiration for sperm retrieval in non-obstructive azoospermia

Objective: To investigate the feasibility of obtaining mature spermatozoa for intracytoplasmic sperm injection (ICSI) by testicular fine needle aspiration (TEFNA) in men diagnosed non-obstructive azoospermia. Methods: TEFNA was performed in 121 patients with a mean of 15 punctures and aspirations from each testis with a #23 butterfly needle connected to a 20 mL syringe with an aspiration handle. Results: One hundred and twenty-one patients underwent 176 TEFNA cycles. Testicular sperm were recovered in 56.3 % (99/176) cycles from 57 % (69/121) of patients. The sperm recovery rate was 46.7 % (21/45) in patients with Sertoli cell-only syndrome, 45.7 % (16/35) in patients with maturation arrest, 96.1 % (25/26) in patients with hypospermatogenesis and 63.6 % (7/11) in patients of non-mosaic Klinefelter's syndrome as judged by testicular histology. No sperm were found in 3 cases with post-irradiation fibrosis and one, after resection and chemotherapy of unilateral testicular cancer. In 87 cycles of ICSI using     

Histology and sperm retrieval among men with Y chromosome microdeletions

In this review of Y chromosome microdeletions, azoospermia factor (AZF) deletion subtypes, histological features and microTESE sperm retrieval rates are summarized after a systematic literature review. PubMed was searched and papers were identified using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Approximately half of infertile couples have a male factor contributing to their infertility. One of the most common genetic etiologies are Y chromosome microdeletions. Men with Y chromosome microdeletions may have rare sperm available in the ejaculate or undergo surgical sperm retrieval and subsequent intracytoplasmic sperm injection to produce offspring. Azoospermia or severe oligozoospermia are the most common semen analysis findings found in men with Y chromosome microdeletions, associated with impaired spermatogenesis. Men with complete deletions of azoospermia factor a, b, or a combination of any loci have severely impaired spermatogenesis and are nearly always azoospermic with no sperm retrievable from the testis. Deletions of the azoospermia factor c or d often have sperm production and the highest likelihood of a successful sperm retrieval. In men with AZFc deletions, histologically, 46% of men demonstrate Sertoli cell only syndrome on biopsy, whereas 38.2% have maturation arrest and 15.7% have hypospermatogenesis. The microTESE sperm retrieval rates in AZFc-deleted men range from 13-100% based on the 32 studies analyzed, with a mean sperm retrieval rate of 47%.