Ultrasonographically determined size of seminiferous tubules predicts sperm retrieval by microdissection testicular sperm extraction in men with nonobstructive azoospermia.

OBJECTIVE: To investigate the value of the ultrasonographically determined size of seminiferous tubules and other conventional parameters for predicting sperm retrieval by microdissection testicular sperm extraction (micro-TESE). DESIGN: Clinical retrospective study. SETTING: Two urological clinics. PATIENT(S): Eight hundred six men with nonobstructive azoospermia. INTERVENTION(S): Micro-TESE. MAIN OUTCOME MEASURE(S): Sperm retrieval. RESULT(S): Sperm retrieval was successful in 240 (29.8%) of the 806 men. In a receiver operating characteristic analysis of sperm retrieval, the area under the curve (AUC) for seminiferous tubules, assessed as 0, 100, 200, 250, or 300 µm, was no less than 0.82 (95% confidence interval [CI] 0.79-0.85). Sensitivity and specificity at a cutoff point of 250 µm were 76.7% and 80.7%, respectively. An AUC of 0.85 (95% CI, 0.81-0.88) was attained in a parsimonious multiple logistic regression model that included age (<30, 30-39, and 40-59 years), low follicle-stimulating hormone (<14 IU/L), history of cryptorchidism, and sex chromosome abnormality in addition to the diameter of seminiferous tubules. CONCLUSION(S): The gray-scale image in testicular ultrasound was shown to be highly predictive of sperm retrieval in micro-TESE in a large series of men with nonobstructive azoospermia.

The management of obstructive azoospermia: a committee opinion.

Infertility due to obstructive azoospermia may be treated effectively by surgical reconstruction or by retrieval of sperm from the epididymis or testis, followed by in vitro fertilization with intracytoplasmic sperm injection. This replaces the ASRM documents titled "Sperm retrieval for obstructive azoospermia" and "The management of infertility due to obstructive azoospermia," last published in 2008.

Changes in practice patterns in male infertility cases in the United States: the trend toward subspecialization.

OBJECTIVE: To assess changes in the practice patterns of urologists performing male infertility procedures (vasal reconstruction, sperm retrieval, varicocelectomy) from 2004 to 2015 in the United States. DESIGN: Examination of self-reported procedural volumes from urologists undergoing certification and recertification using case log data provided by the American Board of Urology. The study period was stratified into early (2004-2007) and recent (2012-2015) time periods. SETTING: Not applicable. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOMES MEASURE(S): Temporal variations in male infertility practice patterns among different urologic subspecialties between the early and recent time periods. RESULT(S): The overall proportion of total male infertility procedures performed by andrologists significantly increased between the early and recent groups (23% to 26%). This growth was driven by a significant increase in the proportion of varicocele repairs being performed by andrologists between the early and recent periods (19% to 25%). Most notably, an assessment of total number of male infertility procedures performed by newly certifying urologists showed that there was a significant increase in the overall proportion of all male infertility procedures being performed by recently trained andrologists (24% to 35%). This significant increase was seen individually among all three types of male infertility procedures. CONCLUSION(S): With the increased trend in urologists obtaining fellowship training, male infertility surgical volume is beginning to shift from general urologists to subspecialized andrologists.

Should a Couple with Failed In Vitro Fertilization or Intracytoplasmic Sperm Injection and Elevated Sperm DNA Fragmentation Use Testicular Sperm for the Next Cycle?

There is growing evidence indicating that intracytoplasmic sperm injection with testicular sperm rather than ejaculated sperm might be advantageous in achieving pregnancy for couples in which the male has high levels of sperm DNA fragmentation (SDF). Meta-analysis has shown that SDF rates are markedly lower in testicular sperm than in ejaculated sperm, and the odds of achieving pregnancy and a live birth are significantly higher.

Should we be offering fertility preservation by surgical sperm retrieval to men with Klinefelter syndrome?

Advances in surgical sperm retrieval have greatly increased the chances of men with Klinefelter syndrome achieving biological paternity. Despite this, the vast majority of attempts to achieve fertility by using extracted gametes to fertilize eggs in vitro do not result in viable pregnancies. A powerful obstacle to success lies with the natural history of seminiferous tubule and germ cell function in Klinefelter syndrome, which typically peak (and thereafter steeply decline) up to a decade before most individuals would be contemplating paternity. Herein we discuss, in relation to a real clinical case, both the exciting technical advances surgical sperm retrieval and the logistic and ethical factors that, in practice, may act to limit their successful application.

Diagnosis and treatment of infertility-related male hormonal dysfunction.

