Does Surgical Retrieval of Testicular Spermatozoa Enhance ICSI Outcomes for Patients With Virtual Azoospermia?

Abstract

To determine if there is an effect on ICSI outcome in men with virtual azoospermia whether spermatozoa are surgically retrieved or ejaculated spermatozoa. Case controlled analysis A chart review was performed on ICSI cycles from 1995 to 2004 in which male partners had virtual azoospermia on ejaculated samples, defined as no spermatozoa on initial semen analysis and ≥ 100 spermatozoa after centrifugation for sperm selection. Only couples that underwent at least one ICSI cycle with fresh ejaculate and one ICSI cycle with TESE (testicular sperm extraction) were used. The indication of the TESE cycles was obviously non-obstructive azoospermia. Nine couples fit the inclusion criteria. Of the 36 cycles reviewed, only 34 were analyzed because in one cycle mixed insemination of spermatozoa occurred and the other was cancelled secondary to poor response. In total, there were 21 cycles with fresh ejaculate and 13 cycles with TESE. At first, a comparison was carried out between the pooled cycles with ejaculated spermatozoa versus the entirety of attempts with TESE. Analysis was also carried out after ranking the cycles according to the initial sperm concentrations grouped as ≥ 100, ≥ 10, ≥ 5, and ≥ 1. To limit confounding factors such as a progressive testicular failure, a sub-analysis was carried out for each patient by considering only the ejaculated cycle closest in time to the first TESE cycle. For this sub-group, a comparison between the cycles where the two sperm sources were used was also carried out within the descending sperm concentration categories. The average age of the female partners was 31.2 ± 5 yrs (M ± SD) and 36.7 ± 5 yrs for the male partners. The average time period between the closest ejaculated cycle and the earliest TESE cycle was 8.9 months. The overall number of spermatozoa harvesting did not significantly differ between the ejaculated and TESE cycles. The percentage of normal fertilization was 60.8% in the ejaculate cycles and 62.0% in the TESE cycles. The percentage of abnormal fertilization was 3.9% in the ejaculated cycles and 5.5% in the TESE group. Most embryos were transferred on day 3, only in one patient was a blastocyst transfer performed. In addition, the mean number of embryos transferred did not vary between the two groups. Clinical pregnancies as defined by the identification of at least one fetal heart by ultrasound occurred in 28.6% (6/21) of ejaculated group and 46.2% (6/13) of TESE cycles. The delivery rate was 23.8% (5/21) in ejaculated cycles and 46.2% (5/13) in TESE cycles. No difference was observed in terms of normal or abnormal fertilization rates between the ejaculate and testicular spermatozoa. In spite of a more favorable trend in the TESE cycles, in terms of clinical pregnancy and delivery rates, no mathematical difference was observed. In patients with virtual azoospermia, surgical retrieval of spermatozoa did not significantly improve ICSI outcomes when compared to fresh ejaculated spermatozoa. This data shows that using ejaculated spermatozoa is still a viable option for those couples where spermatozoa can be identified in the ejaculate.