Testicular sperm extraction: comprehensive analysis with simultaneously performed histology in 1418 biopsies from 766 subfertile men.

The introduction of intracytoplasmic sperm injection (ICSI) has revolutionized treatment of male-factor infertility. Even with a single spermatozoon a pregnancy can be achieved. In cases of azoospermia due to obstruction or highly impaired spermatogenesis, spermatozoa can be retrieved directly from testicular tissue recovered by testicular biopsy followed by sperm extraction. The predictive value of histology from semi-thin sections of testicular biopsies was assessed in relation to testicular sperm extraction (TESE) results, using 1418 biopsy samples from 766 subfertile men which were evaluated simultaneously using a modified Johnsen score and an ordinal classification system for spermatozoa in TESE samples. In 655 men bilateral samples were available. Based on histological findings and TESE results, the quality of spermatogenesis in the right testes was significantly better than that in the left testes. There was a difference between the two sides in 35.7% of all patients for histology and 32.7% for TESE results. When best results from either testis were used for analysis, 76.9% of all men revealed spermatozoa in TESE preparations, although during histological evaluation of semi-thin sections only 64% of all men had shown mature spermatids. In a core group of 250 azoospermic men without anamnestic hints to obstruction and most likely to benefit from ICSI, TESE was successful in 62.8% men. Subdivision of this group dependent on follicle stimulating hormone (FSH) serum concentrations revealed that even in cases of increased FSH concentration, between 39.1 and 64.7% of men showed mature spermatids in their TESE samples. A subset of 70 azoospermic men from the main sample with symptoms and history suggestive of an obstruction and considered as positive controls showed a positive TESE result in all patients. The histology had failed to predict this in 2.9% of all cases. Nevertheless, in five men an early stage of testicular tumour (carcinoma in situ = CIS) was detected. Two of these males suffered from bilateral CIS. This reflects a prevalence of 0.7% testicular malignancy in the group of patients without a history of excurrent duct obstruction. The data demonstrate that a trial TESE with histology based on the semi-thin sectioning technique is a powerful diagnostic and therapeutic procedure, which justifies the invasive nature of sperm retrieval for ICSI. In addition, the results stress the importance of bilateral biopsies to gain optimal diagnostic and therapeutic results.

Successful testicular sperm extraction (TESE) in spite of high serum follicle stimulating hormone and azoospermia: correlation between testicular morphology, TESE results, semen analysis and serum hormone values in 103 infertile men.

Spermatozoa recovered from testicular biopsies can be used through intracytoplasmic sperm injection (ICSI) to achieve a pregnancy. To assess the likelihood of successful testicular sperm extraction (TESE) in men suffering from severe oligo- or azoospermia, bilateral biopsy specimens were obtained. Following semi-thin sectioning, the morphology of testicular samples was graded according to a modified Johnsen score. TESE was performed in parallel to this histological examination. The number of isolated spermatozoa was assessed in a semiquantitative way. From 103 patients investigated, 64 (62.1%) showed azoospermia in a preceding semen analysis and 29 (28.2%) patients had sperm concentrations between 0.1 and 1 x 10(6)/ml. In 10 patients who had higher sperm counts, most spermatozoa were non-motile. Spermatozoa could be detected after TESE in the testicular tissue of 49 (77%) azoospermic men. When follicle stimulating hormone (FSH) concentration was normal, most patients had detectable spermatozoa after TESE. Nearly one-third of patients with mildly elevated FSH had no spermatozoa. Thirty-nine percent of patients in whom FSH was elevated to more than twice normal and 50% of patients with grossly elevated FSH had no detectable spermatozoa. In all, 82.8% of men with sperm concentrations between 0.1 and 1x10(6)/ml in their ejaculate showed spermatozoa in the tissue sample after TESE. Our data demonstrate that, contrary to previous recommendations, infertile men with azoospermia and high FSH values should be reconsidered for testicular biopsy, provided that tissue samples can be cryopreserved for later TESE/ICSI treatment.

Noninvasive parameters of bone metabolism.

