Testicular Sperm Extraction Procedure Research Articles

P-741 Standard IV Cannula Aspiration (SIVCA): A step-by-step video demonstration of the minimally invasive testicular sperm aspiration technique with technical improvements after 4 years of experience

Abstract Study question Is there room for further technical improvements in the Standard IV Cannula Aspiration (SIVCA), for a more efficient testicular issue aspiration and sperm extraction procedure? Summary answer A more efficient SIVCA procedure can be achieved by using a higher flow-rate cannula, less negative pressure aspiration and a Luer Lock syringe. What is known already Standard IV Cannula Aspiration (SIVCA) was introduced in 2022. It showed comparable sperm retrieval rates (SRR) to mTESE (56.2 vs 57.3%; McNemar P = 1.000). But given the novelty of the technique, some technical difficulties were encountered: The 14G cannula frequently kinked during the back and forth motions of aspiration, thus having to be replaced several times during the procedure; and the aspirating syringe often detached from the catheter mid-procedure, due to the absence of a lock mechanism securing it to the flashback chamber of the cannula. Study design, size, duration 224 men were enrolled in this prospective 24 months cohort study conducted at a specialized IVF center. The men had testicular tissue aspiration performed via SIVCA, either for azoospermia or increased seminal sperm DNA fragmentation, in anticipation of their partners’ ovum pick-up for an ICSI cycle. If enough testicular tissue was aspirated, it was examined for sperm. If not more than 0.2 gm of tissue could be aspirated from either testis, the patient underwent mTESE. Participants/materials, setting, methods After general anesthesia, 5cc of Xylocaine (lidocaine HCl) 2% was instilled into each spermatic cord. A standard 14-G 310 ml/min flow-rate IV cannula was introduced into the testis. After withdrawing the needle, a 3cc Luer Lock syringe was secured to the cannula. The plunger was maximally retracted to generate −250 Torr of negative pressure and clamped. Back and forth motions were performed, mapping and aspirating tissues from different regions of each testis at a time. Main results and the role of chance Out of a total of 224 cases, an adequate testicular tissue sample of more than 0.2 gm was successfully aspirated from 218 cases, with a 0.97 probability of success. Mild hematoma and pain were encountered in 5.8% of cases (n = 13/224) and subsided within two to three weeks (Grade I on the Clavien Dindo Scale). In a previous series, 130 cases of SIVCA were performed by fully retracting the plunger of a regular 20cc syringe, generating about −520 Torr of negative pressure, while the syringe was connected - but not secured - to the flashback chamber of a 270ml/min flow-rate cannula. In that series, adequate tissue samples could successfully be aspirated in 122 cases, showing a 0.93 probability of success. By using a higher flow-rate 14G IV cannula (310 ml/min vs 270 ml/min), less negative pressure (−250 Torr vs − 520 Torr) and a Luer Lock syringe; fewer number of cannulas were lost to kinking per procedure and no inconvenient disconnections occurred mid-procedure between the cannula and the aspirating syringe owing to the Luer Lock mechanism; all while maintaining a high success rate of aspiration of sufficient testicular tissue (X2 (1, N = 354) = 2.6156, p = .10582). Limitations, reasons for caution Whenever sclerosis and/or fibrosis of testicular tissue rendered aspiration of adequate amounts of testicular tissue difficult or challenging, we reverted to surgical m-TESE. Ice packs should be applied for at least 48 to 72 hours post-procedure to forestall hematomas. Further blinded randomized control studies with larger datasets are recommended. Wider implications of the findings SIVCA is a safe, efficient and easily reproducible method of testicular sperm aspiration. Its allowance for mapping different regions of the testes in order to extract sufficient amounts of tissues, makes it an ideal initial alternative to surgical m-TESE for testicular tissue aspiration and sperm searching. Trial registration number NCT05247723

P-072 Fresh testicular sperm seems to yield more fertilization abnormalities and early pregnancy loss than frozen testicular sperm

