ABSTRACT
Objective: To
determine the reproductive outcome after the application of intracytoplasmic
sperm injection treatment with testicular sperms obtained by fine needle
aspiration.
Methods: Between August 2005 and December 2007, a total of 55
infertile women (age 21-41 years) underwent intracytoplasmic sperm injection
treatment due to male factor. All male partners (age 25-71 years) were
azoospermic. Duration of infertility ranged from two to 17 years. The
demographic, hormonal and treatment data of both male and female partner along
with the reproductive outcome were analyzed.
Results: Of the 55 male partners, 12 (21.2%) men had
obstructive azoospermia, and 43 (78.8%) had non-obstructive azoospermia. After intracytoplasmic
sperm injection treatment, the fertilization and implantation rates were 68.8%
and 21.1%, respectively. Twenty-eight of 55 (50.9%) women achieved pregnancy. Seven
women of 28 (25%) had multiple pregnancy. Delivery took place in 23 women (41.8%)
of which 16 (69.6%) were full-term and seven (30.4%) were preterm pregnancies
(<37 weeks). Abortion occurred in five
women (17.8%). No complications after the testicular fine needle aspiration procedure
were encountered.
Conclusion: Intracytoplasmic
sperm injection treatment is associated with high pregnancy rate after
testicular fine needle aspiration of sperms from patients with obstructive and
non-obstructive azoospermia. The procedure is simple, noninvasive, repeatable
with no/or minimal complications.
Key words: Azoospermia, Fine needle aspiration, Intracutplasmic
sperm injection, Pregnancy
JRMS
September 2010; 17(3): 5-9
Introduction
The cause of infertility may be in the male partner in
as many as 50% of infertile couples.(1) Azoospermia and
oligospermia (<20 million sperm per milliliter) mandate detailed evaluation
of the male partner both to determine the etiology and to plan therapy. Azoospermia
defined as the absence of spermatozoa in ejaculated semen, is the most severe
form of male factor infertility and is present in approximately 10% of all
investigated infertile couples.(1) The introduction of
intracytoplasmic sperm injection (ICSI) not only has improved significantly the
prospects of fertility after assisted reproduction by using spermatozoa
obtained from the seminal tract, but also has allowed extension of the spectrum
of sperm recovery techniques.
Several procedures were performed to retrieve sperms
from the infertile men with obstructive and non-obstructive azoospermia. These
include: MESA
(Microsurgical epididymal sperm aspiration), TESE (Testicular sperm extraction),
TESA (Testicular sperm aspiration), PESA (Percutaneous epipidymal sperm
aspiration) and PSFNA (Percutaneous sperm fine needle aspiration).(2-5)
Until recently, testicular biopsy was considered the
method of choice to ascertain the presence and the quality of spermatogenesis. The
invasiveness of the procedure limited its use, and therefore the less invasive
alternative use of the fine needle aspiration (FNA) to recover testicular
sperms was adopted.(6-9)
An excellent agreement between testicular biopsy histology and the fine
needle aspiration cytology has been reported.(8,10) Recovery of spermatozoa from azoospermic men
with obstructive and non-obstructive azoospermia followed by intracytoplasmic
sperm injection (ICSI) is a recent advance in the treatment of male infertility.
It has been found that ICSI with testicular spermatozoa recovered by FNA yields
results comparable to those obtained with spermatozoa recovered by open biopsy
in azoospermic patients.(5)
In this situation, the pregnancy rate was reported to range between 27%
and 50%.(2,8,11,12) We
conducted this retrospective analysis to determine the reproductive outcome
after the application of ICSI treatment with testicular sperms obtained by FNA.
Methods
A total of 68 couples with male factor infertility
were studied retrospectively at Prince
Rashed Bin
Al-Hassan Hospital
between August 2005 and December 2007. All male partners were azoospermic (12
with obstructive and 56 with non-obstructive azoospermia). The mean age of the
patients was 36.7 years (range 25-71). The mean duration of infertility was 5.3
years (range 2-17. They were evaluated with seminal fluid analysis (on two
occasions), history (medical and surgical), hormonal assay, ultrasonographic
examination and clinical examination to identify any testicular pathology
(varicocele, epididymal cyst or enlargement). Their hormonal profile included
follicle stimulating hormone (FSH), luteinizing hormone (LH), thyroid
stimulating hormone (TSH), prolactin (PRL) and testosterone (T). Differentiation
between obstructive and non-obstructive azoospermia was based on history,
testicular volume, hormonal profile, ultrasonography and the FNA findings, as
described elsewhere.(10,13) All female partners underwent
infertility work-up including history, clinical examination, hormonal profile
and hysterosalpingography. The mean age of women was 32.4 years (range 22-41). Of
the 68 women, only 55 underwent embryo transfer. The other 13 women did not so
because of the failed fertilization and the cell division arrest.
