Potential for artificial intelligence in medicine and its application to male infertility.

Background: The third AI boom, which began in 2010, has been characterized by the rapid evolution and diversification of AI and marked by the development of key technologies such as machine learning and deep learning. AI is revolutionizing the medical field, enhancing diagnostic accuracy, surgical outcomes, and drug production. Methods: This review includes explanations of digital transformation (DX), the history of AI, the difference between machine learning and deep learning, recent AI topics, medical AI, and AI research in male infertility. Main Findings Results: In research on male infertility, I established an AI-based prediction model for Johnsen scores and an AI predictive model for sperm retrieval in non-obstructive azoospermia, both by no-code AI. Conclusions: AI is making constant progress. It would be ideal for physicians to acquire a knowledge of AI and even create AI models. No-code AI tools have revolutionized model creation, allowing individuals to independently handle data preparation and model development. Previously a team effort, this shift empowers users to craft customized AI models solo, offering greater flexibility and control in the model creation process.

Feasibility of high-frequency ultrasound for seminiferous tubule assessment and correlation of B-mode imaging with pathological findings in the testis in azoospermia.

PURPOSE: To determine the feasibility of high-frequency ultrasound (HFUS) for assessing seminiferous tubules and to understand high-resolution B-mode images of the testes in cases of azoospermia. METHODS: We verified how the histopathological images of testicular biopsy specimens can be observed using HFUS images and measurement analysis of seminiferous tubules was performed to 28 testes of 14 cases with azoospermia who underwent preoperative ultrasound and microdissection testicular sperm extraction (micro-TESE). The population consisted of obstructive azoospermia (OA) and non-obstructive azoospermia (NOA), including Sertoli cell-only syndrome (SCOS), and the other pathologies. Statistical verification of differences in seminiferous tubule diameters among preoperative ultrasound examination, ultrasound examination of pathological specimens, and histopathological specimens. We also examined the imagingpathology correlation via a case series presentation, aiming to identify imaging markers of testicular pathology and determine the possibility of predicting each condition. RESULTS: A comparison between HFUS images and histopathology from the same biopsy specimens suggested that ultrasonography could be seen as stereoscopic images due to its significantly greater slice thickness. The diameters of tubules were generally larger in pathological tissues as compared to ultrasonographic findings in OA and SCOS, but not in the other conditions. Comparisons provided insights into the predictability of SCOS and revealed imaging findings such as gaps between tubules and decreased diameter reflective of testicular damage. CONCLUSION: Seminiferous tubules can be observed however the diameter of seminiferous tubules varies in imaging and histopathology depending on the pathology. Imaging findings that reflect testicular damage and the predictability of SCOS were revealed in this study, but further verification is required.

Parameters affecting the success rate of microscopic testicular sperm extraction in male patients with a solitary testis and non-obstructive azoospermia.

PURPOSE: We aimed to compare the success rate of spermatozoa retrieval through microscopic testicular sperm extraction (mTESE) in non-obstructive azoospermic (NOA) men with a solitary testis with that of mTESE in NOA men with bilateral testes and the parameters affecting these rates. METHODS: A retrospective cross-sectional study of factors contributing to infertility in NOA patients with a solitary testis and men with bilateral testes was carried out. In this multicenter study, 74 patients with NOA with a solitary testis were matched with 74 patients with bilateral testes in terms of age, duration of infertility, and volume of the solitary testis from 2770 patients with NOA with bilateral testes. Hormonal parameters, presence of varicocele, history of varicocelectomy, history of undescended testis and karyotype analysis results were compared. RESULTS: Spermatozoa were obtained from 40 (54.1%) patients with a solitary testis and 42 (56.76%) patients with bilateral testes. No differences were found regarding age, duration of infertility, or mean testicular volume between patients with a solitary testis and patients with bilateral testes. When serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels were compared regardless of sperm retrieval status, it was observed that both levels were greater in the group of patients with a solitary testis (p < 0.01). Patients with solitary and bilateral testes from whom spermatozoa were obtained had larger testes than those from whom spermatozoa could not be obtained (p < 0.05). Similarly, the serum levels of FSH and LH were significantly greater in patients with a solitary testis than in those with bilateral testes (p < 0.05). CONCLUSIONS: To the best of our knowledge, this is the first study in the literature to evaluate the parameters that influence mTESE outcome in NOA patients with a solitary testis and NOA patients with bilateral testes. Greater testicular volume was found to positively affect spermatozoa retrieval for patients with a solitary testis. The higher levels of FSH and LH in patients with a solitary testis than in patients with bilateral testes of similar testicular volume may be due to a compensatory mechanism developed by the hypothalamic-pituitary-gonadal axis. The fact that these hormones are higher in patients with a solitary testis does not mean that the number of spermatozoa obtained through mTESE will be decreased.

