Detection of AZF microdeletions and analysis of reproductive hormonal profiles in Hainan men undergoing assisted reproductive technology.

BACKGROUND: Male infertility has become a global health problem, and genetic factors are one of the essential causes. Y chromosome microdeletion is the leading genetic factor cause of male infertility. The objective of this study is to investigate the correlation between male infertility and Y chromosome microdeletions in Hainan, the sole tropical island province of China. METHODS: We analyzed the semen of 897 infertile men from Hainan in this study. Semen analysis was measured according to WHO criteria by professionals at the Department of Reproductive Medicine, the First Affiliated Hospital of Hainan Medical University, where samples were collected. Y chromosome AZF microdeletions were confirmed by detecting six STS markers using multiple polymerase chain reactions on peripheral blood DNA. The levels of reproductive hormones, including FSH, LH, PRL, T, and E2, were quantified using the enzyme-linked immunosorbent assay (ELISA). RESULTS: The incidence of Y chromosome microdeletion in Hainan infertile men was 7.13%. The occurrence rate of Y chromosome microdeletion was 6.69% (34/508) in the oligozoospermia group and 7.71% (30/389) in the azoospermia group. The deletion of various types in the AZF subregion was observed in the group with azoospermia, whereas no AZFb deletion was detected in the oligozoospermia group. Among all patients with microdeletions, the deletion rate of the AZFc region was the higher at 68.75% (44 out of 64), followed by a deletion rate of 6.25% (4 out of 64) for the AZFa region and a deletion rate of 4.69% (3 out of 64) for the AZFb region. The deletion rate of the AZFa region was significantly higher in patients with azoospermia than in patients with oligozoospermia (0.51% vs. 0.39%, p < 0.001). In comparison, the deletion rate of the AZFc region was significantly higher in patients with oligozoospermia (3.08% vs. 6.30%, p < 0.001). Additionally, the AZFb + c subregion association deletion was observed in the highest proportion among all patients (0.89%, 8/897), followed by AZFa + b + c deletion (0.56%, 5/897), and exclusively occurred in patients with azoospermia. Hormone analysis revealed FSH (21.63 ± 2.01 U/L vs. 10.15 ± 0.96 U/L, p = 0.001), LH (8.96 ± 0.90 U/L vs. 4.58 ± 0.42 U/L, p < 0.001) and PRL (263.45 ± 21.84 mIU/L vs. 170.76 ± 17.10 mIU/L, p = 0.002) were significantly increased in azoospermia patients with microdeletions. Still, P and E2 levels were not significantly different between the two groups. CONCLUSIONS: The incidence of AZF microdeletion can reach 7.13% in infertile men in Hainan province, and the deletion of the AZFc subregion is the highest. Although the Y chromosome microdeletion rate is distinct in different regions or populations, the regions mentioned above of the Y chromosome may serve an indispensable role in regulating spermatogenesis. The analysis of Y chromosome microdeletion plays a crucial role in the clinical assessment and diagnosis of male infertility.

Downregulation of miR-211 expression in the blood plasma of infertile men compared to the fertile controls.

OBJECTIVES: Infertility is inability to conceive after 12 months of regular unprotected sex. MiRNA expression changes can serve as potential biomarkers for infertility in males due to impaired spermatogenesis. This research was conducted to measure the expression level of miR-211 in plasma samples as a factor identifying infertility in comparison with the control group. METHODS: In this study, blood plasma were taken from the infertile men (n = 103) nonobstructive azoospermia (NOA) or severe oligozoospermia (SO) and the control group (n = 121). The expression of circulating miR-211 in plasma was assessed by qRT-PCR. A relative quantification strategy was adopted using the 2-ΔΔCT method to calculate the target miR-211 expression level in both study groups. RESULTS: Plasma miR-211 levels were significantly lower in infertile men compared to the control group (0.544 ± 0.028 and 1.203 ± 0.035, respectively, p < 0.001). Pearson's correlation analysis showed that miR-211 expression level has a positive and significant correlation with sperm parameters, including sperm concentration, sperm total motility, progressive motility, and normal morphology (p < 0.001). CONCLUSIONS: Decreased expression of miR-211 in blood plasma seems to be associated with male infertility. This experiment showed that miR-211 can be considered as a biomarker for evaluation, diagnosis, and confirmation of the results of semen analysis in male infertility.

[Tumor necrosis factor in the ejaculate as an indicator of reduced fertility].

