Assisted reproduction for the treatment of
azoospermia
Anat Safran1, Benjamin E.Reubinoff, Anat Porat-Katz,
Joseph G.Schenker and Aby Lewin
IVF Unit, Department of Obstetrics and Gynecology, Hadassah Hebrew
University Medical School, Ein-Kerem, P.O.Box 12000,
Jerusalem IL-91120, Israel
'To whom correspondence should be addressed
Azoospermia, the most severe form of male infertility, is caused by obstructions in the genital tract or by testicular failure. Microsurgical techniques
are available for the correction of some of these obstructions but no effective
treatment is available for testicular failure. In recent years, methods have
been developed for direct surgical sperm sampling from either the epididymis
or the testis to be used by intracytoplasmic sperm injection. The main
approach proven to be effective for the retrieval of spermatozoa from
the epididymis in patients with obstructive azoospermia is microsurgical
epididymal sperm aspiration, although recently the retrieval of spermatozoa
by fine needle aspiration was shown to be equally effective. Recovery of
spermatozoa is also now performed in patients with severely deficient
spermatogenesis using testicular open biopsy as well as aspiration by fine
needle. The ultimate choice of sperm retrieval method in these patients
will depend not only on sperm availability, but also on the physiological
consequences of the different techiques on testicular function. This article
summarizes the recent advances achieved in the treatment of azoospermic
patients using these assisted reproduction surgical techniques.
Key words: ICSI/IVF/male factor infertility/sperm aspiration
Introduction
Male factor is one of the most frequent causes of infertility and presents a
variety of endocrine, genetic and immunological aetiologies, as well as sexual
malfunction, varicocele and genital infections. The most severe form of male
infertility is azoospermia, a term originating from the Greek words azoos (lifeless)
and sperma (seed). Thus, azoospermia defines the condition of absence of
spermatozoa in the semen and is due to either obstruction in the genital tract or
testicular failure. In obstructive azoospermia the process of spermatogenesis is
not impaired. The most common causes of obstruction are epididymovasal
occlusions caused by infections, congenital bilateral absence of the vas deferens
(CBAVD) and ligation or resection of the vas deferens during hernia repair,
prostatic and vesicle surgery or vasectomy. Several microsurgical techniques are
Human Reproduction Volume 13 Supplement 4 1998
© European Society for Human Reproduction and Embryology
47
A.Safran et al.
available for surgical correction of these obstructions. Epididymovasostomy, the
main procedure performed for the correction of post-infection obstruction, was
shown to provide 32-47% success in achieving patency. Vasovasostomy is
performed mainly for reversal of vasectomy and patency was reported to be
achieved in 30-88% of patients with a pregnancy rate of 18-53%. The major
advantage of successful microsurgical intervention is the possibility of achieving
multiple pregnancies following a single operation. Thus, when the operative
skills are available, microsurgery is offered to patients for reversal of vasectomy
and for selected cases with epididymovasal occlusions. With the new advances
in assisted reproductive techniques, patients with poor surgical prognosis can
now be referred to surgical procedures of sperm aspiration to be used for in-vitro
fertilization (IVF).
Non-obstructive azoospermia is defined as a condition in which there is an
impairment of various degrees in the process of spermatogenesis. For patients
with testicular failure (with the exception of hypogonadotropic hypogonadism),
no corrective approach is available, since all attempts at medical treatment failed.
The condition of hypogonadotrophic hypogonadism is caused by pituitary or
hypothalamic deficiency and treatment includes hormonal supplementation for
the duration of time required for resumption of spermatogenesis. Thus, the only
approach for treatment for non-hypogonadotrophic, non-obstructive, azoospermic
patients is a surgical intratesticular attempt for the retrieval of spermatozoa. The
correct differential diagnosis of obstructive and non-obstructive azoospermia is
important for the implementation of proper treatment, prognosis and counselling.
Traditional clinical criteria defining these two groups are summarized in Table I.
Nevertheless, in some cases, a poor correlation was found between the preoperative
clinical features and testicular histology. Furthermore, recent surgical attempts
to recover spermatozoa in cases of apparent testicular failure have proved
successful in many cases, thus further reducing the prognostic value of the
clinical parameters. Final prognosis of sperm availability in azoospermic patients
can therefore be achieved only with the combination of the clinical parameters
and direct surgical sperm sampling.
