This web only provides the extract of this article. If you want to read the figures and tables, please reference the PDF full text on Blackwell Synergy. Thank you.
- Original Article -
Outcome of repeated micro-surgical testicular sperm
extraction in patients with non-obstructive azoospermia
Halit Talas1, Onder
Yaman1, Kaan Aydos2
1Department of Urology, School of Medicine, University of Ankara, Ankara 06550, Turkey
2Research Center on Infertility, School of Medicine, University of Ankara, Ankara 06550, Turkey
Abstract
Aim: To evaluate the outcome of repetitive micro-surgical testicular sperm extraction (mTESE) attempts in
non-obstructive azoospermia (NOA) cases, in relation to patients' initial testicular histology
results. Methods: A total of 68 patients with NOA in whom mTESE had been performed in previous intracytoplasmic sperm injection (ICSI)
attempts were reviewed. Results: Among the 68 patients with NOA, the first mTESE yielded mature sperm for ICSI
in 44 (64%) (Sp+), and failed in the remaining 24 (36%)
(Sp_). Following their first trial, 24 patients decided to
undergo a second mTESE. Of these 24 patients, no spermatozoa were obtained in 5 patients, and
Sp+ but no fertilization/pregnancy were achieved in 19. In these 24 cases, mTESE was successively repeated for two
(n = 24), three (n = 4) and four
(n = 1) times. The second attempt yielded mature
sperm in 3/5 patients from the Sp- group and
16/19 patients from the Sp+ group. At the third and fourth trials, 4/4 and 1/1 of the original
Sp+ patients were Sp+ again,
respectively. Distribution of main testicular histology included Sertoli cell-only syndrome (16%), maturation arrest
(22%), hypospermatogenesis (21%) and focal spermatogenesis (41%). Overall, in repetitive mTESE, 24/29 (82%) of
the attempts were finally Sp+.
Conclusion: Repeated mTESE in patients with NOA is a feasible option, yielding
considerably high sperm recovery rate. In patients with NOA, mTESE may safely be repeated one or more times to
increase sperm retrieval rate, as well as to increase the chance of retrieving fresh spermatozoa to enable ICSI.
(Asian J Androl 2007 Sep; 9: 668-673)
Keywords: azoospermia; intracytoplasmic sperm injection; micro-surgical testicular sperm extraction; non-obstructive azoospermiarepetitive
testicular sperm extraction
Correspondence to: Dr Halit Talas, Department of Urology, University of Ankara, School of Medicine, Ankara 06550, Turkey.
Tel: +90-312-5082-817 Fax: +90-312-3112-167
E-mail: halittalas@yahoo.com
Received: 2006-09-25 Accepted: 2007-02-08
DOI: 10.1111/j.1745-7262.2007.00273.x
1 Introduction
Approximately 1% of all men and 10% of infertile men are affected by testicular failure as a result of obstructive
or nonobstructive azoospermia (NOA) [1]. Sertoli cell-only syndrome (SCOS), maturational arrest,
hypospermatogenesis and tubular sclerosis are the main histological findings of NOA. In patients with NOA, the testis
is the only source of sperm cells. Mature testicular spermatozoa can be found in NOA men [2]. Testicular sperm
extraction (TESE) combined with intracytoplasmic sperm injection (ICSI) offers such men the possibility of having
their own genetic children. TESE with ICSI has become the standard treatment for patients with no source of
spermatozoa except the testis [3]. However, there are no clinical or laboratory methods that can predict the presence
of sperm with TESE reliably and accurately.
In patients with deficient spermatogenesis as a cause of absolute or
virtual azoospermia sperm, recovery rates after treatment with TESE and ICSI are reported to be 50%
[4]. Also, if testicular sperm is found in patients with NOA, the
pregnancy rate after one cycle of ICSI is low [5, 6], so
repeated testicular biopsies combined with repetitive ICSI
cycles are often needed.