Achieving an optimal pregnancy outcome through the combined utilization of micro-TESE and ICSI in cryptorchidism associated with a non-canonical splicing variant in RXFP2.

PURPOSE: To identify the genetic cause of a cryptorchidism patient carrying a non-canonical splicing variant highlighted by SPCards platform in RXFP2 and to provide a comprehensive overview of RXFP2 variants with cryptorchidism correlation. METHODS: We identified a homozygous non-canonical splicing variant by whole-exome sequencing and Sanger sequencing in a case with cryptorchidism and non-obstructive azoospermia (NOA). As the pathogenicity of this non-canonical splicing variant remained unclear, we initially utilized the SPCards platform to predict its pathogenicity. Subsequently, we employed a minigene splicing assay to further evaluate the influence of the identified splicing variant. Microdissection testicular sperm extraction (micro-TESE) combined with intracytoplasmic sperm injection (ICSI) was performed. PubMed and Human Genome Variant Database (HGMD) were queried to search for RXFP2 variants. RESULTS: We identified a homozygous non-canonical splicing variant (NM_130806: c.1376-12A > G) in RXFP2, and confirmed this variant caused aberrant splicing of exons 15 and 16 of the RXFP2 gene: 11 bases were added in front of exon 16, leading to an abnormal transcript initiation and a frameshift. Fortunately, the patient successfully obtained his biological offspring through micro-TESE combined with ICSI. Four cryptorchidism-associated variants in RXFP2 from 90 patients with cryptorchidism were identified through a literature search in PubMed and HGMD, with different inheritance patterns. CONCLUSION: This is the first cryptorchidism case carrying a novel causative non-canonical splicing RXFP2 variant. The combined approach of micro-TESE and ICSI contributed to an optimal pregnancy outcome. Our literature review demonstrated that RXFP2 variants caused cryptorchidism in a recessive inheritance pattern, rather than a dominant pattern.

Clinical management of nonobstructive azoospermia: An update.

Approximately 1% of the general male population has azoospermia, and nonobstructive azoospermia accounts for the majority of cases. The causes vary widely, including chromosomal and genetic abnormalities, varicocele, drug-induced causes, and gonadotropin deficiency; however, the cause is often unknown. In azoospermia caused by hypogonadotropic hypogonadism, gonadotropin replacement therapy can be expected to produce sperm in the ejaculate. In some cases, upfront varicocelectomy for nonobstructive azoospermia with varicocele may result in the appearance of ejaculated spermatozoa; however, the appropriate indication should be selected. Each guideline recommends microdissection testicular sperm extraction for nonobstructive azoospermia in terms of successful sperm retrieval and avoidance of complications. Sperm retrieval rates generally ranged from 20% to 70% but vary depending on the causative disease. Various attempts have been made to predict sperm retrieval and improve sperm retrieval rates; however, the evidence is insufficient. Further evidence accumulation is needed for salvage treatment in cases of failed sperm retrieval. In Japan, there is inadequate provision on the right to know the origin of children born from artificial insemination of donated sperm and the rights of sperm donors, as well as information on unrelated family members, and the development of these systems is challenging. In the future, it is hoped that the pathogenesis of nonobstructive azoospermia with an unknown cause will be elucidated and that technology for omics technologies, human spermatogenesis using pluripotent cells, and organ culture methods will be developed.

ICSI outcome after microdissection testicular sperm extraction, testicular sperm aspiration and ejaculated sperm.

