The Feasibility of Cryopreservation of Sperm Harvested Intraoperatively During Vasectomy Reversals

Purpose

Intracytoplasmic sperm injection during in vitro fertilization involves the microinjection of a single sperm into each egg from the partner. Pregnancies have resulted from this powerful new technology when fewer than 100 motile sperm were present in the semen, or when sperm were obtained from the epididymis or testicle by open operations or needle aspirations. Some surgeons have cryopreserved sperm obtained from the vas or epididymis during vasectomy reversals. However, cryopreservation of nonmotile sperm serves no useful purpose.

Materials and Methods

We performed a retrospective analysis of 603 vasectomy reversals in which the intraoperative vasal and/or epididymal fluid was examined microscopically. The motility of the sperm obtained intraoperatively was used as a gauge for the potential use of such sperm for in vitro fertilization and intracytoplasmic sperm injection after cryopreservation and thawing, should the vasectomy reversal fail.

Results

Motile sperm were present in the intraoperative vasal or epididymal fluid in 35% of all vasectomy reversals (34% of first and 39% of repeat procedures). The percentage of reversals in which motile sperm were present in the intraoperative fluid was not related to the time from vasectomy until reversal.

Conclusions

The absence of motile sperm in the intraoperative vasal or epididymal fluid precludes consideration of sperm cryopreservation during vasectomy reversals. Although to our knowledge the minimum percentage of sperm motility needed for in vitro fertilization and intracytoplasmic sperm injection after cryopreservation and thawing has not been established, our results provide surgeons with information to judge the merit of sperm harvesting and cryopreservation during vasectomy reversals.     

Clearance after vasectomy with a single semen sample containing < than 100 000 immotile sperm/mL: analysis of 1073 patients

Study Type – Diagnostic (non‐consecutive)
Level of Evidence 3b

OBJECTIVE

To evaluate the safety and efficacy of a new semen analysis protocol after vasectomy, where clearance is given to patients who provide a single semen sample with <100 000 immotile sperm/mL at ≥3 months after vasectomy.

PATIENTS AND METHODS

Between 1 July 2005 and 31 March 2008, 1073 men provided a first semen sample at ≥3 months after vasectomy. Semen was first evaluated on a wet‐slide preparation. Those samples with no (‘azoospermia’) or sporadic immotile spermatozoa could be cleared without further analysis. Samples with motile sperm were immediately labelled as potentially fertile, while those with a significant number of immotile sperm were re‐analysed using a Neubauer haemocytometer. All samples with <100 000 immotile sperm/mL were cleared.

RESULTS

Of men providing semen at 3 months after vasectomy, 96% could be cleared. No sperm were seen (‘azoospermia’) in 51.3% of samples, and 44.7% of samples contained <100 000 immotile sperm. No paternity has been reported in the cleared group after a follow‐up of at least 1 year.

CONCLUSIONS

A protocol stipulating that patients can be cleared after a single semen sample containing <100 000 immotile sperm/mL at ≥3 months after vasectomy is safe and dramatically reduces the number of men who cannot be cleared at 3 months after vasectomy.     

Quality of cryopreserved testicular sperm in patients with obstructive and nonobstructive azoospermia

PURPOSE: Sperm retrieved by testicular sperm extraction is routinely used to attempt pregnancy by in vitro fertilization-intracytoplasmic sperm injection. We evaluated the efficacy of cryopreserving testicular sperm collected by testicular sperm extraction at diagnostic biopsy. MATERIALS AND METHODS: A total of 73 men with obstructive and 42 with nonobstructive azoospermia underwent testicular sperm extraction at diagnostic biopsy. Sperm was retrieved and cryopreserved in all cases of obstruction and in 15 of nonobstructive azoospermia cases. Before freezing we determined sperm count, motility, morphology and viability, and after thawing we assessed sperm motility and viability. In 17 couples a total of 20 cycles of in vitro fertilization-intracytoplasmic sperm injection were performed and fertilization, cleavage and pregnancy rates were determined in cases of obstruction and nonobstruction. RESULTS: Sperm count and morphology were lower in the testicular biopsies of men with nonobstructive versus obstructive azoospermia. Motility was low or absent in all testicular sperm extraction specimens. Importantly, pre-freeze (63%) and post-thaw (31%) viability was the same in both patient groups. After in vitro fertilization-intracytoplasmic sperm injection using frozen and thawed testicular sperm the fertilization, cleavage, implantation and clinical pregnancy rates were 60, 86, 16 and 50%, respectively. Using cryopreserved sperm we observed no differences in outcome of any in vitro fertilization-intracytoplasmic sperm injection procedure in patients with obstructive versus nonobstructive azoospermia. CONCLUSIONS: Cryopreservation of testicular sperm provides enough good quality sperm after thawing to result in excellent in vitro fertilization-intracytoplasmic sperm injection outcomes. Cryopreservation does not adversely affect intracytoplasmic sperm injection outcomes, including pregnancy rate. Therefore, we recommend routine testicular sperm extraction and cryopreservation of sperm at testicular biopsy.     

