Microdissection Testicular Sperm Extraction Research Articles

Oncological microdissection testicular sperm extraction (Onco-microTESE) outcomes for fertility preservation of patients with testicular cancer with azoospermia or severe oligoasthenoteratozoospermia.

To determine the success rate of oncological microdissection testicular sperm extraction (onco-microTESE) in patients with testicular cancer (TC) with azoospermia and severe oligoasthenoteratozoospermia (OAT; <1 million/mL sperm) and to explore any factors that may predict success. Case series of outcomes from all consecutive patients (42 testes in 38 patients) that presented or were referred to a single specialist tertiary referral centre for fertility management in the context of TC with severe OAT or azoospermia between August 2015 and August 2022. Biochemical, radiological, and histological parameters were collected for all patients. All patients underwent onco-microTESE (simultaneous radical inguinal orchidectomy with ex vivo microTESE of the affected testis). Those with unsuccessful surgical sperm retrieval (SSR) from the affected testis underwent contemporaneous contralateral microTESE, if no contraindication was present. The primary outcome was successful SSR from the affected testicle sufficient for assisted reproductive techniques. Secondary outcomes included contralateral microTESE success, the time from referral to procedure, and the total successful fertility preservation rate. Initial onco-microTESE was successful in 19 of 31 patients (61%) with azoospermia. Contralateral microTESE was successful in a further two of eight patients with azoospermia with failed onco-microTESE. Overall, 22/31 patients with azoospermia (71%) had successful fertility preservation in this series. In addition, six of seven patients with severe OAT had further sperm harvested by onco-microTESE to maximise their fertility preservation. All surgery was performed within median (interquartile range) of 7 (5-13) days from presentation. Onco-microTESE represents an effective method of fertility preservation for sub-fertile patients with TC without delaying oncological treatment. Knowledge of the fertility status at first presentation is essential to allow for such additional options for optimal fertility preservation in TC.

Microdissection testicular sperm extraction outcomes in azoospermic patients post-orchidopexy surgery: A systematic review and meta-analysis.

Cryptorchidism is a common cause of male infertility, often necessitating microdissection testicular sperm extraction (m-TESE) for sperm retrieval post-surgery. However, uncertainties persist regarding m-TESE outcomes and influencing factors following cryptorchidism surgery. A systematic review and meta-analysis were conducted to evaluate sperm retrieval rates (SRR) among patients undergoing m-TESE after cryptorchidism surgery. Factors including age at orchidopexy, age at m-TESE, type of cryptorchidism, serum hormone levels, testicular volume, and interval from surgery to m-TESE were analyzed for their impact on SRR.Nine studies encompassing 935 patients were included. The overall SRR was 57% (95% confidence interval [CI] 51% to 63%). Compared to patients with negative sperm retrieval (SR-), patients with positive sperm retrieval (SR+) underwent m-TESE at an older age (1.81 years; 95% CI 1.17 to 2.45) and orchidopexy at a younger age (-3.35 years; 95% CI -6.34 to -0.36). Different types of cryptorchidism (including high scrotal, inguinal canal, intra-abdominal) significantly influenced SRR (P<0.05). Serum testosterone, follicle-stimulating hormone, luteinizing hormone levels and testicular volume showed no significant correlation with SRR (P>0.05). Furthermore, SR- patients typically experienced shorter intervals from orchidopexy to m-TESE compared to SR+ patients (34.09 months; 95% CI 0.40 to 67.77). Earlier orchidopexy and much later m-TESE procedures, as well as undescended testis closer to the scrotum, increase the likelihood of successful sperm retrieval. Orchidopexy for cryptorchidism should be done as early as possible, whether it is performed before 18 months of age or detected at a much older age. In patients with undetected cryptorchidism and azoospermia after puberty, m-TESE should not be performed immediately after orchidopexy, the optimal interval from orchidopexy to m-TESE still requires further study.

Pregnancy outcomes in patients with non-obstructive azoospermia undergoing micro-TESE: comparison of fresh vs. frozen-thawed testicular sperm.

The relative merits of fresh or frozen testicular sperm in ICSI remain a matter of contention. This study aims to compare the reproductive outcomes of non-obstructive azoospermia patients undergoing ICSI using fresh and frozen-thawed microdissection testicular sperm extraction (micro-TESE) sperm. A total of 223 men with non-obstructive azoospermia underwent micro-TESE to collect testicular spermatozoa. ICSI cycles were performed using fresh and frozen-thawed spermatozoa. The cleavage states and grading of embryos, fertilization, and pregnancy outcomes were compared between the groups to assess the impact of cryopreservation of testicular spermatozoa on embryo quality and ICSI outcomes. A total of 223 cases were evaluated, with fertilization observed in 208 cases and no fertilization observed in 15 cases. The number of day 3 total embryos and the number of cleavage embryos differed between the fresh and frozen micro-TESE groups, whereas the number of two-pronuclei oocytes, grading of embryos, fertilization, pregnancy, and live birth rates were found to be similar between the two groups. The cryopreservation of spermatozoa obtained by micro-TESE does not affect the fertilization rate or pregnancy outcome in cases of non-obstructive azoospermia. The present findings, when considered in conjunction with the extant evidence, may serve to alleviate concerns regarding the utilization of frozen-thawed micro-TESE sperm in patients with non-obstructive azoospermia.

Future prospects for the advancement of treatment of men with NOA: focus on gene editing, artificial sperm, stem cells, and use of imaging.