Abstract Study question How do ICSI outcomes using fresh testicular sperm, compare to those using frozen samples cryopreserved from the previous fresh testicular sperm extraction (TESE)? Summary answer Although fresh testicular sperm led to a better fertilization and pregnancy rate,it yielded more fertilization abnormalities and miscarriages than frozen sperm for the same couples. What is known already Testicular biopsies can be performed in cases of severe male infertility to search for spermatozoa. In the current era of advanced reproductive techniques, ICSI in association with TESE may be an effective treatment for patients with azoospermia. TESE could be performed the day of oocyte pick-up, or instead, it may be accomplished previously, and in this case TESE spermatozoa are cryopreserved for the future ICSI cycles. However, when reviewing the literature, not a lot of papers tried to compare the ICSI outcomes between fresh and frozen testicular sperm in the same couples. Study design, size, duration This retrospective study included the clinical and embryological data of pairs of fresh and frozen sperm injection cycles from couples after TESE between 2010 and 2023. The first ICSI was performed with fresh spermatozoa retrieved from TESE. The subsequent ICSI cycles used frozen spermatozoa from the first TESE. Participants/materials, setting, methods All infertile couples that underwent ICSI+TESE with testicular sperm cryopreservation in the study period were identified (110 couples). Of whom, 34 couples who underwent 40 subsequent ICSI cycle using frozen spermatozoa from the previous TESE were included. ICSI cycles were divided in: Group 1:ICSI with TESE and fresh testicular sperm injection Group 2:ICSI with frozen testicular sperm injection ICSI outcomes were compared for: fertilization/fertilization abnormalities rate, embryo quality, pregnancy and miscarriages rate, and live birth rate. Main results and the role of chance The average age of men who underwent ICSI was 42 years, while that of women was 33 years. On average, the couples had their ICSI with frozen sperm within 1.7 years after the TESE. There were no significant differences in women’s clinical parameters, the type of ovarian stimulation used nor its primary outcome between the two ICSI attempts. Although the primary outcome of ICSI showed a significantly higher fertilization rate for fresh testicular sperm compared to frozen sperm (64.4% vs 44.8%; p = 0.003), there was a tendency for more fertilization abnormalities when fresh testicular sperm was used (8.3% vs 6.2%, p = 0.4). Despite a better quality of cleavage embryos in ICSI with fresh testicular sperm (43.9% vs 39.2%, p = 0.6) and a higher pregnancy rate for the same group (21.9% vs 15.9%, p = 0.52), the miscarriage rate was twice as high when compared to the miscarriage rate of ICSI with frozen testicular sperm (6.7% vs 3.4%, p = 0.8), indicating that cryopreservation of testicular sperm could play a role in selecting better sperm for micro-injection. As for the live birth rate, ICSI with frozen sperm led to not statistically inferior rates when compared with ICSI with fresh sperm in the same couples (6.7% vs 10%, p = 0.6). Limitations, reasons for caution Due to our inclusion criteria, the study population may seem to be too reduced to reach significant results. To gain more informative insights, we recommend combining results from different centers and referring to the etiology of azoospermia that led to the TESE procedure. Wider implications of the findings Genetic testing and chromosomal aberration detection on testicular spermatozoa before and after cryopreservation could be proposed to compare the proportion of defected spermatozoa in both types of samples. Trial registration number not applicable

Successful cryptozoospermia management with multiple semen specimen collection

To determine the prevalence of sperm suitable for intracytoplasmic sperm injection (ICSI) in fresh ejaculated semen samples provided by men scheduled for a microdissection testicular sperm extraction (mTESE) procedure. Secondary objectives included an evaluation of the effect of a short abstinence period on semen quality and ICSI outcomes for men with cryptozoospermia. Retrospective cohort study. Academic medical center. All men were scheduled to undergo a mTESE procedure by a single, high-volume surgeon at an academic center from September 1, 2015, to May 1,2021. Presence of sperm suitable for ICSI in the ejaculate on the day of scheduled mTESE. Prevalence of sperm suitable for ICSI in the ejaculate among previously diagnosed men with azoospermia. Secondary outcomes included changes in semen parameters, clinical pregnancy rate, and live birth rate. Of 727 planned mTESE procedures, 69 (9.5%) were canceled because sperm suitable for ICSI were identified in a fresh ejaculated sample produced on the day of scheduled surgery (typically one day before oocyte retrieval). Overall, 50 men (50/727, 6.9%) used these rare, ejaculated sperm for ICSI. Semen samples obtained with <24 hours of abstinence were more likely to have better motility than the sample initially provided on the day of the planned mTESE. The live birth rate per ICSI attempt using these rare, ejaculated sperm was 36% (19/53). Providing a fresh ejaculated semen sample on the day of mTESE allows nearly 10% of men with azoospermia to avoid surgery with satisfactory ICSI outcomes. Providing multiple ejaculated samples over a short period of time does not adversely affect sperm concentration and may enhance sperm motility in men with cryptozoospermia.