This article summarizes the advances achieved during recent years in the
treatment of patients with both obstructive as well as non-obstructive azoospermia
using assisted reproductive techniques.
Sperm retrieval methods for the treatment of obstructive azoospermia
The first azoospermic patients to be treated by assisted reproduction techniques
were those with obstructive azoospermia. Microsurgical epididymal sperm
aspiration (MESA) combined with IVF has led to the achievement of viable
pregnancies (Temple Smith et al., 1985; Silber et al., 1990) but was found to
offer limited success primarily due to low fertilization and implantation rates
(Hirsh et al., 1994). The introduction of intracytoplasmic sperm injection (ICSI)
by Palermo et al. (1992) has opened new horizons for the treatment of these
48
Treatment of azoospermia
Table I. Clinical features related to obstructive and non-obstructive azoospermia
Obstructive (excretory)
Patient's history
Epididymitis
Hernia repair
Prostatic or bladder surgery
Cystic fibrosis
Vasectomy
Neurogenic disorders:
Retrograde ejaculation
Impaired contractility of vas and vesicles in
diabetes following lymph node dissection
(testicular tumour)
Serum follicle stimulating hormone
Usually normal
Physical examination
Normal testicular size
Scrotal testicular location
Possible absence of vas
Possible induration of epididymis
Non-obstructive
Cryptorchidisma
Mumps orchitis
Torsion
Trauma
Chemotherapy
Irradiation
Elevated/normal
Low in hypogonadotropic hypogonadism
Small/normal testicular size
Scrotal testicular location/cryptorchidism
Gynaecomastia in Klinefelter
Seminal markers
Normal/absent/low fructose (seminal vesicles)13 Normal fructose and carnitine
and low carnitine (epididymis)
Testicular biopsy
Normal spermatogenesis
Germinal hypoplasia (hypospermatogenesis)
Spermatogenic arrest (maturation arrest)
Germinal aplasia (Sertoli cells only)
Tubular hyalinization
Testicular fibrosis
a
Cryptorchidism may cause irreversible testicular damage and azoospermia, depending on the
timing and efficiency of medical (human chorionic gonadotrophin) and surgical treatment.
b
Fructose is absent or low in some patients with congenital absence of the vas deferens and in
some patients with obstructions of the ejaculatory ducts.
patients. The efficacy of combining MESA with ICSI for the treatment of
infertility due to CBAVD was analysed (Tournaye et al., 1994), demonstrating
high fertilization (58%) and pregnancy (35.7%) rates even with the use of grossly
impaired epididymal spermatozoa. MESA is generally performed under general
anaesthesia. After unilateral hemiscrototomy, the epididymis is explored using
an operating microscope and carefully dissected to open several epididymal
tubules by microscissors. The epididymal fluid is aspirated using a glass pipette
and transferred into a conical test tube. Sperm preparation usually includes
separation on a two-layer Percoll gradient. A randomized comparative study
aimed to determine whether ICSI could achieve better results than conventional
IVF with microsurgical aspiration of spermatozoa in patients with CBAVD or
49
A.Safran et al.
irreparable obstructions (Silber et al., 1994). Results showed high fertilization
rates and the development of normal embryos in 82% of MESA/ICSI cycles as
compared to 19% with conventional IVF. Overall fertilization and pregnancy
rates were significantly higher using ICSI, being 45% and 47% as compared to
6.9% and 4.5% for conventional IVF, respectively. It was thus suggested that
ICSI may be mandated for all future MESA patients. It has been suggested that
the aetiology of obstruction may affect treatment results. Indeed, in a recent
study by Mansour et al. (1997), a significant difference in pregnancy rate was
observed when epididymal spermatozoa were obtained from patients with CB AVD
(20.4%) as compared with patients without genetic cause of obstruction (37%).
