In the era of micro-dissection sperm retrieval (m-TESE) is an isolated testicular biopsy necessary in the management of men with non-obstructive azoospermia?

OBJECTIVES: To assess the outcome of sperm retrieval using micro-dissection-TESE (m-TESE) and simultaneous diagnostic biopsy in NOA to determine if the final definitive histology correlated with the outcome of sperm retrieval by m-TESE in men with NOA. To determine if there was a correlation between FSH levels and positive sperm retrieval rates and assessed the success rate of m-TESE as either a primary or a salvage procedure after previous negative sperm retrieval. The EAU guidelines (2010) recommend that in men with non obstructive azoospermia 'a testicular biopsy is the best procedure to define the histological diagnosis and the possibility of finding sperm'. However, these guidelines do not identify which patients should have a diagnostic biopsy and if this biopsy should be performed as an isolated procedure or synchronously with sperm retrieval. It is also suggested that there is a correlation between the histological diagnosis and possibility of finding sperm on testis biopsy. PATIENTS AND METHODS: 100 men with NOA underwent a m-TESE sperm retrieval between 2005 and 2010 at a single centre. All patients underwent hormonal analysis (serum FSH, Testosterone and LH levels) and genetic analyses after full counselling including; Y-deletion, CF-gene analysis and karyotype. Thirty five men had previously undergone unsuccessful TESA/TESE or diagnostic biopsy at other centres. All patients underwent synchronous sperm retrieval and biopsy of the testis, which was sent for histopathological examination on the day of an ICSI cycle or as an isolated procedure. RESULTS: Mean age of patients was 37.25 (range 29-56 years). The mean serum FSH levels in the Sertoli cell only, maturation arrest and hypospermatogenesis groups were 21.3 IU/L (2.8-75), 16.18 (1.6-67) and 14.17 IU/L (0.8-42.3) respectively. SR rates in the respective groups were 42.85%, 26.6% and 75.86% (P= 0.023). There were no post-operative complications. In the 35 men who had previously undergone unsuccessful procedures elsewhere, the SR rates were 57.1%. The overall sperm retrieval rate was 50%. There was no correlation between SR and FSH levels (P= 0.28). CONCLUSION: M-TESE should be considered the gold standard for retrieval of testicular sperm in NOA, even in cases where there has been previously unsuccessful attempts. FSH levels and histology cannot be used to predict the success of sperm retrieval. An isolated diagnostic testicular biopsy is not recommended in men with NOA, as a significant proportion of men undergoing m-TESE will have successful a sperm retrieval irrespective of previous histology or previous unsuccessful surgery.

Analysis of the outcome of intracytoplasmic sperm injection using fresh or frozen sperm.

OBJECTIVES: • To compare the outcome of first-attempt intracytoplasmic sperm injection (ICSI) ICSI--embryo transfer (ET) cycles using frozen-thawed testicular sperm (FTTS), fresh testicular sperm (FTS), frozen-thawed epididymal sperm (FTES) and fresh epididymal sperm (FES) so as to determine which of these has the most successful ICSI outcome with respect to fertilization rate (FR), pregnancy rate (PR) and birth rate. • To assess the outcomes according to the underlying aetiology of azoospermia. PATIENTS AND METHODS: • The records of 493 patients undergoing first-attempt ICSI between 1993 and 2008 were reviewed retrospectively. FTS was used in 112 cycles, FTTS in 43 cycles, FES in 279 cycles, and FTES in 59 cycles. • Within each group, the aetiology of the azoospermia was recorded according to history, clinical examination and histological analysis (n = 316). • The FR, clinical PR and delivery rate were calculated for each group with respect to the type of sperm retrieval used. RESULTS: • Analysis of the data showed no significant differences between any of the four groups in the FR, PR or delivery rate (P > 0.05). • There were no significant differences seen between fresh sperm (FTS and FES) and frozen sperm (FTTS and FTES) or between epididymal sperm (FES and FTES) and testicular sperm (FTS and FTTS) in any of the outcomes measured (P > 0.05). However, subset analysis showed a statistically higher FR and PR for FTTS over fresh sperm. • When comparing aetiologies, there was no significant difference in the FR, clinical PR and delivery rate between obstructive azoospermia (OA) and non-obstructive azoospermia (NOA) groups. However, sub-set analysis showed a higher PR and birth rate for FTTS over fresh sperm in both OA and NOA groups. CONCLUSIONS: • The results of the present study suggest that using frozen sperm in ICSI cycles is a reliable and favourable method with the same outcome as fresh sperm. • Testicular and epididymal sperm have similar ICSI outcomes for both fresh and frozen samples. However, results suggest a tendency for higher PRs and birth rates for frozen than for fresh testicular sperm in both OA and NOA aetiologies. • The aetiology of azoospermia does not significantly affect the outcome of first-attempt ICSI. The higher rates in the frozen groups suggest that these patients have had better quality semen when they were initially harvested and frozen.