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PubMed1994

Cryopreservation of microsurgically extracted ductal sperm: pentoxifylline enhancement of motility.

Microscopically extracted ductal sperm can be successfully cryopreserved using motility as the outcomes measure. The optimal regimen for cryopreservation of microscopically extracted ductal sperm awaits further determination. Pentoxifylline treatment improves initial post-thaw motility of cryopreserved microscopically extracted ductal sperm. The clinical efficacy of this practice awaits further determination. However, the best potential use for cryopreserved microscopically extracted ductal sperm may be IVF with subzonal or intracytoplasmic microinjection. If intracytoplasmic sperm injection becomes more widely available, then enhancement of motility with pentoxifylline may not be necessary. This approach allows for potential fertility insurance at the time of microsurgical bypass of obstruction, and it may preclude, the need for the andrologic surgeon to accurately time his sperm retrieval procedures with IVF. The latter potential advantage would significantly aid current logistical difficulties in the operating room.

Cryopreservation↗
PubMed1985

Properties of human epididymal sperm obtained from an alloplastic spermatocele: motility assessment and penetration of zona-free hamster oocytes in the presence and absence of caffeine.

Sperm were collected over a period of months from a human alloplastic spermatocele implanted at the corpus/caudal epididymal junction and were evaluated for their maturity, motility, and ability to capacitate and acrosome react, as assessed by the hamster zona-free oocyte sperm penetration assay (SPA). A mean of 11 X 10(6) sperm were obtained with each aspiration, with 34% to 40% being mature, normal forms. Motility was poor; 15% +/- 5% showing nonprogressive movement. SPA results were 22% +/- 3% oocyte penetration. Addition of 7.5 mM caffeine markedly enhanced motility and improved the SPA results. After 30 minutes' exposure, the motility was 45% +/- 5%, with all spermatozoa exhibiting progressive movement. This stimulation was maintained over a 24-hour period. When caffeine was present during the 2-hour preincubation for the SPA, penetration rates increased to 50% +/- 10% (P less than 0.05). These results demonstrate that the poor-quality sperm retrieved from a human alloplastic spermatocele can be improved with exogenous stimulation and suggest that their fertilizing capacity may be enhanced by this treatment.

Adult↗
PubMed2000

Diagnostic and therapeutic testis biopsy.

Testicular biopsy has been traditionally used as a diagnostic tool in the management of infertility. With the advent of assisted reproductive technology, testicular biopsy is now used therapeutically to retrieve sperm for intracytoplasmic sperm injection (ICSI). The feasibility of testicular sperm extraction for ICSI is reviewed in this article. Although less invasive techniques such as testicular fine needle aspiration and percutaneous needle biopsy are efficacious, particularly in cases of obstructive azoospermia, studies in the current literature support that open testicular biopsy is a more reliable method to obtain testicular specimen. Different measures to reduce the complication rate of open testicular biopsy, including the application of microsurgical techniques, are addressed here. Other areas of recent development related to testicular biopsy that are reviewed include processing of testicular tissue, cryopreservation of retrieved spermatozoa, in vitro maturation of spermatozoa, and microinjection of immature spermatogenic precursor cells.

Biopsy, Needle↗
PubMedDate not supplied

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.

Chromosome Deletion↗
PubMedDate not supplied

Probability of sperm detection in nonobstructive azoospermic men undergoing testicular sperm extraction procedures unrelated to clinical parameters.

The study was conducted to evaluate the significance of preoperative clinical parameters for detection of mature testicular sperm cells in nonobstructive azoospermic men. Sixty-five consecutive men with nonobstructive azoospermia underwent testicular sperm extraction procedures. Testicular samples were analyzed histologically with patterns classified as mature spermatogenesis (normal or partial), arrest of spermatogenesis, and Sertoli cell only. Testicular sperm cells were isolated for use in an IVF/ICSI program. Histologic patterns and detection rate of sperm cells were correlated to clinical characteristics. Mature sperm cells were found in all levels of serum FSH. The men were divided into 3 groups based on their clinical characteristics (serum FSH level and testicular size). The distribution of the different testicular histologic patterns, as well as detection rate of sperm cells, was similar in all groups. No correlation was found between serum levels of FSH, LH, prolactin, or testosterone and sperm presence. None of these parameters, nor the testicular size and consistency, can serve as predictive variables of the histological pattern or the presence of mature sperm cells in the testicular biopsies in cases of nonobstructive azoospermia. Until an effective predictive tool is available, a trial of sperm retrieval is recommended for all azoospermic men independent of their clinical characteristics.

