Testicular needle biopsy, open biopsy, epididymal aspiration and intracytoplasmic sperm injection in obstructive azoospermia

Testicular or epididymal spermatozoa were obtained for in-vitro fertilization and intracytoplasmic sperm injection (ICSI) in 27 cycles out of 33 (in six men the azoospermia proved to have testicular causes). Testicular needle biopsy carried out in addition to surgical open biopsy proved to be an effective method to obtain spermatozoa for ICSI from patients with obstructive azoospermia. Thus it might be possible to replace scrotal operations by simple needle biopsies. Embryos resulting from ICSI with testicular spermatozoa were used in 19 transfers that resulted in six pregnancies. One pregnancy resulted from six embryo transfers from ICSI after microsurgical-epididymal sperm aspiration (MESA). The normal fertilization rates with testicular (37.3%) and MESA spermatozoa (53.7%) did not differ significantly from each other, but with testicular spermatozoa the rate was significantly lower than that obtained with ejaculated spermatozoa and ICSI (59.7%) in the matched couples. The abnormal fertilization of oocytes with one pronucleus was significantly higher with testicular spermatozoa than with ejaculated spermatozoa in the control couples.     

The usefulness of MESA-ICSI (microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection) in cases of obstructive azoospermia]

Till the end of March 1998 first seven trials of MESA-ICSI (microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection) in the Ist Chair and Clinics of Obstetrics and Gynecology of the Silesian Medical Academy in Bytom were performed in cooperation with an urologist from the IInd Chair and Clinics of Urology in Zabrze in couples suffering from sterility caused by obstructive azoospermia. In all the cases both contraindications and conditions of MESA-ICSI were respected. Fertilization rate of the MII oocytes was on average 62% and cleavage rate of the fertilized oocytes 76.9%. After embryo transfer at least two pregnancies occurred, from them one is ongoing well. The result of the last procedure is not known yet. The data obtained permit to conclude, that MESA-ICSI makes a real chance to possess their own children by couples with sterility caused by obstructive azoospermia.     

The effect of female age and ovarian reserve on pregnancy rate in male infertility: treatment of azoospermia with sperm retrieval and intracytoplasmic sperm injection

Factors other than spermatozoa could be the major determinant of the success of assisted reproduction treatment in cases of male infertility. Our aim was to evaluate the effect of the wife's age and ovarian reserve on assisted reproduction success rates in the most severe type of male infertility, i.e. azoospermia. A total of 249 consecutive couples suffering from male infertility caused by azoospermia underwent microsurgical epididymal sperm aspiration (MESA) or testicular sperm extraction (TESE) with intracytoplasmic sperm injection (ICSI). Of these men, 186 had irreparable obstructive azoospermia, and 63 had non-obstructive azoospermia due to testicular failure. Neither the pathology, the source, the quantity, nor the quality of spermatozoa had any effect on fertilization or pregnancy rates. Maternal age and ovarian reserve (number of eggs) had no effect on fertilization or embryo cleavage, but did dramatically affect the embryo implantation, pregnancy and delivery rates. Wives of azoospermic men who were in their 20s had a 46% live delivery rate per cycle, wives aged 30-36 years had a 34% live delivery rate per cycle, wives aged 37-39 years had a 13% live delivery rate per cycle, and wives > or = 40 years had only a 4% live delivery rate per cycle. The number of eggs retrieved also affected pregnancy and delivery rate, but to a lesser extent than age. In virtually all cases of obstructive azoospermia, and in 62% of cases with non-obstructive azoospermia caused by germinal failure, sufficient spermatozoa could be retrieved to perform ICSI, with normal fertilization and embryo cleavage. However, the pregnancy rate and the live delivery rate were dependent strictly on the age of the wife, and on her ovarian reserve. Unfortunately, exaggerated claims of high pregnancy rates can thus easily be made by manipulating, in a very simple way, selection for female factors.     

Microsurgical epididymal sperm aspiration versus epididymal micropuncture with perivascular nerve stimulation for intracytoplasmic sperm injection to treat unreconstructable obstructive azoospermia

A novel sperm collection method by epididymal micropuncture combined with perivascular nerve stimulation has been developed to obtain as many clean sperm as possible for IVF for patients with surgically irreparable vasal obstruction. To assess whether the new technique could improve the fertilization and pregnancy rates obtained when attempting microsurgical epididymal sperm aspiration (MESA) to retrieve epididymal sperm from such patients, a prospective randomized comparative study was conducted. Twenty-nine cycles of conventional MESA with ICSI were performed on 25 couples with congenital bilateral absence of the vas deferens (CBAVD) and four failed vasovasostomy cases (group 1). Thirty cycles of epididymal micropuncture with nerve stimulation with ICSI were performed on 28 couples with CBAVD and two failed epididymovasostomy cases (group 2). The mean volume of epididymal fluid and sperm motility in group 2 was significantly higher than that in group 1 (p < .001). Both fertilization and pregnancy rates in group 2 were significantly higher than those in group 1 (p < .001 and p < .03). This novel epididymal sperm collection method for ICSI can provide significantly higher fertilization and pregnancy rates than conventional MESA for ICSI.     

