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

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

无精子症患者睾丸内精子存在的评估

目的　检测无精子症患者睾丸内精子存在情况。　方法　睾丸活检病例 5 0例 ,每例均作血内分泌激素检测、睾丸体积测量、睾丸组织学检查及睾丸精子提取 (TESE) ,分析促卵泡生成素(FSH)、睾丸体积和睾丸组织学与睾丸内精子存在的相关性。　结果　血FSH和睾丸体积预测睾丸精子是否存在准确性不强 ,而睾丸组织学结果与TESE一致 (敏感性 96 % ,特异性 10 0 % ,准确性10 0 % )。　结论　血FSH高和睾丸体积小的无精子症患者 ,应行睾丸活检并同时行TESE以明确睾丸内是否有精子。     

Serum inhibin B and follicle-stimulating hormone levels as markers in the evaluation of azoospermic men: a comparison

Inhibin B is a glycoprotein hormone produced mainly by Sertoli cells of the testes in the adult male. It selectively suppresses the secretion of pituitary follicle-stimulating hormone (FSH) and has local paracrine actions in the testes. Its measurement is useful for investigating the role of inhibin B in male gonadal dysfunction. The objective of this study was to investigate the efficacy of serum inhibin B in men with nonobstructive azoospermia in comparison with FSH. Serum concentration of FSH was measured using microparticle enzyme immunoassay, inhibin B by specific solid phase sandwich enzyme-linked immunosorbent assay in men with nonobstructive azoospermia (n = 46) and control fertile men (n = 5). Mean inhibin B and FSH level was 104.6 pg ml(-1) and 4.0 mIU ml(-1) in control men whereas the value for nonobstructive azoospermic men was 17.06 pg ml(-1) and 31.1 mIU ml(-1) respectively. Inhibin B and FSH levels were significantly different in azoospermia than controls (P < 0.0001). There were six cases of nonobstructive azoospermia with normal inhibin B. Testicular histology did not find any evidence of spermatogenesis in three cases with normal inhibin B. This demonstrated that inhibin B was not a superior predictor for testicular function in our study.     

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.     

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.     

Predictive factors of successful testicular sperm recovery in non-obstructive azoospermia patients

Recovery of testicular spermatozoa from non-obstructive azoospermic patients for intracytoplasmic sperm injection (ICSI) is a recent advance in the treatment of male infertility. The purpose of this study is to identify predictive factors for sperm recovery in non-obstructive azoospermic patients. A total of 178 men with non-obstructive azoospermia had multiple testicular sperm extraction (TESE) procedures to recover spermatozoa for intracytoplasmic sperm injection (ICSI) from June 1996 to February 1999. Testicular volume, serum follicle stimulating hormone (FSH) level and testicular histology were examined as positive predictive factors for sperm recovery. Testis biopsies were categorized as severe hypospermatogenesis, maturation arrest and Sertoli cell-only syndrome based on the most advanced pattern of spermatogenesis seen on histology. Sperm retrieval success rates for the patients in three histopathological categories were compared. Spermatozoa were successfully recovered in 94 of 178 (52.8%) men. Sperm were retrieved in 13 of 80 (16.3%) with Sertoli cell-only syndrome, 15 of 24 (62.5%) with maturation arrest, and 66 out of 74 (89.2%) with severe hypospermatogenesis. Spermatozoa recovery has no correlation with testicular volume or serum FSH level. When compared against Sertoli cell-only syndrome, the odds of sperm retrieval success rate was 44.3 times higher in severe hypospermatogenesis and 8.4 times in maturation arrest. These results demonstrate meaningful correlation between successful testicular sperm recovery and testis histopathology. Only testicular histopathology can be used as a predictor of successful sperm recovery.     