Proteomic Analysis of Testicular Interstitial Fluid in Men with Azoospermia

BackgroundThe primary microenvironment of the testis comprises testicular interstitial fluid (TIF) surrounding the seminiferous tubules and testicular interstitial tissue. The pathological alterations of germ and Sertoli cells could affect the TIF composition and might contain putative biomarkers for monitoring active spermatogenesis. ObjectiveWe identified differentially expressed proteins in the TIF of patients with obstructive (OA) or nonobstructive (NOA) azoospermia to elucidate the underlying etiology of defective spermatogenesis. Design, setting, and participantsWe prospectively enrolled nine patients, including three men with OA and six with NOA with (n = 3) and without (n = 3) successful sperm retrieval. Their TIF was collected during the testicular sperm extraction procedure. Outcome measurements and statistical analysisTIF was analyzed using liquid chromatography-tandem mass spectrometry to identify differentially expressed proteins specific to OA and NOA with or without successful sperm retrieval. The dysregulated protein was further validated using Western blotting. Results and limitationsAmong the 555 TIF proteins identified in NOA patients, 14 were downregulated relative to OA patients. These proteins participate in biological processes such as proteolysis, complement activation, and immune responses; complement and coagulation cascade pathways were also enriched. Furthermore, 68 proteins with significantly higher levels were identified in the TIF of NOA patients with successful sperm retrieval than in those with failed sperm retrieval; these are mainly implicated in oxidation-reduction processes. The expression of calreticulin, which can distinguish successful and failed testicular sperm retrieval in the NOA group, was validated by Western blotting. ConclusionsWe provide the first scientific evaluation of TIF protein composition in men with azoospermia. These findings will help identify the physiological and pathological roles of each protein in regulating sperm production. Thus, our study underscores the potential of TIF in sperm retrieval biomarker discovery and would serve as a foundation for further studies to improve treatment strategies against azoospermia. Patient summaryUsing a proteomic approach, we identified and analyzed the total protein content of testicular interstitial fluid in humans with defective spermatogenesis for the first time and discovered altered protein expression patterns in patients with nonobstructive azoospermia (NOA). Proteins related to oxidation-reduction processes were upregulated in NOA patients with successful sperm retrieval compared with those with failed sperm retrieval. This can aid the development of novel diagnostic tools for successful testicular sperm retrieval.

Repeat Microdissection Testicular Sperm Extraction in Azoospermic Men with Nonmosaic Klinefelter Syndrome

Introduction. To investigate the predictive factors for successful repeat microdissection testicular sperm extraction attempts in patients with Klinefelter syndrome. Methods. A total of 28 azoospermic men with nonmosaic Klinefelter syndrome who have received microdissection testicular sperm extraction twice with successful initial microdissection testicular sperm extraction attempts in our institute were studied. Outcome variables (age, serum follicle-stimulating hormone, luteinizing hormone, testosterone, prolactin, and estradiol) of azoospermic men with nonmosaic Klinefelter syndrome and a successful 2nd surgical sperm retrieval attempt (group A) were compared to those with an unsuccessful 2nd sperm retrieval attempt (group B). Results. Twenty-one patients (75%) had successful sperm recovery at the 2nd microdissection testicular sperm extraction attempt. The mean testosterone level at baseline and before the 1st microdissection testicular sperm extraction attempt was higher in group A than in group B (2.7 vs. 0.9 ng/mL, p &lt; 0.01 , and 3.9 vs. 1.1 ng/mL, p = 0.02 ). Receiver operating characteristic curve analysis identified the threshold baseline testosterone concentration (1.5 ng/mL) of patients with Klinefelter syndrome in predicting successful 2nd sperm retrieval attempts and revealed positive and negative predictive values of 94.44% and 60%, respectively. Conclusion. Azoospermic men with Klinefelter syndrome presenting with low testosterone levels and successful sperm recovery during the first microdissection testicular sperm extraction procedure are unlikely to retrieve sperm on the 2nd microdissection testicular sperm extraction attempt. Hence, these patients should be properly counseled before sperm retrieval.