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.     

The motility of epididymal or testicular spermatozoa does not directly affect IVF/ICSI pregnancy outcomes

Our objective was to determine whether the presence of motility in surgically obtained sperm samples improves fertilization and pregnancy rates for patients undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). This was a retrospective study in a hospital-based infertility center. Sixty-seven couples with a diagnosis of azoospermia or severe oligozoospermia who had undergone a sperm retrieval procedure in conjunction with 100 IVF/ICSI cycles from 1995 to 2004 were evaluated. The impact of sperm motility on fertilization and clinical pregnancy rates was determined. The motile and nonmotile sperm groups differed in the number of mature oocytes retrieved (10.7 +/- 5.8 vs 13.4 +/- 6.0), but fertilization (56.7% vs 59.1%) and embryo cryopreservation rates (35.9% vs 39.3%) were statistically similar. Clinical pregnancy rates did not differ between the motile (38.5%) and nonmotile (31.2%) groups, nor did they differ between obstructive and nonobstructive patients (35.3% vs 26.7%). There was also no statistical difference in pregnancy rates between testicular and epididymal aspiration (35.3% vs 26.7%), although epididymal sperm were significantly more likely to be motile than testicular sperm (100% vs 39.3%, P < .0001). Epididymal aspiration is more likely to produce motile sperm than testicular sperm retrieval. The use of motile sperm from epididymal or testicular samples, however, does not appear to enhance fertilization or clinical pregnancy rates.     

The kinetics of the return of motile sperm to the ejaculate after vasectomy reversal

PURPOSE: In prior analyses we observed that the achievable patency rate after vasectomy reversal is a key factor in whether reversal surgery is more cost-effective than in vitro fertilization-intracytoplasmic sperm injection for fertility after vasectomy. Because pregnancies will occur sooner with an earlier time to patency, this clinical parameter becomes important with advanced maternal age. We hypothesize that there are predictors of time to patency after reversal that are valuable for patient counseling and intraoperative decision making in cases of advanced maternal age. MATERIALS AND METHODS: We retrospectively reviewed a cohort of consecutive men who underwent vasectomy reversal. Data obtained included patient demographics, semen analyses, intraoperative findings, patency rates and time to achieve patency. RESULTS: A total of 150 patients met the inclusion criteria. Mean patient age was 42.9 years (range 27 to 61) and mean followup was 12.5 months (range 1 to 90). The presence of motile sperm in vasa predicted faster patency rates postoperatively. Of patients with motile sperm 95% achieved patency by 6 months whereas 76% of patients without motile sperm achieved patency within 6 months (p = 0.04). An obstructive interval of 8 years or less and undergoing vasovasostomy instead of epididymovasostomy predicted faster time to patency within the first 3 months after reversal. Patient age was not associated with time to patency after bilateral vasovasostomy. CONCLUSIONS: Motile sperm found intraoperatively at the testicular vas, undergoing vasovasostomy and an obstructive interval of 8 years or less predict shorter time to patency after vasectomy reversal. Patient age does not appear to affect patency kinetics after reversal. Patient counseling regarding fertility after vasectomy may benefit from this information especially in the setting of advanced maternal age.     

VASECTOMY REVERSAL ASSOCIATED WITH INCREASED REACTIVE OXYGEN SPECIES PRODUCTION BY SEMINAL FLUID LEUKOCYTES AND SPERM

Purpose

Reactive oxygen species, which are primarily produced by leukocytes, are generally detrimental to sperm. High reactive oxygen species levels are found in men with abnormal sperm function. Since men often have poor sperm characteristics and infertility after vasectomy reversal, fertile men to determine if reactive oxygen species were elevated in the former group.

