Testicular sperm extraction prediction for patients with nonobstructive azoospermia by Raman spectroscopy.

The value of repeat testicular sperm retrieval in azoospermic men

To assess seminal plasma anti-Müllerian hormone (AMH) level relationships in fertile and infertile males. Eighty-four male cases were studied and divided into four groups: fertile normozoospermia (n = 16), oligoasthenoteratozoospermia (n = 15), obstructive azoospermia (OA) (n = 13) and non-obstructive azoospermia (NOA) (n = 40). Conventional semen analysis was done for all cases. Testicular biopsy was done with histopathology and fresh tissue examination for testicular sperm extraction (TESE) in NOA cases. NOA group was subdivided according to TESE results into unsuccessful TESE (n = 19) and successful TESE (n = 21). Seminal plasma AMH was estimated by enzyme linked immunosorbent assay (ELISA) and serum follicular stimulating hormone (FSH) was estimated in NOA cases only by radioimmunoassay (RIA). Mean seminal AMH was significantly higher in fertile group than in oligoasthenoteratozoospermia with significance (41.5 +/- 10.9 pmol/L vs. 30.5 +/- 10.3 pmol/L, P < 0.05). Seminal AMH was not detected in any OA patients. Seminal AMH was correlated positively with testicular volume (r = 0.329, P = 0.005), sperm count (r = 0.483, P = 0.007), sperm motility percent (r = 0.419, P = 0.021) and negatively with sperm abnormal forms percent (r = -0.413, P = 0.023). Nonsignificant correlation was evident with age (r = -0.155, P = 0.414) and plasma FSH (r = -0.014, P = 0.943). In NOA cases, seminal AMH was detectable in 23/40 cases, 14 of them were successful TESE (57.5%) and was undetectable in 17/40 cases, 10 of them were unsuccessful TESE (58.2%). Seminal plasma AMH is an absolute testicular marker being absent in all OA cases. However, seminal AMH has a poor predictability for successful testicular sperm retrieval in NOA cases.

A Nomogram Predicting Testicular Sperm Extraction Success in Men With Non-obstructive Azoospermia: A Multi-center Study

The Prognostic Value of Y Chromosome Microdeletions Involving the AZFb Region in Testicular Sperm Extraction

Testicular spermatozoa can be retrieved successfully by the testicular sperm extraction (TESE) procedure and used for intracytoplasmic sperm injection. Disruption in the blood-testis barrier can lead to the production of antisperm antibodies (ASA). The aim of this prospective study was to investigate the frequency of ASA formation in couples after TESE procedure. Thirty-seven couples were included in the study at the Urology Clinic of the Dr. Zekai Tahir Burak Women's Health Training and Research Hospital. History, physical examination, spermiogram, and endocrine profiles were obtained for all male patients. All the male patients in this study had been diagnosed with nonobstructive azoospermia (NOA) and underwent microdissection TESE. Secondary and tertiary cases were also included in the study. Serum samples were obtained from all 74 patients before TESE, and at three and 12 months after TESE. Serum ASA levels were determined. ANOVA was performed for statistical analysis for serum Follicle-Stimulating Hormone (FSH), testosterone and testicular volume. P < 0.05 was considered significant. There were no differences in the testicular volumes, serum FSH and testosterone levels before and after TESE. None of the patients or their partners developed significant levels of ASA as a result of the TESE procedure. TESE procedure does not cause ASA production in either males or their female partners.