Treatment of infertility-related hormonal dysfunction in men requires an understanding of the hormonal basis of spermatogenesis. The best method for accurately determining male androgenization status remains elusive. Treatment of hormonal dysfunction can fall into two categories - empirical and targeted. Empirical therapy refers to experience-based treatment approaches in the absence of an identifiable aetiology. Targeted therapy refers to the correction of a specific underlying hormonal abnormality. However, the tools available for inferring the intratesticular hormonal environment are unreliable. Thus, understanding the limitations of serum hormonal assays is very important for determining male androgen status. Furthermore, bulk seminal parameters are notoriously variable and consequently unreliable for measuring responses to hormonal therapy. In the setting of azoospermia owing to spermatogenic dysfunction, hormonal therapy - relying on truly objective parameters including the return of sperm to the ejaculate or successful surgical sperm retrieval - is a promising treatment. This approach to the treatment of fertility-related hormonal dysfunction in men contrasts with the current state of its counterpart in female reproductive endocrinology. Treatment of male hormonal dysfunction has long emphasized empirical therapy, whereas treatment of the corollary female dysfunction has been directed at specific deficits.

Efecto de la cámara de recuento utilizada sobre los parámetros espermáticos, analizados con el ISASv1® / Effect of counting chamber on seminal parameters, analyzing with the ISASv1®

Introducción: El uso de las cámaras de recuento condiciona los valores de concentración y movilidad espermática debido a su tipo de carga (capilaridad o desplazamiento de la gota) y a la altura que presenten. Recientemente, se han introducido nuevas cámaras, tanto desechables (ISAS®D4C) como reusables (Spermtrack®) con diversas alturas en cada caso. Objetivo: El objetivo del presente trabajo es validar su uso, analizando diversos parámetros espermáticos con un sistema CASA, el ISASv1®. Material y método: Se analizaron muestras de donantes voluntarios (10 para las desechables y 5 para las reusables), analizando el efecto del tipo de cámara, de la altura, del tiempo de carga y del tiempo de análisis. Resultados: Los resultados obtenidos no mostraron diferencias significativas con el tiempo de carga para las cámaras reusables ni con el tiempo de análisis en ninguna de las cámaras. Discusión: La cámara reusable de 10 μm y las desechables de 10, 16 y 20 μm no mostraron diferencias entre sí, mientras que la reusable de 20 μm presentó resultados significativamente diferentes con respecto a las demás, por lo que su uso (siguiendo la recomendación de la Organización Mundial de la Salud) debe hacerse teniendo en cuenta este hecho. Conclusión: Las nuevas cámaras ofrecen un resultado muy homogéneo, con independencia del tiempo de carga o de análisis (AU)

Introduction: The use of counting chambers conditions the sperm concentration and motility values by their type of filling (capillary or drop displacement) and chamber height. We have recently introduced new chambers, both disposable (ISAS®D4C) and reusable (Spermtrack®), with different heights in each case. Objective: This study has aimed to validate its use by analyzing different sperm parameters with a CASA system, that is, the ISASv1®. Material and method: Samples from volunteer donors (10 for the disposable and 5 for reusable), analyzing the effect of chamber type, height, filling and analysis time, were used. Results: The results obtained showed no differences within the filling time for the reusable chambers, or the analysis time in any cases. Discussion: The 10 microns reusable chamber and disposable, 10, 16 and 20 microns showed no differences between them. However, the reusable 20 microns showed significantly different results, so its use (as recommended by WHO) should be taking this into account. Conclusion: The new chambers offer very consistent results, independent of filling or time of analysis (AU)

The natural history of endocrine function and spermatogenesis in Klinefelter syndrome: what the data show.

Once thought to be a chromosomal aberration associated with absolute sterility, Klinefelter syndrome may now be potentially treatable by testicular sperm retrieval coupled with intracytoplasmic sperm injection. With these therapeutic advances, azoospermic 47,XXY men now may have an opportunity for biological paternity. However, our knowledge of the basic mechanisms underlying germ cell loss and Leydig cell compromise is lagging, and is just now beginning to evolve and provide answers to some of the field's most vexing questions: how to maximize and preserve fertility in Klinefelter males many years or even decades before they wish to actively pursue fatherhood. This article reviews the development of the androgenic and spermatogenic compartments of the Klinefelter testis through puberty, and recommends that it is only with a clear understanding of the basic facts that a rational, considered approach to fertility optimization and preservation can be determined.

Klinefelter syndrome: how, what, and why?

Klinefelter syndrome is commonly encountered by the physician dealing with male infertility. Despite the success of sperm retrieval and ICSI, there remain many areas of controversy about the mechanisms and natural history of spermatogenesis, as well as the appropriate management of these patients. This collection of articles provides a state of the art review of what is known and what is unknown about this syndrome and reports a variety of management approaches to these patients.

Klinefelter syndrome: an argument for early aggressive hormonal and fertility management.

