Management Of Nonobstructive Azoospermia Research Articles

Role of Platelet-Rich Plasma in the Management of Non-obstructive Azoospermia

Role of Platelet-Rich Plasma in the Management of Non-obstructive Azoospermia

Global Practice Patterns and Variations in the Medical and Surgical Management of Non-Obstructive Azoospermia: Results of a World-Wide Survey, Guidelines and Expert Recommendations.

Non-obstructive azoospermia (NOA) is a common, but complex problem, with multiple therapeutic options and a lack of clear guidelines. Hence, there is considerable controversy and marked variation in the management of NOA. This survey evaluates contemporary global practices related to medical and surgical management for patients with NOA. A 56-question online survey covering various aspects of the evaluation and management of NOA was sent to specialists around the globe. This paper analyzes the results of the second half of the survey dealing with the management of NOA. Results have been compared to current guidelines, and expert recommendations have been provided using a Delphi process. Participants from 49 countries submitted 336 valid responses. Hormonal therapy for 3 to 6 months was suggested before surgical sperm retrieval (SSR) by 29.6% and 23.6% of participants for normogonadotropic hypogonadism and hypergonadotropic hypogonadism respectively. The SSR rate was reported as 50.0% by 26.0% to 50.0% of participants. Interestingly, 46.0% reported successful SSR in <10% of men with Klinefelter syndrome and 41.3% routinely recommended preimplantation genetic testing. Varicocele repair prior to SSR is recommended by 57.7%. Half of the respondents (57.4%) reported using ultrasound to identify the most vascularized areas in the testis for SSR. One-third proceed directly to microdissection testicular sperm extraction (mTESE) in every case of NOA while others use a staged approach. After a failed conventional TESE, 23.8% wait for 3 months, while 33.1% wait for 6 months before proceeding to mTESE. The cut-off of follicle-stimulating hormone for positive SSR was reported to be 12-19 IU/mL by 22.5% of participants and 20-40 IU/mL by 27.8%, while 31.8% reported no upper limit. This is the largest survey to date on the real-world medical and surgical management of NOA by reproductive experts. It demonstrates a diverse practice pattern and highlights the need for evidence-based international consensus guidelines.

Testicular sperm aspiration has a poor effect in predicting micro-TESE outcomes in NOA patients with AZFc deletion

BackgroundTesticular sperm aspiration (TESA) is widely used in the diagnosis and management of nonobstructive azoospermia. However, its ability for predicting microdissection testicular sperm extraction in nonobstructive azoospermia (NOA) patients with AZFc deletion remains uncertain. To investigate whether TESA affected the sperm retrieval rate (SRR) in NOA patients with AZFc deletion, a retrospective analysis of the clinical data of NOA patients with AZFc deletion who underwent microdissection testicular sperm extraction (micro-TESE) was conducted. The effects of age, testicular volume, follicle-stimulating hormone (FSH) levels, luteinizing hormone (LH) levels, testosterone (T) levels and TESA on the SRR were analyzed in this group of patients.ResultsA total of 181 individuals had their sperm successfully collected and underwent micro-TESE, with an SRR of 67.4%. The patients were separated into two groups based on their micro-TESE results (sperm acquisition and nonsperm acquisition), with no significant variations in age, testicular volume, FSH levels, LH levels, or T levels between the two groups. There was no significant difference in the SRR between any of the groups into which patients were classified based on reproductive hormone reference value ranges. Binary logistic regression was used to explore the absence of significant effects of age, testicular volume, FSH levels, LH levels, and T levels on sperm acquisition in patients undergoing micro-TESE. In the preoperative testicular diagnostic biopsy group, the sperm acquisition and nonsperm acquisition groups had SRRs of 90.1% and 65.1%, respectively. More significantly, there was no significant difference in the SRR between the negative preoperative testicular diagnostic biopsy group and the nonpreoperative testicular diagnostic biopsy group (65.1 vs. 63.8%, p = 0.855).ConclusionThere is a high probability of successful sperm acquisition in the testis of men undergoing micro-TESE. In this group of patients, age, testicular volume, FSH levels, LH levels, and T levels may have little bearing on the micro-TESE outcome. In patients whose preoperative TESA revealed the absence of sperm, the probability of obtaining sperm by micro-TESE remained high (65.1%); negative TESA results appeared to not influence the SRR (63.8%) in patients undergoing micro-TESE.