Study question Can WES-based analysis identify genetic causes of NOA and predict sperm recovery rates after testicular sperm extraction (TESE)? Summary answer Mutational status in candidate genes correlates with sperm retrieval success, supporting the diagnostic and prognostic value of genetic testing in NOA to improve clinical management. What is known already Nearly 75% of infertile men experience varying degrees of oligozoospermia, ranging from mildly reduced sperm concentrations to complete absence of sperm (azoospermia). For men with non-obstructive azoospermia (NOA), testicular sperm extraction (TESE) offers the best chance of retrieving sperm for IVF, though success remains largely unpredictable. Recently, genes involved in gametogenesis have been identified as crucial for male reproductive competence, providing both a genetic basis of infertility and a means to predict isolated spermatogenesis in the testes. Whole-exome sequencing (WES) enables broad mutational analysis, offering a more targeted approach to identifying genetic factors influencing male fertility. Study design, size, duration This is an observational retrospective study based on individuals with idiopathic NOA. It included 60 patients who had previously undergone TESE procedures at collaborating IVF centres in Scandinavia from February 2014 to November 2024. Relevant clinical information about the enrolled subjects was blindly compiled from the clinics. After the genetic analysis, it was revealed that the distribution was 2:3 ratio between the presence and absence of sperm respectively from testicular tissue after TESE. Participants/materials, setting, methods Blood samples collected were sequenced using a clinically validated WES methodology on Novaseq6000 platform (Illumina). Raw data were subsequently analysed using custom bioinformatics pipelines. Mutational analysis was solely focused on a curated panel of 240 genes, whose germline mutations have been confidently linked to monogenic NOA phenotype. Gene variants were annotated according to population frequency &amp;lt;5% and protein-altering effect predicted by CADD, AlphaMissense, and/or REVEL. The association between genotype and sperm retrieval was statistically evaluated. Main results and the role of chance In total, 30 patients (50.0%, 95CI%=37.7-62.3%) were identified as carriers of putatively pathogenic variants. According to the expected Mendelian inheritance pattern, the genes involved were 70.0% autosomal dominant, 20.0% autosomal recessive and 10.0% X-linked. Specifically, these mutations were found in 59% (N = 20) of patients with unsuccessful TESE procedures compared to 44% (N = 10) of patients with successful TESE procedures (Fisher test: OR = 1.82, 95%CI=0.56-6.21, p-value=0.29), showing a trend towards sperm absence in carriers. An association test based on the burden of rare damaging variants in each gene revealed candidate genes that were significantly associated with a positive (HFM1, ZMYND15) and negative (SOX30) TESE outcome. Notably, HFM1 and ZMYND15 are implicated in cell replication and gene expression and are associated with male infertility in humans, ranging from NOA to phenotypes of oligozoospermia, macrozoospermia, teratozoospermia. Conversely, SOX30 is predicted to be involved in the differentiation of male germ cells with post-meiotic arrest, as described in animal models. Finally, principal component analysis (PCA) was performed to explain the effect of mutational status on patient grouping for sperm retrieval. Based on individuals carrying at least one genetic variant, the successful outcome differed significantly from unsuccessful outcome (Wilcoxon test: p-value=0.006). Limitations, reasons for caution This study is affected by the lack of ethnic diversity in our cohort (mainly Scandinavians/Caucasians). At present, the sample size and the use of an in-silico panel may underestimate the carrier rate. However, WES technology offers the possibility to extend the analysis to more individuals and genetic factors later. Wider implications of the findings This study contributes to ongoing research by providing a genetic basis for idiopathic NOA and predicting sperm recovery success prior to surgical intervention, enhancing clinical decision-making and patient counselling. Additionally, these results provide further insight into the impact of impaired genes on testicular morphology and function. Trial registration number No