Nonobstructive azoospermia (NOA) affects about 60% of men with azoospermia, representing a severe form of male infertility. The current approach to manage NOA primarily involves testicular sperm retrieval methods such as conventional testicular sperm extraction (c-TESE) and microdissection testicular sperm extraction (micro-TESE). While combining testicular sperm retrieval with intracytoplasmic sperm injection (ICSI) offers hope for patients, the overall sperm retrieval rate (SRR) stands at around 50%. In cases where micro-TESE fails to retrieve sperm, limited options, like donor sperm or adoption, can be problematic in certain cultural contexts. This paper delves into prospective treatments for NOA management. Gene editing technologies, particularly clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated (Cas) protein 9 (CRISPR/Cas9), hold potential for correcting genetic mutations underlying testicular dysfunction. However, these technologies face challenges due to their complexity, potential off-target effects, ethical concerns, and affordability. This calls for research to address key challenges associated with NOA management within the clinical settings. This also necessitate ongoing research essential for developing more sensitive diagnostic tests, validating novel treatments, and customizing current treatment strategies for individual patients. This review concluded that the future of NOA management may entail a combination of these treatment options, tailored to each patient's unique circumstances, providing a comprehensive approach to address NOA challenges.

Successful Sperm Retrieval and Clinical Pregnancies Following Micro-TESE and ICSI Treatments in Patients with Nonobstructive Azoospermia Due to Various Etiologies.

(1) Background: Nonobstructive azoospermia (NOA) etiologies affect the sperm retrieval rate (SRR) by microdissection testicular sperm extraction (micro-TESE) and the clinical outcomes following intracytoplasmic sperm injection (ICSI); (2) Methods: We investigated seven NOA etiologies. The SRR and clinical outcomes of 627 patients were analyzed between November 2017 and July 2022 in the Reproductive and Genetic Hospital of China International Trust and Investment Corporation-Xiangya (CITIC-Xiangya); (3) Results: The overall SRR was 39.4% (247/627). The SRR according to NOA etiologies were: Y chromosome azoospermia factor c microdeletions (26/46, 56.5%), Klinefelter syndrome (KS), 36/85, 42.4%), idiopathic (110/398, 27.6%), cryptorchidism (20/29, 69.0%), chromosome anomalies (7/13, 53.9%), orchitis (45/50, 90.0%), and cancer (3/6, 50.0%). The SRR were different for spermatogonia arrest (26/96, 27.1%), maturation arrest (76/177, 42.9%), and SCOS (30/80, 37.5%) according to histological examinations. The clinical pregnancy rate was similar among the NOA etiologies. The high-quality embryo rate differed between successful (54.7%) and unsuccessful (40.9%) pregnancies. Moreover, the successfully pregnant women (28.99 years) were younger than the unsuccessfully pregnant ones (30.92 years); (4) Conclusions: The SRR from patients with NOA was associated with the etiology and histological categories, while the clinical outcome was associated with the high-quality embryo rate and the female partner's age.

Artificial intelligence interpretation of touch print smear cytology of testicular specimen from patients with azoospermia.

Identification of mature sperm at microdissection testicular sperm extraction (mTESE) is a crucial step of sperm retrieval to help patients with non-obstructive azoospermia (NOA) proceed to intracytoplasmic sperm injection. Touch print smear (TPS) cytology allows immediate interpretation and prompt sperm identification intraoperatively. In this study, we leverage machine learning (ML) to facilitate TPS reading and conquer the learning curve for new operators. One hundred seventy-six microscopic TPS images from the testicular specimen of patients with azoospermia at Taipei Veterans General Hospital were retrospectively collected, including categories of Sertoli cell, primary spermatocytes, round spermatids, elongated spermatids, immature sperm, and mature sperm. Among them, 118 images were assigned as the training set and 29 images as the validation set. RetinaNet (Lin et al. in IEEE Trans Pattern Anal Mach Intell. 42:318-327, 2020), a one-stage detection framework, was adopted for cell detection. The performance was evaluated at the cell level with average precision (AP) and recall, and the precision-recall (PR) curve was displayed among an independent testing set that contains 29 images that aim to assess the model. The training set consisted of 4772 annotated cells, including 1782 Sertoli cells, 314 primary spermatocytes, 443 round spermatids, 279 elongated spermatids, 504 immature sperm, and 1450 mature sperm. This study demonstrated the performance of each category and the overall AP and recall on the validation set, which were 80.47% and 96.69%. The overall AP and recall were 79.48% and 93.63% on the testing set, while increased to 85.29% and 93.80% once the post-meiotic cells were merged into one category. This study proposed an innovative approach that leveraged ML methods to facilitate the diagnosis of spermatogenesis at mTESE for patients with NOA. With the assistance of ML techniques, surgeons could determine the stages of spermatogenesis and provide timely histopathological diagnosis for infertile males.

Technologies to improve sperm retrieval in men undergoing micro-TESE for NOA.

Nonobstructive azoospermia (NOA) is considered the most challenging clinical scenario for infertile men and current treatments leave many men unsuccessful at being able to achieve a pregnancy with their partner using their own sperm. Microdissection testicular sperm extraction (micro-TESE) is the choice for men with NOA desiring to father children with their own gametes. Micro-TESE results in the highest numbers of sperm cells retrieved for use with in vitro fertilization/intracytoplasmic sperm injection. With suboptimal micro-TESE success rates of sperm retrieval and then pregnancy and live birth using the retrieved sperm with in vitro fertilization/intracytoplasmic sperm injection, advances to improve outcomes are necessary. This article comprehensively reviews the technologies investigated to date to improve the outcomes for men undergoing micro-TESE.