MP30-05 CONCORDANCE OF TESTIS HISTOLOGY AMONG MEN UNDERGOING BILATERAL TESTICULAR SPERM EXTRACTION PROCEDURES

You have accessJournal of UrologyCME1 Apr 2023MP30-05 CONCORDANCE OF TESTIS HISTOLOGY AMONG MEN UNDERGOING BILATERAL TESTICULAR SPERM EXTRACTION PROCEDURES Jessica Marinaro, Jonathan Gal, and James Kashanian Jessica MarinaroJessica Marinaro More articles by this author , Jonathan GalJonathan Gal More articles by this author , and James KashanianJames Kashanian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003258.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: For men undergoing a microdissection testicular sperm extraction (mTESE) procedure, if sperm are not found in one testis, a bilateral procedure is typically performed; however, this invasive dissection may have adverse effects. While testicular histology may predict sperm retrieval rates (SRRs), little is known about the concordance of histology between testes. Since this may inform the utility of performing a bilateral versus unilateral dissection, our objective was to assess the rate of histological concordance between left and right testis biopsies and as well as the overall sperm retrieval rate (SRR) for these patients. METHODS: We retrospectively reviewed electronic medical records using CPT codes 55899 and 54505 for 1 surgeon from 6/2016 to 8/2022. Men were included if they underwent a testicular sperm extraction (TESE) or mTESE procedure. Biopsies were evaluated by 4 pathologists at our institution. Histology was classified as Sertoli-cell only (SCO), maturation arrest (MA; early or late), active spermatogenesis (AS), or tubular atrophy (TA). Each pattern was reported as a percentage contributing to a total of 100%. A successful sperm retrieval was defined as the presence of sperm after processing by an andrology lab. RESULTS: Of 128 men who underwent a TESE or mTESE, 38 (29.7%) had a bilateral procedure. Mean demographics for these 38 men included an age at surgery of 39.4 ± 7.0 years, baseline testosterone 400.1 ± 198.0 ng/dL, baseline FSH 18.7 ± 14.9 mIU/mL, right testis volume 10.1 ± 6.4 mL, and left testis volume 10.2 ± 6.4 mL. Thirty-one men (31/38, 81.6%) had biopsies sent for histology from both testes. Of these, 9 (29.0%) had the same histology in the same proportions bilaterally, 14 (45.2%) had the same predominant histology but in variable proportions, and 8 (25.8%) had discordant predominant histology. Ten of 31 men (32.3%) had sperm retrieved; of these, 6 (60%) had no evidence of spermatogenesis on either histology specimen. CONCLUSIONS: While it is known that there is often heterogeneity within the testis, this study confirms that there is also significant heterogeneity between each testis for >25% of men. Though histology may help to predict SRRs, this study emphasizes that histology alone is not reliable in determining which men will have sperm present after processing by an andrology lab. Ultimately, while histology may provide patients and providers with useful information on testicular architecture, it should not be the only factor in clinical decision making, such as who should undergo a bilateral procedure or repeat procedure. Source of Funding: Authors JM and JG are supported in part by the Frederick J. and Theresa Dow Wallace Fund of the New York Community Trust. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e392 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jessica Marinaro More articles by this author Jonathan Gal More articles by this author James Kashanian More articles by this author Expand All Advertisement PDF downloadLoading ...