Adult↗
PubMed2001

Gamete retrieval in terminal conditions.

There has been a growing interest and requests by patients facing intensive chemotherapy or surgically ablative procedures for gamete retrieval and preservation for future procreative efforts. There are technical difficulties in this area but little ethical discomfort. More troubling are the issues that arise with a terminally ill, incapable patient-one who is in a persistent vegetative state or who is declared brain dead or who is neurologically devastated with no hope for recovery, but not yet in either of the above states-or with a person who has suddenly died. In these cases, the surviving spouse, partner, or family members may request gamete retrieval for future reproductive efforts. Discussion of this topic within the Ethics Consultation Service at the University of Virginia demonstrated a need for development of insight derived from facts and ethical deliberation to help formulate a policy that would apply to such cases. A group was assembled with the expertise to explore the issue and to help formulate a policy that could be suggested for adoption by the hospital administration. The group consisted of a urologist with experience in sperm retrieval from terminally ill patients; the director of the laboratory supporting the assisted reproductive facility in the Department of Obstetrics and Gynecology; the chairperson of the Ethics Consultation Service (who is also a neonatologist); and 2 members of the Ethics Consultation Service, one a genetic counselor and the other an obstetrician-gynecologist with a master's degree in biomedical ethics. Current literature was reviewed, the expertise of the urological member and the reproductive laboratory director was explored, and the insight of the members of the Ethics Consultation Service was added. We explored the technical aspects of both male and female gamete retrieval and preservation and the reproductive potential of these stored gametes. We present a review of the current literature on both the technical and ethical aspects of the topic. Finally, we present a policy that we deem acceptable for adoption and that should be of value to other practitioners and facilities as they contemplate facing requests for gamete retrieval.

Advance Directives↗
PubMed1995

The use of epididymal and testicular spermatozoa for intracytoplasmic sperm injection: the genetic implications for male infertility.

The results and rationale of using testicular and epididymal spermatozoa with intracytoplasmic sperm injection (ICSI) for severe cases of male infertility are reviewed. A total of 72 consecutive microsurgical epididymal sperm aspiration (MESA) cases were performed for congenital absence of the vas (CAV) and for irreparable obstructive azoospermia. ICSI was used to obtain normal embryos for transfer and fertilization in 90% of the cases. The overall fertilization rate was 46% with a normal cleavage rate of 68%. The pregnancy and delivery rates per transfer were 58 and 37% respectively. The delivery rate per cycle was 33%. In many cases, no epididymal spermatozoa were available and so testicular sperm extraction (TESE) was used for sperm retrieval. The transfer rate was lower with TESE (84 versus 96%) and the spermatozoa could not be frozen and saved for use in future cycles. However, there was little difference in pregnancy rates using epidiymal or testicular spermatozoa. The results were not affected by whether the obstruction was caused by CAV or failed vasoepididymostomy. Both fresh and frozen spermatozoa gave similar results; the only significant factor appeared to be the age of the female. Because of the consistently good results obtained using epididymal sperm with ICSI when compared with conventional IVF, and the similarly good results with testicular tissue spermatozoa, ICSI is mandatory for all future MESA patients. All CAV patients and their partners should be offered genetic screening for cystic fibrosis; hence pre-implantation embryo diagnosis should be available in any full service MESA programme. It is now clear that even with non-obstructive azoospermia, e.g. Sertoli-cell only, or maturation arrest, there are usually some small foci of spermatogenesis which allow TESE with ICSI to be carried out. This means that even in men with azoospermia due to absence of spermatogenesis or to a block in meiosis, there are usually a few spermatozoa available in the testes that are adequate for successful ICSI. Finally, it is likely that some forms of severe male factor infertility are genetically transmitted and although ICSI offspring have been shown to be completely normal, it is possible that the sons of these infertile couples will also require ICSI when they grow up and wish to have a family.

Adult↗
PubMed2001

Impaired spermatogenesis in men with congenital absence of the vas deferens.