There is no clear information about the recovery rates
of mature spermatozoa in previous negative biopsies with
the use of the microsurgical method. Therefore, in the
present study we aimed to evaluate the outcome of
repetitive micro-TESE (mTESE) attempts in relation to the
initial testicular histology.
2 Materials and methods
In this retrospective study, the patient population
consisted of 68 men who presented with clinical and
laboratory data indicating NOA. The mean age was 36.5
(25_65) years. Azoospermia was confirmed by at least two
separate seminal analyses that were carried out as
described in the World Health Organization (WHO) manual
[7]. Subjects underwent a full clinical evaluation
including medical and reproductive histories, and physical
examination of vas deferenses, epididymes and testes.
Testicular size and texture were evaluated with scrotal
ultrasonography. Endocrine evaluation included
radioimmunoassays of serum follicle stimulating hormone
(FSH), luteinizing hormone (LH) and testosterone (T)
(Vitros Immunodiagnostic Products; Ortho-Clinical Diagnostics, Amersham, UK). The absence of ductal
obstruction was confirmed at the time of the diagnostic
biopsy or at the time of mTESE by direct observation.
The diagnosis of NOA was based on the finding of azoospermia in the presence of small volume testes
and/or elevated serum FSH and the absence of obstruction.
In all patients peripheral blood karyotype analyses were
performed using standard techniques. Informed consent was obtained from all couples.
All mTESE procedures were performed by the same
surgeon, in conjunction with planned in
vitro fertilization cycles with ICSI for the female partner. Tissue samples
were obtained by microdissection testicular sperm
extraction technique; namely mTESE, as described
previously [8]. Briefly, a 0.5_3.0 cm measuring incision was
made on an avascular region of tunica albuginea, selected
with the aid of optical magnification of an operating
microscope (× 8). Direct examination of the testicular
parenchyma was carried out at higher magnification (× 20)
to identify typically dilated and more opaque
seminiferous tubules. Small volumes of testicular samples,
including these tubules, were extracted by traction and
excised sharply. If no morphologically normal tubules
were identified, the incision was extended to expose
multiple areas and then any tubules that differed from
the remainder of the tissue in their size or large strips of
tissue when all tubules were seen to have an identical
morphological appearance were removed. In cases with
spermatozoon could not be extracted in one testicle, then
the other one was searched by similar fashion. Surgery
was stopped when spermatozoa quantitatively and
qualitatively sufficient for ICSI procedure was found or when
the whole testicular mass was bilaterally sampled at
random. At the end of the procedure, the tunica
albuginea was closed with a 5_0 vicryl suture.
After this, all testicular tissue pieces were transferred
to a Petri dish filled with HEPES-buffered modified
Eagle's MEM solution, and taken to the adjacent laboratory. In the laboratory, mature spermatozoa were
searched for by using a mechanical extraction technique,
mincing the wet preparation of testicular tissue fractions
using two fine needles. When needed,
erythrocyte-lysing buffer was used to increase the chance of visualizing
any spermatozoa present. Microscopic examination of
the suspension was carried out under an inverted
microscope (Nikon, Japan) with Hoffman modulation equipment. If spermatozoa were found, then the next
step was ICSI. Whenever sperm has not been found after mechanical mincing, enzymatic digestion of the
testicular tissue using collagenase type IV and DNase was
performed [9].
At the same time as the testicular intervention, a
surgically-obtained small tissue specimen was placed in
Bouin's solution and sent to histology. Biopsies were
obtained unilaterally from testes in which spermatozoa
were found by mechanical searching. If no
spermatozoon was found, a biopsy was taken in a randomly
selected area. Testicular histology was classified (as in
Friedler et al. [10]) into hypospermatogenesis (all stages
of spermatogenesis present but proportionate reduction
at each level), maturation arrest (an interruption in the
development of spermatogonia to mature sperm at the
level of spermatogonia, spermatocytes or spermatids) and
SCOS (the absence of germ cells in the seminiferous
tubules) [10]. Isolated seminiferous tubules with
spermatogenetic activity observed in the field of
seminiferous tubules that were otherwise maturation arrest or
SCOS pattern were classified as focal spermatogenesis.