Can an externally validated model, based on biological variables, be developed to predict successful sperm retrieval with testicular sperm extraction (TESE) in men with non-obstructive azoospermia (NOA) using a large nationwide cohort? Our prediction model including six variables was able to make a good distinction between men with a good chance and men with a poor chance of obtaining spermatozoa with TESE. Using ICSI in combination with TESE even men suffering from NOA are able to father their own biological child. Only in approximately half of the patients with NOA can testicular sperm be retrieved successfully. The few models that have been developed to predict the chance of obtaining spermatozoa with TESE were based on small datasets and none of them have been validated externally. We performed a retrospective nationwide cohort study. Data from 1371 TESE procedures were collected between June 2007 and June 2015 in the two fertility centres. All men with NOA undergoing their first TESE procedure as part of a fertility treatment were included. The primary end-point was the presence of one or more spermatozoa (regardless of their motility) in the testicular biopsies.We constructed a model for the prediction of successful sperm retrieval, using univariable and multivariable binary logistic regression analysis and the dataset from one centre. This model was then validated using the dataset from the other centre. The area under the receiver-operating characteristic curve (AUC) was calculated and model calibration was assessed. There were 599 (43.7%) successful sperm retrievals after a first TESE procedure. The prediction model, built after multivariable logistic regression analysis, demonstrated that higher male age, higher levels of serum testosterone and lower levels of FSH and LH were predictive for successful sperm retrieval. Diagnosis of idiopathic NOA and the presence of an azoospermia factor c gene deletion were predictive for unsuccessful sperm retrieval. The AUC was 0.69 (95% confidence interval (CI): 0.66-0.72). The difference between the mean observed chance and the mean predicted chance was <2.0% in all groups, indicating good calibration. In validation, the model had moderate discriminative capacity (AUC 0.65, 95% CI: 0.62-0.72) and moderate calibration: the predicted probability never differed by more than 9.2% of the mean observed probability. The percentage of men with Klinefelter syndrome among men diagnosed with NOA is expected to be higher than in our study population, which is a potential selection bias. The ability of the sperm retrieved to fertilize an oocyte and produce a live birth was not tested. This model can help in clinical decision-making in men with NOA by reliably predicting the chance of obtaining spermatozoa with TESE. This study was partly supported by an unconditional grant from Merck Serono (to D.D.M.B. and K.F.) and by the Department of Obstetrics and Gynaecology of Radboud University Medical Center, Nijmegen, The Netherlands, the Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, Den Bosch, The Netherlands, and the Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands. Merck Serono had no influence in concept, design nor elaboration of this study. Not applicable.

The study aims to evaluate the correlation of testicular sperm extraction (TESE) and histopathology with various features of non-obstructive azoospermia (NOA) cases who consulted to our university-based infertility clinic, and the probability of prompting couples about TESE success and to investigate the cost reduction chance through cost-beneficial aspects. One hundred and twenty-five patients were enrolled in this study. Age, unprotected intercourse period, age of puberty, and concomittant diseases were noted. Testicular volumes were measured. The correlations between genetic test results and serum levels of Follicle-Stimulating Hormone (FSH), Luteinizing Hormone (LH), free testosterone, prolactine were investigated. The incidence of NOA among infertile men was found to be 15.1%. Median age of the cases was 33.1 years. Decrease in TESE success rate was seen in the group aged >30, and those who practiced unprotected intercourse for more than 10 years. TESE success rate was 40 percent. The required negative correlation between FSH levels, and testicular volume was not observed when the patient had additional diseases and/or genitourinary surgery. FSH and LH levels were significantly different between TESE- positive and negative groups (p=0.006, and p=0.001 respectively). Success rate in bilateral TESE group was 14.2%, and 96% of TESE- negative patients had bilateral TESE. Fifteen of 118 patients had Y chromosome microdeletions. These results were similar in both TESE- positive and negative group. None of the parameters investigated herein predicted succesful TESE outcomes. However, in cases with increased FSH and AZFa/AZFb deletion before application of bilateral TESE, in cases of increased FSH and AZFa/AZFb deletion, detailed information should be given to these patients about low success rates and risk of disease inheritance which may reduce procedural costs. Knowing groups with poor prognosis, may help rearrangement of the appropriation of infertility in health policies.

PREDICTION OF SUCCESSFUL OUTCOME OF MICRODISSECTION TESTICULAR SPERM EXTRACTION IN MEN WITH IDIOPATHIC NONOBSTRUCTIVE AZOOSPERMIA

(336) Sperm Retrieval Success During Tese: Prognostic Factors in Non-obstructive Azoospermia Patients