68 - Management of non-obstructive azoospermia with extracorporeal shock wave therapy and platelet-rich plasma

68 - Management of non-obstructive azoospermia with extracorporeal shock wave therapy and platelet-rich plasma

Update on the Management of Non-Obstructive Azoospermia: Current Evidence and Unmet Needs

Azoospermia, defined as the absence of sperm in the ejaculate after examination of the centrifuged specimens, affects about 1% of the male population and 10-15% of infertile men [...].

Success rate and ART outcome of microsurgical sperm extraction in non obstructive azoospermia: A retrospective study.

BackgroundThe management of non-obstructive azoospermia (NOA) disease relies on microdissection testicular sperm extraction (micro-TESE). Few studies have assessed the role of micro-TESE in men with NOA in our country.Objective The aim of the current study was to investigate the success rate of micro-TESE.Materials and MethodsThis retrospective descriptive-analytical study was conducted on 463 men with NOA in Yazd Reproductive Sciences Institute during September 2017 through September 2019. Sperm were retrieved and frozen according to the rapid sperm freezing protocol. After preparing the oocyte of the male partner's spouse, sperms were thawed and then entered the intracytoplasmic sperm injection process. The clinical pregnancy of individuals was confirmed via ultrasound. Demographic data were extracted from medical records.ResultsThe success rate of micro-TESE was 38% and successful fertilization, biochemical pregnancy, clinical pregnancy, and live birth were observed in 111 (85.4%), 29 (22.3%), 29 (22.3%) and 14 (10.7%) men, respectively. A significant difference was seen between the two groups, regarding age (p = 0.01). In addition, the mean follicle-stimulating hormone in men with positive micro-TESE was significantly lower than in men with negative micro-TESE (p = 0.02).Conclusion The success of pregnancy in couples with NOA managed via micro-TESE was significant. The study found that the success rate of micro-TESE was higher in older men and in those with lower follicle-stimulating hormone levels.

MP21-12 THE IMPACT OF MALE INFERTILITY FACULTY ON UROLOGY RESIDENCY TRAINING: WHAT ARE THE EFFECTS ON FERTILITY KNOWLEDGE, IN-SERVICE EXAM SCORES, AND SURGICAL CONFIDENCE?

You have accessJournal of UrologyInfertility: Epidemiology & Evaluation I (MP21)1 Sep 2021MP21-12 THE IMPACT OF MALE INFERTILITY FACULTY ON UROLOGY RESIDENCY TRAINING: WHAT ARE THE EFFECTS ON FERTILITY KNOWLEDGE, IN-SERVICE EXAM SCORES, AND SURGICAL CONFIDENCE? Kian Asanad, David Nusbaum, John Rodman, Gerhard Fuchs, and Mary Samplaski Kian AsanadKian Asanad More articles by this author , David NusbaumDavid Nusbaum More articles by this author , John RodmanJohn Rodman More articles by this author , Gerhard FuchsGerhard Fuchs More articles by this author , and Mary SamplaskiMary Samplaski More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002006.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Given the lack of consistent male infertility faculty exposure in urology residency programs, we sought to understand the impact of having a dedicated reproductive urologist (RU) faculty on resident male infertility training. We surveyed urology residents to determine the effects on self-competence in male infertility knowledge, procedures, and In-Service Exam scores. METHODS: A 42-question anonymous survey was emailed to American urology residencies assessing exposure to RU faculty in the clinic and operating room, fertility knowledge in management of non-obstructive azoospermia (NOA), and self-competence in performing infertility procedures. Fisher’s Exact test was performed to examine the association between formal microsurgical training and self-reported male infertility knowledge and procedural competence. Multivariable linear regression analysis was used to identify significant predictors of higher In-Service Exam Infertility/Sexual Medicine subscores. RESULTS: Infertility comprises ≤10% of training in 75% of respondents. Residents exposed to RU faculty are more likely to self-rate their infertility understanding as “excellent” or “good” (p=0.04 and p=0.02, respectively) and 14.4-times more likely to feel confident performing infertility procedures, versus residents lacking faculty (p<0.001). Residents with formal microsurgical training have better self-rated global infertility understanding (p<0.001), NOA management (p=0.01), and competency performing infertility procedures (p<0.00). Those that rate their knowledge of NOA management as ‘excellent’ scored, on average, 65.8 points higher on the 2019 In-Service Exam Infertility/Sexual Medicine section than those that rate their knowledge as ‘awful’ (p-value=0.007 and <0.001, respectively). CONCLUSIONS: Infertility comprises a minority of urology residency training. Most residents (80.8%) plan to perform infertility procedures in practice, despite two-thirds lacking confidence performing these. Having an RU faculty and formal microsurgical training significantly improves residents’ surgical confidence, NOA management, and global understanding of male infertility. Better knowledge in management of NOA correlates with higher In-Service Exam Infertility/Sexual Medicine subscores. A structured educational curriculum may improve resident male infertility training. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e350-e351 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kian Asanad More articles by this author David Nusbaum More articles by this author John Rodman More articles by this author Gerhard Fuchs More articles by this author Mary Samplaski More articles by this author Expand All Advertisement Loading ...