Controlled comparison of percutaneous and microsurgical sperm retrieval in men with obstructive azoospermia

A controlled comparison of the efficacy and reliability of sperm retrieval by testicular fine needle aspiration (TFNA), percutaneous testicular needle biopsy (PercBiopsy) and microsurgical epididymal sperm aspiration (MESA) was performed in nine patients with obstructive azoospermia. During a planned MESA procedure, sperm retrieval was attempted on the same testis with TFNA and PercBiopsy. Spermatozoa were obtained from all patients using MESA and PercBiopsy. Spermatozoa were retrieved using TFNA from 6/9 (67%) men. The mean number of epididymal spermatozoa retrieved with MESA (15 x 106) was significantly higher (P = 0.003) than that retrieved percutaneously from the testis. The mean number of spermatozoa obtained by PercBiopsy was 0.116 x 10(6) while TFNA recovered 0.014 x 106 spermatozoa (P = 0.025). MESA is the optimal choice to retrieve the greatest number of spermatozoa with highest motility for assisted reproduction and subsequent cryopreservation. However, percutaneous testicular retrieval does not require microsurgical expertise and is less invasive. Our results suggest that the optimal percutaneous procedure for sperm retrieval from the testis involves percutaneous testicular needle biopsy with an automatic biopsy gun.     

Intracytoplasmic sperm injection for treatment of non-obstructive azoospermia

Four cases from a tertiary care teaching medical center were studied to assess the potential of sperm extraction, fertilization and the establishment of pregnancy in couples with non-obstructive azoospermia. Four couples with non-obstructive azoospermia underwent intracytoplasmic sperm injection after testicular sperm extraction. Multiple small biopsies were obtained from each testis under general anesthesia in search for sperm, and to establish a histologic diagnosis. The histopathology includes incomplete maturation arrest, hypospermatogenesis, germ cell hypoplasia and incomplete tubular sclerosis. Testicular sperm extraction resulted in the retrieval of immotile sperm from three patients, and a few motile sperm from one patient. Of 60 oocytes which were injected with testicular sperm, 32 (53.3%) fertilized and 27 of these (84.4%) cleaved. Twelve embryos were transferred to three patients and the remaining 15 embryos were cryopreserved. In one patient, no embryos resulted. One clinical pregnancy was established and a normal female infant, weighing 7 lbs 11 oz, was delivered vaginally in August 1996. This study shows that sperm can be extracted from patients with non-obstructive azoospermia when multiple biopsies are obtained. Fertilization, cleavage, clinical pregnancy and delivery of normal babies can be achieved using intracytoplasmic injection of extracted sperm.     

Fertilization and pregnancy using intentionally cryopreserved testicular tissue as the sperm source for intracytoplasmic sperm injection in 10 men with non-obstructive azoospermia

Testicular tissue extraction (TESE) to obtain spermatozoa for use with intracytoplasmic sperm injection (ICSI) has recently been employed in patients with non-obstructive azoospermia. Standard protocol is to retrieve a new sample of testis tissue on the day of oocyte recovery. Unfortunately, approximately 30% of men will possess no spermatozoa in their tissue, making ICSI an impossibility. We investigated whether testicular tissue that was intentionally obtained well before any planned ICSI cycle and cryopreserved could then serve as an efficacious sperm source in a subsequent ICSI cycle. This study reports on 10 men with non-obstructive azoospermia who did have spermatozoa found within their testis tissue at the time of TESE and who chose to use their frozen samples as the source of spermatozoa for a later cycle of ICSI. In 19 cycles the overall fertilization rate was 48%. Embryo transfer occurred in 89% of cycles. Two couples have achieved pregnancy (one ongoing, one delivered). All patients except one had multiple vials of frozen tissue remaining following their first cycle. This approach is offered as an alternative to repeated testicular tissue sampling, as the availability of spermatozoa is assured prior to the initiation of ovulation induction. This tissue can be harvested at the same time as diagnostic biopsy, thereby minimizing the number of surgical procedures.     