Evaluation of the Results of Intracytoplasmic Sperm Injection and Microdissection Testicular Sperm Extraction Treatments in Patients with Nonobstructive Azoospermia According to Etiological Factors: A Retrospective Analysis

Objective: This study aimed to retrospectively compare the results of microdissection testicular sperm extraction (microTESE) and Intracytoplasmic sperm injection (ICSI) treatments in nonobstructive azoospermia (NOA) patients with different aetiologies. Determinants (clinical characteristics) for microTESE outcomes were compared between patients with successful sperm retrieval (SSR) and sperm retrieval failure (SRF). Methods: A total of 510 NOA patients who underwent microTESE between January 2015 and January 2024 were included in this study. Patients were classified according to the cause of NOA and SSR, fertilisation rate, clinical pregnancy, and overall live birth rate were evaluated. Results: The SSR rate was 44.1% in the whole population. The idiopathic patient group had the lowest SSR rate (X2: 34.81; p&lt;0.01). There was no difference between the groups in terms of fertilisation rate, clinical pregnancy and overall live birth rate. There was a negative correlation between age and SSR rates in patients with idiopathic NOA (t:-0.27; p&lt;0.01). SSR rates were higher in patients with cryptorchidism (right: t:0.8; P:0.003; left: t:0.72; p:0.002) and mumps orchitis (right: t:0.76; P&lt;0.01; left: t:0.76; p=0.003). Conclusion: Etiology has a significant role in terms of SSR in patients with NOA. SSR was found to be significantly less in patients with idiopathic NOA compared to other causes. In addition, age and testicular volume were significant predictive factors for SSR in patients with idiopathic and acquired NOA.

Secondary azoospermia after a successful natural pregnancy: a primary prospective study

BackgroundTo date, there is a lack of studies conducted on males with secondary azoospermia as a potential cause of male infertility who had previously fathered children through natural conception. The current study aims to investigate the potential causes of secondary azoospermia as a presentation of male infertility as well as the prognostic factors that can impact sperm retrieval rate (SRR) while undergoing microdissection testicular sperm extraction (microTESE).ResultsThirty two patients were recruited from the andrology outpatient clinic from August 2023 till January 2024. The mean age of the patients was sixty-two years old. All patients had varicoceles. Twenty seven patients (84%) had palpable varicocele grade 2 and 3 on both sides. Further multivariate logistic regression analysis of the significant factors in the univariate regression revealed that younger age (OR 0.7, 95% C.I. 0.7-1.0, p = 0.03) and having a history of coronary artery disease (CAD) were predictable factors for negative TESE outcome (OR 123.1, 95% C.I. 3.2-4748.5, P = 0.01).ConclusionIt appears that the etiopathogenesis of secondary azoospermia are multifactorial. Varicocele and CAD are major factors to be considered. Future studies should be implemented deploying larger pools of patients suffering from the same condition to affirm the findings of this primary study.

Development of a deep-learning model for detecting positive tubules during sperm recovery for nonobstructive azoospermia.

To enhance surgical testicular sperm retrieval outcome for men with nonobstructive azoospermia, a deep-learning model was developed to identify positive seminiferous tubules by labeling 110 images with sperm-containing tubules sampled during microdissection testicular sperm extraction as training and validation data. After training, the model achieved an average precision of 0.60.

Clinical predictors of successful outcomes for couples with nonobstructive azoospermic male partners undergoing micro-TESE.

Nonobstructive azoospermia (NOA) is the most challenging and complex clinical scenario for infertile men. Besides circumstances such as hypogonadotropic hypogonadism, surgical sperm retrieval is typically necessary, and microdissection testicular sperm extraction (micro-TESE) is the procedure of choice for men with NOA desiring to father children with their own gametes. Micro-TESE results in the highest numbers of sperm cells retrieved for use with in vitro fertilization/intracytoplasmic sperm injection (ICSI) in comparison to all other techniques for surgical sperm retrieval in men with NOA. Several factors may affect sperm retrieval rate and ICSI outcomes, including the patient's age, testicular volume, histopathological and genetic profile, and serum hormone levels. This article aims to review the medical literature describing predictors of successful micro-TESE and the outcomes of ICSI in men with NOA.

Second chance in fertility: a comprehensive narrative review of redo micro-TESE outcomes after initial failure.

When microdissection testicular sperm extraction (micro-TESE) fails, a redo procedure may be the only option for patients who want a biological child. However, there are many gaps of knowledge surrounding the procedure, which need to be addressed to help clinicians and patients make informed decisions. This review explores redo micro-TESE in the context of nonobstructive azoospermia (NOA). Literature was searched using Google Scholar, Medline, and PubMed. Search terms were "NOA" AND "second microdissection testicular sperm extractions" AND "redo microdissection testicles sperm extraction" AND "repeat microdissection testicular sperm extractions" AND "failed microdissection testicular sperm extractions" AND "salvage microdissection testicular sperm extractions". Only original articles in English were included. A total of nine articles were included, consisting of four retrospective and five prospective studies. The time gap between the first and second micro-TESE varied from 6 months to 24 months. Most of the included studies reported successful surgical sperm retrieval (SSR) in the second micro-TESE in the range of 10%-21%, except in one study where it reached 42%. It has not been presented any definitive information about the use of hormonal treatment or the benefit of varicocelectomy prior to the second micro-TESE. Patients with hypospermatogenesis and Klinefelter syndrome (KS) had the highest chance of success in redo surgery. In conclusion, redo micro-TESE following a negative procedure can lead to sperm recovery in 10%-21%. Patients with hypospermatogenesis and KS have a higher chance of success. There is no enough evidence to conclude which is the best hormonal stimulation if any before a redo surgery.