Can a machine-learning-based model trained in clinical and biological variables support the prediction of the presence or absence of sperm in testicular biopsy in non-obstructive azoospermia (NOA) patients? Our machine-learning model was able to accurately predict (AUC of 0.8) the presence or absence of spermatozoa in patients with NOA. Patients with NOA can conceive with their own biological gametes using ICSI in combination with successful testicular sperm extraction (TESE). Testicular sperm retrieval is successful in up to 50% of men with NOA. However, to the best of our knowledge, there is no existing model that can accurately predict the success of sperm retrieval in TESE. Moreover, machine-learning has never been used for this purpose. A retrospective cohort study of 119 patients who underwent TESE in a single IVF unit between 1995 and 2017 was conducted. All patients with NOA who underwent TESE during their fertility treatments were included. The development of gradient-boosted trees (GBTs) aimed to predict the presence or absence of spermatozoa in patients with NOA. The accuracy of these GBTs was then compared to a similar multivariate logistic regression model (MvLRM). We employed univariate and multivariate binary logistic regression models to predict the probability of successful TESE using a dataset from a retrospective cohort. In addition, we examined various ensemble machine-learning models (GBT and random forest) and evaluated their predictive performance using the leave-one-out cross-validation procedure. A cutoff value for successful/unsuccessful TESE was calculated with receiver operating characteristic (ROC) curve analysis. ROC analysis resulted in an AUC of 0.807 ± 0.032 (95% CI 0.743-0.871) for the proposed GBTs and 0.75 ± 0.052 (95% CI 0.65-0.85) for the MvLRM for the prediction of presence or absence of spermatozoa in patients with NOA. The GBT approach and the MvLRM yielded a sensitivity of 91% vs. 97%, respectively, but the GBT approach has a specificity of 51% compared with 25% for the MvLRM. A total of 78 (65.3%) men with NOA experienced successful TESE. FSH, LH, testosterone, semen volume, age, BMI, ethnicity and testicular size on clinical evaluation were included in these models. This study is a retrospective cohort study, with all the associated inherent biases of such studies. This model was used only for TESE, since micro-TESE is not performed at our center. Machine-learning models may lay the foundation for a decision support system for clinicians together with their NOA patients concerning TESE. The findings of this study should be confirmed with further larger and prospective studies. The study was funded by the Division of Obstetrics and Gynecology, Soroka University Medical Center, there are no potential conflicts of interest for all authors.

STUDY QUESTION Can a machine-learning-based model trained in clinical and biological variables support the prediction of the presence or absence of sperm in testicular biopsy in non-obstructive azoospermia (NOA) patients? SUMMARY ANSWER Our machine-learning model was able to accurately predict (AUC of 0.8) the presence or absence of spermatozoa in patients with NOA. WHAT IS KNOWN ALREADY Patients with NOA can conceive with their own biological gametes using ICSI in combination with successful testicular sperm extraction (TESE). Testicular sperm retrieval is successful in up to 50% of men with NOA. However, to the best of our knowledge, there is no existing model that can accurately predict the success of sperm retrieval in TESE. Moreover, machine-learning has never been used for this purpose. STUDY DESIGN, SIZE, DURATION A retrospective cohort study of 119 patients who underwent TESE in a single IVF unit between 1995 and 2017 was conducted. All patients with NOA who underwent TESE during their fertility treatments were included. The development of gradient-boosted trees (GBTs) aimed to predict the presence or absence of spermatozoa in patients with NOA. The accuracy of these GBTs was then compared to a similar multivariate logistic regression model (MvLRM). PARTICIPANTS/MATERIALS, SETTING, METHODS We employed univariate and multivariate binary logistic regression models to predict the probability of successful TESE using a dataset from a retrospective cohort. In addition, we examined various ensemble machine-learning models (GBT and random forest) and evaluated their predictive performance using the leave-one-out cross-validation procedure. A cutoff value for successful/unsuccessful TESE was calculated with receiver operating characteristic (ROC) curve analysis. MAIN RESULTS AND THE ROLE OF CHANCE ROC analysis resulted in an AUC of 0.807 ± 0.032 (95% CI 0.743-0.871) for the proposed GBTs and 0.75 ± 0.052 (95% CI 0.65-0.85) for the MvLRM for the prediction of presence or absence of spermatozoa in patients with NOA. The GBT approach and the MvLRM yielded a sensitivity of 91% vs. 97%, respectively, but the GBT approach has a specificity of 51% compared with 25% for the MvLRM. A total of 78 (65.3%) men with NOA experienced successful TESE. FSH, LH, testosterone, semen volume, age, BMI, ethnicity and testicular size on clinical evaluation were included in these models. LIMITATIONS, REASONS FOR CAUTION This study is a retrospective cohort study, with all the associated inherent biases of such studies. This model was used only for TESE, since micro-TESE is not performed at our center. WIDER IMPLICATIONS OF THE FINDINGS Machine-learning models may lay the foundation for a decision support system for clinicians together with their NOA patients concerning TESE. The findings of this study should be confirmed with further larger and prospective studies. STUDY FUNDING/COMPETING INTEREST(S) The study was funded by the Division of Obstetrics and Gynecology, Soroka University Medical Center, there are no potential conflicts of interest for all authors.

