Can spermatozoa be retrieved in non-obstructive azoospermic patients with high FSH level?: A retrospective cohort study.

We aimed in this retrospective study to evaluate non-surgical preoperative parameters and testicular histopathology in determining the sperm retrieval rate (SRR) in non-obstructive azoospermic (NOA) patients. We evaluated the data of 1,395 consecutive patients who underwent 1st time micro-dissection testicular sperm extraction (micro-TESE) that was done by fifteen different senior andrologists and a consequent undefined number of biologists assisting them in the operative rooms from January 2010 to May 2013 in a specialised IVF centre. Our study did not demonstrate any statistical significance between the mean age, the mean duration of infertility and finally, the mean of FSH levels of the patients with positive and negative micro-TESE outcomes (p-value 0.391, 0.543, 0.767 respectively). Moreover, our study did not demonstrate any association between different types of hormonal therapy prior to micro-TESE and patients with positive micro-TESE outcome (p-value 0.219). Interestingly, our study showed positive associations between the testicular histopathology SCO (sertoli cell only syndrome) and high FSH and sperm retrieval rate (p < 0.001, 0.02 respectively). Logistic regression analysis revealed high statistical significance between sperm retrieval rate and high FSH level and testicular histopathology (OR 1.6, 0.21, 95% CI lower 1.2, 0.008 and upper 2.1, 0.06 and finally p 0.003, <0.001 respectively). This study reveals that preoperative testicular biopsy is unnecessary to predict the sperm retrieval rate in NOA patients.

Estimation of B-inhibin and anti mullerian hormone in functional azoospermia and their correlations with surgical sperm retrieval: A prospective case-control study.

OBJECTIVES: The current study estimated the levels of anti mullerian hormone (AMH) and inhibin-B and reproductive hormones in non obstructive azoospermic (NOA) cases and obstructive azoospermic (OA) cases as well as comparing between them as regards the sensitivity and specificity in determining the sperm retrieval hope in the NOA cases. Finally, we analyzed any potential correlation between all the hormones measured in the current study. METHODS: The current case control study was conducted at the andrology outpatient clinic from June (2021) to March (2022). The study recruited 135 participants divided equally into three groups NOA cases, OA cases and controls, respectively. RESULTS: The mean inhibin-B was significantly lower in the NOA cases compared to the OA cases and the controls. There was a positive moderate correlation between AMH and Inhibin-B. Also, there was a positive moderate correlation between inhibin-B and free testosterone (FT) and positive weak correlation between beta Inhibin and leutinizing hormone (LH). CONCLUSIONS: The current study asserts the observation that inhibin-B is also expressed by Leydig cells as it has demonstrated positive correlations with FT and LH.

Evaluation of the Utility of Seminal Plasma Resistin and Leptin in Predicting Successful Surgical Sperm Retrieval in Men with Non-Obstructive Azoospermia.

Background: The purpose of the current study was evaluation of the utility of seminal plasma (SP) resistin and leptin in predicting successful surgical sperm retrieval (SSR) in men with non-obstructive azoospermia (NOA). Methods: This prospective comparative study was conducted in the andrology clinic of a specialized fertility center. In total, 53 NOA men as candidates for either first time micro-testicular sperm extraction (micro-TESE) or repeat micro-TESE and 28 normozoospermic controls were included. ELISA was used for measurement of SP resistin and leptin levels in all participants. Significance level was defined as p<0.05. Results: The current study demonstrated a significant positive correlation between estradiol (E2) level in serum and SP resistin (r=0.342, p=0.025). Also, there was a highly significant positive correlation between SP leptin and SP resistin (r=0.568, p= 0.001). Interestingly, SP leptin was the only variable that demonstrated a significant correlation with eventful micro-TESE outcome in men who underwent micro-TESE for the first time. Finally, ROC curve showed that SP leptin level of 4.05 ng/ml predicted successful SSR in men who underwent micro-TESE for the first time with a sensitivity of 73.3% and a specificity of 75% as 11 out of 27 (41%) cases showed eventful micro-TESE at or above this cut-off level [AUC of 0.747, 95% CI, lower bound of 0.555, and upper bound of 0.939, p=0.030]. Conclusion: SP leptin can be used as a non-invasive biomarker to predict successful SSR in NOA cases undergoing first time micro-TESE, while SP resistin failed to play the same role.