INTRODUCTION: Pro-inflammatory cytokine - tumor necrosis factor-alpha (TNF) is one of the components of the seminal plasma proteome; its meaning has not been definitively revealed. A comparative analysis of the concentration of this protein in the blood serum and in the ejaculate and changes in its level in the semen of men with infertility is f scientific interest. THE PURPOSE OF THE STUDY: determination of TNF- level in the blood serum and seminal plasma of healthy men and patients with reduced fertility. MATERIALS AND METHODS: 70 men of reproductive age with azoospermia (main group, n=18), with oligoastenozoospermia (comparison group, n=18) and with normal spermogram parameters (control group, n=34) were examined. The ejaculate was examined using an SQA-V semen analyzer (MES, Israel). In seminal plasma samples, the concentration of TNF was determined using the alpha-TNF-ELISA-BEST test system (A-8756, Vector-Best LL, Russia). RESULTS: The concentration of TNF- in blood serum had a significant variation (CV=85.31%) and amounted to 2.75+/-2.18 pg/ml, which is 2.55 times lower than the same indicator in seminal plasma (7.01+/-5.98 pg/ml, CV=126.15%, p<0.00001). When comparing the content of TNF- in seminal plasma, significant differences were found in the examined patients (Kruskal-Wallis test H=24.75991; p<0.00001). Pairwise comparison revealed a statistically significant difference in the level of TNF- in seminal plasma between the comparison and control groups (p2-3=0.000023), as well as between the main group and the comparison group (p1-2=0.000043); there were no significant differences between the main and control groups (p>0.05). When determining the content of TNF- in the blood serum, there was no statistically significant difference between the groups (p>0.05). There were no correlations between the concentration of TNF- in blood serum and in seminal plasma (R=0.295374), and the total number of spermatozoa in the ejaculate (R=-0.027945); and the concentration of spermatozoa in the ejaculate (R=-0.042902). DISCUSSION: It is unlikely that TNF crosses into seminal plasma from serum against a concentration gradient. It is most likely that TNF is produced locally in the organs of the reproductive system by resident immune cells or cells involved in spermatogenesis. An increased content of TNF- in seminal plasma in patients of the comparison group may indicate the presence of an inflammatory process in the reproductive system and a reduced fertility of the ejaculate. CONCLUSION: The physiological role of TNF in sperm, its sources in the organs of the male reproductive system, and the pathogenetic mechanisms of the participation of the TNF in pathological processes in male reproductive system still remain unclear. All this justifies the need for further study of the TNF level in seminal plasma in normal conditions and in diseases of the urogenital tract in men.

Quantifying Heterogeneity of Testicular Histopathology in Men with Nonobstructive Azoospermia.

PURPOSE: We sought to determine if testicular histopathological heterogeneity is associated with sperm retrieval rates (SRRs) in men with nonobstructive azoospermia (NOA) who are undergoing microdissection testicular sperm extraction (mTESE). MATERIALS AND METHODS: All patients undergoing mTESE by a single, high-volume surgeon at a tertiary infertility referral center between 2010 and 2020 were evaluated. Pathology reports from testis biopsy at the time of mTESE reported by fellowship-trained genitourinary pathologists were reviewed. Testicular heterogeneity was correlated to absolute SRRs. Logistic regression was used to determine if heterogeneity was associated with sperm retrieval. RESULTS: A total of 918 men with mTESE were included. Of these, 391 men (43%) had 1 pathology, 388 men (42%) had 2, 108 (12%) had 3, and 31 (3.4%) had 4. Overall, the most common histopathology was Sertoli-cell only, followed by maturation arrest. The overall SRR was 42% with a clinical intrauterine gestation rate of 30%. Increasing histopathological variety was associated with higher SRRs (p <0.01); a SRR of 33% was observed when one histopathological subtype was present vs 94% with 4 subtypes. Furthermore, men with any foci of spermatogenesis had higher SRRs. CONCLUSIONS: In men with NOA, increasing testicular histopathological heterogeneity is correlated with higher SRRs driven by the identification of focal areas of spermatogenesis. This is an important, although predictable, observation. While diagnostic biopsy is not routinely required, these findings emphasize the value of having histology to perhaps predict the chance of sperm retrieval for future mTESE procedures.

Clinical application value of Inhibin B alone or in combination with other hormone indicators in subfertile men with different spermatogenesis status: A study of 324 Chinese men.