O-222 The impact of psychological counselling on decision-making of sperm donation among the couples with nonobstructive azoospermia after unsuccessful microdissection testicular sperm extraction

Abstract Study question Is nonobstructive azoospermia (NOA) couples with psychological counselling likely to choose sperm donation after unsuccessful microdissection testicular sperm extraction (MD-TESE)? Summary answer Couples with psychological counselling were significantly 2.9 times likely to choose sperm donation than couples without psychological counselling by Cox proportional hazard regression analysis. What is known already For NOA, although MD-TESE and intracytoplasmic sperm injection offer the only chance to become biological parenthood, 70% of NOA cannot get sperm by MD-TESE, and they have to end treatment and seek another life course. When diagnosing NOA, almost all male patients (88.9%) have severe depressive symptoms (Bak, 2012). Germany, England, Australia, and New Zealand have shown that psychological counselling for ending treatment and decision making in alternative life courses, such as sperm donation, is theoretically recommended in their guidelines (BKiD 2014; BICA 2015; ANZICA 2018). However, no study has yet examined the efficacy of psychological care. Study design, size, duration This was a retrospective cohort study. The sample size calculation estimated a total of 90 couples. The couples who experienced unsuccessful MD-TESE at a university hospital from August 1, 2020, to September 30, 2021, were observed to receive psychological counselling and a reference to another hospital for sperm donation treatment for 300 days after MD-TESE. Participants/materials, setting, methods Participants: The 88 NOA couples after unsuccessful MD-TESE in a university hospital between August 2020 and September 2021. Methods: After unsuccessful MD-TESE, doctors recommended psychological counseling for all couples; 44 couples (counselling group) received psychological counselling, whereas 44 couples (non-counselling group) did not. Intervention: Semi-structured single-session psychological counselling was conducted for the counselling group. This includes psychological care for grieving unsuccessful treatment, giving up their biological children, and deciding what life course they choose. Main results and the role of chance The reference ratio to the sperm donation hospital was 50% for the counselling group and 18.2% for the non-counselling group (χ2(1)= 9.913, p=.002, φ=.336). The average duration from MD-TESE to the reference was 103.8 days for the counselling group whereas 80.1 days for the non-counselling group, which was not statistically significant. Analyzing the cumulative non-referral rate using the Kaplan-Meier estimation method, the counseling group was more likely to have a decline in the cumulative non-referral rate than the non-counseling group. The log-rank test result was significant (χ2(1) = 8.284, p = .004). The Cox proportional hazard regression with covariates of male chromosomal abnormality, the period of infertility, and females’ age, shows that the counseling group are significantly more likely to make the referral letter earlier than the non-counseling group (adjust hazard ratio, 2.931; 95%Cl, 1.271-6.758). When unsuccessful MD-TESE, NOA couples with semi-structured psychological counselling can recover from loss and grief and can consider and decide on sperm donation treatment urgently compared to non-counselling couples. Limitations, reasons for caution We calculated an appropriate sample size from the results and found that at least 45 persons were needed in each group. Therefore, it is necessary to conduct future studies with sufficient sample sizes. Wider implications of the findings Couples with NOA after unsuccessful MD-TESE may recover from loss and grief, and may consider and decide their future life-course urgently through semi-structured psychological counseling for grieving unsuccessful treatment, giving up their biological children, and deciding what life courses they choose. Trial registration number UMIN000053508

O-260 Identifying seminiferous tubules for sperm retrieval during microdissection testicular sperm extraction (M-TESE) using deep learning

Abstract Study question Is it possible to utilize artificial intelligence (AI) in the selection of seminiferous tubules for sperm retrieval during microdissection testicular sperm extraction (M-TESE)? Summary answer AI algorithm was able to segment seminiferous tubules deemed to be good candidates for sperm retrieval with IoU of 0.746 and F1 score of 72.5%. What is known already M-TESE is an advanced surgical procedure reserved for sperm retrieval in men with non-obstructive azoospermia (NOA). Meta-analysis have shown M-TESE might be superior in relation to sperm retrieval rates and postsurgical complications when compared to conventional techniques. Limitations of the technique are the relatively long learning curve for the surgeons and the longer intraoperative time required to identify the tubules with active spermatogenesis. Convolutional neural networks (CNNs) have been shown to successfully identify areas of interest in medical images such as CT and MRI scans. The possibility of utilizing trained CNNs in M-TESE procedures has so far not been studied. Study design, size, duration This is a cross sectional study analyzing image data gathered during M-TESE procedures including the first five men enrolled in a prospective study designed specifically to test the utilization of AI in the treatment of NOA. All participants signed written informed consent. Images were collected intraoperatively with low and high resolution cameras according to predefined protocol. Participants/materials, setting, methods CNN model with down and upsampling architecture was trained using patch-based technique with corresponding labelled truth image pairs based on combination of semi-automated hue saturation value thresholding and manual segmentation of seminiferous tubules. Tubules were allocated into two different classes by the operating surgeon according to the visual perception of their morphology as type 1 (i.e. larger, opaque, good candidates for micro dissection) and type 2 (i.e. sclerotic or atrophic; unlikely to harbor active spermatogenesis). Main results and the role of chance CNN models were trained on 1809 patches with corresponding ground truth segmented images. Two algorithms were tested: the first was trained solely to detect and semantically distinguish type 1 seminiferous tubules. The second was trained to semantically segment the major anatomical structures: tunica albuginea, testicular parenchyma, blood vessels; lobules and the two types of seminiferous tubules describe above. Validation was performed on 988 image patches not previously shown to the algorithm. After grid search for optimal learning rate and augmentation the first algorithm was able to segment type 1 tubules with F1 score of 72.5% and Jaccard Index (IoU) of 0.746. Training took 856 minutes on 48 core high performance computer (HPC) equipped with single graphics processing unit (GPU). Same computational environment was used in the training of the second algorithm. This model was able to segment anatomical structures such as parenchyma (IoU=0.732) and testicular lobules (IoU=0.683) but performed sub optimally on the clinically relevant type 1 tubules (IoU=0.432). The first trained algorithm was able to segment a single high resolution surgical image in 3.4 seconds on an HPC. However, the same procedure took 5.5 minutes on standard desktop computer with 8 core Intel processor without GPU. Limitations, reasons for caution The number of patients is relatively small and therefore more training data would be needed to achieve robust performance. Training data were labelled by single surgeon limiting the generalizability and possibly biasing the selection process. The need of HPC environment for real time segmentation can limit the clinical use. Wider implications of the findings This pilot study shows the potential of AI to help in choosing suitable tubules for micro dissection, shortening the learning curve for young andrological surgeons. The access to cluster based computation is getting easier by the day and can soon allow instant intraoperative AI segmentation, thus shortening the surgical procedure. Trial registration number NA