Comparative study between two techniques for artificial shrinkage of blastocysts prior to vitrification: LASER pulse versus micro-needle technique in increasing chemical, clinical pregnancy and live birth rates after ICSI, a randomized controlled trial.

PURPOSE: This work investigates ICSI outcome between LASER Artificial Shrinkage (LAS) and Micro-Needle Artificial Shrinkage (MNAS) before vitrification. PATIENTS AND METHODS: Four hundred and nine women were included in the study; which were randomly divided into two groups according to the technique used for artificial shrinkage step of the blastocyst before vitrification: in the first group, Laser beam was used while in the second group the micro-needle was used. Ovarian stimulation was done before the ICSI procedure either by long, short or antagonist protocol. RESULTS: The statistical analysis of our study revealed that there was no statistically significant difference between the two groups regarding age, number of cases, AMH, Basal FSH, BMI, male factor, usage ovarian stimulation protocol, high quality blastocysts, the mean number of transferred embryos. While, there was a statistically significant difference between two groups after thawing with p-value < .001 in favor of the LAS method regarding the morphology of originally high quality blastocysts, blastocysts healthiness (not degenerated), pregnancy rate, the implantation rates. CONCLUSION: LASER artificial shrinkage of human blastocysts is a promising technology that could be implemented on a wider basis to improve ART practice, as our study revealed that the usage of LASER pulse for artificial shrinkage of blastocysts before vitrification has better implantation rate as well as better chemical and clinical pregnancy rate in comparison to the usage of micro-needle artificial shrinkage of blastocysts before vitrification. There is a statistically significant difference regarding live birth rate being more in the LASER group as compared to needle group, also the number of twins ether identical or non-identical are larger in laser group than in needle group but with no statistically significant difference. Clinical trials.gov ID: NCT04125017.

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.

Assessment of male serum anti-Mullerian hormone as a marker of spermatogenesis and ICSI outcome.

OBJECTIVE: To assess serum anti-Mullerian hormone (AMH) as a marker of spermatogenesis among fertile and infertile males, as well as its relation to ICSI outcome. METHODS: A total of 77 male partners of infertile couples seeking infertility treatment were recruited for this study. They were classified according to the WHO criteria of semen analysis into three groups; azospermia, oligospermia, and normal. All participating patients had a serum assay of the level of AMH. Thirty-three couples out of the previously mentioned 77 couples underwent controlled ovarian stimulation and ICSI. RESULTS: There were 41 patients with azospermia, 14 patients with oligospermia, and 22 patients with normal count. There was no significant difference among the three groups regarding the AMH levels. There was no significant correlation between the AMH levels from all patients and the sperm concentration (rho = 0.03, p = 0.82). Among patients who underwent ICSI, there was no significant correlation of the AMH with the age, sperm concentration, fertilisation percent or number of embryos. The age of male partners was significantly correlated with sperm concentration, fertilisation percent and the total number of embryos. In the logistic regression model used, serum AMH had no significant relation to clinical pregnancy. CONCLUSION: Male serum AMH levels are not indicative of spermatogenesis and cannot differentiate between fertile and infertile males. Serum AMH levels were not predictive of ICSI outcome as well.

Fresh vs frozen testicular sperm for assisted reproductive technology in patients with non-obstructive azoospermia: A systematic review.