We conducted a case-controlled single-center cohort study to evaluate the intracytoplasmic sperm injection (ICSI) outcome in severe male infertility with different methods of sperm obtention. The data was compiled from a tertiary university hospital. The micro-TESE procedures were performed from 2008 to 2023, with a sperm recovery rate (SRR) of 45 %. The ICSI treatments were carried out between 2011 and 2023. The aim of the study was to compare the ICSI outcome using sperm obtained by microdissection testicular extraction (micro-TESE), testicular sperm aspiration (TESA), and ejaculated sperm with sperm concentration less than 15 million per milliliter. We included a total of 462 ICSI cycles, of which 340 ICSIs with ejaculated sperm of men with oligozoospermia, with or without asthenozoospermia or teratozoospermia (OAT group), 51 ICSIs with TESA sperm of men with obstructive azoospermia (OA, TESA group), and 71 ICSIs with micro-TESE sperm of men with non-obstructive azoospermia (NOA, micro-TESE group). The patient characteristics, fertilization rate, pregnancy rate, and pregnancy outcome data were similar between the groups. The fertilization rates were 66.0 % in the OAT group, 68.3 % in the TESA group and 62.8 % in the micro-TESE group and live birth rate per embryo transfer were 23.7 %, 28.9 %, and 25.0 %, respectively, without statistical difference. The obstetrical outcome was similar in all the groups. The overall clinical results in all ICSI cycles performed for treating severe male factor infertility were similar, independent of the method of collection of spermatozoa. The results also confirm the efficacy of micro-TESE in the treatment of severe male factor infertility.

Financial decision analysis based on "willingness to pay" for surgical sperm retrieval approaches among men with non-obstructive azoospermia in the United States.

OBJECTIVE: To determine the most financially optimal surgical approach for testicular sperm retrieval for men with non-obstructive azoospermia. DESIGN: A decision tree was created examining five potential surgical approaches for men with non-obstructive azoospermia pursuing one cycle of intracytoplasmic sperm injection. An expected financial net loss was determined for each surgical option based on couples' willingness to pay for one cycle of intracytoplasmic sperm injection resulting in pregnancy. The branch with the lowest expected net loss was defined as the most optimal financial decision (minimizing loss to a couple). Fresh testicular sperm extraction implied testicular sperm extraction was performed in conjunction with programmed ovulation induction. Frozen testicular sperm extraction implied testicular sperm extraction was performed initially, and ovulation induction/intracytoplasmic sperm injection was canceled if sperm retrieval failed.  The surgical options included fresh conventional testicular sperm extraction, with and without "back-up" sperm cryopreservation, fresh microsurgical testicular sperm extraction, with and without "back-up" sperm cryopreservation, and frozen microsurgical testicular sperm extraction. Success was defined as pregnancy after one intracytoplasmic sperm injection cycle. MATERIALS AND METHODS: Probabilities of successful sperm retrieval with conventional testicular sperm extraction/microsurgical testicular sperm extraction, post-thaw sperm cellular loss following frozen microsurgical testicular sperm extraction, ovulation induction/intracytoplasmic sperm injection cycle out-of-pocket costs, intracytoplasmic sperm injection pregnancy rates for men with non-obstructive azoospermia, standard conventional testicular sperm extraction cost and average willingness to pay for intracytoplasmic sperm injection cycle were gathered from the systematic literature review. Costs were in USD and adjusted to inflation (as of April 2020). Two-way sensitivity analysis was performed on varying couples' willingness to pay for one cycle of intracytoplasmic sperm injection and varying microsurgical testicular sperm extraction out-of-pocket costs. RESULTS: According to our decision tree analysis (assuming minimum microsurgical testicular sperm extraction cost of $1,000 and willingness to pay of $8,000), the expected net loss for each branch was as follows: -$17,545 for fresh conventional testicular sperm extraction, -$17,523 for fresh microsurgical testicular sperm extraction, -$9,624 for frozen microsurgical testicular sperm extraction, -$17,991 for fresh conventional testicular sperm extraction with "backup", and -$18,210 for fresh microsurgical testicular sperm extraction with "backup". Two-way sensitivity analysis with a variable willingness to pay values and microsurgical testicular sperm extraction and in-vitro fertilization costs confirmed that frozen microsurgical testicular sperm extraction consistently presented the lowest net loss compared to other options. Interestingly, when directly comparing fresh microsurgical testicular sperm extraction and conventional testicular sperm extraction with "back-up", scenarios with decreasing willingness to pay and lower microsurgical testicular sperm extraction costs demonstrated fresh conventional testicular sperm extraction with "back-up" as more optimal than fresh microsurgical testicular sperm extraction with "back-up". CONCLUSIONS: For those couples who must pay out of pocket, our study suggests that frozen microsurgical testicular sperm extraction is the most financially optimal decision for the surgical management of non-obstructive azoospermia, regardless of microsurgical testicular sperm extraction cost and the couple's willingness to pay.

[Testicular and epididymal sperm extraction surgery]. / Chirurgies d'extraction de spermatozoïdes testiculaires et épididymaires.

