Microsurgical testicular sperm extraction for testicular failure: the South African experience and first successful pregnancy.

BACKGROUND: In men with non-obstructive azoospermia (NOA), biological fatherhood is only possibly by specialised microsurgical sperm retrieval techniques (micro-TESE), only recently introduced to South Africa. This study aimed to analyse the spectrum of causes of NOA and the outcomes of micro-TESE, including live births, following the use of this technique in South Africa. METHODS: This was a retrospective review of all micro-TESE cases performed in South Africa by a single surgeon from 2014 to 2018. Data collected prospectively included: patient demographics, preoperative blood results, cause of azoospermia, intraoperative findings and postoperative complications. The primary outcome measured was surgical success of micro-TESE, which was defined as testicular sperm successfully retrieved and cryopreserved. Subsequent live births from assisted reproductive technology (ART) using the cryopreserved sperm were also documented. RESULTS: Twenty-six men with NOA underwent micro-TESE between May 2014 and April 2018. Mean preoperative total testosterone level was 12.0 nmol/l (IQR 5.2) and follicle-stimulating hormone level 23.5 IU/l (IQR 15.6). Genetic testing was performed as part of the preoperative work-up in only 10 of the 26 patients. A specific cause of NOA was identified in 9 of the 26 patients and included Klinefelter syndrome (1 patient), Y-chromosome AZFc microdeletion (1 patient), undescended testicles (5 patients) and chemotherapy (2 patients). The average testicular volume was 9.05 ml (IQR 5.6), and the mean duration of surgery 95.8 minutes (IQR 28.0). The overall sperm retrieval rate was 34.6%. A single pregnancy and subsequent live birth were recorded from a total of eight cycles of intracytoplasmic sperm injection (ICSI): four female partners had one ICSI cycle each and two females underwent two cycles each. Frozen and thawed sperm was used in seven of the ICSI cycles and fresh sperm in one cycle. CONCLUSION: In this South African series, sperm retrieval rates of micro-TESE for non-obstructive azoospermia were comparable to those reported internationally. Preoperative genetic testing should be increased to optimise the selection of surgical candidates.

Fallopian tube reanastomosis by laparotomy versus laparoscopy: a meta-analysis.

OBJECTIVE: To compare efficacy of sterilization reversals by laparotomy versus laparoscopy. DESIGN: Meta-analysis. SEARCH STRATEGY: Electronic searches were carried out for randomized controlled trials and retrospective and prospective clinical studies. Search engines such as PubMed, Science Direct, Medline and the Cochrane database were made use of. Our restrictions were English human studies published from 1989 to January 2010. INTERVENTIONS: Microsurgical tubal reanastomosis performed comparing laparoscopy with laparotomy using a microsurgical technique. OUTCOME MEASURES: Primary: overall pregnancy rates, including positive clinical pregnancy, intrauterine and ectopic pregnancy rates. Secondary: surgery time. RESULTS: Three retrospective comparative studies were retrieved from international data that investigated laparotomy versus laparoscopy. A total number of 184 patients were included, 88 and 96 respectively undergoing laparoscopy and laparotomy. Pregnancy rates achieved by laparoscopy ranged from 65 to 80.5% (mean 74.43%) and by laparotomy from 70 to 80% (mean 71.33%). A subanalysis of two of the three comparative studies show that laparoscopy reversal surgery requires a statistically significant longer operative time than does laparotomy (p < 0.00001). CONCLUSIONS: There is no difference between the laparoscopy and laparotomy approach to tubal reanastomosis when regarding overall pregnancy rates, intrauterine and ectopic pregnancy rates.

Is metformin indicated as primary ovulation induction agent in women with PCOS? A systematic review and meta-analysis.

