Successful pregnancy and birth after intrauterine insemination using caput epididymal sperm by percutaneous aspiration

Asian J Androl 2003 Mar; 5: 73-75             

Keywords: percutaneous epididymal sperm aspiration; intrauterine insemination; obstructive azoospermia; caput epididymis; fertilization

Abstract

Aim: To manage male infertility with obstructive azoospermia by means of percutaneous epididymal sperm aspiration (PESA) and intrauterine insemination (IUI). Methods: Ninety azoospermic patients with congenital bilateral absence of the vas deferens (BAVD, n=58) or bilateral caudal epididymal obstruction (BCEO, n=32) requesting for fine needle aspiration (FNA), PESA and IUI were recruited. The obstruction was diagnosed by vasography and determination of the fructose, carnitine and alpha-glucosidase levels in the seminal fluid. Results: The mean sperm motility, density, abnormal sperm and total sperm count of the caput epdidymis were 16 %22 %, (1231)10⁶/mL, 55 %36 % and (164)10⁶, respectively. In the 90 couples, a total of 74 PESA procedures and 66 cycles of IUI were performed. Three pregnancies resulted, including one twin pregnancy giving birth to two healthy boys, one single pregnancy with a healthy girl and another single pregnancy aborted at week 6 of conception. The pregnancy rate per IUI cycle was 4.5 %. Conclusion: The birth of normal, healthy infants by IUI using PESA indicates that the caput epididymal sperm possess fertilization capacity. The PESA-IUI programme is a practical and economical procedure for the management of patients with obstructive azoospermia.

1 Introduction

The management of male factor infertility has undergone significant changes in the last few years. Certain obstructive azoospermic males have fathered children after microscopic vaso-epididymostomy [1], resection of the ejaculatory ducts [2], conventional microsurgical epididymal sperm aspiration (MESA)-intracytoplasmic sperm injection (ICSI) [3] or percutaneous vasal sperm aspiration (PVSA)intrauterine insemination (IUI) [4]. Shrivastav et al. [5] and Craft et al. [6] made use of the spermatozoa retrieved by percutaneous epididymal sperm aspiration (PESA) in ICSI. Charterjee et al. [7] reported a pregnancy rate of 20 % per cycle for PESA-IUI.

In the present paper, the use of PESA-IUI pro-gramme for the management of congenital bilateral absence of the vas deferens (BAVD) or bilateral caudal epididymal obstruction (BCEO) in Chinese patients was reported. Three pregnancies were achieved with full term normal deliveries in two.

2 Materials and methods

Between March 1996 and June 2001, 90 azoospermic males, aged 25~38 years, requested for treatment were recruited. A general physical examination was performed in all subjects with the testicular volume assessed by the Prader's system [8]. In 58 cases, both vasa deferentia were impalpable, while they were palpable in the rest 32. The female partners were 26~36 years of age, all nulligravida and had regular menstrual cycles of 24~36 days; Tubal patency was confirmed by hysterosalpingography. Forty-two males with normal fertility served as the controls.

The testicular cytology was studied with fine needle aspiration in accordance with Foresta et al. [9], the levels of fructose, carnitine and alpha-glucosidase in the seminal fluid were determined by routine methods [10,11] and vasography was done according to Qiu et al [4].

The PESA procedures described by Shrivastav et al.[5] and Craft et al. [6] were followed under local anesthesia (2 % lidocaine). A standard 22 gauge needle connected to a 20-mL syringe containing 0.5 mL Ham's F-10 medium (GIBCO Laboratories, Grand Island, USA) was used. The testis was stabilized by the surgeon's left hand and the caput epididymis was held between the thumb and forefinger. The needle was inserted into the caput epididymis and the epididymal content aspirated. We modified the needle by drilling small holes close to the tip to avoid any obstruction that might occur and more epididymal fluid could be aspirated. Spermatozoa thus obtained were incubated at 37 for 30~40 minutes before IUI.

Ovarian stimulation was brought about by the administration of a mixture of clomihpene citrate, hMG and hCG. Ovulation was monitored by ultrasonography on days 13~16 of the menstrual cycles. When the leading follicles developed to >20 mm in diameter, hCG 10,000 IU was administered and IUI was carried out 12~24 h later.

Data were expressed in meanSD. Statistical analysis was done with the Student t-test and P<0.05 was considered significant.

3 Results

In the 58 patients with impalpable vasa deferentia, the seminal fructose, carnitine and alpha-glucosidase were 0~1.5 µmol/mL, 40~80 nmol/mL and 1.2~3.1mU/mL, respectively. They were significantly lower than those of the controls (P<0.01, Table 1). On the basis of the seminal biochemistry and the impalpable vasa deferentia, the diagnosis of bilateral absence of the vas deferens (BAVD) could be confirmed in these patients. The testicular cytology was normal in 26, interrupted in 24 and arrested in 8 patients. In the remaining 32 patients with palpable vasa deferentia, the testicular cytology was all normal and the seminal fructose, carnitine and alpha- glucosidase were 6.9~14.5 µmol/mL (within the normal range), 40~86 nmol/mL and 2.5~8.6 mU/mL, respectively (Table 1). Vasography revealed that both vasa deferentia was patent.