BACKGROUND: In this study, we investigated the clinical value of serum Inhibin B alone or in combination with other hormone indicators in subfertile men. METHODS: This is a multicenter study involving 324 men from different cities in China. Testicular volume, routine semen analysis, serum Inhibin B, anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, estradiol, and prolactin were measured. Testicular tissue samples were also analyzed in 78 of 129 patients with azoospermia to distinguish impaired spermatogenesis from obstructive azoospermia. RESULTS: The concentration of Inhibin B, FSH, and AMH is related to spermatogenesis. For men with impaired spermatogenesis, including mild-to-moderate oligozoospermia (IMO) and severe oligozoospermia (ISO), serum levels of Inhibin B and FSH are highly correlated with sperm counting. However, in patients with idiopathic moderate oligozoospermia or severe oligozoospermia, there was no significant correlation between Inhibin B (or FSH) and sperm concentration. The upper cutoff value of Inhibin B to diagnose ISO is 58.25 pg/ml with a predictive accuracy of 80.65%. To distinguish between nonobstructive azoospermia (NOA) and obstructive azoospermia (OA), the area under the curve (AUC) for AMH + Inhibin B + FSH is very similar to Inhibin B (0.943 vs. 0.941). The cutoff level of Inhibin B to diagnose nonobstructive azoospermia is 45.9 pg/ml with a positive and negative prediction accuracy of 97.70% and 85.71%, respectively. CONCLUSION: In summary, Inhibin B is a promising biomarker alone or in combination with other hormone indicators for the diagnosis of testicular spermatogenesis status, helping clinical doctors to distinguish NOA from OA.

FSH levels and testicular volumes are associated with the severity of testicular histopathology in men with non-obstructive azoospermia.

PURPOSE: The purpose of this study is to assess a potential association between FSH levels and testicular volumes with the severity of testicular histopathology on testicular biopsy in men with non-obstructive azoospermia (NOA) undergoing microdissection testicular sperm extraction (microTESE). METHODS: A retrospective chart review was performed from the electronic health records of men who underwent microTESE with NOA. RESULTS: Eighty-six men with NOA underwent microTESE with concomitant testicular biopsy for permanent section to assess the testicular cellular architecture. The histopathological patterns were categorized by severity indicating the odds of sperm retrieval into 2 categories. The unfavorable category included Sertoli cell only pattern and early maturation arrest (n = 50) and the favorable category included late maturation arrest and hypospermatogenesis patterns (n = 36). In the men with unfavorable histopathologic patterns, the mean FSH level was 22.9 ± 16.6 IU/L, and the mean testicular volume was 10.4 ± 6.0 cc. This was in comparison to men with favorable histopathologic patterns revealing a mean FSH level of FSH 13.3 ± 12.0 with a mean testicular volume of 13.3 ± 5.9 cc. There was a statistically significant higher FSH level in men with unfavorable histopathology than favorable (p = 0.004) as well as a significant smaller mean testicular volume in men with unfavorable histopathology (p = 0.029). CONCLUSIONS: Higher serum FSH levels and smaller testicular volumes are associated with more severe testicular histopathological patterns in men with NOA.

Hormonal markers as noninvasive predictors of sperm retrieval in non-obstructive azoospermia.

Non-obstructive azoospermia (NOA) is one of the leading causes of male factor infertility, which results from impaired spermatogenesis. Currently, the sole feasible therapeutic option for men with NOA to father their biologic children is sperm retrieval by testicular sperm extraction (TESE) approaches followed by an intracytoplasmic sperm injection program. Nevertheless, the rate of sperm retrieval from NOA men following TESE has remained as low as 50%, leading to a significant number of unsuccessful TESE operations. Given that TESE is associated with multiple side effects, the prediction of TESE outcome preoperatively can abolish unnecessary operations and thereby prevent NOA patients from sustaining adverse side effects. As the process of spermatogenesis is under the regulation of hormones, the hormonal profile of serum and/or seminal plasma may contain useful information about spermatogenesis status and can potentially predict the chance of sperm retrieval from NOA patients. A large body of literature is available on the predictive capability of different serum and seminal plasma hormones such as FSH, LH, testosterone, inhibin B, AMH, estradiol, prolactin, and leptin in a stand-alone basis or combinational fashion with respect to the TESE outcome. The present review aimed to evaluate the potential of these hormonal markers as noninvasive predictors of sperm retrieval in men with NOA.

Reference range and cutoff value of serum inhibin B to predict successful sperm retrieval: A cross-sectional study of 30 613 Chinese men.