OBJECTIVE: To investigate the impact of early hormone replacement therapy (HT) on sperm retrieval rates in patients with Klinefelter syndrome (KS). DESIGN: A systematic review of the relevant literature using the PubMed NLM database. RESULT(S): There are no randomized controlled trials evaluating the impact of HT on sperm retrieval or reproductive outcomes in men with KS. On average, surgical sperm retrieval rates in men with KS are around 51%, with a range of 28%-69%. Young patient age is the most consistent positive predictor of sperm retrieval. Lower retrieval rates have been reported in a small subset of KS adults who previously received exogenous T, although the nature, duration, and reason for such therapy in these patient subsets are unknown. CONCLUSION(S): Early HT is recommended in patients with KS, but its effect on fertility potential has not been definitively studied. Larger studies are needed to better answer this question. Cryopreservation of sperm-containing semen or testicular tissue from a significant proportion of affected adolescents is possible, even when containing very low numbers of spermatozoa, and should be considered to maximize future fertility potential.

Aplicación de las especificaciones de calidad analíticas al cálculo de los límites admisibles de error en Programas de Evaluación Externa de la Calidad para concentración espermática / Application of the analytical quality specifications to the calculation of the allowable limits of error in Programs of External Quality Assessment for sperm concentration

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[Treatment of azoospermia: surgical sperm retrieval (MESA, TESE, micro-TESE)]. / Therapie der Azoospermie : Operative Spermiengewinnung (MESA, TESE, Mikro-TESE).

The introduction of intracytoplasmic sperm injection (ICSI) into the spectrum of assisted reproductive technologies has offered men who suffer from severe disorders of spermatogenesis and azoospermia the possibility of fathering a child. Different surgical techniques can be used to extract spermatozoa from these men from either the epididymis and/or the testis. Surgical sperm retrieval offers a treatment for patients with testicular and/or obstructive azoospermia in cases where microsurgical refertilization is not an option or has already failed. Among surgical techniques that have been explored over the years, microsurgical epididymal sperm aspiration (MESA) and testicular sperm extraction (TESE) have become the most popular. Percutaneous techniques (such as TEFNA) are available but have disadvantages versus open surgical procedures. Together with cryopreservation of extracted spermatozoa, these techniques facilitate retrieval of spermatozoa for several ICSI attempts by a single surgical intervention.

[Preservation of fertility in tumour patients]. / Erhaltung der Fertilität bei Tumorerkrankungen.

The success rates of present-day chemotherapy have provoked a rising awareness with regard to the preservation of quality of life among successfully treated patients. Among other factors, quality of life also implies the capacity to procreate. Unfortunately, both in men and women chemotherapy often irreversibly destroys the production of gametes, thereby causing permanent infertility. By its long-standing experience with the cryopreservation of oocytes, zygotes and embryos, reproductive medicine may offer assistance to those patients. Whereas the storage of cryopreserved semen has now become standard in most institutions, the options for the preservation of fertility in women suffering of malignant disease are still limited. Although cryopreservation of non-fertilized oocytes or of pronuclear cells has been established, both the number of oocytes that can be collected within the short time interval between the first detection of the tumour and the initiation of chemotherapy and the modest developmental capacity per frozen/thawed oocyte markedly limit the option of ovarian hyperstimulation and assisted reproduction. Several successful deliveries of healthy infants have now proven the feasibility of ovarian tissue cryopreservation and later orthotopic transplantation after successful tumour therapy. Further refinement of the techniques involved, but also the formation of multidisciplinary networks are expected to offer a solution for young women struck by cancer but striving to survive and to lead a fulfilled life.

Recent advances in cooled-semen technology.

The majority of horse registries approve the use of artificial insemination, and horse breeding has widely taken benefit from the use of cooled-stored semen. New insights into cooled-semen technology open possibilities to reduce problems such as impaired semen quality after cooled-storage in individual stallions. The stallion itself has major impacts on quality and fertility of cooled-stored semen. Dietary supplementation of antioxidants and polyunsaturated fatty acids improves semen quality in a variety of species, but only few studies on this topic exist in the horse. Proper semen collection and handling is the main key to the maintenance of semen quality during cooled-storage. Semen collection should be achieved by minimal sexual stimulation with a single mount; this results in high sperm concentration, low content of seminal plasma and minimal contamination with bacteria. Milk-based semen extenders are most popular for semen processing and storage. The development of more defined extenders containing only the beneficial milk ingredients has made extender quality more constant and reliable. Semen is often centrifuged to decrease the seminal plasma content. Centrifugation results in a recovery rate of only 75% of spermatozoa in the semen pellet. Recovery rates after centrifugation may be improved with use of a "cushion technique" allowing higher centrifugation force and duration. However, this is not routinely used in cooled-semen technology. After slow-cooling, semen-storage and shipping is best performed at 5 degrees C, maintaining semen motility, membrane integrity and DNA integrity for up to 40 h after collection. Shipping containers created from Styrofoam boxes provide maintenance of semen quality at low cost.