OBJECTIVE: : To review the debate about the routine use of cryopreserved testicular sperm for intracytoplasmic sperm injection (ICSI) from patients with non-obstructive azoospermia (NOA), as some authors suggest repeating sperm retrieval in such cases due to poorer ICSI results when frozen-thawed testicular sperm is used compared with fresh sperm. METHODS: : A systematic literature review was performed in August 2020 using the Medical Literature Analysis and Retrieval System Online (MEDLINE), Web of Science databases and the Excerpta Medica dataBASE (EMBASE), and we included 26 studies that were considered eligible for this systematic review. RESULTS: : In all, 1189 publications were screened and 26 articles were included in the systematic review. Three meta-analysis reviews were included and they all concluded that the use of fresh and frozen sperms for ICSI from patients with NOA showed comparable fertilisation and pregnancy rates. CONCLUSION: : The use of frozen testicular sperm from men with NOA results in fertilisation and clinical pregnancy rates similar to those of fresh sperm. This may encourage fertility centres to use frozen testicular sperm samples, as this policy has certain advantages that would help with organising their workflow.Abbreviations: CPR: clinical pregnancy rate; 2PN%: two pronuclei % fertilisation rate; ICSI: intracytoplasmic sperm injection; NOA: non-obstructive azoospermia; OA, obstructive azoospermia; SCO: Sertoli cell-only syndrome; (micro-)TESE: (microsurgical) testicular sperm extraction.

Assessment of correlation between asthenozoospermia and mitochondrial DNA mutations in Egyptian infertile men.

BACKGROUND: Asthenozoospermia is a chief reason for male seminal pathologies with an impression of around 19% of infertile patients. Spermatozoa mitochondrial DNA variations seem to link with low sperm motility. The objective of the study was to assess the relation between mitochondrial mutations and male sterility, especially in asthenozoospermia. The patient semen samples were investigated by studying the sperm physical characters; motility, viability, and morphological parameters were then classified into normozoospermia and asthenozoospermia. In addition, the level of malondialdehyde (MDA) as a bio-indicator of lipid peroxidation, seminal fructose, and total antioxidant capacity (TAC) were estimated. For molecular analysis, DNA from the semen samples was extracted using a DNA extraction kit. ND1, ND2, and ATPase6 genes were amplified by using a specific primer. After the purification procedure, each PCR product was sequenced to identify the single nucleotide polymorphisms (SNPs) in selected genes. RESULTS: A significant negative correlation between seminal plasma malondialdehyde levels and sperm motility was detected. Meanwhile, TAC analysis revealed significantly lower activity (p ≤ 0.05) in the sample of asthenozoospermic than in normozoospermic men. As regards the seminal plasma fructose, there was no significant difference in the fructose level of normozoospermia and asthenozoospermia cases. At the molecular level, 31 diverse nucleotide substitutions were recognized in mitochondrial DNA. Only ten (10) mutations led to amino acid transformation: four have deleterious effects, four are benign, and the other two have conflicting effectiveness. CONCLUSIONS: This study is the first in Egypt that is concerned with studying the relationship between the mitochondrial DNA mutations in human spermatozoa of asthenozoospermic patients and fertility. The results displayed scientific indications evidenced that there is an association between mitochondrial mutations and male infertility.

Effect of cryoprotectant-free vitrification versus conventional freezing on human testicular sperm motility: a prospective comparative study.

This study aimed to demonstrate the effect of conventional freezing versus cryoprotectant-free vitrification on the recovery of testicular sperm motility. Testicular samples were obtained from 50 patients with azoospermia for testicular biopsy ± potential sperm storage. We retrieved 100 spermatozoa from each patient divided equally into two straws. They were frozen using conventional freezing as a control group and cryoprotectant-free vitrification in micro-capillary system using open-pulled straws. Seven days later, cryopreserved straws were thawed and assessed in duplicate. The mean sperm motility between the original spermatozoa sample and the post warming sample was reduced after conventional freezing compared to cryoprotectant-free vitrification (4.48 ± 2.09% versus 3.25 ± 1.92%, p < 0.001; 4.48 ± 2.09% vs 3.68 ± 1.93%, p < 0.001, respectively). There was a significant difference between the two methods regarding the mean sperm motility after warming (3.38 ± 1.86% versus 3.76 ± 1.88%, p = 0.015). The mean recovery percent of testicular sperm motility from the original sperm sample was lower (p = 0.02) after conventional freezing compared to cryoprotectant-free vitrification (78.4 ± 28.17% versus 85.37 ± 23.63%). Overall, the rate of post-thaw recovery of human testicular sperm motility improved using cryoprotectant-free vitrification compared to conventional freezing.