BACKGROUND: The power of inhibin B to predict competent spermatogenesis is not fully understood. The aims of this study were to identify the reliable reference range of inhibin B among normozoospermic men in China and to evaluate the diagnostic accuracy of serum inhibin B level as a complementary predictor of successful sperm retrieval in patients with azoospermia. METHODS: This was a cross-sectional study. The male partners of 30 613 infertile couples who visited our hospital were investigated between March 2017 and March 2019. We analysed semen parameters, serum levels of reproductive hormones (inhibin B, FSH and testosterone) and sperm retrieval results from PESA/TESE in Chinese men. RESULTS: The normal reference range of inhibin B was 87.42-299.93 pg/mL among men with normozoospermia in China. Inhibin B levels were negatively correlated with age (r = -.111; P < .001) but positively correlated with total sperm counts in the overall population, reference group and case group (r = .311, r = .208 and r = .444, respectively; P < .001). Stepwise multiple regression analyses revealed that compared with the FSH and testosterone levels, the inhibin B level had the closest relationship with the total sperm count. The best cutoff value of inhibin B for predicting the retrieval outcome of testicular/epididymal sperm was >77.72 pg/mL (sensitivity = 59.14%, specificity = 92.00% and AUC = 0.801). The inhibin B:FSH ratio (cutoff value > 6.98, sensitivity = 56.99%, specificity = 96.00% and AUC = 0.814) performed better than either the inhibin B level or the FSH level alone. CONCLUSION: A new reference range for serum inhibin B was established in China. However, neither serum inhibin B, FSH nor their ratio is adequate for men to decide whether to undergo PESA/TESE to determine the adequacy of spermatogenesis.

Identification of KISS1R gene mutations in disorders of non-obstructive azoospermia in the northeast population of China.

BACKGROUND: Non-obstructive azoospermia (NOA), a serious phenotype of male spermatogenesis failure, is a multifactorial disease which is regulated by genetic, epigenetic, and environmental factors. Some gene structural variants have been demonstrated to be related to NOA. Loss-of-function mutations of KISS1R cause normosmic idiopathic hypogonadotropic hypogonadism (IHH) which result in azoospermia at the pre-testicular level. The objective of this research was to investigate genetic variants of KISS1R in NOA patients. METHODS: The entire coding region of 52 spermatogenesis-associated genes (KISS1R included) was sequenced from 200 NOA patients. Mutation screening was performed to identify genetic variations of these genes by targeted exome sequencing. Sequencing data analysis was carried out by a series of bioinformatics tools. Candidate variants confirmation was performed by Sanger sequencing. Functional analysis of candidate variants was evaluated using SIFT and PolyPhen-2. RESULTS: Three heterozygous missense variants in KISS1R were identified in three patients, respectively. No deleterious variations in other candidate genes were found in the three patients. Two of these three variants, p.A211T and p.G186E, had been reported in the ExAC and dbSNP database, respectively, while the other variant p.A301D was novel. These variants were all predicted to be likely pathogenic by in silico analysis. CONCLUSION: Our study revealed three heterozygous missense variants in KISS1R which expanded the mutation spectrum of KISS1R in infertile men with NOA in the northeast of China.

Investigation of serum vitamin D and ischaemia-modified albumin levels in infertile Turkish men.

Our aim was to explore the existence of a possible relationship of sperm motility with serum 25-hydroxyvitamin D3 (25-OH VD) levels and with ischaemia-modified albumin (IMA) levels in infertile Turkish men. A total of 30 men with nonobstructive azoospermia (no spermatozoa in ejaculate), 30 men with oligospermia (total progressive motile sperm count (TPMSC) <15 × 106 /ml) and 33 fertile men with normospermia (with at least one child, as the control group) were enrolled in the study. The mean 25-OH VD levels for groups 1, 2 and 3 were 9.31 ± 6.46, 19.71 ± 12.80 and 30.52 ± 12.49 respectively (p < .05). There was a statistically significant difference in serum IMA levels among the groups (479.32 ± 307.56 vs. 296.37 ± 127.27 vs. 150.04 ± 81.05, respectively; p < .05). A positive correlation between serum 25-OH VD levels and TPMSC, and a negative correlation between TPMSC and serum IMA levels were determined. Infertile men had lower serum 25-OH VD and higher IMA levels than fertile men, with a positive correlation between serum 25-OH VD levels and TPMSC, and a negative correlation between TPMSC and serum IMA levels. Vitamin D supplementation may increase the sperm motility.

From exome analysis in idiopathic azoospermia to the identification of a high-risk subgroup for occult Fanconi anemia.