Induction of spermatogenesis in men with azoospermia or severe oligoteratoasthenospermia after antegrade internal spermatic vein sclerotherapy for the treatment of varicocele

Aim:To evaluate the treatment outcome of antegrade internal spermatic vein sclerotherapy in men with non-obstruc-tive azoospermia or severe oligoteratoasthenospermia(OTA)as a result of varicocele.Methods:Between September1995 and January 2004,47 patients(mean age 33.8±6.3 years)underwent antegrade internal spermatic vein sclero-therapy for the treatment of varicocele with azoospermia(14 patients)or severe OTA(33 patients).Testicular corebiopsy was also performed in complete azoospermic patients who provided informed consent.The outcome wasassessed in terms of improvement in semen parameters and conception rate.Results:Forty-two(89.4%)of 47patients had bilateral varicocele,Serum follicle stimulating hormone(FSH)did not differ between patients withazoospermia and severe OTA.After the follow-up of 24.8±9.2 months,significant improvement was noted in meansperm concentration,motility and morphology in 35 patients(74.5%).Comparison between groups during thefollow-up revealed significantly higher values of sperm concentration,motility and normal morphology in the severeOTA group.Pregnancy was achieved in 14 cases(29.8%).Testicular histopathology of the azoospermic patientswith postoperative induction of spermatogenesis revealed maturation arrest at spermatid stage,Sertoli-cell-only(SCO)with focal spermatogenesis or hypospermatogenesis.None of the patients with pure SCO pattern or maturation arrestat spermatocyte stage achieved spermatogenesis after the treatment.Preoperative serum FSH levels didn't relate totreatment outcome.Conclusion:Antegrade internal spermatic vein sclerotherapy is an easy and effective treatmentfor symptomatic varicocele.It can significantly reverse testicular dysfunction and improve spermatogenesis in menwith severe OTA,as well as induce sperm production in men with azoospermia,improving pregnancy rates insubfertile couples.(Asian J Androl 2006 Sep;8:613-619)     

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

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

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

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

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.     

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.     

Impact of testicular histopathology as a predictor of sperm retrieval and pregnancy outcome in patients with nonobstructive azoospermia: correlation with clinical and hormonal factors

In this study, our objective was to evaluate the impact of testicular histopathology on the outcome of intracytoplasmic sperm injection (ICSI) cycles of patients with nonobstructive azoospermia and correlate with clinical and hormonal parameters. For this purpose, 271 patients with nonobstructive azospermia (NOA) who underwent testicular sperm extraction (TESE) for ICSI cycles were retrospectively evaluated for sperm retrieval, fertilisation, embryo cleavage, clinical pregnancy and live birth rates among different testicular histology groups. We also correlated hormonal and clinical factors with histological findings. Sperm retrieval and fertilisation rates (FR) were found to be significantly different among all testicular histological groups of NOA except for embryo cleavage, clinical pregnancy and live birth rates. Furthermore, serum follicle stimulating hormone (FSH) level was the most significant variable to predict sperm recovery on TESE. Separate analyses within each testicular histological group revealed that higher FSH was also associated with lower pregnancy rates in only maturation arrest group. In conclusion, testicular histology significantly influences sperm retrieval and FRs but not pregnancy and live birth rates in nonobstructive azoospermia. However, FSH is the best predictor of a successful TESE.     

Age as only predictive factor for successful sperm recovery in patients with Klinefelter’s syndrome

The study was performed to determine factors affecting successful sperm retrieval by testicular sperm extraction in patients with nonmosaic Klinefelter’s syndrome (KS). From May 2001 to February 2007, 27 azoospermic patients were diagnosed as having nonmosaic KS. All patients underwent sperm testicular extraction. Patient’s age, testicular volume, serum follicle‐stimulating hormone (FSH) and inhibin B were assessed as predictive factors for successful sperm recovery. Of the 27 Klinefelter’s patients examined, eight (29.6%) had successful sperm recovery. The comparisons of serum FSH, inhibin B and testicular volume between patients with and without successful sperm retrieval did not show any statistical significance. The patients with successful sperm recovery were significantly younger (28.6 ± 3.11 years) than those with failed attempts (33.9 ± 4.5 years, P = 0.002). The rate of positive sperm retrieval was significantly higher in patients younger than 32 years compared with patients older than 32 years (P = 0.01, chi‐squared test). The study showed that clinical parameters such as FSH, inhibin B and testicular volume do not have predictive value for sperm recovery in patients with KS. The mean age of our patients with successful sperm recovery was significantly lower than that of men with unsuccessful results. Testicular sperm extraction or testicular sperm aspiration should be performed before the critical age of 32 years.     