All males underwent testicular FNA before commencing
the ICSI cycle to confirm the presence of spermatozoa. Testicular sperm FNA was
performed as described elsewhere.(10) Briefly, by using 21- gauge
butterfly needles attached to a 20 ml plastic syringe serving as an aspiration
device. While holding the testicle between the index finger and thumb, 3-5
different entries were made in each testicle after passing directly through the
scrotal skin into the testis, moved up and down at various sites. Following
each aspiration, the aspirate was deposited in tubes containing special media
with heparin. Then the aspirates were immediately examined under the microscope
at X200 and X400 magnification to detect the presence of sperms. The aspirate
was collected and transferred to 6ml conical tubes and centrifuged at 300g for
10min.
All female partners did undergo a standardized
pituitary down-regulation protocol as described elsewhere.(14)
Briefly, the long-luteal pituitary down-regulation using the GnRH analogue
triptorelin (Decapeptyl: Ipsen, Paris; France) was commenced on day 21 of the
current menstrual cycle. Ovarian stimulation with human menopausal
gonadotropins (HMG) was started in all patients on the third day of menses of
the second menstrual cycle. Transvaginal ultrasound follow up for follicular
growth was commenced on day eight of ovarian stimulation and repeated every 3-4
days thereafter. When at least 3 follicles reached a mean diameter of 17 mm, a
single dose of 10.000 IU of hCG was administered. After 36 hours,
transvaginal-guided oocyte retrieval was performed under general anesthesia.
Fertilization was considered successful after noting the presence of two
pronuclei and second polar body 20-24 hours after the ICSI procedure. Embryos
were graded as previously described by Coskun et al.(15)
Good embryos included those with even-sized blastomeres and no obvious fragmentations
or even-sized with <10% fragmentations or uneven-sized with no obvious or
<10% fragmentations. Fair embryos included those with 10-30% fragmentation.
Embryos with >30% fragmentations were considered poor.
The best 1-3 embryos were
transferred 72 hours following oocyte retrieval by using Wallace catheter
(Marlow Surgical Technology, Willoughby, OH; USA).
Pregnancy rate was calculated considering only clinical pregnancies, defined as
the visualization of intrauterine gestational sac with positive fetal heart
activity by transvaginal ultrasound 4-5 weeks after embryo transfer. Early pregnancy loss was defined as pregnancy loss before 12 weeks gestation. Statistical analysis was presented as means, SD and percentages. Hormonal assays including FSH, LH, TSH, PRL and testosterone were performed in all patients by standard radioimmunoassay (RIA) kits (Diagnostic Product Corporation, USA). Informed consent was obtained from all women. The study was approved from the scientific and ethical committee of the Royal Medical Services .
Table
I. The demographic, clinical and
hormonal data of the 55 azoospermic men
|
Age
(year)
Duration
of infertility (year)
Type
of azoospermia
- Obstructive
- Nonobstructive
Medical
history
- Drug ingestion
- Diabetes mellitus
- Genitourinary tract infection
Surgical
history
- Varicocelectomy
- Orchidopexy
- Herniorrahpy
Testicular
volume (ml)
Hormonal
assay
- FSH (mIU/ml)
- LH (mIU/ml)
- TSH (mIU/ml)
- PRL (ng/ml)
- Testosterone (ng/ml)
|
36.7 (25-71)
5.3 (2-17)
12 (21.2%)
43 (78.8%)
5 (9.1%)
2 (3.6%)
3 (5.5%)
2 (3.6%)
1 (1.8%)
2 (3.6%)
17.3 (12-24)
7.8 (4.2-15.7)
7.5 (3.1-12.3)
3.9 (1.5-4.7)
16.4 (8-27)
388.6 (199-769)
|
FSH=
Follicle stimulating hormone LH= Luteinizing hormone TSH= Thyroid stimulating hormone PRL= Prolactin
Table
II. Demographic, hormonal and
treatment data and reproductive outcome of 55 women who underwent embryo
transfer.
|
No of patients underwent ET
Age (year)
Day
3 FSH (mIU/ml)
No of oocytes retrieved
No of oocytes fertilized
No of embryos transferred
Implantation rate (%)
Pregnancy rate / ET (%)
- Multiple PR
- Abortion rate
Delivery of alive baby rate
(%)
- Full-term delivery
- Premature delivery (<37 weeks)
|
55
32.4 (22-41)
5.2 (3.8-13)
708
487
179
36/179 (20.1)
28/55 (50.9)
7/28 (25)
5/28 (17.8)
23/55 (41.8)
16/23 (69.6)
7/23 (30.4)
|
ET=
Embryo transfer FSH=Follicle
stimulating hormone
Data are expressed as
percentages and mean SD. Clinical characteristics were analyzed using Student’s
t-test. All other analyses were performed using Chi-Square test and Fisher’s
exact test. A p-value < 0.05 was considered statistically significant.