Oocyte maturation and intracytoplasmic sperm injection

Intracytoplasmic sperm injection (ICSI), treatment of severe male infertility allows an accurate evaluation of oocyte maturity at recovery after corona-cell removal. In cycles comprising a GnRH analog desensitization and a stimulation by hMG or FSH, 12% of oocytes aspirated from follicles (> 14 mm), 34 hours post-hCG are still immature, in prophase or metaphase 1. They are able to achieve meiosis in vitro in 66% of the cases and will be fertilized (2 PN) by ICSI in 51% of the cases as the in vivo mature oocytes of the same cohort. Nevertheless, the quality of cytoplasmic maturation and consequently of embryonic viability remains to be assessed as there still are few pregnancies arising from in vitro matured oocytes. ICSI also represents the only way to obtain normal fertilization in some exceptional but observed anomalies of oocyte maturation, particularly when there is a lack of zona reaction leading to repetitive polyspermy in conventional IVF.     

A simple approach to intracytoplasmic sperm injection

OBJECTIVE: To describe a simple injection apparatus and method for performing intracytoplasmic sperm injection in a clinical IVF program. DESIGN: A prospective clinical trial of intracytoplasmic sperm injection. SETTING: A private office-based fertility program. PATIENTS: Five couples undergoing IVF-ET with intracytoplasmic sperm injection as a treatment for male factor infertility. INTERVENTIONS: Intracytoplasmic sperm injection was performed at room temperature (23.5 to 24.5 degrees C) in a simple zwitterion-buffered medium. MAIN OUTCOME MEASURES: Fertilization rates, cleavage rates, clinical pregnancy rates, implantation rates. RESULTS: Intracytoplasmic sperm injection was performed on 44 fresh oocytes from five patients. Twenty-three oocytes fertilized (52.3%) and 22 zygotes cleaved (95.7%). Three of five patients became pregnant (60%), resulting in the live birth of one normal male infant, one continuing singleton pregnancy, and one continuing twin gestation (46XX, 46XY). The implantation rate was 23.5%. CONCLUSION: Intracytoplasmic sperm injection can be performed successfully in a simple medium at room temperature using commercially available microtools.     

Patients with absolutely immotile spermatozoa and intracytoplasmic sperm injection

The microinjection of completely immotile spermatozoa may impair the outcome of intracytoplasmic sperm injection (ICSI). Eleven couples underwent an initial ICSI cycle with 100% immotile freshly ejaculated spermatozoa. Two-pronuclear fertilization ensued in 18 of 145 (12.4%) successfully injected oocytes. None of these cycles resulted in a pregnancy. Nine couples underwent ICSI in subsequent cycles (n = 16). Ejaculated spermatozoa were injected in 15 cycles and testicular spermatozoa in one cycle. In 10 of the 15 cycles, motile spermatozoa were available at the time of injection. Motile testicular spermatozoa could also be injected. In the subsequent cycles, 91 of 176 (51.7%) successfully injected oocytes fertilized normally and four patients became pregnant. In the subsequent cycles where again immotile spermatozoa had to be injected no pregnancies occurred. In four subsequent cycles embryo cryopreservation was carried out. After replacement of two frozen-thawed embryos one additional pregnancy was obtained. In all, five healthy infants were born. It has been ascertained that motile spermatozoa can be detected either in repeated ejaculates or after testicular biopsy. The causes of total asthenozoospermia are variable and the problem is a sporadic rather than a permanent condition.     

Assisted fertilization by subzonal insemination and intracytoplasmic sperm injection

The results of 600 consecutive treatment cycles of subzonal insemination (SUZI) and intracytoplasmic sperm injection (ICSI) are described in couples with failed fertilization after standard IVF or insufficient spermatozoa in the ejaculate for IVF. More oocytes were damaged by ICSI (16.3%) than by SUZI (8.5%) and the normal fertilization rate was substantially higher after ICSI (49.1% v. 16.6%). Subsequent development of two-pronuclear oocytes in vitro was 80% after SUZI and 73.9% after ICSI. Significantly more triple embryo replacements were carried out after ICSI than after SUZI. Embryo transfers were possible in 421 of the 600 cycles. There were 63 pregnancies after ICSI (215 transfers) and 23 after SUZI (156 transfers); 10 additional pregnancies were achieved after 50 transfers of a mixture of SUZI and ICSI embryos. The results of fetal karyotypes and follow-up of the children do not indicate an increase in congenital malformations.     