Sperm Selection Procedures for Optimizing the Outcome of ICSI in Patients with NOA.

Retrieving spermatozoa from the testicles has been a great hope for patients with non-obstructive azoospermia (NOA), but relevant methods have not yet been developed to the level necessary to provide resolutions for all cases of NOA. Although performing testicular sperm extraction under microscopic magnification has increased sperm retrieval rates, in vitro selection and processing of quality sperm plays an essential role in the success of in vitro fertilization. Moreover, sperm cryopreservation is widely used in assisted reproductive technologies, whether for therapeutic purposes or for future fertility preservation. In recent years, there have been new developments using advanced technologies to freeze and preserve even very small numbers of sperm for which conventional techniques are inadequate. The present review provides an up-to-date summary of current strategies for maximizing sperm recovery from surgically obtained testicular samples and, as an extension, optimization of in vitro sperm processing techniques in the management of NOA.

Role of microsurgical varicocelectomy in the management of non-obstructive azoospermia with varicocele: our tertiary care centre experience

BackgroundVaricocele is an abnormal dilation and tortuosity of the internal spermatic veins within the pampiniform plexus of the spermatic cord. Varicocele is associated with progressive testicular damage and infertility. Azoospermia is associated with a varicocele in approximately 4–14% cases. For men with azoospermia or severe oligoasthenospermia, varicocele repair may result in modest improvement in semen quality which may have a significant advantage on couple’s fertility options. The aim of the study was to evaluate the role of microsurgical varicocelectomy in the men of non-obstructive azoospermia (NOA) with clinical varicocele.MethodsThis was a retrospective study conducted between August 2012 and January 2017, a backward review of 104 patients with the diagnosis of infertility and NOA with palpable varicocele that underwent microsurgical varicocelectomy at our institution was performed. In addition, microdissection testicular sperm extraction (MDTESE) results of these post-varicoceletomy patients were compared with the patients of NOA without varicocele.ResultsA total of 104 patients underwent varicocelectomy; out of these, 19 patients (18.26%) had sperm on sperm analysis post-operatively. Two of them had spontaneous pregnancy (10.5%), and 3 had children by intracytoplasmic sperm injection (15.78%). Out of the 85 patients who had MDTESE, 29 patients (34.11%) had sperms in their testis. The fertilization rate was 89.65%. Sperm retrieval rate (SRR) in NOA men with varicocele was 34.11% which was higher from those who had NOA without varicocele (24.03%). Live birth rate was 31.03% in NOA men who had varicocelectomy which was more in comparison to NOA men without varicocele (24%).ConclusionsIn NOA men with varicocele microsurgical varicocelectomy may have favourable effects which results in recovery of motile sperms in the post-operative ejaculate and also on spontaneous or assisted pregnancies, but it appears that this effect was more remarkable on MDTESE results when following successful intracytoplasmic sperm injection. Importantly, Sperm retrieval rate, pregnancy rate and subsequent live birth rate were higher in these patients in comparison to patients affected by NOA alone. In patients with NOA and coexisting varicocele, varicocelectomy can be considered to be essential to the overall reproductive outcome in these patients.