It is generally assumed that men with congenital bilateral absence of the vas deferens (CBAVD) have azoospermia because of obstruction and that sperm production is normal. This study examines spermatogenesis in men with CBAVD to assess the validity of this assumption. We identified all men with CBAVD who had undergone either a diagnostic or therapeutic fertility procedure. Procedures included diagnostic biopsy, testis fine needle aspiration (FNA) mapping, microscopic epididymal sperm aspiration (MESA), and testis sperm extraction (TESE). Among 33 CBAVD men, 18 underwent testis biopsy, 27 had MESA/TESE, and 10 had FNA mapping. On evaluation of these procedures, normal spermatogenesis was present in 29 men. Four men (12%) demonstrated impaired spermatogenesis. One patient had FNA testis cytology consistent with late maturation arrest, another demonstrated hypospermatogenesis on biopsy and low sperm yield by MESA, and two patients had pure Sertoli cell only histology on biopsy. Aetiologies for impaired spermatogenesis included varicocele and underlying genetic abnormalities. Although patients with CBAVD are assumed to have normal spermatogenesis and infertility due simply to obstruction, the potential for concomitant defects in sperm production exists. A clinical suspicion of testis failure should prompt further diagnostic evaluation of spermatogenesis prior to sperm retrieval. In addition, genetic counselling should be offered and testing for genetic lesions, including cystic fibrosis gene mutations and/or variants, Y chromosome microdeletions, and karyotype abnormalities, should be considered.

Adult↗
PubMed2004

Cumulative live birth rates after transfer of cryopreserved ICSI embryos.

A cohort follow-up study was designed to assess the efficacy of an intracytoplasmic sperm injection cryopreservation programme through analysis of cumulative live birth rates in successive frozen-thawed cycles in a tertiary referral centre. There were 2013 patients and they underwent 2680 frozen-thawed embryo transfer cycles. The follow-up period was between 1992 and 2001. Only frozen-thawed embryo transfer cycles up to the fourth trial were included. Crude cumulative live birth rates were calculated in five age subgroups, i.e. <30, 30-34, 35-37, 38-39 and >/=40 years old and in surgically or non-surgically retrieved sperm subgroups. Expected cumulative live birth rates were calculated only for the total number of patients. Outcome measure was a live birth occurring after 25 weeks of gestation. Overall, the expected cumulative live birth rate was as high as 26.7% after four cycles while the crude cumulative delivery rate was 10.5%. Multiple cryopreserved embryo transfer cycles increase the chance of a couple to achieve a live birth.

Adult↗
PubMed1995

The influence of bladder management on fertility in spinal cord injured males.

Male infertility is a well recognised problem following spinal cord injury. The techniques of vibration induced ejaculation and transrectal electroejaculation have significantly increased the likelihood of sperm retrieval in spinal cord injured males; however, the reproductive capacity remains markedly reduced due to poor semen quality. The Spinal Injuries Unit at Royal North Shore Hospital has developed a programme to achieve seminal emission and enhance fertility. This study analysed the results of the first sample obtained at stimulation in 70 spinal cord injured males with respect to procedure performed, neurological level, completeness of lesion, bladder management, infection, age and duration since injury. Our study demonstrated that bladder management and neurological level were significant factors affecting the presence of motile sperm. Individuals managing their neuropathic bladder by catheter (intermittent self-catheterisation, indwelling urethral or suprapubic catheter) had significantly enhanced semen quality compared to those voiding by reflex or straining. Differences were also noted within the catheter group itself with intermittent self-catheterisation achieving a higher percentage of motile sperm present.

Adult↗
PubMed2003

Cryopreservation of a small number of spermatozoa in yolk-filled human zonae pellucidae.

OBJECTIVES: Conventional sperm freezing procedures need the addition of a relatively large volume of cryoprotectant. The dilution of extremely poor sperm suspensions from ejaculate or testicular tissue may make the recovery of viable spermatozoa difficult at the moment of the intracytoplasmic sperm injection (ICSI) procedure. The cryopreservation of a few spermatozoa in empty zonae pellucidae is an interesting solution for crypto-azoospermic infertile men. We have modified this procedure by filling empty human zonae with TEST Yolk Buffer, an optimal cryoprotective medium, in order to analyse the number of zonae lost after thawing, the number of recovered spermatozoa per zona after thawing, and the sperm motility rate before freezing and after thawing. MATERIALS AND METHODS: Fifty empty human zonae pellucidae previously filled with TEST Yolk Buffer were injected with 750 motile spermatozoa from ten infertile men (15 spermatozoa per zona). Sterile straws containing two zonae each were frozen following a two-phase protocol. RESULTS: All of the zonae and 445/750 spermatozoa (59%) were recovered. The mean number (+ SD) of spermatozoa per zona was 8.9 +/- 1.9 (range: 5-12). The recovery rate of motile spermatozoa was 73% (327/445), with a mean number of motile spermatozoa per zona of 6.5 +/- 1.7 (range: 3-10). CONCLUSIONS: The cryopreservation of a small number of motile spermatozoa within empty zonae pellucidae using TEST Yolk Buffer as a freezing medium is possible without any major loss of spermatozoa and with an appreciable maintenance of sperm motility. This procedure seems to avoid: i) uncertain sperm retrieval after a laborious and time-consuming search on the day of oocyte aspiration; ii) the need for a repeated testicular biopsy; and iii) the need for heterologous insemination or oocyte cryopreservation (11).