Evaluation of neoadjuvant gonadotropin administration with downregulation by testosterone prior to second time microsurgical testicular sperm extraction: A prospective case-control study.

PURPOSE: The aim of this prospective study was to determine whether there is a beneficial role of combining gonadotropin administration with testosterone downregulation in non-obstructive azoospermia patients prior to a second time microsurgical testicular sperm extraction after a negative one. METHODS: A total of 40 non-obstructive azoospermia men were recruited from a specialized IVF center from 2014 to 2016. Participants were divided equally into two groups: Group A was subjected to testosterone downregulation alone for 1 month and then combined with gonadotropin administration for 3 months prior to second time testicular sperm extraction; Group B (controls) underwent second time microsurgical testicular sperm extraction without prior hormonal therapy. RESULTS: Mean baseline follicle-stimulating hormone levels of the controls and the cases were 26.9 ± 11.8 and 25.4 ± 8.7, respectively. One month after testosterone downregulation, follicle-stimulating hormone level of the cases was normalized and became 2.4 ± 1.2. There was no statistically significant difference between baseline follicle-stimulating hormone levels of the controls and cases (p = 0.946). Remarkably, two cases were positive after downregulation (10%) and no controls were positive at second testicular sperm extraction (0%). There was no statistically significant difference between sperm retrieval after the second microsurgical testicular sperm extraction in the controls and the cases (p = 0.072). CONCLUSION: Patients who underwent first time testicular sperm extraction with unfavorable outcome due to different techniques may benefit from testosterone downregulation combined with neoadjuvant gonadotropin administration as it had shown positive sperms retrieval in 2 out of the 20 cases, especially those with hypergonadotropic azoospermia.

Factors determining the sperm retrieval rate in fresh versus salvage micro-TESE: a comparative cohort study.

PURPOSE: We studied prospectively the role of FSH, testis volume, age, duration of infertility, hormonal therapy, varicocelectomy and testicular histopathology in determining the sperm retrieval rate (SRR) in fresh versus salvage micro-TESE. METHODS: Our study analysed retrospectively the prospectively maintained database of 330 NOA patients who underwent micro-TESE either 1st or 2nd or 3rd timers from January 2017 to August 2018 from the Andrology Clinic of a specialized IVF centre. They were divided equally into 3 groups, group (1) were 1st timers, group (2) were 2nd timers and group (3) were 3rd timers, respectively. RESULTS: Interestingly, our study demonstrated a positive correlation between high FSH level and favourable micro-TESE outcome in 1st timers who underwent micro-TESE (p 0.015). Additionally, our study revealed a positive correlation between age and favourable micro-TESE outcome in 2nd timers who underwent micro-TESE (p 0.031). Further, our study revealed a positive correlation between right testicular volume and favourable micro-TESE outcome in 1st timers who underwent micro-TESE (p 0.023). Eventually, there was a significant positive correlation between histopathology which was mainly sertoli cell only syndrome and favourable micro-TESE outcome in 1st timers micro-TESE (p 0.001). CONCLUSION: Our study demonstrates that sperms can be retrieved despite high FSH level, and preoperative histopathology is not essential in predicting SRR in NOA patients. Further, age can be considered a good prognostic factor in patients who undergo salvage micro-TESE for the 2nd time.

Semen parameters in men with spinal cord injury: changes and aetiology.