Management of nonobstructive azoospermia: a committee opinion

The management of nonobstructive azoospermia in the context of fertility treatment is discussed. This document replaces the ASRM document titled "Evaluation of azoospermia," last published in2008.

New insights into the morphological and hormonal characteristics of spermatogenic arrest

The reported sperm retrieval rate (SRR) in patients with nonobstructive azoospermia (NOA) due to spermatogenic arrest (SA) is highly variable in the literature. This discrepancy could be explained by the heterogeneity of testicular tissues. Surprisingly, even though inhibin B levels reflect directly Sertoli cell function; no studies have evaluated this parameter in SA. We aimed to clarify the morphological and biological profile in 158 men with SA. From the total population, patients whose seminiferous tubules diameter was below 165µm have higher SRR (46.9% vs. 27.4%, p<0.05), lower inhibin levels and a higher frequency of nonuniform SA (71.9% vs. 38.7%, p<0.001). On multivariate analysis, patients with late SA and a history of cryptorchidism were positively associated with successful sperm extraction. Patients with successful SRR and uniform SA exhibited inhibin levels twofold lower than those with failed TESE (45pg/ml vs. 95pg/ml, p<0.05), whereas FSH levels were similar in the two groups. In this study, we showed for the first time that the mean diameter of the seminiferous tubules may be of value in the diagnosis of SA. Our results suggest that inhibin levels could be useful in the management of NOA with SA, along with FSH levels and testicular volume.

Proper diagnosis and management of nonobstructive azoospermia: NYU Case of the Month, June 2017.

Proper diagnosis and management of nonobstructive azoospermia: NYU Case of the Month, June 2017.

Innovations in surgical management of nonobstructive azoospermia

Testicular sperm extraction (TESE) technique and intra-cytoplasmic sperm injection are breakthrough fertility treatments for men with nonobstructive azoospermia (NOA). Newer advances such as the microdissection-TESE (micro-TESE) technique have continued to build upon past success by improving sperm retrieval and minimizing the postoperative complications compared to TESE. However, even with micro-TESE, sperm retrieval success has ranged from 40% to 60% due to the technique's dependence on surgeon and embryologist experience. While postoperative complications are minimal relative to the traditional TESE technique, testicular tissue must still be extracted without the knowledge of whether sperm are present in biopsies. In this review, we discuss the innovations in the surgical management of men with NOA and describe the novel experimental approaches that can improve sperm retrieval success.

WITHDRAWN: Surgical management of nonobstructive azoospermia

WITHDRAWN: Surgical management of nonobstructive azoospermia

Optical coherence tomography: a novel modality for scrotal imaging

BACKGROUND: For patients with nonobstructive azoospermia, sperm retrieval rates remain modest. We describe the use of optical coherence tomography to improve retrieval rates and to decrease tissue destruction. METHODS: Four patients underwent diagnostic testicular biopsy and imaging with the Niris optical coherence tomography device. We performed a descriptive comparison between optical coherence tomographic images and conventional histology. RESULTS: The measured seminiferous tubule diameter differed by 16 mum between comparative imaging from optical coherence tomography and conventional histology using hematoxylin and eosin staining. CONCLUSION: We illustrate the usefulness of optical coherence tomography in the setting of testicular biopsy and the management of nonobstructive azoospermia.

Alternate indications for varicocele repair: non-obstructive azoospermia, pain, androgen deficiency and progressive testicular dysfunction

Varicocele repair is indicated for infertile men with clinical varicoceles. Some men with scrotal pain, low testosterone, non-obstructive azoospermia, and who are at risk for testicular dysfunction may also benefit from varicocelectomy.