BACKGROUND: Testicular and epididymal sperm extraction surgery is a frequent procedure. However, to date, there has been no French consensus on the technique to be preferred in the various situations of male infertility and on the best way to perform them. We therefore decided to proceed with a formalized expert consensus, using the method recommended by the French National Authority for Health. The aim was to provide the French urology community with practical advice on how best to perform these procedures. METHODS: Twenty-six international experts met online for the consensus. A research committee carried out a comprehensive literature review and prepared the 55 statements submitted to the rating group. After 2 rounds of scoring, 50 recommendations were validated in March 2023, having achieved a consensus of more than 85% among the experts. RESULTS: The consensus covered (1) preparation for sperm extraction surgery, (2) the different sperm extraction surgery techniques (Microsurgical epididymal sperm aspiration [MESA], Percutaneous epididymal sperm aspiration [PESA], Conventional Testicular Sperm Extraction [TESE], Microsurgical Testicular Sperm Extraction [micro-TESE]), (3) advice to be given to the patient concerning the postoperative period, before presenting the results of the sperm extraction surgeries. CONCLUSIONS: The expert consensus meeting on the performance of sperm extraction surgery presented a set of clinical guidelines based on the available literature and expert opinion. These guidelines should have a favourable effect on the development of this activity in France.

Testicular sperm aspiration has a poor effect in predicting micro-TESE outcomes in NOA patients with AZFc deletion.

BACKGROUND: Testicular sperm aspiration (TESA) is widely used in the diagnosis and management of nonobstructive azoospermia. However, its ability for predicting microdissection testicular sperm extraction in nonobstructive azoospermia (NOA) patients with AZFc deletion remains uncertain. To investigate whether TESA affected the sperm retrieval rate (SRR) in NOA patients with AZFc deletion, a retrospective analysis of the clinical data of NOA patients with AZFc deletion who underwent microdissection testicular sperm extraction (micro-TESE) was conducted. The effects of age, testicular volume, follicle-stimulating hormone (FSH) levels, luteinizing hormone (LH) levels, testosterone (T) levels and TESA on the SRR were analyzed in this group of patients. RESULTS: A total of 181 individuals had their sperm successfully collected and underwent micro-TESE, with an SRR of 67.4%. The patients were separated into two groups based on their micro-TESE results (sperm acquisition and nonsperm acquisition), with no significant variations in age, testicular volume, FSH levels, LH levels, or T levels between the two groups. There was no significant difference in the SRR between any of the groups into which patients were classified based on reproductive hormone reference value ranges. Binary logistic regression was used to explore the absence of significant effects of age, testicular volume, FSH levels, LH levels, and T levels on sperm acquisition in patients undergoing micro-TESE. In the preoperative testicular diagnostic biopsy group, the sperm acquisition and nonsperm acquisition groups had SRRs of 90.1% and 65.1%, respectively. More significantly, there was no significant difference in the SRR between the negative preoperative testicular diagnostic biopsy group and the nonpreoperative testicular diagnostic biopsy group (65.1 vs. 63.8%, p = 0.855). CONCLUSION: There is a high probability of successful sperm acquisition in the testis of men undergoing micro-TESE. In this group of patients, age, testicular volume, FSH levels, LH levels, and T levels may have little bearing on the micro-TESE outcome. In patients whose preoperative TESA revealed the absence of sperm, the probability of obtaining sperm by micro-TESE remained high (65.1%); negative TESA results appeared to not influence the SRR (63.8%) in patients undergoing micro-TESE.