Study question Does testicular histology predict successful or unsuccessful TEsticular Sperm Extraction (TESE) in Non-Obstructive Azoospermia (NOA) patients? Summary answer Testicular histology failed to predict successful TESE in 1 of 3 NOA patients. What is known already The management of patients with Non-Obstructive Azoospermia (NOA) involves TEsticular Sperm Extraction (TESE) combined with IntraCytoplasmic Sperm Injection (ICSI). Sperm retrieval is successful in up to 50% of men with NOA; however, there is no single clinical finding or investigation that can accurately predict a positive outcome. Previous studies have concluded that testicular histology is the best predictor of a successful or unsuccessful TESE. Study design, size, duration This is a retrospective study of 525 patients who underwent TESE between January 2018 and December 2020 in Humanitas Fertility Center. Participants/materials, setting, methods The cohort was dived in five groups: 287 NOA, 95 necrozoospermia, 18 anejaculation, 1 testicular trauma and 124 Obstructive Azoospermia (OA) patients. Main results and the role of chance Sperm was retrieved and cryopreserved in 218/287 patients with NOA (75,95%), 55/95 in necrozoospermia (57,89%), 18/18 anejaculation (100%), 1/1 testicular trauma (100%) and 120/124 in OA patients (96,77%). Interesting that, when we compare sperm recovery data through TESE with the histological assessment (HA) of corresponding testicular biopsy, we found discordance against HA. In particular we retrieved spermatozoa in 218 NOA patients but in 74 of them HA failed to detect them (33,94%). Moreover HA failed to detect spermatozoa in 8/55 (14,54%) in case of necrozoospermia, 1/18 (5,55%) in anejaculation and 10/120 (8,33%) in OA patients. Limitations, reasons for caution Testis's heterogeneity is a limitation of the study. Wider implications of the findings We found a discordance when HA is compared with sperm recovery data of corresponding testicular biopsy. This data suggest that in case of testicular diagnostics histology in 33,94% of NOA cases there is a wrong diagnosis and 1 of 3 patients it doesn’t retrieve and cryopreserve spermatozoa when it could. Trial registration number N A

Microsurgical versus conventional single-biopsy testicular sperm extraction in nonobstructive azoospermia: a prospective controlled study

Testicular sperm extraction (TESE) with ICSI is becoming the first-line treatment for non-obstructive azoospermia (NOA). Recently, the sperm retrieval rate (SRR) by microdissection TESE was reported to be higher than by conventional TESE. However, a comprehensive comparison between multiple and microdissection TESE patients including histological findings has not been reported. Patients with NOA who underwent microdissection TESE (n = 56) or multiple TESE (n = 37) were compared. Pre-operative characteristics were similar between groups. In addition, microscopic findings during microdissection TESE also were investigated. Operative time was significantly longer for microdissection TESE than for multiple TESE. Histological examination suggested that spermatogenesis was relatively more impaired in the microdissection TESE group than in the multiple TESE group. Despite this, SRR by microdissection TESE (42.9%) appeared higher than by conventional TESE (35.1%) although this observation failed to reach statistical significance. Seventeen of 26 patients (65.4%) with heterogeneous tubule were successful for sperm retrieval. No severe operative complications occurred in any patient in either group, and no patient required post-operative hormone replacement to treat hypogonadism. Microsurgical technique is safe and may improve SRR for TESE in a variety of patients with NOA, especially patients with heterogeneous testicular tubules.