Characteristics of infertile men with intermittent non-obstructive complete asthenospermia

Abstract

Objective: Male factor patients with a history of low sperm counts often exhibit low or absent motility. This variability in semen quality presents a clinical challenge during ART cycles as “back up” plans and procedures are necessary at the time of egg retrieval to ensure that viable sperm are available for ICSI. We present the clinical features, natural history and a management strategy, including the use of FNA mapping, in a cohort of intermittent nonobstructive asthenospermic patients. Design: Case controlled, retrospective review of a consecutive patients at a single institution. Materials and Methods: Over 2 years, 15 men presented with infertility characterized by intermittent complete asthenospermia, defined as at least 1 documented semen analysis showing motile sperm and another without. All patients underwent formal evaluation with history, physical exam, semen with centrifuged pellet analysis, and hormones. In addition, patients were offered fine needle aspiration (FNA) mapping to localize testis sperm prior to IVF-ICSI. Semen quality at ICSI and the need for “back up” TESA/TESE procedures were assessed. Results: Prior paternity was documented in 3/15 (20%) patients. Medical diagnoses included varicocele (5/15, 33%), idiopathic (4/15, 27%), diabetes (2/15, 13%), DES exposure (2/15, 13%), partial hypogonadotropic hypogonadism (1/15), and balanced translocation (1/15). Mean testis volumes were 15.6 mL on right and 14mL on left. Mean testosterone and FSH levels were 305 (normal 260–1000) and 9.7 (normal 1–8), respectively. Range of semen volume was 2–4.5mL, total sperm count was 10 sperm to 3 million sperm, and motility ranged from 0–50%. On pre-ICSI, FNA mapping (n=15 patients), mature sperm were found in 14/15 (93%) patients; 1 patient had elongated spermatids. Roughly half of testis maps showed an “even” sperm distribution in the testis and the other half showed “pockets” of sperm. The mean interval from FNA mapping to ICSI was 4.7 months (range 1–23 months). At ICSI (n=13 patients), sufficient motile ejaculated sperm were obtained in 5/13 (39%) patients (motile sperm count range: 20–400,000) and “back up” procedures were needed in 8/13 (61%) patients due to lack of motile sperm. ICSI “back up” procedures included unilateral TESA (n=3), bilateral TESA (n=2), bilateral TESE (n=1) and unilateral Micro-TESE (n=2) at which time sufficient sperm were found in 6/8 patients. Conclusion: Successful management of male infertility due to severe oligoasthenospermia is a complex challenge for ICSI programs. Among these patients, systemic medical diagnoses are likely present, and “back up” plans and procedures are likely to be employed at ICSI.