Buffers↗
PubMed1992

Motility longevity of sperm samples processed for intrauterine insemination.

This study demonstrates that sperm from men with male factor infertility and sperm obtained by electroejaculation have reduced motility longevity when compared with normal specimens. After 24 hours, normal samples lost only 34% of initial motility, whereas male factor patients lost 48%, and electroejaculation patients dropped 66%. Based on these data and previous clinical studies of insemination timing, it is recommended that sperm retrieval and artificial insemination for male factor infertility, especially when electroejaculation is necessary, be performed 24 to 36 hours after urinary detection of the LH surge or as close to the time of ovulation as possible.

Ejaculation↗
PubMed2004

Prediction of successful outcome of microdissection testicular sperm extraction in men with idiopathic nonobstructive azoospermia.

PURPOSE: Microsurgical techniques in testicular sperm extraction can improve sperm retrieval in patients with nonobstructive azoospermia (NOA). However, spermatozoa retrieval rates have still been reported to be around 50% for patients with NOA. Thus, a reliable prediction method for successful outcome is needed to avoid unnecessary surgery. In this retrospective study we determined the diagnostic and predictive values of noninvasive parameters used in the treatment of patients with NOA. MATERIALS AND METHODS: We analyzed 9 preoperative factors including patient age, testicular volume and endocrinological data of 100 patients with NOA using multivariate logistic modeling. Testicular spermatozoa were retrieved successfully in 41 of the 100 patients (41%). RESULTS: We found that the concentrations of follicle-stimulating hormone (FSH), total testosterone (TT) and inhibin B were considered the most influential preoperative factors. We developed a formula to calculate the probability of successful outcome, P = [1 + exp(5.201 - 0.048 x FSH - 0.449 x TT - 0.021 x inhibin B)](-1). Association of predicted probabilities and observed responses was 0.77. A predicted probability of more than 15.7% was found to be the best cutoff. Sensitivity was 71.0% and specificity was 71.4% as determined by receiver operating characteristic analysis. CONCLUSIONS: We concluded that our formula should be useful for doctors considering microdissection testicular sperm extraction for patients with NOA because our equation uses noninvasive parameters without a preoperative testicular biopsy, which is a relatively invasive examination.

Adult↗
PubMed2005

Etiology-specific outcomes of intracytoplasmic sperm injection in azoospermic patients.

OBJECTIVE: To assess fertilization, pregnancy, and miscarriage rates after intracytoplasmic sperm injection (ICSI) with epididymal or testicular spermatozoa from different types of azoospermia. DESIGN: Retrospective study. SETTING: Academic medical center and private fertility center. PATIENT(S): Two hundred twelve patients underwent 257 ICSI cycles. INTERVENTION(S): Cycles of ICSI were divided into four groups according to the etiology of azoospermia: A (nonobstruction), B (postvasectomy), C (congenital obstruction), and D (obstruction due to infection). Testicular sperm aspiration and percutaneous epididymal sperm aspiration were the sperm retrieval methods used for ICSI. MAIN OUTCOME MEASURE(S): Fertilization, pregnancy, and miscarriage rates. RESULT(S): Normal fertilization rates were higher in groups C (67.7%) and B (64.1%) compared with groups A (47.3%) and D (58.9%). Although lower pregnancy rates were seen in group A, no statistical differences were detected among groups. However, the miscarriage rate was higher in group A (45.6%) compared with groups B (25.25%), C (24%), and D (22.58%). CONCLUSION(S): Although no differences were detected in the pregnancy rates across groups, fertilization and implantation rates were higher in patients with congenital obstruction of the seminal path. The pregnancy rate was higher and the miscarriage rate lower when epididymal sperm was used compared with testicular sperm.

Abortion, Spontaneous↗
PubMed2000

New concepts in operative andrology: a review.