O-258 Clinical factors associated with sperm retrieval success in hypogonadal nonobstructive azoospermic males undergoing microdissection testicular sperm extraction

Abstract Study question What factors are associated with sperm retrieval (SR) success through microdissection testicular sperm extraction (micro-TESE) in nonobstructive azoospermic (NOA) males with biochemical hypogonadism? Summary answer The SR success in hypogonadal NOA males is associated with FSH levels, pre-micro-TESE hormonal stimulation, presence of clinical varicocele, varicocelectomy history, and testicular histopathology results. What is known already Previous studies have investigated clinical predictors for SR success in NOA males, such as testicular volume, genetic status, and testicular histopathology, but these factors cannot be modified before SR. On the other hand, pre-SR hormonal stimulation and varicocele repair have shown potential for improving SR rates, although the evidence is inconclusive due to heterogeneity in patients and treatments. This lack of information makes it difficult for clinicians to determine whether medical or surgical interventions should be used before SR in NOA patients. Study design, size, duration This observational cohort study involved 616 hypogonadal NOA patients with primary spermatogenic failure who underwent micro-TESE at a University-affiliated center for male reproductive health between 2014 and 2021. Biochemical hypogonadism was defined as total testosterone (T) levels &amp;lt;350 ng/dL, measured from morning venous samples. All patients were naïve concerning previous SR attempts and were categorized into two groups based on whether they received pre-SR hormonal stimulation with recombinant gonadotropins (hCG alone or combined with FSH). Participants/materials, setting, methods Patients aged 23-55 underwent comprehensive clinical, laboratory, and histopathological evaluations for NOA. Multivariable logistic regression analysis explored the associations between patient variables and micro-TESE success. Adjusted risk ratio (aRR) assessed the relationship between SR success and relevant predictors. SR rates were compared between patients receiving hormonal stimulation and those who did not. Logistic regression analysis evaluated the effect of baseline FSH levels, stratified by normogonadotropic (&amp;lt;12 IU/L) and hypergonadotropic (≥12 IU/L) classes, on SR success. Main results and the role of chance The overall micro-TESE success rate was 56.6%. Independent predictors of SR success included baseline FSH levels (aRR 0.98, 95% CI 0.96-0.99, p = 0.04), pre-SR hormonal stimulation (aRR 1.52, 1.28-1.73, p = 0.0002), the presence of clinical varicocele (aRR 0.09, 0.01-0.66, p = 0.04), history of previous varicocelectomy (aRR 1.53, 1.14-1.84, p = 0.01), and testicular histopathology results (p &amp;lt; 0.05). Patients who received hormonal stimulation achieved higher SR success rates than untreated patients (62.5% [182/291] vs. 51.4% [167/325], p = 0.006; aRR 1.52, 95% CI 1.28-1.73). Among patients receiving hCG-based hormonal stimulation, pre-micro-TESE T levels and Delta T (absolute increase in T levels from baseline) were associated with SR success (p &amp;lt; 0.0001). A pre-micro-TESE T level of 418.5 ng/dL (AUC: 0.78) and a Delta T of 258 ng/dL (AUC: 0.76) distinguished treated patients with positive and negative SR outcomes. Subgroup analysis by baseline FSH levels showed that normogonadotropic individuals (aRR 1.41, 1.16-1.58, p = 0.002) benefited from hormonal stimulation, whereas hypergonadotropic subjects did not (aRR 1.20, 0.86-1.50, p = 0.23). The frequency of patients showing biochemical hypogonadism after hCG stimulation was reduced to 22.3% (65/291). The micro-TESE postoperative complication rate was 2.3% (14/616), while the frequency of patients exhibiting adverse effects presumably attributed to hormonal stimulation was 10.3% (30/291). Limitations, reasons for caution Limitations of the study include its observational nature and the absence of pregnancy data. The study focused on micro-TESE as the SR method and hormonal stimulation solely based on hCG (as monotherapy or associated with FSH), so results may differ with other treatments. Wider implications of the findings Our study underscores the complexity of counseling hypogonadal men with NOA, stressing the significance of assessing various factors. While our findings suggest potential benefits from pre-SR interventions, particularly hormonal stimulation and varicocele repair, none of the identified predictors can definitively determine the likelihood of successful SR. Trial registration number NCT05110391

O-259 Seminal plasma cell-free RNA to predict testicular biopsy sperm retrieval outcome in azoospermic men