Testicular Sperm Retrieval in Azoospermic Men

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

Possible relationship between seminal plasma inhibin B and spermatogenesis in patients with azoospermia

Inhibin B is bidirectionally secreted by Sertoli cells, basal secretion into the circulation exerts negative feedback on follicle-stimulating hormone secretion, and serum inhibin B is considered a marker of spermatogenesis. The precise role of apical secretion is unknown. The objective of our work was to study the relationship between seminal inhibin B and spermatogenesis. Dimeric inhibin B was measured by immunoassay in seminal plasma of volunteers with normozoospermia (n = 10, group 1), in men after vasectomy (n = 10, group 2), and in men with azoospermia (n = 50, group 3). Testicular biopsy and testicular sperm extraction were performed in men with azoospermia. Seminal inhibin B levels were higher in men in group 1 than in men in groups 2 and 3 (P <.0001). In seminal plasma, inhibin B presents a positive correlation with alpha glucosidase activity (r =.37, P =.002). Seminal inhibin B is inversely related with serum FSH (r = -.58, P <.001), and presents a weak positive correlation with serum testosterone concentration (r =.29, P =.03). No difference was found between inhibin B levels in seminal plasma of patients with nonobstructive or obstructive azoospermia, and between positive or negative outcome of TESE. We conclude that inhibin B secretion by Sertoli cells is differentially regulated. The contribution of accessory sex glands limits the use of seminal plasma inhibin B as a marker of spermatogenesis.     

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.     

Significance of Serum FSH Levels and Testicular Morphology in Infertile Males

Objectives: To determine the relationship between plasma levels of FSH and testicular spermatogenic patterns. Methods: Testicular biopsies were obtained from 99 infertile men. Biopsies were performed either in order to distinguish the type of azoospermia (obstructive/non-obstructive) or because of severely subnormal semen variables. Serum FSH was measured by immunoassay (normal range is less than 7 mIU/ml). Results: Statistically significant difference was detected between patients with Sertoli cell only syndrome and normal spermatogenesis, hypospermatogenesis and maturation arrest (p<0.01, p<0.01, p<0.05, respectively). No statistically significant differences were found between normal spermatogenesis, hypospermatogenesis and maturation arrest. Conclusion: Our study revealed that elevation of serum FSH correlates only with the appearance of Sertoli cell only syndrome. We think that azoospermic or severely oligoasthenoteratozoospermic patients with highly elevated plasma FSH levels (three times the normal) could be excluded from separate testicular biopsy, because these patients are not suitable for conventional treatments. If he is willing to undergo an IVF program the sperm will often be present, no matter what the testicular histology is to be used for assisted reproductive techniques, particularly ICSI.     

High prevalence of urogenital infection/inflammation in patients with azoospermia does not impede surgical sperm retrieval

