Salvage micro-dissection testicular sperm extraction; outcome in men with non-obstructive azoospermia with previous failed sperm retrievals.

OBJECTIVE: To assess the outcome of micro-dissection testicular exploration sperm extraction (m-TESE) as a salvage treatment in men with non-obstructive azoospermia (NOA) in whom no sperm was previously found on single/multiple TESE or testicular sperm aspiration (TESA). PATIENTS AND METHODS: In all, 58 men with NOA underwent m-TESE. All the patients had previously undergone either single/multiple TESE or TESA with no sperm found. All the patients underwent an m-TESE using a standard technique. Serum follicle-stimulating hormone (FSH), testosterone and histopathological diagnosis were examined as predictive factors for sperm recovery. All patients underwent preoperative genetic screening. One patient was found to have an azoospermic factor c (AZFc) micro-deletion and five were diagnosed with Kleinfelter's syndrome. RESULTS: The mean (range) patient age was 39.0 (26-57) years. Spermatozoa were successfully retrieved in 27 men by m-TESE (46.5%). The mean (range) FSH level was 19.4 (1.6-58.5) IU/L. There was no correlation in age (mean age retrieved 38.1 years, not retrieved 39.7 years, P = 0.38), FSH levels (mean FSH retrieved 21.4 IU/L, not retrieved 17.7 IU/L, P = 0.3) and the ability to find sperm by m-TESE. However, there was a significant difference in testosterone levels and sperm retrieval (mean testosterone retrieved 14.99 nmol/L, not retrieved 11.39 nmol/L, P < 0.05). Patients with a diagnosis of Sertoli-cell-only (SCO) syndrome [14/35 (40%)] and maturation arrest [four of 11 (36%)] had lower sperm retrieval rates than those in the hypospermatogenesis group [nine of 12 (75.0%)] (P < 0.05). There were no significant complications after m-TESE. CONCLUSIONS: In men with NOA who have undergone previous attempts at sperm retrieval with negative results, a salvage m-TESE offers a significant chance of finding sperm even in SCO syndrome. There does seem to be a correlation between preoperative testosterone levels and the ability to successfully find sperm.

Test of long-term uterine survival after allogeneic transplantation in rabbits.

AIM: To see if: (i) a large vessel aortocaval vascular patch technique may bring about long-term graft survival after allogeneic uterine transplantation (UTn) in a rabbit model; and (ii) fertility can be achieved following natural mating post-allogeneic UTn. METHODS: Allogeneic uterine cross transplantations were performed in New Zealand white rabbits using an aortocaval macrovascular patch harvested as part of the uterine allograft. Five rabbit recipients received a uterine graft from five unrelated donor rabbits. All female rabbits were unrelated and were of proven fertility with at least one previous litter each. Tacrolimus was administrated for immunosuppression post-transplant. Natural mating was attempted if long-term survival had been achieved. The main outcome measures were: (i) long-term recipient survival; (ii) long-term adequate uterine perfusion; and (iii) successful pregnancy post-UTn. RESULTS: All five recipient animals survived the surgery with satisfactory immediate postoperative recovery. Recipients 1, 2 and 4 died within the first 4 postoperative days. Both long-term survivors failed to conceive following introduction of a proven male breeder despite evidence of mating. Necropsy at 9 and 11 months showed a lack of patency of uterine cornua at the point of anastomosis, albeit a small uterus in recipient 3 and a reddish brown amorphous material at the site of the transplanted uterus in recipient 5. CONCLUSION: We have demonstrated the feasibility of uterine allotransplantation using a macrovascular patch technique, but could not demonstrate conception because of blocked cornua. To address this, we propose using embryo transfer techniques in order to achieve conception.

Reporting on longitudinal live birth rates and cumulative delivery rates are more realistic outcome measures than sperm retrieval rates in couples undergoing mTESE-ICSI.

The live birth rates (LBRs) in men with non-obstructive azoospermia (NOA) undergoing microdissection TESE (mTESE) are under reported, with surgical sperm retrieval rate often used as the primary outcome measure. We analysed longitudinal and cumulative delivery rates following mTESE- intracytoplasmic sperm injection (ICSI) in NOA. Sperm was retrieved in 45% of patients undergoing mTESE. Median male and female age were 42 years (IQR 37-47) and 35 years (IQR 31-38) respectively. A total of 141 ICSI cycles and 23 frozen embryo transfers resulted in 62 pregnancies and 37 LBRs. The longitudinal LBR, crude and expected cumulative delivery rates after five cycles were 15.5%, 48.7% and 71.1%, respectively. Reassuringly, there was no significant difference in pregnancy rate (PR) (p = 0.37) or LBR (p = 0.68) using fresh or frozen sperm or embryo (p = 0.74). Sperm retrieval was significantly correlated with Johnsen score (JS) (p = 0.006) and hypospermatogenesis (HS) (p = 0.04), whilst LBR only significantly correlated with female age (p = 0.04). The longitudinal LBR for a couple embarking on mTESE for azoospermia is only 15.5%, although the cumulative delivery rates are promising. Reassuringly, the outcomes using fresh versus frozen embryos or sperm are comparable. Reporting on delivery rates from a single mTESE procedure are more objective and realistic measures of treatment success in men with NOA.