PURPOSE: In about 10% of patients affected by Fanconi anemia (FA) the diagnosis is delayed until adulthood, and the presenting symptom in these "occult" FA cases is often a solid cancer and cancer treatment-related toxicity. Highly predictive clinical parameter(s) for diagnosing such an adult-onset cases are missing. METHODS: (1) Exome sequencing (ES), (2) Sanger sequencing of FANCA, (3) diepoxybutane (DEB)-induced chromosome breakage test. RESULTS: ES identified a pathogenic homozygous FANCA variant in a patient affected by Sertoli cell-only syndrome (SCOS) and in his azoospermic brother. Although they had no overt anemia, chromosomal breakage test revealed a reverse somatic mosaicism in the former and a typical FA picture in the latter. In 27 selected SCOS cases, 1 additional patient showing compound heterozygous pathogenic FANCA variants was identified with positive chromosomal breakage test. CONCLUSION: We report an extraordinarily high frequency of FA in a specific subgroup of azoospermic patients (7.1%). The screening for FANCA pathogenic variants in such patients has the potential to identify undiagnosed FA before the appearance of other severe clinical manifestations of the disease. The definition of this high-risk group for "occult" FA, based on specific testis phenotype with mild/borderline hematological alterations, is of unforeseen clinical relevance.

A risk prediction model of sperm retrieval failure with fine needle aspiration in males with non-obstructive azoospermia.

STUDY QUESTION: Can we predict the risk of sperm retrieval failure among men with non-obstructive azoospermia (NOA) before they undergo fine needle aspiration (FNA)? SUMMARY ANSWER: Our model, which includes FSH level, age and testicular volume as variables, can predict the risk of sperm retrieval failure with FNA. WHAT IS KNOWN ALREADY: Combined with ICSI, testicular sperm aspiration (TESA) can enable patients with NOA to have their own genetic offspring. Nearly all reproductive medicine centres in China have applied FNA, but approximately half of patients with NOA experience testicular sperm retrieval failure. Nevertheless, the models developed to predict the likelihood of obtaining spermatozoa with testicular sperm extraction (TESE) cannot accurately predict sperm retrieval, and few of these models have been sufficiently validated. STUDY DESIGN, SIZE, DURATION: This study involved three cohorts including 597 men with NOA. From 1 January 2015 to 31 July 2017, a retrospective cohort of 317 males with NOA who underwent FNA procedures at a university affiliated hospital were included to build a risk prediction model of sperm retrieval failure with FNA. Then, from 25 October 2017 to 31 March 2018, two prospective cohorts of 61 and 219 males with NOA from the same hospital and one other reproductive specialist hospital respectively, were recruited to validate the risk prediction model. PARTICIPANTS/MATERIALS, SETTING, METHODS: All men with NOA undergoing their first TESE procedure as part of a fertility treatment were included. The primary end-point was the presence of one or more spermatozoa (regardless of their motility) obtained with FNA. A binary multivariable logistic model was built to predict the risk of sperm retrieval failure after TESA using the dataset from the retrospective cohort. A cut-off value for risk was calculated with receiver operating characteristic (ROC) curve analysis. Two validation sets from the prospective cohort were used to validate the risk prediction model by measures including prediction accuracy and the true positive rate. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 327 (54.8%) males with NOA experienced sperm retrieval failure with FNA. FSH level, age and testicular volume were included in the prediction model for sperm retrieval failure risk. The model had an AUC of 82.3% (95% CI: 77.6-87.1%) and a cut-off value of 64.61% with a sensitivity of 0.677 and specificity of 0.863 for predicted risk. The predictive accuracies were 85.25 and 83.56% in the external validation sets from two centres. Specifically, 85.71 and 85.15% of NOA patients from two centres that experienced sperm retrieval failure were correctly identified using our model. LIMITATIONS, REASONS FOR CAUTION: A small proportion of males with NOA in whom sperm were successfully retrieved with FNA were misclassified; therefore, TESA techniques with higher sperm retrieval rates may be attempted in patients with high predicted risks of sperm retrieval failure rather than terminating the efforts to produce a genetic offspring. In addition, the ability to achieve a live birth using sperm retrieved with FNA was not tested in this study. WIDER IMPLICATIONS OF THE FINDINGS: We would recommend the use of micro-TESE for men with NOA and a high predicted risk of FNA failure. STUDY FUNDING/COMPETING INTEREST(S): This study was partly supported by National Key R&D Program of China (No. 2017YFC0907305), the National Natural Science Foundation of China (No.81803332), Sichuan Science & Technology Program (No. 2018SZ0144, 2016SZ0066, 2018SZ0284 and 2018FZ0043), Chengdu Science & Technology Bureau (No. 2018-YF05-01265-SN), Postdoctoral Research foundation of Sichuan University (No. 2018SCU12012) and West China Second University Hospital of Sichuan University (No. kx027). There are no competing interests related to this study. TRIAL REGISTRATION NUMBER: Not applicable.