The striking finding in the retrieval of spermatozoa from the chronically obstructed
epididymis was the inversion of the expected pattern of motility, usually best in
the most proximal region (Silber et al., 1990). Furthermore, a remarkably high
pregnancy wastage was reported by Tournaye et al. (1994), who retrieved
spermatozoa mainly from the cauda. The observation that sperm cells from a
more proximal region of the epididymis provide high fertilization rates by ICSI
may indicate that although passage through the epididymis is required for normal
fertilization, it is not a prerequisite for a sperm cell to gain its intrinsic ability
to fertilize the egg and result in normal embryo development once penetration
is accomplished by ICSI. The combination of MESA/ICSI also enabled the
freezing of epididymal spermatozoa to be used successfully in additional ICSI
cycles (Devroey et al., 1995b) avoiding repeated scrotal surgery. In a recent
study by Oates et al. (1996), frozen-thawed epididymal spermatozoa were shown
to lead to equivalent fertilization and pregnancy rates as compared with fresh
epididymal spermatozoa. Based on these results, a new approach was suggested
in which sperm and oocyte harvesting need not be performed simultaneously.
This scheme may ease the burden of partner scheduling and assure the availability
of spermatozoa prior to ovulation induction, thus avoiding unnecessary ovarian
stimulation and oocyte retrieval.
In some patients requiring MESA for obstructive azoospermia, often no
spermatozoa can be retrieved from the epididymis due to extensive scarring from
previous corrective microsurgery or MESA procedures, or due to hypoplasia. In
some cases the epididymis on both sides is completely absent. In these patients,
the only source of spermatozoa is within the testicles. The fertilizing ability of
testicular spermatozoa obtained by open testicular biopsy was demonstrated for
the first time in a patient in which epididymal aspiration failed (Craft et al,
1993). The first pregnancy following the use of testicular spermatozoa obtained
by testicular biopsy in a patient in which epididymal sperm retrieval failed
(Schoysman et al., 1993), offered a new opportunity for patients with inoperable
excretory occlusion. In a small series described by Devroey et al. (1994), the
association of testicular sperm extraction (TESE) and ICSI yielded a high
fertilization rate in males with absence of the epididymis. In a larger series of
obstructive patients, a study was undertaken to compare the results obtained
using epididymal spermatozoa to those obtained using testicular spermatozoa
when epididymal aspiration failed or when the epididymis was absent or severely
50
Treatment of azoospermia
scarred (Silber et al, 1995c). The objective of this study was to determine
whether ICSI could salvage the most severe MESA cases where there were
absolutely no epididymal spermatozoa available, by resorting to TESE. The
procedure is usually performed under general anaesthesia. An incision is made
in the scrotal skin and carried through the peritoneal tunica vaginalis. A small
incision is then made in the tunica albuginea and the small portion of extruding
testicular tissue is excised and minced in HEPES-buffered medium. The effluent
is centrifuged and the pellet resuspended in medium and kept in the incubator
until it is used. It was demonstrated in the above study as well as by others
(Mansour et al, 1997) that in obstructive azoospermia, spermatozoa of both
epididymal and testicular origin yield similar fertilization, cleavage and ongoing
pregnancy rates using ICSI, although the main disadvantage of testicular
spermatozoa was the low number of sperm cells retrieved and their poor motility,
making cryopreservation of these cells more problematic than with epididymal
spermatozoa (Silber et al., 1995c). In another study (Nagy et al., 1995), the poor
parameters of testicular spermatozoa were compared to epididymal and ejaculated
spermatozoa. The mean total free sperm count of testicular spermatozoa was
0.54X 106 as compared to 46.2X 106 and 17.8X 106 for epididymal and ejaculated
spermatozoa, respectively. Testicular sperm always showed only a slow and
sluggish local motility, but the number of motile spermatozoa slightly increased
after 1-2 h of in-vitro incubation. It was thus suggested that in cases of obstructive
azoospermia, the MESA/ICSI technique should be attempted first, allowing
multiple aliquots to be frozen and used in subsequent cycles. In cases where
epididymal spermatozoa are not retrievable, testicular biopsy could be a final
resort that is also very effective, providing most patients with embryos for
transfer (Abuzeid et al., 1995; Mansour et al., 1996). Despite the lower number
of sperm cells retrieved from the testis and their extremely poor motility, the
fertilizing ability of these cells was shown to be retained following cryopreservation, as pregnancies were achieved following the injection of cryopreserved
spermatozoa recovered from testicular biopsies in cases of obstructive azoospermia (Gil-Salom et al, 1996; Podsiadly et al, 1996).