A total of 74 PESA procedures were performed in 58 patients (26 BAVD and 32 BCEO) with normal spermatogenesis. A single PESA was performed in 44 patients, two PESAs in 12 patients and three PESAs in 2 patients. In these 58 patients, motile sperm were aspirated in 52 patients and 66 cycles of IUI were carried out. In 8 of the 74 PESAs, the sperm motility, sperm density and total aspirated sperm were less than 15 %, 1510⁶/mL and 1010⁶, respectively, so that IUI was not performed and ICSI-IVF was recommended. In the remaining 66 PESAs, the sperm motility, sperm density, abnormal sperm and total sperm count per PESA were 16 %2 %, (1231)10⁶/mL, 55 %36 % and (1614)10⁶, respectively, and a total of 66 cycle IUIs were carried out, resulting in 3 pregnancies: a twin pregnancy (the husband was a BCEO patient) giving birth to two healthy boys by caesarean section at 36 weeks of gestation, a single pregnancy (husband: BAVD) giving birth to a healthy girl and another single pregnancy (husband: BAVD) aborted at week 6 of conception. The pregnancy rate was 4.5 % per IUI cycle. The sperm parameters of the 3 pregnant couples were shown in Table 2.

In the 8 cases with sperm motility <15 %, 3 were BAVD and 5, BCEO patients. In 66 PESA-IUI procedures, 31 were carried out in BAVD and 35 in BCEO patients. There were no significant differences between the two groups in regard to sperm motility, density, percentage abnormal sperm and total sperm count per PESA (Table 3).

Table 3. Sperm parameters between BAVD and BCEO.

4 Discussion

PESA is a new technique for the treatment of male infertility in the early 90's. The introduction of ICSI-IVF using epididymal spermatozoa by PESA has led to a marked improvement in the management for obstructive azoospermic patients [5, 6]. The cost for ICSI procedure, however, is relatively high and in this clinic, many patients cannot afford the payment. They requested for an alternative method with lower expenditure and in these cases PESA-IUI were employed. PESA can be easily performed with local anaesthsia and be repeated without obvious damage to the epididymis, which has been used successfully to retrieve sperm in men who have irremediable obstructive azoospermia. Chatterjee et al. [7] reported a higher cycle pregnancy rate of 20 % for PESA-IUI; The difference may be due to disparity in patient selection or ethnical differences. In conclusion, although the pregnancy rate of PESA-IUI technique is relatively low (4.5 % per IUI cycle in this paper) and is much lower than that of the ICSI-IVF, it remains to be a good choice for the management of obstructive azoospermia in low income population.

References

[1] Silber SJ. Microscopic vasoepididymostomy: specific micro-anastomosis to the epididymal tubule. Fertil Steril 1978; 30:565-9.
[2] Meacham RB, Hellerstein DK, Lipshultz LI. Evaluation and treatment of ejaculatory duct obstruction in the infertile male. Fertil Steril 1993; 59: 393-7.
[3] Silber SJ, Nagy ZP, Liu J. Conventional in vitro fertilization versus intracytoplasmic sperm injection for patients requiring microsurgical sperm aspiration. Hum Reprod 1994; 9: 1705-9.
[4] Qiu Y, Wang SM, Yang DT. Percutaneous vasal sperm aspiration and intrauterine insemination in the treatment of obstructive azoospermia. Fertil Steril 1997; 68: 1135-8.
[5] Shrivastav P, Nadkami P, Wensvoot S, Craft I. Percutaneous epididymal sperm aspiration for obstructive azoospermia. Hum Reprod 1994; 9: 2058-61.
[6] Craft I, Tsirgotis M, Bennett V, Taranissi M. Percutaneous epididymal sperm aspiration and intracytoplasmic sperm injection in the management of infertility due to obstructive azoospermia. Fertil Steril 1995; 63: 1038-42.
[7] Chatterjee S, Chaudhuri AR, Chowdhuri RG, Rahman S. Percutaneous sperm aspiration followed by intrauterine insemination ?a new approach to achieve a pregnancy in infertility due to obstructive azoospermia. J Indian Med Assoc 2001; 99: 445-7.
[8] Prader A. Testicular size: assessment and clinical importance. Triangle 1966; 7: 240-3.
[9] Foresta C, Varotto A, Scandellari C. Assessment of testicular cytology by fine needle aspiration as a diagnostic parameter in the evaluation of the azoospermic subject. Fertil Steril 1992; 57: 858-65.
[10] Qiu Y, Tian KW, Yang DT, Wang SM. The change of carnitine content in seminal plasma after reversible injection occlusion of vas deferens. Contraception 1995; 51: 261-6.
[11] World Health Organization. Laboratory manual for the examination of human semen and semen-cervical mucus interaction. 4 rd ed. Cambridge: Cambridge University Press. 1999.
[12] Meng XG, Qiu Y, Li J, Fan YJ, Zhang MX, Wang KH, et al. Intracytoplasmic injection using sperm aspirated from the epididymis for treatment of infertility. Reprod Contracep (China) 1999; 19: 235-8.

home

Correspondence to: Dr Yi QIU, Shandong Institute for Family Planning Research, Jinan 250002, China.
Tel: +86-531-297 6014, Fax: +86-531-297 2043
E-mail: qiuyimail@yahoo.com
Received 2002-06-17   Accepted 2003-02-21