Successful mTESE was defined as the ability to find
at least one spermatozoon to inject into the obtained
oocyte. Patients in whom mature testicular sperm were
found after the mTESE were grouped as sperm positive
(Sp+). Those in whom mTESE yielded no sperm
available for ICSI were grouped as sperm negative
(Sp_). A second TESE attempt was proposed both to all sperm
negative patients and to those with fertilization/pregnancy
failure. All mTESE was performed by the authors of the
present study.
3 Results
Among the 68 patients with NOA included in the study, following their first mTESE, no mature sperm
was found in 24 (36%) men. The diagnoses associated
with NOA in the patients are listed in Table 1. A total of
seven aberrant karyotypes were diagnosed in these men,
corresponding to an abnormality rate of 10%.
Chromosomal abnormalities comprised one marker chromosome,
four classic form of Klinefelter's syndrome with 47,XXY
and two 47,XXY/46,XY mosaicism. Two patients had received chemotherapy owing to adolescent malignancies.
One of them had Hodgkin's disease and the other had
non-Hodgkin's lymphoma. Both patients had been treated
with multiple chemotherapeutic agents containing cyclophosphamide. Comparison between the patients,
regarding average age, serum FSH and T levels rendered
no statistically significant difference. Successful
testicular sperm retrieval rates, enabling the success of ICSI,
according to the first mTESE trial are presented in Table 2.
Following their first trial, 24 patients decided to undergo
a second mTESE trial. Of these 24 patients, no
spermatozoa had been obtained in 5 patients and
Sp+ but fertilization/pregnancy had not been achieved in 19.
During the 24 second mTESE attempts, in 3/5 (60%)
patients from the Sp_ group and 16/19 (85%) from the
Sp+ group, sufficient spermatozoa were found to enable
ICSI (Table 3). The histology of these patients showed
germ cell maturation arrest.
Further trials were performed on four patients from
the Sp+ group only. The remaining 15
Sp+ cases with failed fertilization/pregnancy were excluded from the
follow up because they either decided not to continue
the treatment or changed hospitals. Testicular sperm
was obtained by mTESE at the third trial in all four
patients and at the fourth trial in one patient. Overall, in
repetitive mTESE 82% of the attempts (24/29) were
finally Sp+ (Table 2). Correlation of the histopathological
findings with sperm retrieval rates are presented in
Table 4. The chances of finding testicular sperm for
ICSI were significantly higher in the hypospermatogenesis
group, compared with the all the other histological groups.
When we divided the data for focal spermatogenesis into
two groups; in approximately half of the cases (13/28;
46%) focal spermatogenesis within SCOS predominant
pattern was observed; however, focal spermatogenesis
within the predominant pattern of germ cell arrest was
seen in the rest of the patients (54%). Regarding clinical
diagnosis, in all attempts of the cases with nonspecific
orchitis, testicular trauma and idiopathic etiologies, and
in the majority of the attempts in
cryptorchidism/retractile testis and previous genital infections, mTESE yielded
successful sperm recovery for ICSI. In two of the men
with aberrant karyotypes of Klinefelter syndrome with
mosaicism, spermatozoa were found in repetitive mTESE
attempts (Table 1). However, there was no correlation
between the histopathological findings and sperm retrieval
rates in successive mTESE attempts.
Intervals between the successive mTESE attempts
were a minimum of 6 months. Overall, no serious
complication leading to medical treatment or hospital care
from any of the participants was reported. In one
patient scrotal hematoma developed after his first
intervention, but resolved completely in two months.
After the second attempts, in two patients adhesions were
encountered between the parietal layer of tunica vaginalis
and tunica albuginea of testis, so that sharp dissection
was necessary to reach the seminiferous tubules.
During the third and fourth interventions, small hematoma
formations were seen in some focal areas. However,
seminiferous tubules in normal appearance were easily
identified among them.