Materials and Methods

We studied semen samples of men with proved fertility (39) and those with previously proved fertility who had undergone vasectomy reversal (45). The presence of leukocytes was determined by Bryan-Leishman staining. Reactive oxygen species endogenous activity was monitored by luminol dependent chemiluminescence in washed cells, including all cells in the semen, and Percoll density gradient purified sperm.

Results

After vasovasostomy men had significantly lower sperm concentration, motility and computerized motility measurements than fertile men. Mean reactive oxygen species in washed seminal cells after vasovasostomy was 684 relative light units per second compared to 49 for fertile controls (p <0.0001). Density gradient purified sperm had 53 and 0.64 relative light units per second, respectively (p <0.0001). When men with leukocytospermia were excluded from analysis, differences between the groups remained, although 9 times more reactive oxygen species were detected in men after vasectomy reversal with than those without leukocytes in semen.

Conclusions

Higher levels of reactive oxygen species are found in washed seminal cells and purified sperm after vasectomy reversal than in those of fertile men. Although leukocytes are probably a significant source of reactive oxygen species in these groups, they may not account for all of the increased reactive oxygen species after vasovasostomy. Low motility after vasectomy reversal may be related to the detrimental effects of reactive oxygen species produced by leukocytes or sperm, even in men without clinical leukocytospermia.     

Morphology of testicular spermatozoa obtained by testicular sperm extraction in obstructive and nonobstructive azoospermic men and its relation to fertilization success in the in vitro fertilization-intracytoplasmic sperm injection system

The aim of the present study was to evaluate the morphology of testicular spermatozoa by 3 different determinants. Sperm cells were obtained and their morphology was evaluated from 27 testicular sperm extraction (TESE) operations, of which 20 men had nonobstructive azoospermia and 7 had obstructive azoospermia. In 17 cases, 2 biopsies were obtained from 2 different locations of the testis. Only mature spermatozoa presenting full-grown tail (tail dimension about 10-fold greater than the head dimension) were counted. Three characteristics of sperm morphology were evaluated: head dimensions, and acrosome and midpiece irregularities. The percentage of sperm cells with normal morphology (considering the 3 characteristics) in specimens from patients with obstructive and nonobstructive azoospermia were 47% +/- 4.6% and 29 +/- 1.8%, respectively (P < .01). The percentage of spermatozoa with normal head dimensions were 76% +/- 3.2% and 63% +/- 2.6% (P > .05), those with normal acrosome were 58% +/- 4.6% and 41% +/- 3.4% (P < .05), and those with normal midpiece were 74% +/- 4.1% and 67% +/- 1.6% (P > .05), in obstructive and nonobstructive azoospermia, respectively. No significant differences were observed in sperm morphology between different locations of the testis. Sperm morphological characteristics were not associated with fertilization rate in intracytoplasmic sperm injection (ICSI). Follicle-stimulation hormone and luteinizing hormone were inversely correlated with normal morphology of testicular spermatozoa (r = -0.49 and r = -0.47, respectively; P < .05). It can be concluded that a relatively high portion of testicular sperm are morphologically normal. The higher rate of normal spermatozoa in obstructive azoospermia compared with nonobstructive spermatozoa suggests that the factors leading to azoospermia may affect testicular sperm morphology. The morphological characteristics of testicular sperm do not affect fertilization rate in ICSI.     

The Effect of Microsurgical Varicocelectomy on Semen Parameters in Men with Non-Obstructive Azoospermia

Introduction

The aim of this study was to evaluate the effect of microsurgical subinguinal varicocelectomy on semen parameters in azoospermic men with clinical varicocele and to determine the predictive parameters of postoperative improvement.

Methods

Twenty-three men with non-obstructive complete azoospermia and varicocele underwent subinguinal open microsurgical varicocele repair. The outcome was assessed in terms of improvement in semen parameters after surgical repair for varicocelectomy.

Results

Bilateral varicocelectomy was performed on 15 patients and unilateral (left) varicocelectomy was performed on 8 patients. In the post-operative period, of the 23 patients, 7 (30.4%) had motile sperm in the ejaculate. The mean sperm concentration of these patients was 1.34 ± 2.6 × 10⁶/ml and the mean total sperm motility was 37.5 ± 15.5%.