MP30-07 EVALUATION OF MTESE OUTCOMES IN PATIENTS WITH PARTIAL AZFb Y CHROMOSOME MICRODELETIONS

You have accessJournal of UrologyCME1 Apr 2023MP30-07 EVALUATION OF MTESE OUTCOMES IN PATIENTS WITH PARTIAL AZFb Y CHROMOSOME MICRODELETIONS Jonathan Gal, Jessica Marinaro, Anna Mielnik, and Peter Schlegel Jonathan GalJonathan Gal More articles by this author , Jessica MarinaroJessica Marinaro More articles by this author , Anna MielnikAnna Mielnik More articles by this author , and Peter SchlegelPeter Schlegel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003258.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Y chromosome microdeletions (YCMD) are a common cause of non-obstructive azoospermia. While men with deletions in the azoospermia factor C (AZFc) region have a high likelihood of having sperm in the ejaculate, or sperm retrievable with effective microdissection testicular sperm extraction (mTESE) procedure, those with complete deletions in the AZFa or AZFb regions have a poor prognosis for identification of sperm. Men with AZFa deletions typically do not have any germ cells, and no men, to-date, with complete AZFb deletions have had usable sperm identified. Partial deletions of AZFb appear to portend a different prognosis for fertility potential. Our objective was to evaluate semen parameters, sperm retrieval rates and fertility outcomes in men with partial deletions of the AZFb region. METHODS: We retrospectively reviewed 468 men with YCMDs who underwent testing at our institution from 4/1996 to 8/2022. Of these, we identified 20 men with partial AZFb deletions, defined as a deletion of some but not all tested segments from sY1227 to sY1291. Of these, 8 had documented semen analysis and underwent mTESE by a single, high-volume surgeon (PS). Sperm retrieval rate (SRR) was defined as the presence of mature sperm identified after processing by a trained andrologist. RESULTS: Of the 8 men with a partial AZFb deletion, 7 (87.5%) had a sY117-sY1291 deletion, and one (12.5%) had an sY1227-sY1192 deletion. All 8 men (100%) were azoospermic. Mean testosterone levels were 450.5 ± 350.5 (ng/dL), Mean FSH 6.5±2.8 (mIU/mL). After mTESE, 1 of 7 men (14%) with an sY117-sY1291 deletion was found to have sperm, and the 1 man with a sY1227-sY1192 deletion was found to have round spermatids on histology. Overall, the SRR was 12%. All pathology specimens (n=8, 100%) demonstrated maturation arrest. CONCLUSIONS: In this large series, we demonstrate that while patients with partial AZFb deletions are azoospermic, it is possible to find sperm at least for some men with mTESE. Distinguishing partial from complete AZFb deletions may have prognostic value. Further work is needed to determine which men with partial AZFb deletions are more likely to have a successful mTESE procedure. Source of Funding: Author JG is supported in part by the Frederick J. and Theresa Dow Wallace Fund of the New York Community Trust © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e393 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jonathan Gal More articles by this author Jessica Marinaro More articles by this author Anna Mielnik More articles by this author Peter Schlegel More articles by this author Expand All Advertisement PDF downloadLoading ...

Micro RNA in Semen/Urine from Non-Obstructive Azoospermia Patients as Biomarkers to Predict the Presence of Testicular Spermatozoa and Spermatogonia

About half of testicular sperm extraction (TESE) procedures in men with non-obstructive azoospermia (NOA), including men with Klinefelter syndrome (KS), are unsuccessful. To avoid unnecessary invasive surgery, biomarkers for spermatozoa were studied. In addition, markers for spermatogonia in testis tissue were explored. This study aimed to find biomarkers in the semen and/or urine of NOA patients to predict the presence of spermatogonia in the testis. Differentially expressed miRNAs were identified (1) between samples from patients with and without a positive TESE procedure as well as (2) between TESE-negative patients with and without spermatogonia. A total of thirteen upregulated miRNAs (ten in seminal plasma and three in urine) were found in the TESE-negative/spermatogonia-positive group compared to the TESE-negative/spermatogonia-negative group. These miRNAs could be potential biomarkers for spermatogonia; however, more research is necessary to validate their predictive power.

Impact of Spermatozoa Cryopreservation on Clinical Outcomes of Intracytoplasmic Sperm Injection in Patients with Azoospermia: A Retrospective Cross-Sectional Study

Background: This study was undertaken to evaluate the effect of cryopreservation on the clinical outcomes of intracytoplasmic sperm injection (ICSI) cycles using sperm retrieved from testicular sperm extraction (TESE) in patients with azoospermia. Methods: This retrospective analysis included the clinical data of 56 pairs of fresh and frozen sperm injection cycles from 56 couples after TESE from January 2019 to December 2021 at the Reproductive Medicine Center of the First Affiliated Hospital of Sun Yat-sen University, of which 42 pairs were ICSI cycles using fresh and frozen sperm from the same TESE procedure. We compared the embryological and laboratory characteristics and pregnancy outcomes of the subsequent first embryo transfer (ET) cycles between the fresh and frozen groups. Results: There were no significant differences in the fertilization, cleavage, good-quality day 3 embryo, blastocyst formation, and good-quality blastocyst rates between the groups. However, when only paired ICSI cycles of fresh and frozen sperm from the same TESE procedure were analyzed, we observed that the good-quality day 3 embryo rate (44.8% vs 33.2%, p = 0.029) and blastocyst formation rate (57.5% vs 41.3%, p = 0.028) in the fresh group were significantly higher than those in the frozen group. Implantation, clinical pregnancy, early miscarriage, and live birth rates of the first ET cycle were not significantly different in either group. Conclusions: ICSI using fresh testicular sperm after TESE in patients with azoospermia appears to yield better embryological and laboratory outcomes than ICSI using cryopreserved testicular sperm, but the success rate of the subsequent first ET cycles does not seem to be affected.