Abstract Study question Is there a way to assess seminal plasma of NOA men to predict a successful sperm retrieval at testicular biopsy? Summary answer Multi-omics approach in seminal plasma of NOA men provides reliable prediction on the spermatogenic activity within the seminiferous tubule. What is known already Microdissection testicular sperm extraction (m-TESE) in NOA men successfully retrieved spermatozoa in about 60% of the cases. While several algorithms have been investigated aiming at estimating spermatogenic progress such as age, serum FSH, inhibin B, and genetics, there is no specific assay that can do so reliably. Even histopathology is often inconclusive while equally invasive. Recently, epigenetic analysis on testicular biopsy specimens has shown a differential gene expression in relation to the origin of azoospermia and spermatogenic function (Cheung, et al, 2024, in press). Study design, size, duration Over a 4-year period, twenty-eight men were deemed azoospermic following several failed extensive semen analyses. Transcriptomic analysis was performed by RNAseq on seminal fluid and the specific gene expression were evaluated and compared. In addition, DNAseq and proteomics were carried out to confirm our findings. These patients then underwent micro-TESE by a single surgeon and were divided into two cohorts based on whether spermatozoa was successfully retrieved or not. Participants/materials, setting, methods RNA and DNA were isolated from seminal plasma using a commercial kit and sequenced by Illumina HiSeq3000/4000 platform. Differentially expressed genes (DEGs) were assessed and compared to a fertile donor control using DESeq2 and Gene Ontology analysis. An absolute log2fold change of &amp;gt; 1 and a P-value of &amp;lt; 0.0005 were considered statistically significant. Gene mutations were detected by CLC Genomic Server 9.0. Main results and the role of chance Transcriptomic in 28 ejaculates from iNOA men browsed 21,855 genes against a fertile donor. Of 3,505 imbalanced genes, 12 were consistently imbalanced in 12 men, while 19 genes were imbalanced in remaining 16. Among the 2 cohorts, 8 common imbalanced genes were found. Particularly TPTE2, a testis-specific gene that regulates spermatogenesis, was overexpressed in 10/12 men (OE-12-cohort), while underexpressed in the remainder 16 (UE-16-cohort). DNAseq showed that TPTE2 was conserved in the OE-12-cohort, while exhibiting a frameshift mutation in the UE-16-cohort. Most interestingly, NEU1, a gene involved in acrosome development and fertilization, was found to be consistently and concurrently overexpressed in the OE-12-cohort, while being convserly underexpressed in all the men in the UE-16 cohort. DNAseq confirmed the NEU1 gene exhibited a synonymous mutation in the OE-12 and a frameshift mutation in the UE-16-cohort. About 1-2 months after the DEG analysis was completed, all of the patients underwent m-TESE. The 12 men from the OE-12-cohort all had successful retrieval of spermatozoa at m-TESE, conversely the 16 men from the UE-16-cohort all consistently failed to yield spermatozoa at testicular surgery in spite of extensive search for several hours and by multiple embryologists. Moreover, histopathology confirmed spermatogenic status in both OE-12&amp;UE-16-cohorts. Limitations, reasons for caution Using non-invasive RNAseq and DNAseq on the seminal plasma has allowed us to identify DEGs that may be used to predict whether a patient with iNOA would have a successful or failed sperm retrieval with micro-TESE. However, these results are preliminary and should be further validated in larger study cohort. Wider implications of the findings Transcriptomics on the ejaculates of men with iNOA represents a noninvasive tool to detect presence of residual spermatogenesis. If confirmed by further studies, this precision medicine method may be utilized in order to properly counsel patients regarding their future prognosis. Trial registration number Not applicable

O-263 The risk of hypogonadism after microdissection testicular sperm extraction (micro TESE) in non-obstructive azoospermia (NOA) patients with various etiologies

Abstract Study question What is the risk factor of hypogonadism after micro TESE in NOA patients? Summary answer Klinefelter syndrome (KS), past history of cryptorchidism, preoperative testicular volume &amp;lt;8 ml or testosterone &amp;lt;287 ng/dL are significant risk factors of hypogonadism after micro TESE. What is known already Micro TESE combined with intracytoplasmic sperm injection (ICSI) is currently standard procedure to treat infertility in cases of NOA. Although many studies have reported the effectiveness of the treatment concerning about sperm retrieval rates (SRR) and the live birth rates, data on safety, especially on the risk of hypogonadism, are limited. Most previous studies, including our past study, regarding the risk of hypogonadism after TESE have been limited to relatively few in number of patients and the investigations only of the changes of mean serum testosterone levels. Study design, size, duration This study retrospectively investigated 535 NOA patients including 336 cases of unexplained NOA, 91 KS, 16 other chromosomal abnormalities, 31 azoospermia factor (AZF)c deletions, 31 past history of cryptorchidism, and 30 post anticancer chemotherapy, who had undergone micro TESE at our institution from September 2013 to August 2018. All of them had been examined serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone levels before and at least once in 1-3 months after micro TESE. Participants/materials, setting, methods In this study, hypogonadism was defined as total testosterone &amp;lt;250 ng/dL, which is established by the Japanese Society of Men’s Health as diagnostic criteria for late onset hypogonadism syndrome, and/or starting testosterone replacement therapy (TRT). We assessed risk factors of hypogonadism after micro TESE using indicators such as age, preoperative testicular volume and testosterone levels, past medical history, unilateral or bilateral, first time or not micro TESE. Main results and the role of chance In total of 535 men, FSH and LH after micro TESE significantly increased vs baseline (26.2 vs 29.9 IU/L, 9.6 vs 12.8 IU/L, respectively). On the other hand, testosterone levels significantly decreased after surgery (351.2 vs 297.5 ng/dL). Although postoperative hypogonadism was found in 42% (227/535), many of whom were cases of KS or preoperative testosterone levels &amp;lt;250 ng/dL. Sixteen men with KS, 3 men with unexplained NOA, and 2 men with past history of cryptorchidism started TRT because they complained clinical symptoms after micro TESE. Of the 21 men who started TRT, only 5 had new-onset low testosterone levels after micro TESE. According to the assessment of any association of various indicators and low postoperative total testosterone levels using multiple logistic regression analysis, significant risk factors of hypogonadism early after micro TESE were cases of KS (OR 11.4, 95% CI 4.4-29.9), preoperative testosterone levels &amp;lt;287 ng/dL (OR 7.5, 95% CI 4.7-12.0), preoperative testicular volume &amp;lt;8 ml (OR 3.9, 95% CI 2.3-6.4), past history of cryptorchidism (OR 2.9, 95% CI 1.1-7.8). Limitations, reasons for caution Most examinations of postoperative hormone levels were performed in short-term period after micro TESE, so we could only assess the risk of postoperative hypogonadism in a short time course in this cohort study. Wider implications of the findings The strength of the current study is that the risk factors of hypogonadism after micro TESE was assessed in a large population of NOA men with various etiologies. The results of this study provide useful clinical information about the risk of postoperative hypogonadism for NOA patients considering micro TESE. Trial registration number not applicable