Results
Table I summarizes the demographic, clinical and
hormonal data of the 55 azoospermic men whom female partners underwent embryo
transfer. Their age ranged from 25 to 71 years (mean 36.7) with duration of
infertility ranging from two to 17 years (mean 5.3). Forty-three men of 55
(78.8%) suffered from nonobstructive azoospermia and 12 (21.2%) were diagnosed
to have obstructive azoospermia. Ten patients had positive medical history (5
with drug ingestion, 2 diabetics, and 3
with genitourinary
tract
infection) and five previous surgical histories (varicocelectomy 3, orchidopexy
1 and herniorrhaphy 2). Their testicular volume ranged between 12 and 24 mls
(mean 17.3) and serum hormonal levels (FSH, LH, TSH, PRL, Testosterone) were
within normal ranges. The demographic data, treatment characteristics and
reproductive outcome are shown in Table II.
The women’s age ranged between 22 and 41 years (mean
32.4), and their basal FSH levels ranged between 3.8 and 13 mIU/ml. A total of
708 oocytes were retrieved of which 487 fertilized (68.8%) and 179 embryos were
transferred (mean 3.3). The implantation and pregnancy rate were 20.1% and
50.9%, respectively. The pregnancy was achieved in 19 out of 43 (44.2%) women
of the nonobstructive azoospermia-group, and in nine out of 12 (75%) of the
obstructive group. Of the 28 women who achieved pregnancy, seven had multiple
pregnancies (one set triplet and 6 set twins), five aborted, 23 delivered (7
premature deliveries of which 6 were multiple pregnancies and 16 full-term
deliveries).
No complications were encountered in the male patients
during and after the testicular FNA.
Discussion
Different methods for recovering epididymal or
testicular spermatozoa have been described and each has its drawbacks and
advantages. Recovery of testicular spermatozoa from infertile men with
obstructive and non-obstructive azoospermia for ICSI treatment is a recent
advance in the treatment of male infertility. Until recently, testicular biopsy
was considered the method of choice to ascertain the presence and the quality
of spermatogenesis. Recently, testicular fine needle aspiration was introduced.
It is a simple and less invasive procedure compared to microsurgical
intervention on the testis. Comparable results to those obtained with
spermatozoa recovered by open biopsy in azoospermic patients were reported by
performing the testicular sperm fine needle aspiration.(5)
The results of this study show testicular sperm fine
needle aspiration from infertile men with both obstructive and non-obstructive
azoopsermia and the application of ICSI treatment is associated with a high fertilization,
implantation and pregnancy rates (68.8%, 20.1% and 50.9%, respectively). These
results are comparable with those reported previously by other investigators.(9,12)
In a prospective study, Mercan et al.(12)
evaluated 63
infertile men with non-obstructive azoospermia and reported an implantation
rate of 20.7%, fertilization and pregnancy rates of 69.5% and 46%,
respectively. In their series, 50 out of 63 (79.4%) patients had previous TEFNA
before commencing the ICSI treatment. One limitation of their study was the
lack of female demographic data, which might explain the slightly lower
pregnancy rate observed in our study. In a more recent study, Levine et al.(9)
performed 56 procedures for men with non-obstructive azoospermia who underwent
testicular sperm aspiration for ICSI treatment. An adequate number of viable
sperm was obtained in 82% of cases, with fertilization and pregnancy rates of
55% and 44%, respectively. Similar to the previous study, no female demographic
data were mentioned.
In contrast to our results, previous experiences
showed that testicular spermatozoa obtained by FNA for ICSI treatment were
associated with lower rates of fertilization, implantation and pregnancy. Friedler
et al.(11) in 37 rigorously selected patients with
non-obstructive azoopsermia, reported a fertilization rate of 49%, implantation
and pregnancy rates of 13% and 29%, respectively. Moreover, Tournaye et al.(5)
conducted a retrospective controlled study that compared the efficacy of FNA
and the open biopsy for testicular sperm recovery in a group of patients with
obstructive azoospermia. In the TEFNA group, despite the sufficient sperm
recovery in 96% of patients, low rates of fertilization, implantation and
pregnancy were reported in their series (65.6%, 7.8% and 27.5%, respectively).
In these studies, the low fertilization, implantation and pregnancy rates were
attributed to the rigorous preselection and genetic potential of these cases.
The results of this study showed that the pregnancy
rate was higher among cases with obstructive azoospermia when compared to
non-obstructive azoospermia (75% Vs 44.2%). This finding is in agreement with
previous reports.(16,17) It has been reported that spermatozoa from men
with non-obstructive azoospermia may have chromatin defects and DNA abnormalities
as compared to spermatozoa obtained from men with obstructive azoospermia.(18) This may explain the lower fertilization
capacity, implantation and pregnancy rates in cases with non-obstructive
azoospermia.
Several complications have been described after
testicular sperm retrieval techniques. These include inflammation, hematoma and
even testicular devascularization.(19) Fortunately, no
such complications
were encountered in our patients, since butterfly 21-gauge needle was used to aspirates
the sperms with experienced hands.
Conclusion
The results of this study showed that ICSI treatment is
associated with high pregnancy rate after testicular FNA aspiration of sperms
from patients with obstructive and non-obstructive azoospermia. The application
of TEFNA shortly before commencing treatment to confirm the presence of sperms
is helpful to increase the chances of success of the ICSI procedure The
procedure is simple, noninvasive, repeatable with no/or minimal complications.
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