MEN WITH NON-OBSTRUCTIVE AZOOSPERMIA AND HISTORY OF FAILED (MTESE) MICRODISSECTION TESTICULAR SPERM EXTRACTION: OUTCOMES AFTER INTRATESTICULAR INJECTION OF PLATELET RICH PLASMA (PRP)

The aim of the current study was to investigate the effect of intratesticular injection of autologous platelet rich plasma (PRP) on sperm retrieval rates and IVF outcomes in men with non-obstructive azoospermia (NOA) and a history of atleast one previously failed microdissection testicular sperm extraction (mTESE) procedure.

For patients with non-obstructive azoospermia, the outcome of testicular sperm extraction correlates with self-esteem, sexual health and the quality of the couple\u2019s relationship

BackgroundA very small number of studies have indicated that azoospermia or negative testicular sperm extraction (TESE) outcomes are linked to depression or erectile dysfunction. However, the data are often weak, conflicting and gathered with non-validated questionnaires. Hence, we performed a cross-sectional study of 44 men with non-obstructive azoospermia. Levels of self-esteem and the quality of the couple’s sex life and overall relationship were assessed with validated questionnaires before and after the TESE procedure as a function of the TESE outcome.ResultsA positive TESE outcome (n = 24) was associated with a statistically significant increase in self-esteem (particularly with regard to family aspects), sexual health and couples’ adjustment quality. In contrast, a negative TESE outcome (n = 20) was associated with statistically significant decreases in self-esteem, erectile function, intercourse satisfaction, orgasmic function, couples’ adjustment quality and all aspects of the couple’s relationship (consensus, cohesion, satisfaction and affection).ConclusionFor men with non-obstructive azoospermia (NOA), negative TESE outcomes may have a negative impact on self-esteem and the quality of the couple’s sex life and overall relationship. This should be borne in mind when counselling men with NOA and their partners to (ideally) help them to cope with and decrease the harmful impacts of azoospermia and negative TESE.

Histological study on the influence of puberty suppression and hormonal treatment on developing germ cells in transgender women.

STUDY QUESTIONCan transgender women cryopreserve germ cells obtained from their orchiectomy specimen for fertility preservation, after having used puberty suppression and/or hormonal treatment?SUMMARY ANSWERIn the vast majority of transgender women, there were still immature germ cells present in the orchiectomy specimen, and in 4.7% of transgender women—who all initiated medical treatment in Tanner stage 4 or higher—mature spermatozoa were found, which would enable cryopreservation of spermatozoa or testicular tissue after having used puberty suppression and/or hormonal treatment.WHAT IS KNOWN ALREADYGender affirming treatment (i.e. puberty suppression, hormonal treatment, and subsequent orchiectomy) impairs reproductive function in transgender women. Although semen cryopreservation is generally offered during the transition process, this option is not feasible for all transgender women (e.g. due to incomplete spermatogenesis when initiating treatment in early puberty, in case of inability to masturbate, or when temporary cessation of hormonal treatment is too disruptive). Harvesting mature spermatozoa, or testicular tissue harboring immature germ cells, from orchiectomy specimens obtained during genital gender-affirming surgery (gGAS) might give this group a chance of having biological children later in life. Previous studies on spermatogenesis in orchiectomy specimens showed conflicting results, ranging from complete absence of germ cells to full spermatogenesis, and did not involve transgender women who initiated medical treatment in early- or late puberty.STUDY DESIGN, SIZE, DURATIONHistological and immunohistochemical analyses were performed on orchiectomy specimens from 214 transgender women who underwent gGAS between 2006 and 2018. Six subgroups were identified, depending on pubertal stage at initiation of medical treatment (Tanner stage 2-3, Tanner stage 4-5, adult), and whether hormonal treatment was continued or temporarily stopped prior to gGAS in each of these groups.PARTICIPANTS/MATERIALS, SETTING, METHODSAll transgender women used a combination of estrogens and testosterone suppressing therapy. Orchiectomy specimen sections were stained with Mayer’s hematoxylin and eosin and histologically analyzed to assess the Johnsen score and the ratio of most advanced germ cell types in at least 50 seminiferous tubular cross-sections. Subsequently, immunohistochemistry was used to validate these findings using spermatogonia, spermatocytes or spermatids markers (MAGE-A3/A4, γH2AX, Acrosin, respectively). Possibilities for fertility preservation were defined as: preservation of spermatozoa, preservation of spermatogonial stem cells or no possibilities (in case no germ cells were found). Outcomes were compared between subgroups and logistic regression analyses were used to assess the association between the duration of hormonal treatment and the possibilities for fertility preservation.MAIN RESULTS AND THE ROLE OF CHANCEMature spermatozoa were encountered in 4.7% of orchiectomy specimens, all from transgender women who had initiated medical treatment in Tanner stage 4 or higher. In 88.3% of the study sample orchiectomy specimens only contained immature germ cells (round spermatids, spermatocytes or spermatogonia, as most advanced germ cell type). In 7.0%, a complete absence of germ cells was observed, all these samples were from transgender women who had initiated medical treatment in adulthood. Cessation of hormonal treatment prior to gGAS did not affect the presence of germ cells or their maturation stage, nor was there an effect of the duration of hormonal treatment prior to gGAS.LIMITATIONS, REASONS FOR CAUTIONSince data on serum hormone levels on the day of gGAS were not available, we were unable to verify if the transgender women who were asked to temporarily stop hormonal treatment 4 weeks prior to surgery actually did so, and if people with full spermatogenesis were compliant to treatment.WIDER IMPLICATIONS OF THE FINDINGSThere may still be options for fertility preservation in orchiectomy specimens obtained during gGAS since a small percentage of transgender women had full spermatogenesis, which could enable cryopreservation of mature spermatozoa via a testicular sperm extraction procedure. Furthermore, the vast majority still had immature germ cells, which could enable cryopreservation of testicular tissue harboring spermatogonial stem cells. If maturation techniques like in vitro spermatogenesis become available in the future, harvesting germ cells from orchiectomy specimens might be a promising option for those who are otherwise unable to have biological children.STUDY FUNDING/COMPETING INTERESTNone.TRIAL REGISTRATION NUMBERN/A.