BACKGROUND: A recent meta-analysis has proven that metformin (M) is highly effective for ovulation induction in the clomiphene citrate (CC)-resistant patient. There is uncertainty whether M should be introduced as a primary ovulation induction agent in polycystic ovarian syndrome (PCOS). METHODS: We conducted a systematic review and meta-analysis to establish if M is better when given alone or in combination with CC (CC+M) when compared with CC alone. This systematic review studied live birth delivery rate as the primary outcome. RESULTS: We identified 14 prospective trials. Analysis of these results showed a reduction in the live birth rate in the group of patients treated only with M when compared with CC alone (OR = 0.48, 95% CI 0.31-0.73, p = 0.0006). An increase in ovulation (OR = 1.6, 95% CI 1.2-2.1, p = 0.0009) and pregnancy rate (OR = 1.3, 95% CI 1.0-1.6, p = 0.05) with CC+M when compared with CC alone was reported, but no difference was found when live birth rate was analyzed (OR = 1.1, 95% CI 0.8-1.5, p = 0.61). CONCLUSION: CC alone is superior to M alone regarding live birth rate and ovulation. The combination (CC+M) is superior to CC alone as a primary method for ovulation induction and to achieve pregnancy in PCOS. However, when addressing live birth rate, no statistically significant difference could be demonstrated. Because of the side effects profile and contraindications of M, we believe M should not be indicated as a primary ovulation induction agent in women with PCOS.

Is the Use of a GnRH Antagonist Effective in Patients with Polycystic Ovarian Syndrome? A South African Perspective

Introduction. Polycystic ovarian disease (PCOS) can account for up to 35 - 40 of the female factor causes of infertility. These patients present as medically complex cases and are challenging to manage and treat successfully. They are resistant to treatment and are often offered controlled ovarian stimulation (COS) and in vitro fertilisation (IVF) technology. Aim. The aim of this study was to assess whether there was a difference in the pregnancy outcomes of women with PCOS when a standard gonadotrophin-releasing hormone (GnRH) antagonist (cetrorelix) protocol was used for ovarian stimulation; compared with non-PCOS patients undergoing IVF. Methods. A retrospective patient record audit was performed on 142 patients with PCOS and 501 non-PCOS patients undergoing a similar cetrorelix-based COS treatment protocol during a specified time period. Results. The main primary outcome was an ongoing pregnancy at 12 weeks; achieved in 34 of patients in the PCOS group and 27 in the non-PCOS group. This was not significantly different (p=0.07). No patient in the PCOS group experienced severe hyperstimulation syndrome. Conclusion. There was no significant difference in pregnancy rates in patients with PCOS undergoing GnRH-antagonist ovarian stimulation compared with non-PCOS patients. The fact that no hyperstimulation syndrome occurred makes this an attractive option for women with PCOS

Laparoscopic Myomectomy for Infertile Patients with Intramural Fibroids: a Retrospective Study at a Tertiary Endoscopic Centre

Background: The safety of laparoscopic myomectomy has been questioned especially in the case of intramural fibroids. Objectives: To assess the safety of a laparoscopic myomectomy for intramural fibroids and study the subsequent effect on fertility Methods and Settings: A retrospective study of a tertiary endoscopic centre specialising in laparoscopic myomectomy. Results: 87 Patients were studied and there were no major complications. The conversion rate from laparoscopy to laparotomy was 3/87 (3.4) due to multiple fibroids. There was one case of uterine perforation during hysteroscopy. The overall pregnancy rate was 29/64 (45) with a spontaneous pregnancy rate of 18/29 (62). Conclusions: Laparoscopic myomectomy can be regarded as a safe alternative to abdominal myomectomy in the hands of the experienced surgeon resulting in good subsequent pregnancy rates

TUNEL assay and SCSA determine different aspects of sperm DNA damage.

For the determination of sperm DNA damage, different assays are used. However, no further distinction is made and the literature generally speaks about DNA damage. Thus, this study aimed at comparing the sperm chromatin structure assay (SCSA) and the TUNEL assay. In 79 patients, sperm DNA damage was determined flow cytometrically using the SCSA and the TUNEL assay. Moreover, normal sperm morphology was evaluated according to strict criteria. A statistical comparison of the two methods was performed using standard correlations, Bland and Altman plots, Passing-Bablok regressions and concordance correlation. Results show a significant difference between P- and G-pattern morphology only for the mean channel fluorescence of the SCSA. Spearman's rank correlations between the different parameters of both assays, SCSA and TUNEL, revealed significant associations between the parameters of the assays. However, when applying Bland and Altman plots, Passing-Bablok regression and concordance correlation results showed that these methods are not comparable. These different techniques determine different aspects of sperm DNA damage, i.e. 'real' DNA damage for the TUNEL assay and 'potential' DNA damage in terms of susceptibility to DNA denaturation for the SCSA. Thus, one should clearly distinguish between the different assays, not only practically and methodologically but also linguistically.