AIM: To assess the changes in semen parameters in men with spinal cord injury (SCI) and the possible causes of these changes. METHODS: The study included 45 subjects with SCI. Semen retrieval was done by masturbation (2), vigorous prostatic massage (n = 13), penile vibratory stimulation (n = 13) or electroejaculation (n = 17). RESULTS: The semen of men with SCI showed normal volume (2.3 +/- 1.9 mL) and sperm count (85.0 X 10(6) +/- 83.8 X 10(6)/mL) with decreased motility (11.6% +/- 0.1%), vitality (18.5% +/- 5.2%) and normal forms (17.5% +/- 3.4%), and pus cells has been increased (6.0 X 10(6) +/- 8.2 X 10(6)/mL). Total (13.4 +/- 9.9 vs. 7.1 +/- 6.8) and progressive (4.4 +/- 3.9 vs.2.2 +/- 2.1) motility were significantly higher in subjects with lower scrotal temperatures. There was no statistical significant difference between electroejaculation and penile vibratory stimulation groups as regards any of the semen parameters. Subjects'age, infrequent ejaculation, injury duration and hormonal profile showed no significant effect on semen parameters. CONCLUSION: The defining characteristics of the seminogram in men with SCI are normal volume and count with decreased sperm motility, vitality and normal forms, and the increased number of pus cells. The most acceptable cause of the deterioration of semen is elevated scrotal temperature.

Seminal plasma anti-Müllerian hormone level correlates with semen parameters but does not predict success of testicular sperm extraction (TESE).

AIM: To assess seminal plasma anti-Müllerian hormone (AMH) level relationships in fertile and infertile males. METHODS: Eighty-four male cases were studied and divided into four groups: fertile normozoospermia (n = 16), oligoasthenoteratozoospermia (n = 15), obstructive azoospermia (OA) (n = 13) and non-obstructive azoospermia (NOA) (n = 40). Conventional semen analysis was done for all cases. Testicular biopsy was done with histopathology and fresh tissue examination for testicular sperm extraction (TESE) in NOA cases. NOA group was subdivided according to TESE results into unsuccessful TESE (n = 19) and successful TESE (n = 21). Seminal plasma AMH was estimated by enzyme linked immunosorbent assay (ELISA) and serum follicular stimulating hormone (FSH) was estimated in NOA cases only by radioimmunoassay (RIA). RESULTS: Mean seminal AMH was significantly higher in fertile group than in oligoasthenoteratozoospermia with significance (41.5 +/- 10.9 pmol/L vs. 30.5 +/- 10.3 pmol/L, P < 0.05). Seminal AMH was not detected in any OA patients. Seminal AMH was correlated positively with testicular volume (r = 0.329, P = 0.005), sperm count (r = 0.483, P = 0.007), sperm motility percent (r = 0.419, P = 0.021) and negatively with sperm abnormal forms percent (r = -0.413, P = 0.023). Nonsignificant correlation was evident with age (r = -0.155, P = 0.414) and plasma FSH (r = -0.014, P = 0.943). In NOA cases, seminal AMH was detectable in 23/40 cases, 14 of them were successful TESE (57.5%) and was undetectable in 17/40 cases, 10 of them were unsuccessful TESE (58.2%). CONCLUSION: Seminal plasma AMH is an absolute testicular marker being absent in all OA cases. However, seminal AMH has a poor predictability for successful testicular sperm retrieval in NOA cases.

Ropporin gene expression in infertile asthenozoospermic men with varicocele before and after repair.

OBJECTIVE: To assess Ropporin gene expression in the sperm of infertile asthenozoospermic men with varicocele (Vx) before and after repair. METHODS: This study included 24 infertile asthenozoospermic men with Vx. They were subjected to history taking, clinical examination, scrotal color Doppler, and semen analysis with sperm separation. Three months after varicocelectomy, they were subjected to postoperative color Doppler, semen analysis, and sperm semiquantitative Reverse Transcription-Polymerase Chain Reaction assay for Ropporin gene expression levels. RESULTS: Ropporin gene expression is significantly associated with different types of sperm motility, except for nonprogressive sperm motility. There was significant Ropporin gene overexpression postvaricocelectomy that was correlated with improved sperm count, sperm motility, and abnormal sperm morphology with decreased veins diameters. CONCLUSION: Ropporin gene expression is related to the sperm motility. Its abnormal expression in the sperm of asthenozoospermic men with Vx is associated with impaired sperm motility that is improved after varicocelectomy.