Consequently, successful sperm aspiration for the treatment of obstructive
azoospermia was reported using a less invasive approach of sperm retrieval from
the epididymis by fine needle aspiration. In the first study (Shrivastav et al,
1994), percutaneous epididymal sperm aspiration (PESA) was applied for the
treatment of seven patients with obstructive azoospermia. The procedure is
performed either under general or local anaesthesia and the aspiration apparatus
includes a 25-gauge butterfly needle connected to a 1 ml tuberculin syringe. The
needle is directly inserted into the epididymis, suction is applied and the aspirates
are washed into a sterile tube. Spermatozoa are usually prepared by a discontinuous
Percoll gradient. In the study by Shrivastav et al (1994), high sperm counts
were achieved in all cases (0.8-200XlO6/ml) and three pregnancies were
established. In a larger series (Tsirigotis et al, 1996), a high recovery rate
(85.5%) of spermatozoa from the epididymis using the percutaneous aspiration
approach, as well as high fertilization (52.6%) and pregnancy (33.3%) rates were
51
A.Safran et al.
reported. These results were comparable to those achieved applying MESA for
the treatment of obstructive azoospermic patients (Silber et al., 1994). The quality
of spermatozoa retrieved by PESA varied widely and it was suggested that ICSI
should be used to maximize fertilization rates (Craft et al., 1995a). In light of
these studies, it was concluded that the PESA technique is simple, efficient and
does not require specific microsurgical skills. It was also suggested to be
associated with fewer complications than an open microsurgical operation (Craft
et al., 1995a,b). A similar approach of percutaneous sperm aspiration from the
testis (TESA; Craft and Tsirigotis, 1995) evolved from the PESA procedure. It
was suggested that TESA be applied to men with active spermatogenesis, with
or without an obstruction, in situations where spermatozoa are not recovered
following MESA/PESA operations and for some non-obstructive cases of
azoospermia. The advantages of the percutaneous approach raised in relation to
PESA were relevant for the TESA technique as well, especially in view of the
fact that it does not require open surgery and removal of a large volume of tissue.
With the view of circumventing the need for open surgical interventions, we
have also adopted the percutaneous approach combining testicular and epididymal
fine needle aspiration (TEFNA) for the treatment of patients with obstructive
azoospermia (A.Safran et al., unpublished data). The technique is performed in
a similar manner to previous publications (Shrivastav et al., 1994; Craft et al.,
1995b), with some modifications. The aspiration set-up includes a 23-gauge
butterfly needle connected to a 20 ml syringe installed in an aspiration handle
for the creation of steady suction. The needle is introduced into the caput of the
epididymis and suction is established by using the aspiration handle device.
Following each aspiration, when epididymal fluid ceases to accumulate in the
tube, the needle is withdrawn and the aspirate is washed into a 4-well plate
containing HEPES-buffered medium. Sperm is prepared using a two-layer Percoll
gradient. Eleven patients underwent 12 treatment cycles. In 11 cycles, sperm
cells were easily recovered from the caput region of the epididymis and only
one or two punctures were needed. For one patient, spermatozoa could not be
retrieved from the epididymis as a result of severe scarring following previous
MESA operations. Spermatozoa were recovered by fine needle aspiration from
the testes using the same set-up. Mature sperm cells were available in all 12
cycles and five clinical pregnancies (41%) were achieved. In 11 cycles, spare
spermatozoa were cryopreserved. No complications were noted in any of these
patients. We thus concluded that by employing this relatively simple, inexpensive
and well-tolerated technique, sperm recovery can be predicted for almost all
patients with obstructive azoospermia. If spermatozoa are not retrieved from the
epididymis, TEFNA can immediately be performed using exactly the same set-up.
Concern has been expressed as to whether blind needle puncture of the
epididymis or the testis can cause damage and post-operative complications such
as infection and haematoma. In an animal model, a testicular atrophy rate of 5%
has been reported following percutaneous testicular puncture (Goldstein et al.,
1983). It is likely that these adverse effects were a consequence of damage to
the testicular vasculature in the spermatic cord. Such risks are significantly
52
Treatment of azoospermia
reduced in humans because of the use of fine needles, the size of the testis and
the fact that puncture of both the epididymis and the testis is performed away
from the main vascular supply (Craft and Tsirigotis, 1995). Indeed, post-operative
complications of patients undergoing these procedures were minimal, with few
patients complaining of short-term mild pain. Despite the simplicity of the TESA
method, it was still suggested that PESA should be the primary aspiration
technique for men with obstructions, because of the ability to recover larger
numbers of motile spermatozoa from the epididymis, some of which can be
cryopreserved for future use (Tsirigotis and Craft, 1996).