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.

Prediction model for testis histology in men with non-obstructive azoospermia: evidence for a limited predictive role of serum follicle-stimulating hormone.

PURPOSE: The present prediction model was intended to verify whether serum FSH level could be predictive of testis histology in patients with non-obstructive azoospermia (NOA). METHODS: We evaluated two datasets of patients with NOA: the first (San Paolo dataset) comprising 558 patients, 18-63 years old, the second (Procrea dataset) composed by 143 patients, 26-62 years old; bot datasets were combined to obtain a validation set. Multinomial logistic regression was first run with serum FSH and testis volume as independent predictors of testis histology, then, the correctly classified histological subcategories were set as outcome variables of a prediction model in both development and validation sets. RESULTS: Multinomial logistic regression showed that FSH was a significant predictor of testis histology in 58% of cases, although it was unable to correctly classify cases with focal SCO or maturation arrest (MA). A prediction model was then run with hypospermatogenesis (HYPO) and Sertoli-only syndrome (SCO) as outcome variables of a binary logistic regression. FSH significantly predicted both HYPO and SCO, with a sensitivity of 40.9 and 80.7 and a specificity of 84.3 and 46.8 respectively. The model showed a fair discriminative ability (ROC AUC 0.705 and 0.709 respectively) and was adequately calibrated. CONCLUSIONS: Supported by a robust statistical analysis, we conclude that serum FSH level cannot be considered a prognostic marker of spermatogenic dysfunction in patients with NOA.

Exosomal microRNAs in seminal plasma are markers of the origin of azoospermia and can predict the presence of sperm in testicular tissue.

STUDY QUESTION: Are exosomal microRNAs (miRNAs) in seminal plasma (SP) useful as markers of the origin of azoospermia and the presence of sperm in the testis? SUMMARY ANSWER: Our study demonstrated the potential of several miRNAs contained in small extracellular vesicles (sEVs) of seminal fluid as sensitive and specific biomarkers for selecting those azoospermic individuals with real chances of obtaining spermatozoa from the testicular biopsy. WHAT IS KNOWN ALREADY: There are no precise non-invasive diagnostic methods for classifying the origin of the sperm defects in semen and the spermatogenic reserve of the testis in those infertile men with a total absence of sperm in the ejaculate (azoospermia). The diagnosis of such individuals is often based on the practice of biopsies. In this context it is reasonable to study the presence of organ-specific markers in human semen that contains fluid from the testis and the male reproductive glands, which could help in the diagnosis and prognosis of male infertility. Additionally, seminal fluid contains high concentrations of sEVs that are morphologically and molecularly consistent with exosomes, which originate from multiple cellular sources in the male reproductive tract. STUDY DESIGN, SIZE, DURATION: A case and control prospective study was performed. This study compares the miRNA content of exosomes in semen samples obtained from nine normozoospermic fertile individuals (control group), 14 infertile men diagnosed with azoospermia due to spermatogenic failure, and 13 individuals with obstructive azoospermia and conserved spermatogenesis. Additionally, three severe oligozoospermic individuals (<5 × 106 sperm/ml) were included in the study. PARTICIPANTS/MATERIALS, SETTING, METHODS: A differential high-throughput miRNA profiling analysis using miRNA quantitative PCR panels was performed in SP exosomes from azoospermic patients and fertile individuals. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 623 miRNAs were included in the miRNA profiling stage of the study. A total of 397 miRNAs (63.7%) were consistently detected in samples from all groups and statistically analysed, which revealed altered patterns of miRNA expression in infertile patients. We focused on the miRNAs that were differentially expressed between azoospermia as a result of an obstruction in the genital tract (i.e. having conserved spermatogenesis) and azoospermia caused by spermatogenic failure, and described, in a miRNA validation stage of the study, the expression values of one miRNA (miR-31-5p) in exosomes from semen as a predictive biomarker test for the origin of azoospermia with high sensitivity and specificity (>90%). The efficacy of the predictive test was even better when the blood FSH values were included in the analysis. Furthermore a model that included miR-539-5p and miR-941 expression values is also described as being useful for predicting the presence of residual spermatogenesis in individuals with severe spermatogenic disorders with diagnostic accuracy. LIMITATIONS, REASONS FOR CAUTION: Further studies, with an independent second population involving a larger number of samples, are needed to confirm our findings. WIDER IMPLICATIONS OF THE FINDINGS: Our findings contribute to the search for the most valuable genetic markers that are potentially useful as tools for predicting the presence of testicular sperm in azoospermic individuals. STUDY FUNDING/COMPETING INTEREST(S): This work was financially supported by grants from the Fondo de Investigaciones Sanitarias/Fondo Europeo de Desarrollo Regional "Una manera de hacer Europa" (FIS/FEDER) [Grant number PI15/00153], the Generalitat de Catalunya [Grant number 2014SGR5412]. S.L. is sponsored by the Researchers Stabilization Program (ISCIII/Generalitat de Catalunya) from the Spanish National Health System [CES09/020].