Evaluating the equivalence of clomiphene citrate with and without metformin in ovulation induction in PCOS patients.

OBJECTIVE: To evaluate the benefit of Metformin added to Clomiphene Citrate in a primary ovulation induction protocol in PCOS patients. DESIGN: Prospective randomised controlled study. SETTING: Tygerberg Academic Hospital, Stellenbosch University and the Institute of Reproductive Medicine at Vincent Pallotti Hospital, Cape Town. PATIENTS: 107 patients presenting with PCOS. STUDY: Group A was pre-treated with metformin 850 mg twice a day for at least 6 weeks before clomiphene was added and the metformin was used throughout the study period. Group B received clomiphene without pre-treatment with metformin. In both groups clomiphene was given at a starting dose of 50 mg day 4-8 and increase with increments of 50 mg to a maximum of 150 mg if no response was achieved. RESULTS: The ovulation rate achieved in women in the M+C/C arm was 34/52 (65.4%) compared to 36/55 (65.5%) in the C/C arm. The treatment effect ((M+C/C) - C/C) is 0% with 95% confidence interval of -18.1% to 18%. The per protocol ovulation results were 34/42 (81%) in the M+C/C arm compared to 36/48 (75%) in the C/C arm. The ovulation rate difference was 6% with 95% confidence interval -11% to 22%. In a comparison of successful ovulating versus non-ovulating women from the trial the following were significant baseline determinants: lower median weight in the ovulating group (77 kg versus 86 kg, p = .021), lower median bmi (29.0 versus 32.9, p = .009), lower median DHEAS at baseline (4.6 compared to 7.0, p = .049), lower median 17OH-progesterone (2.2 versus 4.6, p = .027) and higher baseline median SHBG ( 37.8 compared to 28.5, p = .036). CONCLUSION: Although identical ovulation rates were observed in both arms equivalence could not be concluded with respect to the specified criteria.

Proximal renal tubular acidosis in pregnancy. A case report and literature review.

Renal tubular acidosis is usually associated with chronic renal conditions and is rarely encountered in pregnancy. It may be inherited causing osteomalacia and rickets in children or acquired following autoimmune diseases or following exposure to nephrotoxic agents. It is known to worsen during pregnancy and if left untreated may cause maternal and foetal morbidity or death. We report a 28-year-old woman, gravida 3 para 2, who presented at 30 weeks gestation with lethargy, weakness and generalized myalgia. Investigation revealed severe hypokalaemia and a systemic metabolic acidosis due to proximal renal tubular acidosis. Her previous pregnancies were both complicated by foetal losses at term. Following prompt correction of her electrolyte disturbance and metabolic acidosis, she went on to deliver a healthy female infant at term. Regular evaluation up to 1 year post-partum revealed mild persistence of her hypokalaemia. At 1 year, the infant showed no signs of the disorder and is growing normally.

Lessons learned from a sperm morphology quality control programme.

Although sperm morphology is the sperm parameter that is consistently correlated with in vitro and in vivo fertilisation, its value is often challenged due to discrepancies in reports. As sperm morphology is subjectively evaluated, the outcome of the report is entirely based on the experience and technical skill of the laboratory technician responsible for semen analyses. The study aimed to record the value of quarterly monitoring and refresher courses on morphology reading skills of technicians over a period of 40 months. Nineteen individuals from 12 different andrology laboratories were enrolled to a sperm morphology quality control programme after initial training sessions. Five of the 19 participants attended annual refresher courses. Two limits of error, namely +/- 0.5 SD and +/- 0.2 SD scores, were used to record technician deviation from the reference laboratory. Fifteen of the 19 individuals (78%) consistently reported sperm morphology readings that were within the +/- 0.5 SD limits of error. Furthermore, five of the participants, who attended annual refresher training courses, consistently reported results that were within the +/- 0.2 SD limits of error. For the first time, it has been illustrated that excellent sperm morphology reading skills can be achieved and maintained by initial training sessions, followed up with a continuous external quality control programme and annual refresher courses.

Postmenopausal bleeding: a diagnostic approach for both private and public sectors.