Early Versus Late Maturation Arrest: Reproductive Outcomes of Testicular Failure

There is a paucity of data characterizing infertile men with maturation arrest. We hypothesized that men with early stage maturation arrest could be clinically distinguished from men with late maturation arrest and would have worse reproductive outcomes. We retrospectively reviewed the records of all patients with nonobstructive azoospermia and cryptozoospermia who underwent testis mapping and sperm extraction from 2002 to 2009 and for whom histopathological findings were available. Patients had uniform maturation arrest if multiple biopsies revealed maturation arrest at the spermatogonia/spermatocyte (early maturation arrest) or the spermatid (late maturation arrest) stage. Clinical parameters and pregnancy outcomes of in vitro fertilization/intracytoplasmic sperm injection were examined. Statistical analysis consisted of univariate and multivariate analysis. Uniform maturation arrest was identified in 49 of 219 men (22.3%) undergoing testicular sperm extraction. On multivariate analysis men with maturation arrest had significantly larger testes (p=0.01), decreased follicle-stimulating hormone (p=0.05) and more detectable genetic abnormalities (p=0.01) than men with other histopathological conditions. Men with late maturation arrest had decreased follicle-stimulating hormone (p=0.02), increased testosterone (p=0.03) and a higher sperm retrieval rate at testicular sperm extraction (p=0.01) than men with early maturation arrest. Predictors of successful sperm retrieval were larger testes, cryptozoospermia, late maturation arrest and hypospermatogenesis (each p≤0.05). Pregnancy outcomes for men with maturation arrest were not significantly different from those for men with other histopathological conditions. Maturation arrest is a common, diverse histopathological subtype of severe male infertility. Compared to men with late maturation arrest those with early maturation arrest have increased follicle-stimulating hormone, decreased testosterone and a decreased probability of mature spermatozoa. In vitro fertilization/intracytoplasmic sperm injection outcomes were similar when spermatozoa were discovered during testicular sperm extraction.

Varicocele Repair in Patients With Nonobstructive Azoospermia: A Meta-Analysis

Multiple small case series have reported sperm in the ejaculate and spontaneous pregnancies in patients with nonobstructive azoospermia after varicocele repair. We hypothesized that men with favorable testicular histopathology on testis biopsy such as maturation arrest or hypospermatogenesis would have a higher probability of success than those with more ablative pathology, eg Sertoli-cell-only. A review of the literature on varicocele repair in patients with nonobstructive azoospermia was performed and 11 publications from the previous 20 years were evaluated. Histopathological data were presented in 8 publications, and were categorized as Sertoli-cell-only, maturation arrest and hypospermatogenesis. Maturation arrest was further differentiated by 4 publications. Early maturation arrest was defined as maturation ending at the secondary spermatocyte and late maturation arrest was defined as maturation ending at the spermatid without spermatozoa present. Success after repair was defined as having sperm in the ejaculate or spontaneous pregnancy. A total of 233 patients were analyzed. After varicocele repair 91 (39.1%) patients had motile sperm in the ejaculate and 14 spontaneous pregnancies were reported. Success rates in patients with maturation arrest (42.1%) or hypospermatogenesis (54.5%) were significantly higher than in those with Sertoli-cell-only (11.3%, p <0.001 in both groups). Patients with late maturation arrest had a higher probability of success (45.8%) than those with early maturation arrest (0%, p = 0.007). Infertile men with nonobstructive azoospermia can have improvement in semen analysis and achieve spontaneous pregnancy after repair of clinical varicoceles. This meta-analysis demonstrates that men with late maturation arrest and hypospermatogenesis have a higher probability of success and, therefore, histopathology should be considered before varicocele repair in men with nonobstructive azoospermia.

Controversies in the management of nonobstructive azoospermia

The fertility potential of patients with nonobstructive azoospermia (NOA) depends on sperm extraction from the tissue sample and then in vitro fertilization with intracytoplasmic sperm injection (IVF/ICSI). Unfortunately, there is no consensus regarding predictors that can identify nonobstructive azoospermic men with a potentially high yield at the time of sperm extraction. This article analyzes two competing approaches to these patients: noninvasive and invasive. The noninvasive approach, based on clinical, laboratory, and ultrasonographic investigations, excludes from IVF/ICSI a significant number of patients owing to errors in predicting the presence of sufficient intratesticular spermatozoa. The invasive approach, with available percutaneous or surgical testicular biopsy techniques followed by morphologic examination and or sperm recovery, permits many patients with NOA to receive a favorable prognosis and therapeutic trial. However, the available testicular biopsy techniques are so variable that their performance parameters cannot be adequately compared. As a result, any progress in optimizing these techniques must involve delineation of specific selection criteria for each NOA patient.