New insights into the morphological and hormonal characteristics of spermatogenic arrest.

The reported sperm retrieval rate (SRR) in patients with nonobstructive azoospermia (NOA) due to spermatogenic arrest (SA) is highly variable in the literature. This discrepancy could be explained by the heterogeneity of testicular tissues. Surprisingly, even though inhibin B levels reflect directly Sertoli cell function; no studies have evaluated this parameter in SA. We aimed to clarify the morphological and biological profile in 158 men with SA. From the total population, patients whose seminiferous tubules diameter was below 165 µm have higher SRR (46.9% vs. 27.4%, p < 0.05), lower inhibin levels and a higher frequency of nonuniform SA (71.9% vs. 38.7%, p < 0.001). On multivariate analysis, patients with late SA and a history of cryptorchidism were positively associated with successful sperm extraction. Patients with successful SRR and uniform SA exhibited inhibin levels twofold lower than those with failed TESE (45 pg/ml vs. 95 pg/ml, p < 0.05), whereas FSH levels were similar in the two groups. In this study, we showed for the first time that the mean diameter of the seminiferous tubules may be of value in the diagnosis of SA. Our results suggest that inhibin levels could be useful in the management of NOA with SA, along with FSH levels and testicular volume.

Do sperm parameters and infertility affect sexuality of couples?

We aimed to analyse the relationship between sperm parameters and International Index of Erectile Function (IIEF) score, the Female Sexual Function Index (FSFI) score, the testosterone (T) level in infertile men and between FSFI score and partners' fertility. Patients were divided into three groups; (group 1: azoospermia [n = 57], group 2: sperm count <15 million [n = 41], group 3: sperm count >15 million [n = 81]). Patients and their partners filled the IIEF and FSFI forms. The normality of the tests was analysed with Kolmogorov-Smirnov and Shapiro-Wilk tests. Spearman's rho test, a nonparametric test, was used to correlate the data. A value of p < .05 was considered statistically significant. There was a positive correlation between the sperm count, other sperm parameters, morphology and motility and IIEF score, FSFI score and T (p = .037, .028 and .041 respectively). We found a positive correlation between IIEF score and FSFI score (p = .182). Infertile partners' FSFI score was lower than fertile partners' scores (p = .023). Male infertility causes severe sexual dysfunction in couples, and female sexual dysfunction increases in parallel to that of men. Male sexual function also tends to decrease with low sperm count. While the clinician evaluates infertile couples, psychological and sexual functions should also be evaluated and patients should not be deprived of appropriate treatment.

Are hormone measurements and ultrasounds really predictors of sperm retrieval in testicular sperm extraction? A case report and literature review.

Azoospermia can be diagnosed in about 10%-15% of the infertile male population. To overcome the problem of failure to produce spermatozoa in the ejaculate in patients with nonobstructive azoospermia (NOA), testicular sperm extraction (TESE) may be performed to find the focal area of spermatogenesis. A 47-year-old man with NOA presented for treatment of secondary couple infertility. The patient underwent a first TESE 7 years earlier with cryopreservation, and an intracytoplasmic sperm injection-embryo transfer ended in a term pregnancy. He reported a history of repeated testicular traumas. At the present time, a complete medical workup was carried out, including clinical history, general and genital physical examination, scrotal and transrectal ultrasounds. Hormone measurements showed follicle-stimulating hormone level of 42.7 IU/L, luteinising hormone of 11.4 IU/L, total testosterone of 2.6 ng/ml and right and left testicular volume, respectively, of 4 and 3.9 ml. He underwent a second TESE, with successful sperm retrieval and cryopreservation. The histological pattern was hypospermatogenesis. In cases of extreme testicular impairment, although in the presence of very high follicle-stimulating hormone value and small testicular volume, estimating poor sperm recovery potential, the integration of clinical and anamnestic data, could help the surgeon to practise the more appropriate method of treatment.

[Impact of plateau environment on seminal characteristics of native Tibetans and immigrated Tibetan Hans].