OBJECTIVE: To assess the optimal diagnostic approach to women with postmenopausal bleeding by comparing transvaginal ultrasound and endometrial sampling with office hysteroscopy. METHODS: A prospective collective study was performed on 102 consecutive patients with postmenopausal bleeding who were evaluated by ultrasound measurement of the endometrial thickness (EL), endometrial sampling by Accurette and outpatient hysteroscopy and directed biopsy. RESULTS: Accurette was inadequate for histological diagnosis in 65 of 136 samples and many repeat investigations were required. In all 16 cases of endometrial polyps, ultrasound measurement of the EL was > or =4 mm and hysteroscopy confirmed the findings. Accurette detected only 5 polyps. All 7 cases of endometrial hyperplasia were detected using an EL of > or =4 mm and hysteroscopy confirmed the findings. Accurette failed to detect 5 out of 7 cases of endometrial hyperplasia. Five cases of endometrial cancer were diagnosed: all had an EL > or =4 mm but were inadequately sampled for diagnostic purposes in 3 cases. A definitive diagnosis was made on hysteroscopy in 4 cases (1 patient did not have a hysteroscopy). CONCLUSION: Accurette is not a good sampling device for the diagnosis of postmenopausal bleeding. An ultrasound measurement of the EL > or =4 mm in patients with postmenopausal bleeding warrants further investigation. Outpatient office hysteroscopy is an accurate and sensitive modality to employ as a first line investigation for definitive diagnosis.

Effect of fibroids on fertility in patients undergoing assisted reproduction. A structured literature review.

OBJECTIVE: The aim of this study is to evaluate the current data to understand the impact of intramural leiomyomata on pregnancy outcome in assisted reproduction. PATIENTS AND METHODS: In this review, articles were found by means of computerized Medline and Cochrane Library search using the key words uterine myomata, leiomyomata, fibroids, implantation, pregnancy, infertility and in vitro fertilization. Limitations were English, human, 1990-2002. Inclusion criteria were pregnancy data on in vitro fertilization, intramural myomata with no cavitary distortion and control groups without myomas for each patient with a myoma. RESULTS: There was a significant negative impact on implantation rate in the intramural myomata groups versus the control groups, 16.4 vs. 27.7% OR 0.62 (0.48-0.8). The delivery rate per transfer cycle was also significantly lower (myomata vs. control), 31.2 vs. 40.9% OR 0.69 (0.50-0.95). CONCLUSION: Our study supports the notion that patients with intramural fibroids have a lower implantation rate per cycle. The studies did not shed new light on the size of intramural myomata that could affect the outcome. In previous failed in vitro fertilization cycles, microsurgical removal of myomata must be considered.

The use of semen parameters to identify the subfertile male in the general population.

AIMS: To present a structured review of the literature published on semen parameters and in vivo fertility potential and to establish fertility/subfertility thresholds for sperm morphology using Tygerberg strict criteria, sperm concentration, and sperm motility. METHOD: The published literature comparing fertile and subfertile populations between 1983 and 2002 was reviewed. RESULTS: A total of 265 articles were identified by the sourcing methodology, but only four articles provided data that could be tabulated and analyzed. Using receiver-operating characteristics curves, morphology proved to be the best predictor of subfertility in 2 of the 4 articles, with concentration and motility also showing good predictive power. The thresholds calculated ranged between 4 and 10% for morphology, between 13.5 x 10(6)/ml and 34 x 10(6)/ml for concentration, and between 32 and 52% for motility. A second set of much lower thresholds was calculated in three of the articles using either a 15 or 50% prevalence of subfertility in the population or the tenth percentile of the fertile population. The adjusted thresholds were between 3 and 5% for morphology, between 9 x 10(6)/ml and 20 x 10(6)/ml for concentration, and between 20 and 30% for motility. CONCLUSIONS: Because these lower thresholds have a much higher positive predictive value, we suggest that thresholds of <5% normal sperm morphology, a concentration <15 x 10(6)/ml, and a motility <30% should be used to identify the subfertile male. The lower threshold for morphology also fits in vitro fertilization and intrauterine insemination data calculated previously. Using the parameters in combination increases the clinical value of semen analysis.

Comparative analysis of pregnancy rates after the transfer of early dividing embryos versus slower dividing embryos.