RéSUMé: CONTEXTE: L'aspiration testiculaire de spermatozoïdes (TESA) est largement utilisée dans le diagnostic et la prise en charge de l'azoospermie non obstructive. Cependant, sa capacité à prédire la présence de spermatozoïdes testiculaires lors de l'extraction par microdissection chez les patients atteints d'azoospermie non obstructive (NOA) et porteurs de la délétion AZFc reste incertaine. Pour déterminer si la TESA affectait le taux de récupération de spermatozoïdes (SRR) chez les patients atteints d'ANO avec délétion AZFc, nous avons mené une analyse rétrospective des données cliniques des patients atteints de NOA et d'une délétion AZFc ayant subi une extraction testiculaire de spermatozoïdes (micro-TESE) par microdissection. Les effets de l'âge, du volume testiculaire, des taux d'hormone folliculostimulante (FSH), d'hormone lutéinisante (LH), de testostérone (T) et de TESA sur le SRR ont été analysés chez ces patients. RéSULTATS: Au total, 181 personnes ont eu leur spermatozoïdes collectés avec succès par micro-TESE, avec un SRR de 67,4%. Les patients ont été répartis en 2 groupes en fonction de leurs résultats à la micro-TESE (obtention de spermatozoïdes et non obtention de spermatozoïdes), sans variations significatives de l'âge, du volume testiculaire, des taux de FSH, LH ou de T entre les 2 groupes. Aucune différence significative du SRR n'a été retrouvée entre les groupes dans lesquels les patients ont été classés en fonction des plages de valeurs de référence des hormones reproductives. La régression logistique binaire a été utilisée pour explorer l'absence d'effets significatifs de l'âge, du volume testiculaire, des taux de FSH, de LH et de T sur la récupération de spermatozoïdes chez les patients bénéficiant d'une micro-TESE. Dans le groupe de biopsie diagnostique testiculaire préopératoire, les groupes avec récupération de spermatozoïdes et sans récupération de spermatozoïdes avaient respectivement des SRR de 90,1% et 65,1%. Plus important encore, il n'y avait pas de différence significative du SRR entre le groupe de biopsie diagnostique testiculaire préopératoire négatif et le groupe sans biopsie diagnostique testiculaire préopératoire (65,1 vs 63,8%, p = 0,855). CONCLUSIONS: Il existe une forte probabilité de récupération réussie de spermatozoïdes testiculaires chez les hommes bénéficiant d'une micro-TESE. Dans ce groupe de patients, l'âge, le volume testiculaire, les taux de FSH, de LH et de T ont peu d'incidence sur le résultat de la micro-TESE. Chez les patients dont la TESA préopératoire a révélé l'absence de spermatozoïdes, la probabilité d'obtenir des spermatozoïdes par micro-TESE est restée élevée (65,1%); les résultats négatifs d'une TESA ne semblaient pas influencer le SRR (63,8%) chez les patients bénéficiant d'une micro-TESE.

Infertility treatment for patients having a microdeletion of azoospermic factor (AZF).

In genetic causes of male infertility, Y chromosome microdeletions are the second most common after Klinefelter's syndrome. Although sperm recovery rate is relatively high for subjects with azoospermic factor (AZF) c chromosome microdeletion, intracytoplasmic sperm injection (ICSI) results using retrieved sperm has been reported to be poor. We retrospectively examined the infertility treatment for subjects with AZF microdeletion. From October 2017 to September 2020, chromosomal examination of 67 azoospermic subjects and 12 cryptozoospermia were performed. Of these, twenty-three subjects (29.1%) had AZF microdeletion. Twelve subjects with AZFc microdeletion and one subtype with unknown classification (Ym-9; P3 deletion) received sperm retrieval surgery due to azoospermia. Two subjects obtained motile sperm by microscopic epididymal sperm aspiration (MESA) and four subjects by microscopic testicular sperm extraction (micro-TESE). Pregnancy and healthy delivery were achieved in 6 of 14 subject (42.9%; including one twin) using ICSI. This was comparable with previous reports. Since there were two cases of obstructive azoospermia, we employed MESA to avoid testicular damage. Following observation of the testis and epididymis under operative microscope, a decision was made to perform sperm retrieval surgery to avoid unnecessary testicular damage. Furthermore, since AZFc microdeletion is passed to the next generation, long term follow-up is necessary.

Histological and immunohistochemical outcomes after microdissection TESE in contrast with hormonal profile, testis volume and genetics in patients with azoospermia.

A limited number of individuals with non-obstructive azoospermia (NOA) may recover spermatozoa through traditional testicular sperm extraction (TESE) techniques. There is an ongoing debate over the effectiveness of microdissection TESE compared to standard TESE methods. Microdissection TESE (micro-TESE) techniques enable the identification of spermatogenesis foci in non-obstructive forms of azoospermia. Only histological examination can provide an objective and definitive assessment of the testicular phenotype. This study aimed to evaluate the correlation between histopathological findings after microdissection TESE (micro-TESE) and the predictive role of various factors in determining the success of sperm retrieval. We evaluated 24 patients with azoospermia who underwent micro-TESE and considered the patient's hormonal profile, testis ultrasound, genetic evaluation, histology, and immunohistology (PLAP antibody) of collected testis biopsies. The preoperative blood FSH level, in conjunction with other parameters, may aid in the prediction of micro-TESE success. Sensitivity increases, and specificity decreases with higher FSH levels. Furthermore, testicular volume and FSH levels are typically normal in patients with maturation arrest. In conclusion, hormones, ultrasound evaluation of the testicles, testis volume, and available genetic tests have a predictive value in differentiating obstructive azoospermia (OA) from NOA with various sensitivity and specificity rates. Histological and immunohistochemical evaluation establishes the testicular phenotype accurately and guides patient management.