Markers of bone formation determined in serum include alkaline phosphatase, bone-specific alkaline phosphatase, osteocalcin [bone gamma-carboxyglutamic acid peptide (BGP) and procollagen type I carboxyterminal propeptide. Recently, advances have been made in the immunoassay of bone-specific alkaline phosphatase. This is a marker for osteoblastic activity; it is very stable and is not primarily dependent on kidney function because it is degraded in the liver. BGP is not specific for bone formation because it increases in serum during bed rest (which involves increased bone resorption), and it is not stable. Furthermore, the elimination of BGP is dependent on glomerular filtration rate. Procollagen type I carboxyterminal propeptide is not as sensitive as bone-specific alkaline phosphatase because it increases less in women after the menopause. Urinary pyridinoline and deoxypyridinoline determined by high-performance liquid chromatography are regarded as the best methods for measuring bone resorption. These might be replaced by type I collagen crosslinked N-telopeptide or CrossLaps in the future in laboratories not equipped with a high-performance liquid chromatography system. Serum markers of bone resorption are currently under investigation. An immunoassay for the tartrate-resistant acid phosphatase in serum should be a very promising tool for the quantification of bone resorption.

[Duration of desire for a child, contraceptive behavior and rate of previous infertility treatment. An epidemiologic study of 750 consecutive patients in labor at the Oldenburg Gynecologic Clinic using a structured interview]. / Kinderwunschdauer, kontrazeptives Verhalten und Rate vorausgegangener Infertilitätsbehandlungen. Eine epidemiologische Untersuchung bei 750 konsekutiv erfassten Wöchnerinnen der Oldenburger Frauenklinik durch strukturiertes Interview.

In order to gain current information, on how long a healthy couple desiring a child has to wait until conception, on previous contraceptive behaviour and prior infertility treatment, 750 women were interviewed within 7 days after delivery between January and November, 1989, using a standardised questionnaire. This sample represents one third of all patients, who delivered a child in an Oldenburg hospital during the time period covered. 544 women had desired a pregnancy, an additional 206 women had not directly planned a pregnancy, and 73 of these had taken no precautions against conception, since they were willing to accept a pregnancy if it should occur. 133 women called their pregnancy an "accident", which in 87 couples occurred despite some kind of contraceptive procedure. The absolute number of contraceptive failures was highest for timed intercourse (n = 38) and users of oral contraceptives (n = 32). Couples without a history of infertility treatment had to wait for an average period of 3.4 months before a conception occurred (95% confidence limits: 3.1-3.8 months). The mean age of the women in this group was 28.1 +/- 0.2 years, whereas on an average their male partners were 30.9 +/- 0.2 years of age. The likelihood to achieve pregnancy within the first 4 months of trying, varied between 13 and 15% per month. After 6 months of waiting, the pregnancy rate per cycle was reduced to 6%, whereas, after one year, the likelihood for conception was only 1%. Half of all couples desiring a pregnancy achieved this within 4 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyaluronic acid as a medium for human sperm migration tests.

Hyaluronic acid was used as a substitute for human cervical mucus as a medium for sperm migration since its viscosity, molecular weight and structure are similar to constituent glycoproteins of human cervical mucus. Parameters of sperm motility were comparable in human cervical mucus and hyaluronate as measured by a computerized sperm motion analysis system (Hamilton-Thorn 2030 and Strömberg-Mika System). Sperm migration rates were also similar in human cervical mucus, bovine mucus and hyaluronic acid and the reproducibility was best in hyaluronic acid. Sperm survival for 24 h was maintained in human cervical mucus and hyaluronic acid but not in bovine mucus. The use of hyaluronic acid in sperm migration tests is recommended.

Evaluation of the Hamilton-Thorn 2030 motility analyser for routine semen analysis in an infertility clinic.

In routine semen analysis of 242 patients the values of sperm concentration, sperm motility and progressive sperm motility were measured with the Hamilton-Thorn semen analyser (HT) and compared to the data obtained by conventional semen analysis according to the guidelines of the WHO. Overall, the HT gave higher values for sperm concentration (mean difference 21.7 +/- 46.2 x 10(6) ml-1, mean +/- SD). Motility values showed a correlation of 0.67 (slope 0.94, P less than 0.001) but were estimated lower by the HT than by conventional analysis (mean difference 7.3 +/- 21.7%); this was caused by the overestimation of sperm concentration. In the range from 0 to 50% motility the HT yielded lower values and higher values from 50 to 100% motility. Progressive motility values of the HT agreed better with conventional analysis (WHO categories a + b): the mean difference of all values was 0.5 +/- 19.5% (r = 0.74, slope = 1.0). The mean lateral head displacement measured by the HT increased with increasing sperm path velocity, but other significant correlations between sperm movement parameters could not be demonstrated. In many instances round cells and debris could not be distinguished from normal sperm. In conclusion, the HT system cannot replace conventional semen analysis in routine diagnosis.

Presence and distribution of leucocyte subsets in the murine epididymis after vasectomy.