P-078 Comparison of embryological and clinical outcomes in mumps orchitis and non-obstructive azoospermia patients treated by Microdissection testicular sperm extraction combined with ICSI (microTESE-ICSI)

Abstract Study question The objective of this retrospective study was to examine the embryological and clinical outcomes in mumps orchitis and non-obstructive azoospermia (NOA) patients undergoing microTESE-ICSI treatment. Summary answer microTESE combined with ICSI is an effective treatment regimen that can help mumps orchitis and NOA patients to have their biological offsprings. What is known already Non-obstructive azoospermia can be caused by different etiologies, and one of factors is mumps orchitis. These patients cannot retrieve spermatozoa via ejaculation, so microTESE is an intervention indicated to retrieve their sperm. Recent studies showed that the combination of microTESE and ICSI increase the success of in-vitro fertilization (IVF) treatment for NOA patients. IVF effectiveness can also be influenced by maternal age; however, most of the previous studies on NOA group reported sperm retrieval rate and male factors. Few studies have focused on embryo development and clinical outcomes, especially, under the adjustment for female partner’s age. Study design, size, duration This retrospective study was conducted to analyze the embryo development and clinical outcomes in 212 patients who had spermatozoa retrieved from microTESE and treated by ICSI from 4/2022 to 10/2023. 212 microTESE-ICSI patients were divided into two groups including mumps orchitis group (n = 101) and NOA group by other etiologies (n = 111). These patients had spouses who were under 35-year-old. Participants/materials, setting, methods Effectiveness of microTESE-ICSI between mumps orchitis and NOA groups was evaluated by comparing the embryological development and clinical outcomes. The mean of fertilization rate, good cleavage embryo rate (following alpha consensus) and good blastocyst rate (embryo quality higher than 2BB at day 5) in two groups were compared to assess embryological outcomes. Pregnancy rate, miscarriage rate, ongoing pregnancy rate (≥ 30 weeks), and live-birth rate were examined to evaluate the clinical outcomes. Main results and the role of chance The mean of paternal age in mumps orchitis group and NOA group was similar (32.0±4.4 vs 32.0±4.9). There was no difference in the mean of maternal age between these two groups (28.7±3.4 vs 27.8±3.8, p &amp;gt; 0.05). The means of retrieved oocytes and mature oocytes in two patient groups were not significantly different (19.4±8.7 vs 20.1±11.3; 13.7±6.5 vs 14.1±8.3, respectively). The fertilization rate of mumps orchitis group was significantly higher than NOA group (66.1% vs 57.7%, p &amp;lt; 0.01). Rate of good embryo on day 3 and rate of blastocyst on day 5 in mumps orchitis group were 17.9% and 49.8% respectively. These rates in NOA group accounted for 13.3% and 43.8% respectively. The pregnancy rate (positive beta hCG-test) in mumps orchitis patients was 80.2% (77/96), and this rate in NOA group was 75.5% (77/102). The miscarriage rates in these two groups were not significantly different (0.03% vs 0.06%, p &amp;gt; 0.05). There were no significant differences in ongoing pregnancy rate between mumps orchitis group and NOA group (38.5% (37/96) vs 37.3% (38/102); p &amp;gt; 0.05, respectively). Live-birth rate of these groups was also similar (mumps orchitis vs NOA: 25% (24/96) vs 20.6 (21/102, p &amp;gt; 0.05). Limitations, reasons for caution This research is a single-center retrospective study performed in a brief time, so our sample size is small. Our study had a lack of information of body mass index and male hormonal factors because the database missed in several patients at the retrospective time. Wider implications of the findings These data suggested that microTESE is an optimal method for mumps orchitis and NOA patients who cannot ejaculate retrieve their own sperm. microTESE-ICSI might increase the success rate of fertility treatment in these patients. Trial registration number Not applicable

P-570 A cell-free DNA test in semen of nonobstructive azoospermic men to predict spermatogenesis