Conclusion

Infertile men with non-obstructive azospermia can have improvement in semen analysis after subinguinal microsurgical repair of varicoceles. Motile sperm in ejaculate were detected after microsurgical varicocele repair.Key Words: Azoospermia, Microsurgery, Motile sperm, Varicocele     

SUCCESSFUL SPERM RETRIEVAL BY PERCUTANEOUS EPIDIDYMAL AND TESTICULAR SPERM ASPIRATION

Purpose

We evaluated the safety and efficacy of percutaneous sperm aspiration from the epididymis or testicle as a diagnostic technique to confirm sperm production and as a therapeutic technique to harvest sperm for use in intracytoplasmic sperm injection.

Materials and Methods

We present our experience with 69 sperm aspiration procedures in men considered to have nonreconstructible obstructive azoospermia. This short outpatient procedure was performed using a butterfly needle with the patient under intravenous sedation and local anesthesia.

Results

Of the 32 diagnostic aspirations 20 demonstrated mature and motile sperm, 9 maturation arrest and 3 germ cell aplasia. In 35 of 37 therapeutic sperm aspirations (95%) adequate samples of sperm after processing (mean of 5.4 million) were obtained. Of 24 epididymal aspirations 13 (54%) had sufficient residual sperm for cryopreservation of 1 to 5 vials (mean 2.5) containing an average of 170,000 sperm per vial. In the 32 intracytoplasmic sperm injection cycles 221 of 392 eggs (56.3%) fertilized (2PN) and 6 resulted in ongoing pregnancies (21.4% per transfer). There have been no acute or chronic complications in this patient population. Ten men underwent a second successful aspiration procedure for intracytoplasmic sperm injection and 3 underwent a third aspiration without added difficulty.

Conclusions

Percutaneous epididymal or testis sperm aspiration is a minimally invasive sperm retrieval technique and appears to be an effective alternative to microsurgical epididymal sperm aspiration, which is more invasive, costly and technically difficult.     

Clomiphene administration for cases of nonobstructive azoospermia: a multicenter study

Clomiphene citrate is a well-established agent that has been empirically used in cases of idiopathic oligospermia. Clomiphene increases endogenous gonadotropin-releasing hormone secretion from the hypothalamus and gonadotropin hormone secretion directly from the pituitary and, thus, increases intratesticular testosterone concentration. Using intracytoplasmic sperm injection (ICSI), very few sperm may be required for fertilization. The objective of this study was to determine if the application of clomiphene citrate in males with nonobstructive azoospermia might produce sufficient sperm for ICSI, either by resulting in sperm identified in the ejaculate or by potentially improving outcomes of surgical testicular sperm extraction. Forty-two patients with nonobstructive azoospermia (age range, 25-39 years) from 3 international centers were evaluated with routine history, physical examination, and hormonal assessment. Initial testicular biopsy demonstrated maturation arrest in 42.9% and hypospermatogenesis in 57.1% of patients. Clomiphene citrate was administered, with the dose titrated to achieve serum testosterone levels between 600 ng/dL and 800 ng/dL, and semen analyses were performed at periodic intervals. In patients remaining azoospermic on semen analysis, surgical testicular biopsy and sperm extraction were performed. After clomiphene citrate therapy, 64.3% of the patients demonstrated sperm in their semen analyses ranging from 1 to 16 million sperm/mL, with a mean sperm density of 3.8 million/mL. Sufficient sperm for ICSI was retrieved by testicular sperm extraction in all patients, even though 35.7% remained azoospermic. Additionally, clomiphene citrate administration resulted in a statistically significant increase in testis biopsy patterns associated with greater likelihood of sperm obtained by surgical extraction (P < .05). We conclude that clomiphene citrate administration may result in sperm in the ejaculate of patients with nonobstructive azoospermia or the simplification of testis sperm retrieval. Surgeons may consider a course of clomiphene citrate administration prior to surgical sperm retrieval in patients with nonobstructive azoospermia.     

The role of testicular biopsy in the modern management of male infertility.