Identification of active spermatogenesis using a multiphoton microscope.

BACKGROUND: The sperm retrieval rate of microdissection testicular sperm extraction varies from 25% to 60%. Therefore, it is necessary to establish objective selection criteria for identifying seminiferous tubules with spermatozoa. OBJECTIVES: Our aim was to develop a method for identifying spermatogenesis without sectioning testicular tissues. MATERIALS AND METHODS: Testicular tissues of 10-week-old normal rats were fixed with 4% paraformaldehyde. Fluorescent labeling of seminiferous tubule nuclei and F-actin was performed, and the specimens were observed without sectioning using a multiphoton microscope. Cryptorchid rats were used as a model lacking elongated spermatids. Multiphoton images were compared with images of normal seminiferous tubules. In addition, seminiferous tubules of 10-week-old normal rats were labeled by testicular interstitial injection of fluorescent probes and observed by a multiphoton microscope without fixation. Terminal deoxynucleotidyl transferase dUTP nick end labeling-stained images of normal and probe-injected testes were compared. RESULTS: In fixed seminiferous tubules, elongated spermatids were identified. In addition, F-actin of apical ectoplasmic specialization was observed around elongated spermatids. Furthermore, spermatogenic stages were identified by an array of nuclei or F-actin. In cryptorchid testes, elongated spermatids and F-actin of the apical ectoplasmic specialization were not observed. In testes injected with fluorescent probes, F-actin of the apical ectoplasmic specialization was observed, and spermatogenic stages were identified without fixation. There was no significant difference in the number of terminal deoxynucleotidyl transferase dUTP nick end labeling-positive cells per seminiferous tubule between normal and probe-injected testes. CONCLUSIONS: Seminiferous epithelium could be observed without sectioning of tissues by fluorescent probes and a multiphoton microscope. Active spermatogenesis was observed by labeling F-actin with and without fixation. Moreover, the toxicity of fluorescent probes was limited. Our method has a potential for live imaging of testicular tissue.

Micro-TESE surgery combined with ICSI regimen in the treatment of non-obstructive azoospermia patients and its effect analysis.

This study aimed to analyze the clinical effects of microdissection testicular sperm extraction (micro-TESE) surgery combined with an intracytoplasmic sperm injection (ICSI) regimen in the treatment of non-obstructive azoospermia (NOA) patients with different etiologies. In total, 128 NOA patients participated in this study, in which they received infertility treatment by micro-TESE surgery combined with an ICSI regimen, and all patients were divided into three groups [the Klinefelter syndrome (KS), the idiopathic and the secondary NOA groups]. In addition, the sperm retrieval rate (SRR), fertilization rate, embryo development status and clinical treatment effects were analyzed. Among the 128 NOA patients, the SRR of KS NOA patients was 48.65%, those of idiopathic and the secondary patients were 33.82% and 73.91%, respectively. Regardless of etiologies, there was no correlation with age, hormone value or testicular volume. Further analysis showed that the SRR of the KS group was positively related with testosterone (T) values, and the SRR of the secondary group had a positive relationship with follicle-stimulating hormone or luteinizing hormone values. In the subsequent clinical treatment, the retrieved sperm was subjected to ICSI and achieved good treatment effects, especially in the secondary group, and the implantation rate (55.56%) and clinical pregnancy rate (68.42%) were both higher than those of the idiopathic group (28.75% and 40.00%) and KS group (22.05% and 30.77%). Micro-TESE surgery combined with ICSI insemination is the most effective treatment regimen for NOA patients. The SRR of NOA patients with different etiologies are related to certain specific factors, and micro-TESE surgery seems to be the ideal and only way to have biological children.

Micro-TESE strategy in patients with NOA caused by AZFc deletion: synchronous or asynchronous?