BACKGROUND: We compared retrospectively the pregnancy outcome in two subgroups of ICSI patients, using early division (26 h post injection) to the 2-cell stage as a criterion for embryo quality and viability (ability to produce a pregnancy). METHODS AND RESULTS: In the early dividing embryo (EDE) group, at least one of the transferred embryos was early dividing. In the late dividing embryo (LDE) group, no early dividing embryo was transferred. Additionally, tubal and uterine transfer in the two groups was also evaluated. Clinical pregnancy rates in the EDE group were significantly increased when compared with that in the LDE group (41.3 versus 20.0%). This was also true for ongoing pregnancy rates (33.3 versus 16.3%). The tubal transfer route showed increased (but not significant) ongoing pregnancy rates when compared with uterine transfer in both EDE (38.5 versus 25.0%) and LDE (22.7 versus 8.3%) groups respectively. In uterine transfer cycles, however, clinical pregnancy rates for EDE were significantly increased compared to LDE (37.5 and 11.1% respectively). The baby rate (number of live babies/embryos transferred) was also significantly increased in the EDE group and the tubal transfer group. Statistical analysis of pregnancy outcome, adjusted for the total number of embryos transferred (expressed as percentage risk difference - %RD), resulted significantly in favour of EDE compared to LDE (RD = 18%, P = 0.02). When adjusted for the combined factors: total number of embryos transferred, EDE and LDE, the pregnancy outcome result was significantly in favour of tubal transfer compared to uterine transfer (RD = 15%, P = 0.05). Pregnancy results of the LDE group only were significantly better in the tube compared to the uterus (RD = 19%, P = 0.04) but not significantly so for the EDE group (RD = 10%, P = 0.4). CONCLUSION: Early division is associated with embryo quality and a very easy and successful embryo transfer selection method. Our results also suggest that when EDE are available, both tubal and uterine embryo transfer can be considered. When only LDE are available, however, tubal transfer should be the preferred transfer route.

Urogenital inflammation: changes of leucocytes and ROS.

The presence of excess leucocytes in the semen has been associated with male infertility. According to the WHO, concentrations of more than 106 leucocytes ml-1 are considered as leucocytospermia, indicating genital tract infections. Up to now, no consensus has been achieved on how leucocytes should be quantified in semen. Using the peroxidase staining and monoclonal antibodies to CD15, CD45 and CD68, we found significant differences between the detection methods. Only 47.4% of the semen samples that were assessed as leucocytospermic by CD45 were identified as such by peroxidase staining. The concentration of peroxidase-positive cells was significantly correlated with polymorphonuclear granulocyte (PMN) elastase (P < 0.0001). However, a negative correlation of peroxidase-positive cells with the sperm concentration was only found in oligozoospermic patients (P < 0.0001). Moreover, the slightly positive correlation with normal sperm morphology seems to be applicable only in cases of oligozoospermia. Significant negative correlation of the number of peroxidase-positive cells were found for both maximal inducible acrosome reaction (P = 0.0219) and the inducibility of acrosome reaction (P = 0.0370), indicating a rather deleterious effect of leucocytes on this important sperm function. Concerning the result in the in vitro fertilization programme, none of the examined parameters (PMN elastase, concentration of round cells and peroxidase-positive cells) showed a correlation with either fertilization or pregnancy. This result seems to be reasonable as severely damaged spermatozoa and leucocytes are eliminated from the ejaculate by different sperm separation methods. Interestingly, a significant negative correlation of the TUNEL assay as a measure of sperm DNA fragmentation was found only with pregnancy (P = 0.006) but not with fertilization. As DNA fragmentation can also be caused by ROS that are generated by leucocytes, this causality should not be neglected.

Factors affecting pregnancy outcome in a gamete intrafallopian transfer (GIFT) programme.