PURPOSE: We evaluate the traditional role of isolated testicular biopsy as a diagnostic tool, as opposed to the value as a therapeutic procedure for azoospermic men. MATERIALS AND METHODS: The medical records of azoospermic patients who were evaluated, and treated between 1995 and 2000 were retrospectively analyzed for history, physical examination findings, endocrine profiles, testicular histology and sperm retrieval rates. Based on these parameters, cases were placed into diagnostic categories that included obstructive or nonobstructive azoospermia. Diagnostic parameters used to distinguish obstructive from nonobstructive azoospermia were subjected to statistical analysis with the t-test, analysis of variance and receiver operating characteristics curve. RESULTS: A total of 153 azoospermic men were included in our analysis. Of men with obstructive azoospermia 96% had follicle-stimulating hormone (FSH) 7.6 mIU/ml. or less, or testicular long axis greater than 4.6 cm. Conversely, 89% of men with nonobstructive azoospermia had FSH greater than 7.6 mIU/ml., or testicular long axis 4.6 cm. or less. Receiver operating characteristics analysis revealed that FSH, testicular long axis, and luteinizing hormone were the best individual diagnostic predictors, with areas 0.87, 0.83 and 0.79, respectively. CONCLUSIONS: In the vast majority of patients obstructive azoospermia may be distinguished clinically from nonobstructive azoospermia with a thorough analysis of diagnostic parameters. Based on this result, we believe that the isolated diagnostic testicular biopsy is rarely if ever indicated. Men with FSH 7.6 mIU/ml. or greater, or testicular long axis 4.6 cm. or less may be considered to have nonobstructive azoospermia and counseled accordingly. These men are best treated with therapeutic testicular biopsy and sperm extraction, with processing and cryopreservation for usage in in vitro fertilization and intracytoplasmic sperm injection if they accept advanced reproductive treatment. Diagnostic biopsy is of no other value in this group. Men with FSH 7.6 mIU/ml. or less, or testicular long axis greater than 4.6 cm. may elect to undergo reconstructive surgery with or without testicular biopsy and sperm extraction, or testicular biopsy and sperm extraction alone depending on their reproductive goals.     

Uniform testicular maturation arrest: a unique subset of men with nonobstructive azoospermia

PURPOSE: We evaluated the clinical characteristics of men with uniform testicular maturation arrest and nonobstructive azoospermia or severe oligospermia, including the frequency of genetic defects and outcome of intracytoplasmic sperm injection with or without testicular sperm extraction. MATERIALS AND METHODS: We identified a group of 32 men with nonobstructive azoospermia or severe oligospermia, uniform maturation arrest (single spermatogenic pattern on biopsy), and normal follicle-stimulating hormone (7.6 IU/l or less). These patients were identified from 150 intracytoplasmic sperm injection candidates with severe oligospermia (less than 10,000/cc) and 600 men with nonobstructive azoospermia undergoing attempted testicular sperm extraction-intracytoplasmic sperm injection between November 1995 and September 2006. These patients were characterized based on the frequency of genetic anomalies (karyotype or Y chromosome microdeletions). Rates of sperm retrieval by testicular sperm extraction, fertilization and pregnancy after ICSI were measured. RESULTS: Genetic anomalies were more common (45%) in men with uniform maturation arrest and normal follicle-stimulating hormone than other men with nonobstructive azoospermia (17%) undergoing testicular sperm extraction at our center (p <0.001). They had a lower sperm retrieval rate with testicular sperm extraction compared to other nonobstructive azoospermia patients (41% vs 60%, p = 0.05). Fertilization rate (37%) and clinical pregnancy (13%) were significantly less common than in other men with nonobstructive azoospermia (54% and 49%, respectively, p <0.01). CONCLUSIONS: Patients with uniform maturation arrest and normal follicle-stimulating hormone are a clinically definable subgroup of men with nonobstructive azoospermia that have different treatment outcomes. They have a higher incidence of chromosomal abnormalities and Y chromosome microdeletions compared to other men with nonobstructive azoospermia. Despite having normal follicle-stimulating hormone and typically normal testicular volume, sperm retrieval may be difficult and the chance of successful pregnancy is limited.     

Does varicocelectomy improve semen in men with azoospermia and clinically palpable varicocele?

The effectiveness of varicocelectomy in nonobstructive azoospermia is controversial. The current study assessed the efficacy of microsurgical subinguinal varicocelectomy in nonobstructive azoospermic men with palpable varicocele and to evaluate predictive parameters of outcome. We reviewed the records of 723 patients who had microsurgical varicocelectomy and diagnostic testicular biopsy between 2012 and 2016 at a tertiary medical centre. Data pertaining to the physical, laboratory (semen analysis and hormonal profile) and histopathology features were examined, exploring the predictors of improvement in semen analysis post-varicocelectomy. In total, 42 patients with mean age 35.71 ± 6.35 years were included. After a mean varicocelectomy follow-up of 6.7 months, motile spermatozoa in the ejaculate could be observed in 11 patients (26.2). Out of all the factors examined, only testicular histopathology significantly predicted post-varicocelectomy outcome, where 8/11 patients exhibited hypospermatogenesis, and 3/11 Sertoli cell-only regained spermatozoa in semen. Microsurgical varicocelectomy in nonobstructive azoospermic men with clinically palpable varicocele can result in sperm appearance in the ejaculate with the highest success expected in hypospermatogenesis.     