Obstetric and perinatal outcome of pregnancies following intracytoplasmic sperm injection

The aim of this study was to describe the obstetric and perinatal outcome for births following intracytoplasmic sperm injection (ICSI). Of 210 infants born, 140 were singletons and 70 were twins. There were no triplets or higher births. The multiple birth frequency was 20%. Overall, 17% of deliveries were preterm, although for singleton pregnancies the incidence was reduced to 9%. The median birth weight of all live born infants was 3168 g and singletons 3470 g. Of all infants, 17% had a low birth weight (<2500 g) and 2% had a very low birth weight (<1500 g). Two major malformations occurred in two singleton children and four minor malformations occurred in four children. This was within the range of expected values in Sweden. Karyotyping was performed in 58 pregnancies. All of them were normal. The perinatal mortality was 0.5%. In conclusion, in this observational study from Sweden of the first infants born after ICSI in our programme, the incidence of multiple births, preterm births, low birth weight babies and congenital malformations was low compared with other series of in-vitro fertilization pregnancies not associated with ICSI.     

Pregnancy rates after intracytoplasmic sperm injection in relation to sperm recovery techniques

Xanthogranulomatous pyelonephritis (XGP) is a rare and aggressive form of chronic pyelonephritis for which partial or complete nephrectomy is mandatory [1.2]. The diagnosis and, in particular, the differentiation from hypernephroma is mostly established by the histopathological examination only. We have reviewed the literature and present an unusual case of XGP with septic spreading into the lungs mimicking pulmonary metastasis and with an inflammatory infiltration of the descending colon.     

Fertilization after intracytoplasmic sperm injection with cryopreserved testicular spermatozoa

The inhibitory effect of dietary supplementation with flavonol quercetin on 7,12-dimethylbenz[a]anthracene (DMBA)-induced hamster buccal pouch carcinogenesis was investigated. Dietary quercetin inhibited the incidence of both papillomas and tumors induced by DMBA. The fluorescence spectra of papillomas and tumors showed different prominent maxima and a characteristic peak around 620-630 nm, which could be attributed to the accumulation of porphyrin compounds. Further, the fluorescence intensities at 630 nm (FI630nm) were elevated, whereas the ratio FI530nm/FI630nm was decreased in DMBA-induced lesions. Quercetin treatment significantly decreased FI630nm and increased the ratio FI520nm/FI630nm when compared with DMBA-induced lesions. It is therefore evident that quercetin has an inhibitory effect on DMBA-induced carcinogenesis and further studies will throw more light on its use as a chemopreventive agent against oral cancer.     

The outcome of intracytoplasmic sperm injection is unrelated to 'strict criteria' sperm morphology

Sperm morphology was assessed according to the 'strict criteria' established for in-vitro fertilization treatment in the semen samples used for 354 consecutive treatment cycles for intracytoplasmic sperm injection (ICSI). The semen samples were classified according to the three predictive categories of the Tygerberg strict criteria: excellent prognosis (>14% morphologically normal spermatozoa), good prognosis (4-14%) and poor prognosis (<4%). It was found that 37 (10.5%) of the ICSI cycles belonged to the excellent prognosis category, 197 (55.6%) to the good prognosis category, and 120 (33.9%) to the poor prognosis category. The outcomes of the ICSI treatments were evaluated and compared with the sperm morphology classification in order to determine whether the strict criteria could aid in predicting the outcome of ICSI. The fertilization rates in the three categories were 61.6, 66.8, and 61.9%, the pregnancy rates per oocyte retrieval 18.9, 24.9, and 28.3%, and the implantation rates 9.9, 13.0, and 14.9% respectively. No significant differences were found in fertilization, pregnancy, or implantation rates between the three prognosis categories, i.e. the poor prognosis category had an equal chance of obtaining pregnancy compared with the good prognosis category. The results indicate that strict sperm morphology is not related to the outcome of ICSI.     

Pregnancy following intracytoplasmic sperm injection treatment with dead husband's spermatozoa: ethical and policy considerations

This paper describes the first pregnancy in a childless widow after intracytoplasmic sperm injection (ICSI) treatment with her deceased husband's spermatozoa which had been stored for nearly 3 years before use. Before his death the husband had received treatment for testicular cancer and he had given the appropriate written consent for the future use of his spermatozoa. Of the 10 eggs injected, six resulted in normal embryos. Three embryos were transferred and the remaining three embryos are currently stored for possible future use. The treatment resulted in a continuing singleton pregnancy. The case demonstrated the suitability of ICSI in those difficult cases where the sperm quality is extremely poor. This success is also compared with a widely debated case of another widow who was refused permission to use her deceased husband's spermatozoa. It is concluded that in the case of posthumous use of frozen spermatozoa, the current laws are conveniently applicable in a chronic illness but not so in an acute illness leading to death. In the light of the wide public debate on the issues raised by this legal case, the UK Government has also decided to conduct a review of consent procedures involving the storage and use of genetic material.     