4 Discussion
Despite extensive damage of most of the
seminiferous tubules in the biopsies of the cases with NOA, a few
tubules presenting normal or nearly normal
spermatogenesis can be found frequently. Currently, no clinical or
laboratory methods can accurately predict the presence
of sperm in testicular tissue samples. Although sperm
aspiration techniques by fine needle (TESA) permits the
retrieval of a large number of sperm for ICSI in patients
with obstructive azoospermia, patients with NOA
usually need to endure a more invasive procedure to
optimize their chances of sperm retrieval. Indeed,
sensitivity of fine needle aspiration cytology (FNAC) in NOA
patients has been reported as 44.6% [11]. This means
that if sperm are not seen by FNAC, they will be present
by TESE in approximately half of the cases. However,
in the majority of the patients with testicular failure
spermatozoa can be extracted by TESE and used for ICSI.
TESE has also been suggested as an option prior to
cancer treatment in azoospermic cancer patients [15].
Several authors have proposed that mTESE be used to
increase sperm retrieval rates from azoospermic patients
[3]. In patients with NOA, mTESE has a significantly
higher yield compared to the aspiration technique and
classical open TESE [8, 10, 13].
Some couples might need a repeat TESE procedure
on the day of oocyte retrieval to improve the chances of
a second pregnancy. Information regarding the outcome
of repetitive TESE procedures and the performance of
ICSI is scarce in the published literature. Although
cryopreservation of remaining testicular tissue is a valid
option to avoid repeated surgery, cryopreservation is not
always feasible in patients with NOA, because of the
substantial risk of not finding sperm suitable for injection.
Therefore, frozen-thawed suspensions will not be used
in approximately 20% of the patients despite extensive
search for sperm, and a fresh biopsy retrieval by a
repeat TESE attempt needs to be carried out at the day of
oocyte retrieval [21]. Donor sperm is another
alternative in such cases; however, this must be agreed with
the couple before the preceding treatment period.
Otherwise, cancellation of the treatment is inevitable.
In the present study, a group of men with no
spermatozoa who had previously unsuccessfully attempted
an ICSI procedure underwent repetitive mTESE trials,
with the hope of finding at least one spermatozoon. Sperm
retrieval on the first TESE attempt was successful in 44
out of the 68 patients (64%). Several studies of patients
with NOA reported sperm retrieval rates similar to our
sperm retrieval rate (44 out of 68 patients, 64%) to be
between 30% and 90% [4, 8, 10, 13, 15, 16]. However,
after extensive search in the 24 remaining men (36%),
no sperm was found to inject oocytes.
We found that during the second TESE procedure the sperm retrieval rate was 82% and these rates increased
in the following TESE sessions if there was any sperm
found during the previous TESE trials. Several published
studies examine the feasibility of repeating TESE and
TESA procedures in patients with primarily testicular
failure. Westlander et al. [17] examined NOA 34 men,
and of these 34, 14, 5, 3 and 1 patient(s) underwent a
second, third, fourth, fifth and sixth TESA attempt,
respectively. According to their data, repeating the
procedure up to a sixth attempt was feasible, but
histological correlation was lacking and definition of NOA was
unclear. In study of Friedler et al. [18], 22 patients with
NOA were examined and the results were correlated with
corresponding histopathology. They conclude that
repeating the TESE procedure up to a fourth attempt is
justified. Vernaeve et al. [19] examined a total of 1 066
azoospermic men and suggest that repeated TESE ensures a high sperm recovery rate even in patients with
NOA. Amer et al. [15] reported their experience in
repetitive TESE for 27 NOA men. They were able to find
sperm in 88.9% of their patients who had sperm at their
first procedure.