Morphological and morphometric attributes of epididymal and testicular spermatozoa following surgical sperm retrieval for obstructive and nonobstructive azoospermia

Whilst the morphological (shape) and morphometric (sperm head size) attributes of ejaculated spermatozoa have been well studied, the morphological and morphometric qualities of testicular and epididymal spermatozoa retrieved from males with obstructive and nonobstructive azoospermia is much less documented. We wished to examine the effect of aetiology of azoospermia and site of retrieval on the attributes of retrieved spermatozoa. This was a prospective observational study of 30 consecutive successful sperm retrievals, six for nonobstructive azoospermia and 24 for obstructive, of which five were retrieved from the epididymis and the remainder from the testis. The proportion of morphologically normal testicular spermatozoa in patients with obstructive and nonobstructive azoospermia was not significantly different (7% versus 7.6%, P = 0.97). Testicular spermatozoa from males with obstructive azoospermia showed an increase in frequency of sperm with small heads [47/180 (26%) versus 97/909 (11%), P = 0.036] as well as small acrosome and increasing vacuole formation over nonobstructive spermatozoa. Similarly, there was a significant increase in tail deformities and decreases in tail lengths in sperm from males with nonobstructive azoospermia. Epididymal spermatozoa showed significantly greater proportion of morphologically normal spermatozoa than testicular (20% versus 13%, P = 0.001) as well as a significant increase in acrosome vacuoles. Furthermore, morphometrically epididymal spermatozoa displayed with smaller head length, width and area than testicular spermatozoa. Testicular spermatozoa from obstructive azoospermia displayed significantly less tail defects (35% versus 57%, P = 0.003) as well as significantly longer tail lengths (30.6 microm versus 10.7 microm). These morphological and morphometric differences between epididymal and testicular and obstructive and nonobstructive spermatozoa may represent part of the natural maturation process. There were no associations between any morphological or morphometric abnormality with any significant parameter in subsequent use in ICSI.     

Semen Parameters Before and After Transurethral Surgery for Ejaculatory Duct Obstruction

Purpose

We examined how transurethral resection of the ejaculatory ducts, performed for infertility, affects semen quality in patients with azoospermia and oligo-asthenospermia.

Materials and Methods

A retrospective review was done of 46 cases of transurethral resection of the ejaculatory ducts for ejaculatory duct obstruction, confirmed by transrectal ultrasound. Clinical course and semen quality were assessed by semen parameter indications.

Results

In 65 percent of the patients transurethral resection of the ejaculatory ducts improved semen quality (greater than a 50 percent increase in total motile sperm count) and 20 percent initiated a pregnancy an average of 6.1 months postoperatively. Statistically significant increases in total motile sperm count were achieved in men with azoospermia and those treated for oligo-asthenospermic indications; the improvement also was shown to be sustainable. Complications occurred in 20 percent of the men.

Conclusions

Significant and durable semen quality improvement can be achieved after transurethral resection of the ejaculatory ducts for all surgical indications. In most unsuccessful cases the reason for failure is unclear.     

The ratio of second to fourth digit length in azoospermic males undergoing surgical sperm retrieval: predictive value for sperm retrieval and on wubsequent fertilization and pregnancy rates in IVF/ICSI cycles

The differentiation of the urogenital system and the appendicular skeleton in vertebrates is under the control of Homeobox (Hox) genes. It has been shown that this common control of digit and gonad differentiation has connected the pattern of digit formation to spermatogenesis and prenatal hormone concentrations in males. We wished to establish whether digit patterns, particularly the ratio between the lengths of the second and fourth digit in males (2D : 4D), was related to spermatogenesis and, more specifically, the presence of spermatozoa in testicular biopsies from azoospermic men undergoing surgical sperm retrieval. Forty-four men were recruited, of whom 16 were diagnosed with nonobstructive azoospermia and 4 with congenital bilateral absence of the vas deferens, and 24 previously fertile men were azoospermic after previous vasectomy. Our results show that men with previous fertility or of an acquired form of azoospermia had significantly lower 2D : 4D ratios than men with nonobstructive azoospermia. In nonobstructive azoospermia, there was a significantly lower 2D : 4D ratio on the left side in men who had successful retrieval than those with unsuccessful retrieval. For these men who had a successful retrieval, none had a 2D : 4D ratio more than 1 on the left side, whereas 4 of 7 men in whom sperm was not found had a 2D : 4D ratio greater than 1. On successful sperm retrieval, subsequent fertilization and clinical pregnancy rates were unaffected by 2D : 4D ratios.     