OBJECTIVE: To identify the factors that most significantly affected pregnancy rates in a gamete intrafallopian transfer (GIFT) programme. METHODS: A total of 863 GIFT cycles were analysed retrospectively. The variables found to be associated significantly with pregnancy were then used to obtain multivariate analysis using logistical regression. RESULTS: Overall and ongoing pregnancy rates were significantly better in patients < or = 38 years than in patients > 38 years (37.3% and 28.4% v. 23.7% and 11.0% respectively), and age was positively associated with success after GIFT (odds ratio (OR) 1.87, 95% confidence interval (CI): 1.22-2.85). Metaphase I (MI) oocytes were negatively associated with pregnancy (OR 1.54, 95% CI: 0.28-1.04). The highest pregnancy rates occurred when 3 metaphase II (MII) oocytes were transferred (39.8%, OR 7.51, 95% CI: 1.74-32.42). With regard to sperm morphology, overall pregnancy rates of 25.5% (< or = 4% normal forms) and 37.2% (> 4% normal forms) were obtained. Morphology of > 4% normal forms was positively associated with pregnancy (OR 1.58, 95% CI: 1.04-2.42). CONCLUSION: The results of this study suggest that the most important factors influencing pregnancy rates in a GIFT programme are the woman's age and those factors pertaining to the characteristics of the gametes. Considering the emotional and financial costs it is important to relate this information to all prospective participants in a GIFT programme.

Intracytoplasmic sperm injection with testicular spermatozoa in men with azoospermia.

PURPOSE: The aim of the study was to gain an insight into the optimal management of the infertile couple with the husband suffering from azoospermia. METHODS: One hundred and forty-two intracytoplasmic sperm injection (ICSI) cycles performed with testicular extracted spermatozoa were retrospectively analysed. The following factors were investigated for their possible influence on fertilization, cleavage, damage, pregnancy, and ongoing pregnancy rates: the use of fresh, cryopreserved, and preincubated (24 h) spermatozoa and the etiology of the husbands' azoospermia (obstructive and nonobstructive). All microinjections were performed with apparently normal spermatozoa--a head with a tail of normal length. In 116 cycles at least two embryos were available for transfer. RESULTS: The overall fertilization, clinical pregnancy, and ongoing pregnancy rates obtained for the 116 cycles were 65.0, 30.2, and 22.4% respectively. Similar outcomes were obtained for cycles using fresh testicular and cryopreserved testicular spermatozoa. Similarly, no significant differences were obtained between the cycles using spermatozoa from obstructive or nonobstructive azoospermic patients. An increase in motility after a 24-h preincubation was observed, and although this group was relatively small (n = 17), a significant improvement in fertilization (73.7%) and pregnancy (53.9%) rate was obtained when the testicular sample was preincubated for 24 h. This improvement prevailed in the obstructive azoospermic group, but was less pronounced in nonobstructive patients. CONCLUSIONS: This study shows that the outcome of fresh and frozen-thawed testicular spermatozoa in ICSI is comparable, obstructive and nonobstructive etiologies perform the same, and that preincubation of testicular spermatozoa results in increased fertilization and pregnancy rates. All testicular biopsies are therefore performed the day before oocyte retrieval, superfluous spermatozoa cryopreserved, and the remaining testicular homogenate preincubated for the 24 h prior to oocyte retrieval. With this regime, most azoospermic patients are treated successfully, irrespective of the use of fresh or frozen-thawed spermatozoa from obstructive or nonobstructive cases.

Ultrastructural evaluation of recurrent and in-vitro maturation resistant metaphase I arrested oocytes.

An infertile couple whose female partner showed recurrent retrieval of immature metaphase I (MI) oocytes that were resistant to in-vitro maturation, was studied. Four spermiograms revealed teratozoospermia. Consistent non-fertilization and negative pregnancy outcomes were obtained after intrauterine insemination, gamete intra-Fallopian transfer and IVF. Two intracytoplasmic sperm injection (ICSI) cycles were finally performed. All oocytes (n = 17) in both cycles were arrested at MI and failed to mature after 48 h culture. ICSI also resulted in total non-fertilization. In the last cycle, two oocytes were analysed by transmission electron microscopy and showed almost identical results. All organelles showed normal characteristics of an MI oocyte. The main abnormality found was related to the MI spindle, with absence of microtubules and dispersion of the female chromosomes. Minor abnormalities were observed (immature fibrous appearance of the zona pellucida; the presence of small vesicle aggregates which formed a foam-like body). The injected sperm nucleus was arrested in the middle of the chromatin decondensation process, with no visible nuclear envelope reformation. Normal disruption of sperm acrosomal and flagellar components were observed. Only a partial cortical reaction was observed. This represents the first documented case of developmental arrest due to complete absence of spindle formation in association with an otherwise mature ooplasm.