There seem to be differences in the number of sperm cells obtained by the
two sperm retrieval techniques in obstructive azoospermic patients, with the
recovery of fewer spermatozoa using the percutaneous approach. The number of
spermatozoa retrieved by TEFNA is in the order of hundreds of thousands to a
few millions. Since only a few dozen motile spermatozoa are required per
treatment cycle, the number of spermatozoa retrieved using TEFNA enabled
their use in all treatment cycles as well as their cryopreservation for several
future attempts in most cases.
A few other reports have been published in which attempts were made to
avoid the need of large tissue sampling for the treatment of obstructive
azoospermia. A modified percutaneous sperm aspiration technique was described
by Cha et al. (1997). A small incision is made in the scrotum, creating a direct
view of the epididymis. Sperm cells are aspirated using a 24-gauge angio-needle
and sperm preparation is performed as in the MESA approach. High fertilization
(77.3%) and pregnancy (43.5%) rates were achieved using this technique and it
was suggested that making this small opening may reduce the trauma caused by
blind puncture of the epididymis. Hovatta et al. (1995) described an alternative
technique of testicular sperm retrieval by using a biopsy gun needle. Using this
approach, small pieces of testicular tissue could be sampled from a wider area
of the testis and spermatozoa were obtained in 82% of cycles. Bourne et al.
(1995) reported successful aspiration of testicular spermatozoa by a 20-gauge
Menghini biopsy needle. Therefore, it seems that simple percutaneous aspiration
or needle biopsy (Watkins et al., 1997) offers a high sperm recovery rate while
being easy to perform, well tolerated by the patients and cost effective.
Sperm retrieval methods for the treatment of non-obstructive
azoospermia
In non-obstructive azoospermia, the process of spermatogenesis is impaired, the
epididymis is usually devoid of spermatozoa, and in some of these patients only
a few foci with complete spermatogenesis may exist in the testicles (Silber et
ah, 1995b). Initially, few case reports were published in which successful sperm
recovery by TESE was achieved in patients with testicular failure. Yemini et al.
(1995) reported fertilization following the injection of few spermatozoa obtained
by open testicular biopsy in an azoospermic patient with almost complete
53
A.Safran et al.
spermatogenic arrest and testicular tubular atrophy. In another study, an azoospermic patient with small testes, high levels of serum follicle stimulating
hormone (FSH) and testicular histology of partial germinal aplasia with focal
spermatogenesis was treated by TESE (Gil-Salom et al, 1995). A few spermatozoa
with 'twitching' motility were recovered, leading to a high fertilization rate
(73%) and a pregnancy. In this case report it was demonstrated for the first time
that patients with almost complete spermatogenic failure and markedly elevated
FSH levels may be successfully treated by TESE combined with ICSI. Concomitantly with these studies, the efficacy of ICSI with TESE in a series of 15 patients
with non-obstructive azoospermia was analysed (Devroey et al, 1995a). In this
study, the inclusion of patients suffering from non-obstructive azoospermia was
mainly based on high FSH concentrations and small testicular size. Consequently,
the histology of these patients revealed severe spermatogenic defects in most
cases. A high sperm recovery rate (86%) was reported, and the fertilization
(47.8%) and pregnancy (25%) rates achieved were remarkably similar to those
obtained using testicular spermatozoa from patients with normal spermatogenesis
(Devroey et al., 1994). Further experience of several groups with TESE and
ICSI for the treatment of non-obstructive azoospermic patients has been recently
published (Tournaye et al., 1995, 1996a; Devroey et al., 1996; Kahraman et al.,
1996a,b; Silber et al, 1996; Friedler et al, 1997). From all these studies few
important conclusions could be drawn. It was suggested that an attempt of sperm
recovery should be offered to all azoospermic patients, irrespective of serum
FSH levels, testicular size or medical history (Tournaye et al, 1995; Mansour et
al, 1997). When the outcome of treatment was analysed in relation to testicular
histology, no correlation was found between histological diagnosis and sperm
recovery in the wet preparation (Tournaye et al, 1996a). This pointed out the
shortcoming of a single testicular specimen in making the correct histological
diagnosis and could be explained by the focal nature of spermatogenesis in
these patients. It was also demonstrated that the normal fertilization rate was
significantly reduced in oocytes injected with spermatozoa deriving from men
with germ-cell aplasia and maturation arrest (Tournaye et al, 1996b). However,
once normal fertilization was achieved, embryonic development was comparable
with other infertility aetiologies. The fertilizing ability of sperm cells recovered
from cryopreserved testicular tissue obtained by TESE, which led to the
achievement of viable pregnancies from non-obstructive azoospermic patients,
was recently demonstrated (Oates et al, 1997). Because of the difficulty in
predicting the availability of spermatozoa in these patients, it was suggested in
this study that sperm recovery should be performed prior to initiation of an ICSI
cycle. If spermatozoa are found, the tissue can be cryopreserved and become the
'sperm source' for multiple ICSI cycles. This approach could prevent surgical
intervention in the female partner when sperm recovery fails.