Histological alterations in Leydig cells and macrophages in azoospermic men

The study aimed to compare the histological features of Leydig cells and macrophages in the testicular interstitium of obstructive versus nonobstructive azoospermia. Thirty‐nine azoospermic men undergoing testicular sperm extraction during intracytoplasmic sperm injection were allocated into obstructive azoospermia group (GI) and nonobstructive azoospermia group (GII) which was subdivided into Sertoli cell‐only syndrome (GIIA), germ cell arrest (GIIB) and hypospermatogenesis (GIIC) subgroups. Serum LH, FSH and testosterone levels were measured. Ultrastructural changes and the mean number of CD68‐positive cells were estimated in the different groups. In GIIA, Leydig cells' processes came in contact with macrophages and showed smooth endoplasmic reticulum dilatation. In GIIB, Leydig cells showed apoptotic changes. Macrophages were commonly encountered in their vicinity demonstrating large number of lysosomes. In GIIC, Leydig cells showed euchromatic nuclei. Macrophages showed expulsion of their lysosomal contents in the interstitium surrounded by apoptotic bodies. The mean count of total CD68‐positive macrophages was higher in cases of obstructive azoospermia with nonsignificant differences compared to nonobstructive azoospermia groups. Significant increase in FSH level was detected in GIIA compared to GI. It is concluded that structural interactions might take place between Leydig cells and macrophages in the interstitial tissue of azoospermic men.     

A novel cost-effective approach to post-vasectomy semen analysis

Study Type – Diagnostic (cost minimisation analysis)
Level of Evidence 3b

OBJECTIVE

• ? To examine compliance, clearance rates and cost‐effectiveness of a novel approach to managing men following vasectomy based on the testing of sperm viability.

PATIENTS AND METHODS

• ? Between January 2003 and March 2005, 832 men undergoing vasectomy were followed prospectively for a minimum of 12 months.
• ? Post‐vasectomy semen analysis (PVSA) was carried out at 16 weeks with repeat at 20 weeks only if sperm were detected on initial PVSA i.e. a single clear PVSA on simple microscopy was deemed sufficient for declaring vasectomy successful.
• ? In men with persistent non‐motile sperm (PNMS) in the second specimen, comprehensive analysis of number and viability of sperm using a fluorescent probe was carried out on a fresh semen specimen taken in accordance with British Andrology Society (BAS) guidelines.

RESULTS

• ? Overall compliance with the PVSA protocol was 81.3% (95% CI 78.5 to 83.8). No sperm were seen in 540 (78.8%) and 70 (10.3%) at the initial and 2^nd PVSA respectively.
• ? Persistent spermatozoa at 20 weeks were present in 66 (9.8%, 7.8 to 12.2) cases with 58 (8.6%, 6.7 to 11.0) having PNMS and 8 (1.2%, 0.6 to 2.3) having motile sperm.
• ? Fluorescent viability testing in 53 of the 58 with PNMS showed viable sperm in 2 (3.8%, 1.0 to 12.8). The failure rate of vasectomy defined by PVSA (8 with motile sperm on 2^nd PVSA and 2 with viable non‐motile sperm on fluorescent testing) was 1.2% (0.7 to 2.2).
• ? Average cost per vasectomy of PVSA using this protocol was £10.77 (US$ 16.67) compared with a minimum likely average cost using BAS guidelines of £18.10 (US$ 28).

CONCLUSION

• ? Demonstrating absence of sperm on simple light microscopy in a single specimen of semen at 16 or 20 weeks post‐vasectomy and reserving comprehensive testing of sperm viability for only the higher risk group with PNMS improves compliance and represents a cost‐effective strategy for declaring surgical success. This reduces the costs of PVSA by least 40% compared with adherence with BAS guidelines without compromising success in determining outcome after vasectomy.

     

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.