Our results indicate that in 15% of the
patients (3/19) with Sp+ at their first TESE, failure to obtain sperm
occurs during repetitive TESE. For this reason, patients
should be warned that finding mature sperm for ICSI in
the present TESE might not completely assure success
in further TESE attempts. Similarly, according to
Friedler's experience, in Sp+ patients failure to obtain
sperm might occur during repetitive TESE at a rate of
11% and 33% during the second and fourth TESE, respectively [18].
In the present study, five out of 24 patients with an
initial negative testicular biopsy had a second mTESE
and three were positive. This indicates that the outcome
of repetitive TESE attempts on patients with an initial
negative testicular biopsy has not been sufficiently
defined and that research with a higher number of cases is
necessary. Some groups do not offer a second TESE in
cases of unsuccessful TESE attempts [19]. However,
in three of our five patients with previous failed surgery,
a second mTESE trial was attempted and sperm could
be extracted. The histology of these patients had showed
maturation arrest without focal spermatogenesis.
During their first and second surgeries, because all tubules
had an identical morphological appearance, large strips
of tissues were taken randomly. However, if the
number of the cases were higher, such a successful
recovery rate might not be obtained. For this reason, we
relate our high recovery rate of second testicular sperm
extractions for patients with severe primary
spermatogenic defects to the nature of the patients and, probably,
to performance of the previous surgery as well as
success of the tissue extraction efforts. Although the
number of the patients is very small, this fact might
encourage us to offer a second mTESE attempt in these patients.
Supporting our results, in a study by Friedler et
al. [18], 1/4 Sp- patients at the first TESE trial became
Sp+ at their second trial. However, Friedler
et al. [18] used classical open biopsy procedure. During mTESE, sperm
could not be retrieved in 33% of our cases in which
mature sperm were identified at histopathological
evaluation and which were described as having focal
spermatogenesis. In fact, foci of active
spermatogenesis on TESE can be present also in azoospermic men
with testicular atrophy [11]. It was, however, shown
that even the presence of mature spermatozoa in a
preliminary testicular biopsy might fail to predict the
presence of sperm at the successive TESE attempts at a rate
of 11% and 33% during the second and fourth TESE, respectively [18]. Similar results have been reported by
others [20]. According to our results, patients with
histopathologically diagnosed focal spermatogenesis should
be informed prior to repetitive TESE that even
performing TESE might result in the failure to find mature sperm
for ICSI in up to one-third of cases.
We conclude that repetitive mTESE in NOA patients
is a safe and feasible option, and yields a high sperm
recovery rate. Despite the absence of apparent clinical
complications in our series, caution should be taken when
counseling patients regarding repetitive TESE.
Repetition of TESE trials obtains a considerably high sperm
recovery rate to enable ICSI and has clinical value in
patients with NOA, even when a first recovery
procedure has been unsuccessful. However, larger series are
needed to confirm the results.
References
1 Su LM, Palermo GD, Goldstein M, Veeck LL, Rosenwaks Z,
Schlegel PN. Testicular sperm extraction with
intracytoplasmic sperm injection for non-obstructive azoospermia:
Testicular hystology can predict success of sperm retrieval. J
Urol 1999; 161: 112_6.
2 Tournaye H, Camus M, Goossens A, Liu J, Nagy P, Silber S,
et al. Recent concepts in the management of infertility because
of non-obstructive azoospermia. Hum Reprod 1995; 10
(Suppl): 115_9.
3 Devroey P, Liu J, Nagy Z, Goossens A, Tournaye H, Camus
M, et al. Pregnancies after testicular sperm extraction and
intracytoplasmic sperm injection in non-obstructive azoospermia.
Hum Reprod 1995;10: 1457_60.
4 Tournaye H, Verheyen G, Nagy P, Ubaldi F, Goossens A,
Silber S, et al. Are there any predictive factors for successful
testicular sperm recovery in azoospermic patients? Hum
Reprod 1997; 12: 80_6.
5 Vernaeve V, Tournaye H, Osmanagaoglu K, Verheyen G, Van
Steirteghem A, Devroey P. Intracytoplasmic sperm injection
with testicular spermatozoa is less successful in
non-obstructive azoospermia than in obstructive azoospermia. Fertil Steril
2003; 79: 529_33.