Beneficial effect of adding pentoxifylline to processed semen samples on ICSI outcome in infertile males with mild and moderate asthenozoospermia: A randomized controlled prospective crossover study.

BACKGROUND: No extensive studies were done that included the use of pentoxifylline or verify its effect on the outcome of ICSI in cases of mild and moderate asthenozoospermia. OBJECTIVE: The aim of this study was to evaluate the effect of pentoxifylline used in preparation of semen samples which doesn't need motility enhancement prior to ICSI. MATERIALS AND METHODS: The study was carried on 30 infertile patients where pentoxifylline was used for semen processing (group I), another 30 patients without pentoxifylline (group II) in addition to 60 infertile patients where crossing over of the semen sample was done further subdividing it into 2 subgroups in which the first half of the semen sample was incubated with pentoxifylline (group IIIA) and the second half of the sample without pentoxifylline (group IIIB). RESULTS: The numbers of oocytes injected, numbers of oocytes fertilized, fertilization rate, the total numbers of embryos, numbers of good embryos and the numbers of embryos transferred of group IIIA were found significantly higher than that of Group IIIB (p=0.00). The overall 6 month pregnancy rate of group I was significantly higher than that of group II (73.3% vs. 60% respectively, p=0.04). The abortion rate of (Group I) and that of (Group II) was found non - significantly different (20% vs. 27.8% respectively, p=0.53). CONCLUSION: Pentoxifylline can be used as a useful compound for improving ICSI outcome in semen samples preparation prior to oocytes injection regardless of the state of sperm motility or the degree of asthenozoospermia. Registration ID in Clinical Trials.gov: NCT01793272.

Single tubule biopsy: a new objective microsurgical advancement for testicular sperm retrieval in patients with nonobstructive azoospermia.

OBJECTIVE: The aim of this study was to measure the diameter of seminiferous tubules (ST) during microdissection testicular sperm extraction (TESE) using a micrometer fixed to one of the eyepieces of the operating microscope to find a correlation between the extracted ST diameter and TESE outcome. DESIGN: A prospective comparative study. SETTING: Adam International Andrology and Infertility Clinic, Giza, Egypt. PATIENT(S): Two hundred sixty-four patients with nonobstructive azoospermia (NOA) were included. INTERVENTION(S): Patients underwent TESE using the open surgical technique. The STs were measured using the micrometer, and the tubule with the largest diameter was excised and freshly examined under an inverted microscope. If no spermatozoa were found, another sample was taken from the second most dilated tubule area and then at random until sperm were found or a maximum six samples were harvested. If no spermatozoa were detected, the contralateral testis was operated upon. MAIN OUTCOME MEASURE(S): The TESE outcome in relation to ST diameter. RESULT(S): The total sperm recovery rate was 105 out of 264 (39.8%). When ST measured >or=300 microm the sperm retrieval rate was 16 out of 19 (84.2%). When ST diameter was <300 microm, the sperm retrieval rate was 36.3% (89 out of 245). CONCLUSION(S): During microdissection TESE, the best cutoff level of the ST diameter for harvesting testicular spermatoza is 110 microm with sensitivity 86.0% and specificity 74.4% (AUC 0.653, 95% confidence interval 0.608-0.663). When ST diameter is 300 microm or more a single tubule biopsy is usually sufficient to harvest enough testicular spermatozoa for intracytoplasmic sperm injection or sperm freezing with minimal tissue excision.

Lymphatic vessel hydrodissection during varicocelectomy.

We report a new technique of preserving the lymphatics during varicocelectomy using saline infusion that we have termed "lymphatic hydrodissection."