OBJECTIVE: To investigate the characteristics of the semen parameters of native Tibetans and immigrated Tibetan Hans in the high-altitude area and analyze the influence of altitude adaptation on male fertility. METHODS: This study included 1 563 infertile male patients, including 698 native Tibetans and 865 immigrated Tibetan Hans, and 56 normal fertile men, including 33 native Tibetans and 23 Tibetan Hans. We obtained semen samples from the subjects for routine semen analysis and sperm DNA fragmentation index (DFI) examination and collected peripheral blood for determination of the reproductive hormone levels. RESULTS: In the infertile patients, the native Tibetans, as compared with the immigrated Hans, showed significantly higher incidence rates of azoospermia (5.87% vs 2.89%, P <0.05), severe oligozoospermia (3.15% vs 1.73%, P <0.05) and abnormal seminal viscosity (43.12% vs 25.89%, P<0.01), but no statistically significant differences in the percentages of normozoospermia (81.08% vs 87.39%, P >0.05), oligozoospermia (5.44% vs 3.93%, P >0.05), severe asthenozoospermia (4.44% vs 4.04%, P >0.05) or severe teratozoospermia (4.58% vs 6.59%, P >0.05). In the normal fertile men, there were no statistically significant differences between the native Tibetans and immigrated Hans in age (ï¼»32.42 ± 4.82ï¼½ vs ï¼»34.57 ± 6.01ï¼½ yr, P >0.05), sperm concentration (ï¼»143.69 ± 85.74ï¼½ vs ï¼»155.11 ± 82.56ï¼½ ×106/ml, P >0.05), straight line velocity (ï¼»25.74 ± 3.94ï¼½ vs ï¼»27.24 ± 3.46ï¼½ µm/s, P >0.05), percentage of morphologically normal sperm (ï¼»8.22 ± 4.35ï¼½ vs ï¼»7.28±2.46ï¼½ %, P >0.05), total testosterone concentration (ï¼»17.97 ± 2.98ï¼½ vs ï¼»15.72 ± 6.38ï¼½ nmol/L, P >0.05), or follicle stimulating hormone level (ï¼»5.51 ± 1.62ï¼½ vs ï¼»4.17 ± 2.08ï¼½ IU/L, P >0.05). However, the immigrated Hans, in comparison with the native Tibetans, exhibited a higher sperm motility (ï¼»79.75 ± 14.67ï¼½ vs ï¼»66.58 ± 17.21ï¼½%, P <0.05), a lower curvilinear velocity (ï¼»60.97 ± 2.71ï¼½ vs ï¼»71.14 ± 82.13ï¼½ µm/s, P <0.05) and a lower level of luteinizing hormone (ï¼»4.28 ± 1.20ï¼½ vs ï¼»5.84 ± 1.15ï¼½ IU/L, P <0.05). CONCLUSIONS: During the acclimatization to the plateau hypoxia environment, the immigrated Tibetan Hans undergo adaptive changes in sperm concentration and motility and have lower incidence rates of azoospermia and severe oligozoospermia than native Tibetan males.

Clinical, Hormonal, and Genetic Evaluation of Idiopathic Nonobstructive Azoospermia and Klinefelter Syndrome Patients.

To investigate the clinical, hormonal, and genetic factors in infertile men with idiopathic nonobstructive azoospermia (NOA) or azoospermic Klinefelter syndrome (KFS), a total of 556 and 96 patients, respectively, were included in this study. All patient samples were analyzed cytogenetically. Serum reproductive hormone levels were measured. Microdeletions in the azoospermia factor (AZF) region of the Y chromosome were detected by multiplex PCR using 16 specific sequence-tagged sites. FSH and LH levels in both NOA and KFS patients were significantly higher than the normal range, and the testosterone level in KFS patients was significantly lower. Ninety-two (95.8%) of the KFS patients showed non-mosaic 47,XXY karyotypes and 47,XXY,inv(9)(p11.1q13); the other KFS patients had mosaic karyotypes of 47,XXY/46,XY, 47,XXY/46,XX, and 47,XXY/48,XXXY/46,XX. Among the 556 idiopathic NOA patients with normal karyotypes, 67 (12.05%) had microdeletions in the AZF region of the Y chromosome. Microdeletions were most frequently detected in the AZFc region, followed by AZFa, AZFb, AZFbc, and partial AZFc deletions. However, Y chromosome microdeletions were not found in any of the azoospermic KFS patients. In view of the hormonal and genetic abnormalities in infertile men with idiopathic NOA and with azoospermic KFS, genetic testing for karyotype, Y chromosome microdeletions, and hormonal parameters is advocated.