Considering infection/inflammation to be an important risk factor in male infertility, the aim of this study was to make a comprehensive evaluation of the prevalence of urogenital tract infection/inflammation and its potential impact on sperm retrieval in azoospermic patients. In this prospective study, 71 patients with azoospermia were subjected to an extensive andrological workup including comprehensive microbiological diagnostics (2‐glass test, semen, testicular swab and testicular tissue analysis) and testicular biopsy/testicular sperm extraction (TESE). Medical history suggested urogenital tract infection/inflammation in 7% of patients, 11% harboured STIs, 14% showed significant bacteriospermia, 15% had seminal inflammation, 17% fulfilled the MAGI definition, and 27% had relevant pathogens. At the testicular level, 1 patient had a swab positive for bacteria, no viruses were detected, tissue specimens never indicated pathogens, whereas histopathology revealed focal immune cell infiltrates in 23% of samples. Testicular sperm retrieval rate was 100% in obstructive and 46% in nonobstructive azoospermia. None of the infection/inflammation‐related variables was associated with the success of sperm retrieval or inflammatory lesions in the testis. The high prevalence of urogenital infection/inflammation among azoospermic men underpins their role as significant aetiologic factors in male infertility. However, this observation does not refer to the chances of sperm retrieval at the time of surgery/TESE.     

Power Doppler ultrasound mapping in nonobstructive azoospermic patients prior to testicular sperm extraction

This study was conducted to localize the testicular regions, which have better blood circulation by power Doppler ultrasonography in patients with nonobstructive azoospermia before testicular sperm extraction (TESE), and to investigate whether these vascularized areas have a high sperm retrieval rate or not. We evaluated 110 testes of 55 cases that were diagnosed as nonobstructive azoospermia. The mean age of the study group was 33 years (range 26 to 42). Patients with Y chromosome microdeletions, karyotype and hormonal abnormalities (except elevated FSH levels) were excluded from the study. In all cases, testes were evaluated by power Doppler ultrasonography before testicular sperm extraction. Testis was divided vertically into five equal parts and the area with maximum vascularity was determined subjectively. During testicular sperm extraction, starting from best-perfused areas, biopsies were done. If no motile or sufficient amount of sperm was found, TESE procedure was tried on the contralateral testis. TESE were performed from 82 testes and for the regions that show good and poor vascularity. The sperm finding rate was 38% and 14%, respectively (OR = 3.55)(p = 0.001). Power Doppler ultrasound mapping of the testis in nonobstructive azoospermic cases is a reliable and informative method to assess spermatogenic foci. It is a noninvasive technique that minimizes the unnecessary removal of hormone producing tissue and gives chance to end the TESE earlier than currently practiced procedures.     

Intracytoplasmic sperm injection by testicular sperm in patients with aspermia or azoospermia after cancer treatment

The aim of this retrospective study was to evaluate the efficiency of testicular biopsy and intracytoplasmic sperm injection (ICSI) in patients with aspermia or non-obstructive azoospermia (NOA) after cancer treatment. From 1996 to 2003, 30 men with a history of cancer, affected by aspermia or NOA and without sperm cryopreserved before cytotoxic treatment underwent testicular sperm extraction (TESE). In these men, clinical, hormonal and histological characteristics were compared; 13 underwent 39 TESE-ICSI cycles using frozen-thawed testicular spermatozoa (TESE-ICSI group). In the same period, 31 ICSI cycles were performed in 20 men with aspermia or NOA using ejaculated sperm frozen before cancer treatment (ejaculated sperm-ICSI group). Fertilization, blastocyst development, pregnancy and miscarriage rates were compared between the groups. Testicular volume, serum follicle-stimulating hormone level and Johnsen score indicated complete although reduced spermatogenesis in men with aspermia and abnormal spermatogenesis in men with NOA. After TESE, sperm retrieval was positive in 92% of men with aspermia and 58% of men with NOA. In TESE-ICSI patients with NOA a significantly lower proportion of embryos developed to the blastocyst stage than in patients with aspermia and in those after ICSI with frozen-thawed ejaculated sperm (23% vs. 43% and 47%, p = 0.03 and p < 0.01 respectively). In all groups the miscarriage rates were high; in patients with aspermia and NOA, characterized by increased age, the miscarriage rate tended to be higher in spite of similar female age and female indications of infertility. In patients affected by aspermia or NOA after cancer treatment and without sperm cryopreserved before treatment, TESE-ICSI using testicular sperm provide a chance to father a child.