6 Nicopoullos JD, Gilling-Smith C, Almeida PA,
Norman-Taylor J, Grace I, Ramsay JW. Use of surgical sperm retrieval in
azoospermic men: A meta-analysis. Fertil Steril 2004; 82:
691_701.
7 World Health Organization. WHO Laboratory Manual for the
Examination of Human Semen and Sperm-cervical Mucus
Interaction. Cambridge: Cambridge University Press; 1999.
8 Schlegel PN. Testicular sperm extraction: microdissection
improves sperm yield with minimal tissue excision. Hum Reprod
1999; 14: 131_5.
9 Aydos K, Demirel LC, Baltaci V, Unlu C. Enzymatic
digestion plus mechanical searching improves testicular sperm
retrieval in non-obstructive azoospermia cases. Eur J Obstet
Gynecol Reprod Biol 2005;120: 80_6.
10 Friedler S, Raziel A, Strassburger D, Soffer Y, Komarovsky D,
Ron-El R. Testicular sperm retrieval by percutaneous fine
needle sperm aspiration compared with testicular sperm
extraction in men with non-obstructive azoospermia. Hum
Reprod 1997; 12: 1488_93.
11 Bettella A, Ferlin A, Menegazzo M, Ferigo M, Tavolini IM, Bassi
PF, et al. Testicular fine needle aspiration as a diagnostic tool in
non-obstructive azoospermia. Asian J Androl 2005; 7: 289_94.
12 Schrader M, Muller M, Straub B, Miller K. Testicular sperm
extraction in azoospermic patients with gonadal germ cell
tumors prior to chemotherapy: A new therapy option. Asian J
Androl 2002;4: 9_15.
13 Ezeh UI, Moore HD, Cooke ID. Correlation of testicular
sperm extraction with morphological, biophysical and
endocrine profiles in men with azoospermia due to primary
gonadal failure. Hum Reprod 1998; 13: 3066_74.
14 Verheyen G, Vernaeve V, Van Landuyt L, Tournaye H, Devroey
P, Van Steirteghem A. Should diagnostic sperm retrieval
followed by cryopreservation for later ICSI be the procedure of
choice for all patients with non-obstructive azoospermia? Hum
Reprod 2004; 19: 2822_30.
15 Amer M, Haggar SE, Moustafa T, Abd El-Naser T, Zohdy W.
Testicular sperm extraction: impact of testicular histology on
outcome, number of biopsies to be performed and optimal
time for repetition. Hum Reprod 1999; 14: 3030_4.
16 Tsujimura A, Matsumiya K, Miyagawa Y, Tohda A, Miura H,
Nishimura K, et al. Conventional multiple or microdissection
testicular sperm extraction: a comparative study. Hum Reprod
2002; 17: 2924_9.
17 Westlander G, Rosenlund B, Soderlund B, Wood M, Bergh C.
Sperm retrieval, fertilization and pregnancy outcome in
repeated testicular sperm aspiration. J Assist Reprod Genet
2001; 18: 171_7.
18 Friedler S, Raziel A, Schachter M, Strassburger D, Bern O,
Ron-El R. Outcome of first and repeated testicular sperm extraction
and ICSI in patients withnon-obstructive azoospermia. Hum
Reprod 2002; 17: 2356_61.
19 Vernaeve V, Verheyen G, Goossens A, Van Steirteghem A,
Devroey P, Tournaye H. How successful is repeat testicular
sperm extraction in patients with azoospermia? Hum Reprod
2006; 21: 1551_4.
20 Vanderzwalmen P, Zech H, Birkenfeld A, Yemini M, Bertin G,
Lejeune B, et al. Intracytoplasmic injection of spermatids
retrieved from testicular tissue: influence of testicular pathology,
type of selected spermatids and oocyte activation. Hum
Reprod 1997; 12: 1203_13.
|