In the treatment of infertile patients with non-obstructive azoospermia (NOA) caused by the deletion of the azoospermia factor c region (AZFc) on the Y chromosome, synchronous and asynchronous surgical strategies are discussed. Clinical data from NOA patients with the AZFc deletion who underwent micro-TESE were analyzed retrospectively. The sperm retrieval rate (SRR) and sperm utilization rate of synchronous and asynchronous operation groups were followed up and compared. The fertilization rate, high-quality embryo rate, clinical pregnancy rate, abortion rate, and cumulative live birth rate of ICSI in patients with successful sperm retrieval were compared between the two groups. The two groups had sperm utilization rates of 98.9% (93/94) and 50.0% (14/28), respectively. The asynchronous group's sperm consumption rates were much lower than those of the synchronous operation group. Fertilization rate, high-quality embryo rate, clinical pregnancy rate of fresh transfer cycle, abortion rate, and cumulative live birth rate of patients in the synchronous operation group with fresh sperm, and the asynchronous operation group with thawed sperm, respectively, were 30.6% vs 33.8%, 33.8% vs 40.7%, 40.0% vs 12.5%, 30.4% vs 7.1%. Between the two groups, there was no significant difference. This suggests that individuals with NOA caused by the AZFc deletion have a high possibility of successfully acquiring sperm using micro-TESE and ICSI to conceive their own offspring. Synchronous micro-TESE is recommended to improve sperm utilization rate and the cumulative live birth rate.

[Molecular markers for predicting the success of micro-TESE in non-obstructive azoospermia].

Non-obstract azoospermia (NOA) is a serious male infertility disease. At present, testicular sperm extraction (micro-TESE) is performed in combination with intracytoplasmic sperm injection (ICSI) technology, NOA patients can have their own consanguine offspring. However, due to the invasiveness and uncertainty of micro-TESE surgery, it is difficult for patients to accept it. Therefore, finding an accurate method to predict the possibility of micro-TESE successful sperm retrival would be beneficial to azoospermia patients. Many genes are transcribed and expressed during spermatogenesis, and molecular assays have irreplaceable sensitivity and specificity in predicting the success sperm retrivel of micro-TESE. This article reviews the methods to predict the success sperm retrivel of micro-TESE including mRNA, non-coding RNA (piRNA, microRNA, cirRNA, tFRNAs) and some protein so far, to provide certain reference value for clinical and subsequent research.

Evaluation of PGK2 and ACR proteins in seminal plasma: suggestion of potential new biomarkers for prediction of sperm retrieval in non-obstructive azoospermia patients.

This study aimed to assess the role of testis-specific proteins, PGK2 and ACR, in the prediction of sperm retrieval results by microdissection testicular sperm extraction (micro-TESE) in men with non-obstructive azoospermia (NOA). This was a case-control study including 48 semen samples of NOA patients undergoing the micro-TESE procedure, 15 semen samples from normozoospermic men as the positive control, and 12 semen samples from obstructive azoospermia/post-vasectomy (OA/PV) as negative controls. We investigated the levels of PGK2 and ACR proteins by ELISA tests in seminal plasma samples. The ELISA results revealed a significantly higher concentration of PGK2 and ACR in the NOA patients with successful sperm retrieval (NOA+) in comparison to NOA patients with failed sperm retrieval (NOA-) group (p = 0.0001 in both cases). For the first time, the data from this study suggests that a seminal PGK2 concentration of 136.3 pg/ml and ACR concentration of 21.75 mIU/ml can be used as cut-off values for the prediction of micro-TESE outcomes in NOA patients. These findings may be useful to avoid unnecessary micro-TESE operations. Overall, the seminal levels of the PGK2 and ACR proteins may be useful in predicting sperm retrieval success by micro-TESE in NOA patients.

Non-invasive molecular biomarkers for predicting outcomes of micro-TESE in patients with idiopathic non-obstructive azoospermia.

Non-obstructive azoospermia (NOA), the most severe type of male infertility, affects approximately 1% of men worldwide. However, the aetiology of most NOA cases is not definite, that is defined as idiopathic NOA (INOA), posing a clinical conundrum worldwide. Most of these patients must receive donor sperm treatment until the emergence of microdissection testicular sperm extraction (micro-TESE). Although this procedure has recently become a promising treatment for INOA, the low sperm retrieval rate and testicular trauma have prompted us to explore appropriate non-invasive molecular biomarkers to predict the outcomes of sperm recovery preoperatively. Previous studies have identified a spectrum of biomarkers to address this challenging issue at various levels in different tissues, such as DNAs, RNAs, protein and steroid levels in the blood and seminal fluid. To better understand and assess the predictive values of diverse molecular biomarkers from different tissues on the outcome of sperm retrieval by micro-TESE in patients with INOA, we summarised recent findings and discussed the potential applications of these methods. The ultimate goal of this study was to provide references for further studies and clinical management.

Circulating microRNAs in seminal plasma as predictors of sperm retrieval in microdissection testicular sperm extraction.