Male mice were vasectomized by 'open-ended' or 'closed' techniques. After 4 weeks the cell-mediated immune reactions were compared with those of sham-operated animals by immunohistochemical localization of leucocytes, using specific monoclonal antibodies. Macrophages and MHC class II antigen-positive cells were the major cell types to appear in all regions of the epididymis after both types of operation. There was recruitment of T-helper/inducer leucocytes but not of T-suppressor-cytotoxic cells. An increased presentation of macrophage-migration inhibiting factor antigen appeared in interstitial and peritubular locations. After 'closed' and 'open-ended' vasectomy granulomata developed in the epididymis. The sperm-containing lumen of these granulomata was invaded by macrophages, MHC class II-positive cells and T-helper/inducer lymphocytes. This mouse model thus reveals a significant epididymal inflammatory response of the epididymis to vasectomy.

Anabolic steroids and semen parameters in bodybuilders.

The influence of high-dose anabolic steroid administration on endocrine and semen parameters of 41 bodybuilders (age, 26.7 +/- 0.7 years [mean +/- SEM]; height, 182 +/- 1 cm; weight, 97.5 +/- 2.0 kg) was investigated. History of anabolic steroid administration was recorded retrospectively, and results of semen analysis were compared with data from 41 consecutively recruited normal volunteers not using any steroids or other drugs. Doses of anabolic steroids taken by bodybuilders exceeded those generally applied for clinical purposes by up to 40-fold. Although only 5 of the normal volunteers had sperm counts below the lower normal limit of 20 x 10(6) sperm/mL, 24 of the bodybuilders showed subnormal values. Depending on the duration of anabolic steroid use and the period since last drug intake before the investigation, percentages of motile and normally formed sperm were significantly reduced in bodybuilders compared with normal volunteers. In those bodybuilders who had stopped consumption of anabolic steroids greater than 4 months previously, sperm numbers were in the normal range. Results suggest that even after prolonged use of extremely high doses of anabolic steroids, sperm production may return to normal.

Bias to routine semen analysis by uncontrolled changes in laboratory environment--detection by long-term sampling of monthly means for quality control.

To detect systematic bias in the results of routine semen analysis over time, monthly means of semen parameters determined by the recommended WHO methods were computed. The analysis was based on a total sample size of 1784 ejaculates and included 18 months of observation. In addition to slight changes of morphology estimates caused by a change of laboratory staff, a major bias in the measurement of sperm motility could be detected. This observation triggered a search for changes in protocols not previously given the required attention. It revealed that the newly introduced use of polypropylene syringes with a mounted needle for accurate measurement of seminal volume impaired sperm motility. More detailed investigation by computerized sperm motion analysis in 10 semen samples treated simultaneously in different ways revealed that predominantly it was the needle which caused the drop in proportion of motile sperm (glass cylinder: 50.3 +/- 4.1% vs. syringe + needle: 26.6 +/- 5.3%; mean +/- SEM) and not the contact with the plastic material alone (syringe alone: 43.4 +/- 4.8%). Other motion parameters such as curvilinear velocity (36.0 +/- 1.6 microns/sec), linearity (78.5 +/- 8.4%) and lateral head displacement (3.8 +/- 0.9) were not influenced by the different methods of handling. The results indicate that long-term sampling of monthly means may serve as part of a quality control scheme in semen analysis.

Combination of 19-nortestosterone-hexyloxyphenylpropionate (Anadur) and depot-medroxyprogesterone-acetate (Clinovir) for male contraception.

Because monotherapy with 19-nortestosterone hexyloxyphenylpropionate (Anadur, Pharmacia Arzneimittel, Ratingen, Federal Republic of Germany) suggested improved results for male contraception compared with available testosterone esters, it was tested for induction of complete azoospermia when combined with depot-medroxyprogesterone acetate (DMPA, Clinovir, Upjohn GmbH, Heppenheim, Federal Republic of Germany). Twelve men were treated for 7 weeks with weekly intramuscular (IM) injections of 200 mg Anadur followed by 3-weekly IM injections of Anadur up to week 15. Clinovir (250 mg) IM was administered at the start of treatment and during weeks 6 and 12. Anadur and Clinovir suppressed serum gonadotropins. Although serum testosterone declined steeply, in general, libido and potency were not impaired. Sperm concentrations were reduced significantly after 3 weeks of treatment. Lowest sperm counts were seen during week 8 of follow-up, when only 2 volunteers showed measurable sperm counts of 2.1 and 3.0 X 10(6)/ml, with a declining tendency. After 43 weeks, sperm concentrations were still below pretreatment range in 2 men, but later returned to pretreatment values. Computerized sperm motion analysis revealed that motility parameters in the residual sperm were reduced. In vitro analysis excluded a direct effect of medroxyprogesterone acetate in seminal plasma on sperm motion. The data indicate that the combination of Anadur with Clinovir increases the rate of azoospermia in normal volunteers seen under Anadur monotherapy, although the goal of azoospermia in all participants was not quite achieved.