Abstract Study question Can a genetic assessment of cell-free DNA, isolated from seminal plasma of nonobstructive azoospermic (NOA) men, predict successful sperm extraction at testicular biopsy? Summary answer Seminal cell-free DNA (cfDNA) isolated from the ejaculates of NOA men with failed testicular sperm retrieval outcomes concurrently and consistently displayed mutations on three genes. What is known already The most puzzling form of azoospermia is the testicular type, where the chances of successful microdissection testicular sperm extraction (micro-TESE) are unpredictable. Therefore, developing a method that could identify or predict individuals with absent spermatogenesis would be most useful. While histopathology is considered the most reliable method for predicting successful micro-TESE, it is invasive and often inconclusive. Recently, cfDNA testing has been gaining momentum as a noninvasive method for prenatal screening and even with the potential for eventually replacing PGT-A. However, the prognostic value of using cfDNA to predict the presence/absence of spermatozoa in men undergoing micro-TESE is relatively unknown. Study design, size, duration Over a period of 8 months, we recruited azoospermic men with normal peripheral karyotypes and for whom an extensive semen analysis did not identify spermatozoa. For consenting patients (n = 12), we performed genetic assessments on cfDNA from their ejaculates (IRB 1006101085). These patients subsequently underwent micro-TESE, and their cfDNA mutation profiles were compared according to whether spermatozoa were successfully retrieved ((+)Sperm, n = 5), or not ((-)Sperm, n = 7). Participants/materials, setting, methods Using a commercially available kit, circulating cfDNA was eluted from the ejaculates of consenting NOA men, as well as a normozoospermic control (n = 2). The isolated cfDNA specimens subsequently underwent whole exome sequencing (WES) on an Illumina HiSeq at 2x150bp. Gene mutations were detected by CLC Genomic Server 9.0 and compared within, as well as between, the +Sperm and -Sperm cohorts in comparison to the control group. Main results and the role of chance All 12 men (35.5±4yrs) had normal peripheral karyotypes and tested negative for Y-microdeletions. They had no history of genetic diseases and were off any supplements, medications, and/or hormones before or during the study. Genetic assessment on cfDNA from the +Sperm cohort (n = 5; 38.3±2yrs) identified 8 genes (ADAMTS7, ATP9B, CBFA2T3, FAM20C, FCGBP, PEBP4, PHF2, RPS9) that were concurrently mutated among all NOA men from this group. Although ADAMTS7 plays a potential role in sperm-egg fusion, the remaining genes are unrelated to sperm production. Whole exome sequencing of cfDNA from the -Sperm cohort (n = 7; 33.5±4yrs) consistently detected mutations on 3 genes, including one involved in spermatogenesis (CFAP54), one essential for oxidative regulation of spermatozoa (GSTT4), and one that encodes testis antigens that are normally expressed during spermatogenesis (BAGE2). Moreover, we concurrently and consistently identified pathogenic mutations on an additional gene in the -Sperm cohort. This gene (MUC2) is involved in the epithelial coating of mucus membrane-containing organs, and its expression has been correlated with spermatogenesis. Interestingly, these genes were all unaffected in men with successful micro-TESE outcomes. Limitations, reasons for caution Although we detected candidate gene mutations that correlate with micro-TESE outcome, these are preliminary findings that need further validation in a larger study cohort. Furthermore, while cfDNA analysis has shown great promise, it is not specific enough on its own and should be corroborated by epigenetic testing. Wider implications of the findings Genetic screening of seminal cfDNA provides a noninvasive alternative to histopathology and can be used to predict the absence of spermatogenesis, sparing these men from unnecessary surgery and cost. This novel biomarker approach lays the groundwork for precision medicine in male infertility testing. Trial registration number n/a

Testicular ultrasonic microvascular density in assessing spermatogenesis and predicting successful sperm retrieval.

The relationship between microcirculatory disorders and testicular spermatogenesis is an area of ongoing interest among urologists. The objective of this prospective observational study was to investigate the correlation between testicular microcirculation and spermatogenesis, as well as the predictive value of ultrasonic microvascular density (UMVD) and ultrasonographic volume estimation (UVE) in successful sperm retrieval among men with non-obstructive azoospermia (NOA). Testicular UMVD derived from Angio PLUSTM Planwave Ultrasensitive Imaging (AP), UVE were obtained. Participants were divided into 4 groups (normozoospermia; asthenozoospermia, teratozoospermia, or asthenoteratozoospermia; oligozoospermia; NOA). The study included a total of 875 participants. No significant difference was found in UMVD-mean between different semen groups (P>0.05). A total of 108 participants with NOA underwent microdissection testicular sperm extraction (micro-TESE). Participants with successful sperm retrieval (40 cases) showed significant differences in testicular UMVD and UVE compared to those with negative retrieval (68 cases) (P<0.01). We generated receiver operating characteristic (ROC) curves for UMVD and testicular UVE to differentiate participants with successful sperm retrieval from those without. The area under the curve (AUC) was 0.760 [95% confidence interval (CI): 0.658-0.849, P<0.01] for UMVD and 0.716 (95% CI: 0.609-0.822, P<0.01) for testicular UVE, respectively. The optimal cutoff value was determined based on the maximum Youden index. When UMVD was set at 28.50/cm2, its sensitivity and specificity were calculated as 57.5% and 85.3%, respectively. For testicular UVE, a cutoff value of 8.94 mL resulted in a sensitivity of 60.0% and specificity of 82.4%. Combining UMVD with testicular UVE improved diagnostic performance (AUC: 0.856, 95% CI: 0.772-0.929, P<0.01) with a sensitivity of 79.4% and specificity of 77.5%. The present study demonstrates the utility of AP as a predictive tool for successful sperm retrieval prior to micro-TESE. Furthermore, the combination of testicular UMVD and UVE provides a highly valuable diagnostic approach for predicting micro-TESE success and can be routinely implemented before the procedure. A testicular UMVD exceeding 28.50/cm2 and a testicular UVE larger than 8.94 mL strongly indicate favorable outcomes in terms of sperm retrieval.