Histological analysis of patients with non-obstructive azoospermia has demonstrated that if the entire testis is carefully sampled, occasional foci of complete
spermatogenesis will be found in more than half of cases (Silber et al, 1995a,b,
1996). It should however be emphasized that in a recent study by Silber et al
54
Treatment of azoospermia
(1997b), the distribution of active areas of spermatogenesis in cases of testicular
failure was suggested to be evenly scattered throughout the testicle, rather than
in a few patchy areas. Nevertheless, the concept of spermatogenesis being
confined to patchy areas in non-obstructive azoospermic patients was the basis
for a study that we undertook in order to evaluate the feasibility of obtaining
spermatozoa by multiple sampling of the entire testis by TEFNA in an azoospermic
patient with maturation arrest (Lewin et al., 1996). Eight sperm cells with
apparently normal morphology and signs of motility were found and one oocyte
was normally fertilized out of four mature oocytes injected. A single embryo
was transferred and a pregnancy and delivery of a healthy boy were achieved.
We postulate that unlike a single testicular biopsy, in cases of testicular failure
the TEFNA approach may enable the surgeon to reach multiple areas and thus
increase the chance of 'hitting' a rare site of active spermatogenesis. Based on
this hypothesis, we initiated a prospective study in which epididymal and
testicular fine needle aspiration was applied to all non-obstructive azoospermic
patients (Lewin, A., Safran, A., Reubinoff, B.P. et al. unpublished data, 1998).
Confirmation of the non-obstructive nature of azoospermia, according to the
classification by Levin (1979), was made from the histological report of either
the diagnostic preoperative biopsy, or from tissue sampling during the sperm
retrieval procedure. Pseudo azoospermia was excluded from this group, as all
men submitted ejaculate samples on two occasions prior to surgery and these
samples underwent extensive examination after high velocity centrifugation and
were all found to be devoid of any spermatozoa. Of 85 patients, spermatozoa
could be recovered in 50 (58.8%) and a pregnancy rate per transfer of 42.8%
was achieved. A low rate of mild complications was recorded in this group as
only three patients suffered pain necessitating treatment with oral analgesia. In
summary, a high sperm recovery rate could be achieved applying TEFNA for
the treatment of non-obstructive azoospermic patients and, once spermatozoa
were retrieved, the outcome was comparable to that achieved by other sperm
retrieval methods. With regard to the dispute concerning the distribution of
spermatogenic sites in the testicles of non-obstructive azoospermic patients, our
experience supports the hypothesis of focal spermatogenesis because, in many
cases during the first search of the wet preparation, spermatozoa could be detected
in one out of a few tens of aspiration samples. Spermatozoa could be recovered
even in four of six cases of Klinefelter syndrome and a delivery following
preimplantation diagnosis and the transfer of a normal 46XY embryo was
achieved (Reubinoff et al., 1998). Sperm recovery from non-mosaic 47XXY
Klinefelter patients using TESE was also reported (Tournaye et al., 1996b) as
well as the constitution of sex chromosomes in the embryos obtained from three
of these patients (Staessen et al., 1996). The conception achieved in our centre
using TEFNA (Reubinoff et al., 1998), is among the first few pregnancies
(Staessen et al., 1997) obtained so far using spermatozoa aspirated from
azoospermic non-mosaic Klinefelter individuals. We thus suggest that TEFNA
may be considered as an alternative approach to TESE for the treatment of nonobstructive azoospermic patients.
55
A.Safran et al.