Pulsatile GnRH-therapy in oligozoospermic men does not improve seminal parameters despite decreased FSH levels.

In order to evaluate GnRH administration for the treatment of infertile men with elevated serum FSH levels we administered GnRH in pulses via portable electronic infusion pumps initially to seven patients with low sperm counts and high FSH values over 12 weeks and later to nine further patients over 24 weeks who also underwent testicular biopsies. Fifty microlitres containing 5 micrograms GnRH were infused subcutaneously for 1 min every 120 min in the short-term study and every 90 min in the long-term study. Although FSH levels could be lowered in both groups of patients, none showed any improvement in sperm count or other seminal parameters. Therefore, pulsatile GnRH treatment cannot be recommended for therapy of severe oligozoospermia with elevated FSH levels.

The antimycotic drug terbinafine in contrast to ketoconazole lacks acute effects on the pituitary-testicular function of healthy men: a placebo-controlled double-blind trial.

Among the side-effects of the antimycotic drug ketoconazole, inhibition of testosterone biosynthesis is highly pronounced. The decrease in testosterone may cause impotence and gynecomastia, and this side-effect has been exploited in drug tests for the treatment of androgen-dependent tumours. Terbinafine, an allylamine derivate, from a new group of antifungal substances, did not show similar inhibiting effects on steroid synthesis in vitro and in vivo in animal experiments. In a double-blind, placebo-controlled study the influence of terbinafine and ketoconazole on the pituitary-testicular axis in normal young men were compared. Serial blood sampling for 12 h was followed by the ingestion of the placebo, ketoconazole (200 mg) or terbinafine (500 mg) on three different occassions in random order. Ketoconazole administration caused a steep decrease of serum testosterone reaching a nadir after 4-5 h. Simultaneously an increase in 17-hydroxyprogesterone occurred with peak values after 5 h. During 12 h after the administration of ketoconazole no changes in LH pulse frequency and amplitude were found, although testosterone serum levels were in the subnormal range for about 8-9 h. Terbinafine showed no effects on testosterone and 17-hydroxyprogesterone levels or on LH pulse frequency and amplitude. Estradiol, prolactin and FSH remained unchanged after ketoconazole and terbinafine ingestion compared with placebo treatment. The study confirms the acute effect of ketoconazole on serum testosterone and 17-hydroxyprogesterone, whereas terbinafine shows no acute influence on the pituitary-gonadal axis.

Indomethacin and oxaprozin lower seminal prostaglandin levels but do not influence sperm motion characteristics and serum hormones of young healthy men in a placebo-controlled double-blind trial.

To evaluate the influence of indomethacin and oxaprozin on reproductive function in healthy young men, 34 volunteers with normal semen parameters were recruited. In a randomized double-blind design, 12 men were treated with placebo, 12 received 600 mg/day of oxaprozin and 10 took indomethacin 25 mg t.i.d. This treatment phase lasted for 14 days after which a follow-up period extended for another 10 weeks. Sperm counts, percentage of motile and normally formed sperm cells, sperm velocity, linearity, lateral head displacement and beat frequency were evaluated by computerized image analysis once before treatment and at weekly intervals during the rest of the study. Prostaglandin levels in seminal plasma were significantly reduced after 2 weeks of treatment and remained suppressed for at least 2 additional weeks. In spite of this long lasting impairment of physiologic prostaglandin concentrations, no changes in any of the measured parameters were detectable when compared with the placebo group. Basal levels of testosterone, estradiol, LH, FSH, TSH and prolactin were unchanged. The response of hypophyseal hormones to a combined GnRH/TRH test before, during and after the treatment also was not affected. Overall, no negative influence of indomethacin or oxaprozin treatment on male reproductive function could be found in healthy volunteers. Since the active treatment phase was only 14 days, one can only speculate about long term effects of the tested drugs on reproductive parameters in men.

Investigation of the cause of low sperm motility in asthenozoospermic patients by multiple quantitative tests.

