Editorial Comment

Abstract

The authors have presented provocative data on a series of 302 patients with cryptozoospermia who were managed with intracytoplasmic sperm injection (ICSI) using either sperm retrieval (testicular sperm aspiration [TESA] or testis dissection sperm extraction [TESE]) or from ejaculated sperm. 1 Cui X. Ding P. Gao G. Zhang Y. Comparison of the clinical outcomes of intracytoplasmic sperm injection between spermatozoa retrieved from testicular biopsy and from ejaculate in cryptozoospermia patients. Urology. 2016; https://doi.org/10.1016/j.urology.2016.08.071 Abstract Full Text Full Text PDF Scopus (16) Google Scholar The overall results are presented with a strong suggestion that men who used testicular sperm had far better results than couples where ejaculated sperm were used for ICSI. Unfortunately, this study has substantial bias in its presentation of data as it is an experiential, retrospective analysis of treatment of couples rather than an effective, direct comparison of use of testicular versus ejaculated sperm. One of the key features to consider is that an “intention-to-treat” analysis is not provided. For example, 302 patients with cryptozoospermia are included, but only 285 men are actually analyzed in the results. Patients with no sperm retrieved using TESA/TESE are excluded, but these couples underwent attempted treatment with testicular sperm. Second, the embryo implantation rate (52% for d3 embryo transfer) after ICSI with testicular sperm is at least twice as high as that reported in the best centers throughout the world. Finally, the only subset of men with cryptozoospermia who have been demonstrated to have “better” sperm within the testis are those men with severely defective sperm DNA fragmentation in the ejaculate. In these cases, testicular sperm extraction may allow retrieval of sperm with less DNA fragmentation and associated higher pregnancy rates. It is possible that the only men who benefited from sperm extraction were those men with abnormal ejaculated sperm. Unfortunately, this study did not involve detailed sperm analysis for defects that could predict a lower chance of ICSI success, including sperm DNA fragmentation.