Recently, the efficiency of testicular sperm retrieval by TEFNA was compared
with open biopsy and TESE "in 37 rigorously selected patients with nonobstructive azoospermia (Friedler et al., 1997). All patients underwent both
retrieval techniques, thus each patient served as his own control. Whereas by
TEFNA, spermatozoa enabling the performance of ICSI were found in four
patients out of 37 (11%), open biopsy and TESE yielded spermatozoa in 16
cases (43%). Several explanations could be given for the discrepancy in the rate
of sperm retrieval achieved in this study as compared to ours, applying TEFNA
for patients with proven testicular failure. In our protocol, the search for
spermatozoa, in most patients, required 5-8 h and in many cases only few
spermatozoa were found after several hours. If the two techniques, TEFNA and
TESE, are performed sequentially on the same day, it is probably impossible to
invest the same amount of time for the search of spermatozoa in both sperm
preparations. In the study of Friedler et al. (1997) up to six fine needle punctures
were performed in one testicle and sperm retrieval by open biopsy was applied
to the other testicle. In our protocol, up to 15 punctures are performed in each
testicle, increasing the amount of testicular aspirates up to 5-fold. Furthermore,
sperm preparation in the study of Friedler et al. (1997) includes treatment of the
cell suspension by erythrocyte-lysing buffer (Nagy et al., 1997), Percoll gradient
separation in some cases and two additional washing steps. This complex
procedure may cause the loss of spermatozoa during the various steps. Our
sperm preparation protocol for testicular spermatozoa includes only one step of
concentration by high speed (1800 g) centrifugation. When comparing these two
methods, one should also take into account the recent observations of Schlegel
and Su (1997). These studies demonstrated that following TESE, 82% of patients
had intratesticular abnormalities present on ultrasound, suggestive of persistent
haematoma and/or inflammation for as long as 3 months following the procedure.
The majority of these lesions were transient and appeared to resolve by 6 months
after the operation. However, permanent devascularization of the testis and
extensive fibrosis were shown to occur following TESE procedures with multiple
biopsies. In contrast, as in our study described above in which fine needle
aspiration was performed, Watkins et al. (1997) found no major complications.
Although the fine needle aspiration approach seems to be less invasive and to
cause fewer complications, more studies on the long-term effects of the two
techniques on testicular tissue is warranted before a consensus can be reached
on the preferred method for the treatment of these patients. Such a prospective
study is currently being performed in our centre.
Conclusions
In the last few years, ICSI has provided a remarkably effective solution for
severe male factor infertility. Clinical interest in the fertilizing ability of
epididymal spermatozoa developed originally from cases of obstructive azoospermia that could not be corrected surgically. It is now well established that ICSI
56
Treatment of azoospermia
using epididymal as well as testicular spermatozoa in men with various causes
of obstruction provides high fertilization and pregnancy rates with normal
deliveries. MESA has been the main method of sperm retrieval in those patients,
but other sperm retrieval techniques (PESA, TESA, TEFNA) were also introduced
and proved to be equally successful.
Recovery of testicular spermatozoa is now performed also in azoospermic
patients with severely deficient spermatogenesis. Various studies have focused
on the remarkable potential of retrieving viable spermatozoa from the testis using
different retrieval methods. Although the ultimate choice of sperm retrieval
method from the testis will depend on a number of factors including the clinical
diagnosis, patient's preference and the availability of the necessary surgical skills,
one of the most important parameters will be the physiological consequences of
these techniques on testicular function. It is also very important to determine the
prognostic factors which may predict a successful recovery procedure. For the
time being, no strong preoperative predictors for successful sperm recovery
except for testicular histology have been established (Silber et al., 1997b;
Tournaye et al., 1997).
It now appears that most types of male infertility, even such extreme cases as
maturation arrest, Sertoli cell only, post-chemotherapy azoospermia and Klinefelter syndrome, can be successfully treated. Ironically, female age and ovarian
reserve, rather then the source, the quantity or the quality of spermatozoa, are
the major determinants of the success of assisted reproduction treatment in these
patients (Silber et al, 1997a).
Finally, although no direct evidence exists whether assisted reproductive
techniques such as ICSI using testicular spermatozoa may compromise the
reproductive health of the progeny by transmission of genetic deletions associated
with azoospermia (Silber et al., 1995a), patients undergoing these procedures
should be properly counselled.
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