Comparison of pregnancy outcome after intracytoplasmic sperm injection and in-vitro fertilization

BACKGROUND: The prognosis of patients with lung cancer is better when the diagnosis is made early; the disease is localized, and radical surgery is possible. Screening for lung cancer with mass radiography or sputum cytology should contribute to a more favorable prognosis. Large-scale screening studies have improved the survival rates for lung cancer but have yielded no reduction in mortality rates. METHODS: The histologic types, stages, treatments, and survival rates were studied in 93 men who were found to have lung cancer in a single chest radiograph screening of more than 33,000 men who smoked and were 50 to 69 years old ("screened cases"), and in 239 men of the same age range whose lung cancer was detected through ordinary health care system ("other cases") during the screening period. RESULTS: The distribution of the histology was similar in the two groups, but screening detected more instances of early-stage disease that were resectable more often than in the other group (37 vs 19%). The 5-year survival rate for men in the screened cases was 19%, and that of men in the other cases was 10% (relative risk, 0.65; 95% confidence interval [CI], 0.50 to 0.84). The survival rate of men in the screened cases remained significantly higher than that of men in the other cases even after adjustments for age, smoking status, histology, stage of the disease, and resectability of the disease (relative risk, 0.74; 95% CI, 0.55 to 1.00). CONCLUSIONS: According to this study, chest radiograph screening might improve the prognosis of lung cancer. Our results are, however, subject to many factors that were only partially controlled for, and they should be interpreted cautiously.     

Development of embryos produced by intracytoplasmic sperm injection of cat oocytes

Development of cat oocytes following intracytoplasmic sperm injection (ICSI) and in vitro fertilization (IVF) was compared in two experiments. Domestic cat donors (used as a model for wild felids) were treated with 150 IU equine chorionic gonadotrophin (eCG) on treatment day 1 or a total of 10-15 IU of follicle-stimulating hormone (FSH) over four days, followed by 100 IU human chorionic gonadotrophin (hCG) on day 5 and follicular aspiration 24-26 h later. A jaguarundi (Herpailurus yaguarondi) female was stimulated twice with FSH (20 IU) or eCG (300 IU) and hCG (250 or 300 IU) before oocyte recovery. After storage at 4 degrees C, domestic cat semen was washed and processed. For ICSI, denuded oocytes were each injected with an immobilised spermatozoon. IVF oocytes were co-incubated with 5 x 10(4) motile spermatozoa/0.5 ml for 4-6 h. Noncleaving oocytes were fixed and stained 24-28 h after injection or insemination. Presumptive zygotes were cultured before transfer on day 5 (experiment I only) or evaluation on day 7 (experiments I and II). In experiment I, fertilization frequency was 67.9% (72/106) and 58.1% (122/210) for IVF and ICSI oocytes, respectively (P > 0.05). Most noncleaving ICSI oocytes (71/88, 80.7%) at 24 h were at metaphase II, of which half (35/71, 49.3%) had an activated spermatozoon (n=4) or premature chromatin condensation (PCC, n=31) of the sperm head. All 69 day 7 IVF embryos developed to morulae (> 16-cells, 46.7%) or blastocysts (53.3%), and 59/63 (93.7%) ICSI embryos reached the morula (50.8%) or blastocyst (42.9%, P > 0.05) stage. Mean cell number in IVF and ICSI embryos was 136 and 116 (P > 0.05); morulae had 77 and 46 (P < 0.05) and blastocysts had 187 and 209 (P > 0.05) cells, respectively. After transfer of 10 or 11 day 5 ICSI morulae to each of four recipients, a total of three kittens were born to two dams at 66 or 67 days. Of 18 fair-to-good quality oocytes recovered from a jaguarundi on two occasions, 10 (55.6%) embryos were produced by ICSI with fresh (n=5) or frozen (n=5) conspecific spermatozoa, but no jaguarundi kittens were born after transfer of these embryos to domestic cat recipients. In experiment II, cleavage frequency following IVF (15/17, 88.2%) and ICSI (31/38, 81.6%) was higher (P < 0.05) than following sham ICSI (13/35, 37.1%). Mean cell number (27 cells) and blastocyst development (0%) on day 7 was lower (P < 0.05) in the sham ICSI group than in the ICSI group (45 cells, 15.6% blastocysts) which, in turn, was lower (P < 0.05) than the IVF group (94 cells, 46.7% blastocysts). We have demonstrated that ICSI can be applied successfully in domestic felids and suggest that the technique will effectively augment other biotechniques being developed for enhancing reproduction in endangered felids.