Background: Because of focal spermatogenesis in some nonobstructive azoospermia (NOA) patients, testicular spermatozoa can be retrieved by microdissection testicular sperm extraction (micro-TESE) for intracytoplasmic sperm injection (ICSI) to achieve successful fertilization. Currently, testicular biopsy is widely performed for the prognosis of micro-TESE; however, it might miss foci with active spermatogenesis because of the 'blind manner' of puncture, highlighting the needs for biomarkers that could indicate actual spermatogenesis conditions in the testis. Thus, we screened microRNAs in the seminal plasma for potential biomarkers to provide a non-invasive and reliable preoperative assessment for micro-TESE. Methods: We screened the seminal plasma microRNAs from NOA patients with and without sperm retrieval (n=6 in each group) together with fertile men (n=6) by RNA sequencing, and the selected microRNAs were validated by quantitative polymerase chain reaction (qPCR). Next, a predictive model was established by performing ordered logistic regression using the qPCR data of 56 specimens, and the predictive accuracy of this model was evaluated using 40 more specimens in a blind manner. Results: Four microRNAs (hsa-miR-34b-3p, hsa-miR-34c-3p, hsa-miR-3065-3p, and hsa-miR-4446-3p) were identified as biomarkers, and the predictive model Logit = 2.0881+ 0.13448 mir-34b-3p + 0.58679 mir-34c-3p + 0.15636 mir-3065-3p + 0.09523 mir-4446-3p was established by machine learning. The model provided a high predictive accuracy (AUC =0.927). Conclusions: We developed a predictive model with high accuracy for micro-TESE, with which NOA patients might obtain accurate assessment of spermatogenesis conditions in testes before surgery.

Intrasurgical Seminiferous Tubular Diameter Correlates with Total Motile Sperm Count in Azoospermia: a Prospective Cohort Study.

We aimed to find a correlation between the intraoperative diameters of the seminiferous tubules evaluated at high magnification during micro-testicular sperm extraction (micro-TESE) and total motile sperm count (TMSC) in non-obstructive azoospermic (NOA) patients. Five hundred four consecutive NOA patients were included and underwent micro-TESE. The change in the mean TMSC and different seminiferous tubular diameters was of high statistical significance (p < 0.001). It should be noted that the highest mean TMSC was reported in the dilated tubules (DTs) group followed by the other study groups 941.72 ± 196.97, 487.37 ± 443.57, and 34.54 ± 60.79, respectively. Furthermore, 21 naïve cases had dilated tubules (DTs) and 18 (85.7%) of them had shown eventful micro-TESE. Conversely, 186 naïve cases had slightly dilated tubules (SDTs), and 101 (54.3%) of them had eventful micro-TESE. Only 8 (24.25%) cases of the 33 cases had non dilated tubules (NDTs) and showed eventful micro-TESE. The frequency of intrasurgical seminiferous tubular diameter and micro-TESE outcome among the naïve cases had demonstrated a highly statistical significance (p < 0.001). Interestingly, all salvaged cases (100%) with DTs and a previous eventful TESE had shown eventful TESE in the current study. The most dilated intrasurgical seminiferous tubular diameter is associated with the highest TMSC in NOA patients including SCO cases.

Does testicular sperm retrieval adversely impact spermatogenesis over the long-term?

Testicular sperm retrieval (TSR) techniques are valuable in the context of severe idiopathic male factor infertility; however, there are few studies in the literature examining the long-term impact of TSR on testicular function. The objective was to determine whether testicular sperm aspiration (TESA) or microdissection testicular sperm extraction (micro-TESE) worsens the pre-existing spermatogenesis deficiency in men with either cryptozoospermia or severe oligozoospermia. The study population consisted of 145 men with either cryptozoospermia or severe oligozoospermia that underwent TESA or micro-TESE and had long-term post-operative semen analyses (SA). Patients with SA prior to and following TSR were included (n = 24). Amongst them, 16 men underwent TESA and 8 underwent micro-TESE. The follow-up SA was obtained at a mean of 3.0 ± 2.0 years following TSR (range: 0.3-8.3 years) amongst all participants. The post-operative semen parameters in the TESA group were similar to the pre-intervention parameters (p > 0.1). Similarly, the micro-TESE cohort did not demonstrate significant alterations in semen parameters post-intervention (p > 0.05). None of the men in the study became azoospermic following the TSR. Our study indicates TESA or micro-TESE do not appear to worsen the pre-existing spermatogenesis deficiencies in cryptozoospermic and oligozoospermic men over a long-term period. Larger studies are required to corroborate these findings.