Multiple tests were done on the ejaculates of 10 asthenozoospermic patients and nine healthy normozoospermic volunteers in an attempt to identify individually the cause of low sperm motility in these patients. Possible defects in the sperm plasma membrane and the motility apparatus of sperm, and in epididymal function affecting the development of motility, were investigated. The presence of seminal sperm antibodies or any motility-inhibiting factors in the seminal plasma that could be removed by washing were also tested. Each test was positive in only one or two patients but axonemal dysfunction was identified in nine patients. Removal of seminal plasma from asthenozoospermic samples did not improve sperm motility to any greater extent than with donor ejaculates, and the motile sperm of these patients exhibited characteristics mostly similar to those of donors under various incubation conditions. Selection procedures are, therefore, required to obtain samples of good quality sperm from such asthenozoospermic ejaculates.

Intra-individual variation of sperm velocity, linearity, lateral head displacement and beat frequency in healthy volunteers.

In an effort to evaluate the intra-individual fluctuations of sperm motion parameters 12 healthy young men with normal semen parameters were recruited. Weekly semen analysis was performed for 13 weeks. Conventional semen parameters such as sperm concentration, percentage of motile and normally formed sperm were determined according to WHO guidelines, while sperm velocity, linearity, lateral head displacement and beat frequency were evaluated by computerized image analysis. Mean and standard deviations (SD) of all parameters were computed for each individual. Coefficients of variation were expressed as the ratio of SD/mean. On average the following coefficients of variation were found: total number of sperm 58 (+/- 5%); concentration of sperm 47 (+/- 4%); lateral head displacement 27 (+/- 4%); volume 24 (+/- 3%); velocity 19 (+/- 2%); linearity 17 (+/- 2%); percentage of motile sperm 12 (+/- 2%); beat frequency: 12 (+/- 2%) and percentage of normally formed sperm 9 (+/- 1%). The low variation of sperm motion parameters and the ease of their determination suggests that computerized motion analysis of sperm may be a valuable research tool to detect subtle effects e.g. of drugs and environmental toxins on reproductive functions in men.

Comparison of computerized semen analysis with the conventional procedure in 322 patients.

To compare the results of computerized image analysis for semen evaluation with classical semen analysis, semen samples from 322 consecutive patients attending our infertility clinic were studied. In men with sperm concentrations less than 20 X 10(6)/ml, major discrepancies existed between both methods for sperm concentration. In many instances, debris could not be distinguished from normal sperm by the computerized system. This caused an overestimation of sperm concentration and led to a reduction of motility estimates. As a consequence, frequency distribution of motility, expressed as the percentage of motile sperm, differed to a major extent in both systems.

[Does sperm penetration in bovine mucus provide additional information to the "classical" spermiogram and motility characteristics?]. / Liefert die Spermienpenetration in bovinen Mukus zusätzliche Information zum "klassischen" Spermiogramm und zu den Motilitätscharakteristika?

In vitro bovine cervical mucus penetration tests (Penetrak) were performed in 30 patients from our fertility clinic and in 33 healthy volunteers with normal semen characteristics. After 90 minutes maximum penetration by sperm (mm) was measured using a capillary filled with bovine midcycle cervical mucus. At the same time classical (sperm motility [%], concentration [mill/ml] and morphology [% oval heads] ) and computerized semen analyses (Cell Soft) were performed (mean velocity [micron/s], lateral head displacement [micron], beat frequency [Hz] and mean linearity). Multiple regression analysis of the depth of sperm penetration in cervical mucus (mm) yielded those semen parameters which allowed correct prediction of the penetration test in 54% of cases. Sperm concentration, morphology, motility and mean velocity alone accounted of 53% of the predictions. In 46% of cases the outcome of the cervical mucus penetration test could not be predicted, regardless of whether classical or computerized semen analysis was performed. This suggests that factors other than those described above must play a role in this aspect of sperm function.

Treatment of severe oligospermia with human chorionic gonadotropin/human menopausal gonadotropin: a placebo-controlled, double blind trial.

In an effort to evaluate the effect of hCG/human menopausal gonadotropin (hMG) treatment on semen parameters in normogonadotropic men suffering from oligospermia, a double blind, placebo-controlled study was conducted. After 2 basal examinations of seminal parameters and reproductive hormones, 39 men were recruited for the trial. Nineteen men, allocated randomly to the active drug group, received im injections of 2500 IU hCG twice a week in combination with 150 IU hMG three times a week for 13 weeks, while 20 men were treated, following the same injection schedule, with NaCl only. After the 13-week treatment period, follow-up examination was performed, followed by 3 additional examinations at 4-week intervals. Of those men receiving hCG-hMG, 2 induced pregnancies in their wives, while no pregnancies were reported in the placebo group. Sperm concentrations, the percentages of motile sperm, and the proportions of normally formed spermatozoa, however, were similar in the 2 groups at all times. It was not possible to predict the outcome of treatment based on results of GnRH and hCG tests performed before the treatment phase.