Several recently published, or about to be published, controversial issues in operative andrology are clarified and reviewed in this paper. The microsurgical technique for sperm retrieval for nonobstructive azoospermia, the round spermatid controversy and the varicocoele dilemma (why does everybody keep doing varicocoelectomy for male factor infertility?) are presented with salient points that have recently been presented elsewhere and referenced. Finally, at the end, we review briefly what is known about the likelihood of genetic transmission of infertility from male factor patients to their offspring as a result of the new ICSI technology.

Chromosome Deletion↗
PubMed2000

Sperm chromosome analysis and outcome of IVF in patients with non-mosaic Klinefelter's syndrome.

OBJECTIVE: The aim of the study was to determine the potential risk for fetal chromosomal anomalies in non-mosaic Klinefelter's syndrome patients undergoing IVF and intracytoplasmic sperm injection. DESIGN: Individually collected spermatozoa were isolated from wet testicular tissue preparations and fixed on glass slides using micromanipulation. Their nuclei were analyzed for chromosomes X, Y, and 18 by fluorescent in situ hybridization. SETTING: Assisted reproductive technology program. PATIENT(S): Consenting patients with non-mosaic Klinefelter's syndrome undergoing testicular biopsy and IVF (fresh specimens) or following such treatment (cryopreserved specimens). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The rates of numerical chromosome abnormalities for chromosomes X, Y, and 18 among spare testicular sperm and the pregnancy outcome following treatment. RESULT(S): Testicular sperm were found in 8 of 20 patients. Four couples became pregnant following embryo replacement. Sperm chromosomes were analyzed in five patients. One hundred and five sperm of 112 analyzed (93.7%) were normal with X to Y ratio of 50:55 (NS) respectively. Among the 112 sperm tested, seven (6.3%) demonstrated chromosomal abnormalities, of which five were related to the sex chromosomes and two to chromosome 18. One set of triplets, one set of twins, and two singletons (four males and three females) with normal karyotypes were born. CONCLUSION(S): Most of the testicular sperm retrieved from Klinefelter's syndrome patients demonstrates a normal pattern of sex chromosome segregation. Therefore, the risk of transmitting numerical sex chromosome abnormalities is relatively low and probably comparable with the rates found in other severe male factor infertility patient groups.

Chromosome Aberrations↗
PubMed2006

Testicular sperm extraction in cancerous testicle in patients with azoospermia: a case report.

The aim of this study is to evaluate the feasibility of testicular sperm extraction (TESE) in a cancerous testicle during orchiectomy for testicular neoplasm. This is a retrospective study and includes case histories of four azoospermic patients with incidental testicular cancer. None of the patients had fathered children prior to surgery and all patients were strongly motivated by the desire to have offspring. Patients underwent surgical exploration via inguinotomy and spermatic cord clamping. After nodule excision, micro-TESE was performed from the same albugineal incision, under microscopic guidance. Frozen section examination was not performed in the case of large nodules (>3 cm in diameter). Two patients showed classic seminoma and underwent orchiectomy. In two patients, a Leydig cell tumour was found (one patient underwent orchiectomy for large nodule size). Micro-TESE was performed in four patients. Spermatozoa were found in three patients and the retrieved sperm was cryopreserved. One ICSI cycle was performed, but pregnancy failed. In azoospermic patients with testicular nodules, TESE in the cancerous testis is feasible and may avoid further surgery, without any oncological risk.

Adult↗
PubMed1998

The use of epididymal spermatozoa in assisted reproduction.

The use of epididymal spermatozoa in assisted reproduction (ART) permits fertility in men with surgically irremediable obstructive azoospermia. When used for conventional IVF (sperm-oocyte co-culture), epididymal spermatozoa show reduced fertilization and pregnancy rates (compared with ejaculated spermatozoa from men with a range of spermatogenic disorders) as evidence of their functional immaturity. However, when used with intracytoplasmic sperm injection (ICSI) either fresh or frozen-thawed epididymal spermatozoa produce ART success rates similar to those of ejaculated spermatozoa. The clinical place of epididymal sperm retrieval for ICSI has come under review as a result of data showing similarly good outcomes with testicular spermatozoa obtained by needle aspiration. In Australia ICSI using epididymal or testicular spermatozoa is an increasingly favoured option for vasectomy-related infertility and in other types of obstructive azoospermia for a number of reasons including better pregnancy outcomes, the less invasive nature of the procedures and less expense involved; however, this cost-benefit analysis will vary in other health systems.

Constriction, Pathologic↗