MP21-03 INHIBIN B IS A PREDICTIVE FACTOR OF SPERM RECOVERY IN NON-OBSTRUCTIVE AZOOSPERMIA

You have accessJournal of UrologyInfertility: Epidemiology & Evaluation I (MP21)1 Sep 2021MP21-03 INHIBIN B IS A PREDICTIVE FACTOR OF SPERM RECOVERY IN NON-OBSTRUCTIVE AZOOSPERMIA Isadora Badalotti-Teloken, Mariangela Badalotti, Guilherme Santiago, Bruna Santos, Bruna Araujo, Ana Karoline Rosa, Alvaro Petracco, and Claudio Teloken Isadora Badalotti-TelokenIsadora Badalotti-Teloken More articles by this author , Mariangela BadalottiMariangela Badalotti More articles by this author , Guilherme SantiagoGuilherme Santiago More articles by this author , Bruna SantosBruna Santos More articles by this author , Bruna AraujoBruna Araujo More articles by this author , Ana Karoline RosaAna Karoline Rosa More articles by this author , Alvaro PetraccoAlvaro Petracco More articles by this author , and Claudio TelokenClaudio Teloken More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002006.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inhibin B is a glycoprotein produced by seminiferous tubules, predominantly by Sertoli cells, and has been proposed as a non-invasive marker of spermatogenesis. This study aimed to assess the potential of inhibin B as a spermatogenesis marker compared with follicle-stimulating hormone (FSH) and in non-obstructive azoospermic men, its association with testicular cyto-histology, and its potential to predict the presence of sperm at testicular sperm extraction (TESE) procedure. METHODS: Clinical and laboratory data of men treated at a Brazilian human reproduction center were reviewed. To evaluate the correlation between inhibin B and FSH, the patients were divided in groups: non-obstructive azoospermia (NOA), severe oligospermia (SO, sperm concentration <5.106/ml), and mild to moderate oligospermia (MO, sperm concentration 5-14.9.106/ml); fertile normozoospermic patients composed the control group (CG). In the NOA group the correlation between inhibin B and testicular cyto-histology (CE–complete spermatogenesis; MA–maturation arrest at level of spermatid; SC–only Sertoli cells, spermatocyte or spermatogonia) was evaluated. Testicular specimens were obtained in 3 different areas of each testi. In patients who underwent TESE, the presence of sperm was evaluated. The statistical analysis was carried out using Kruskal-Wallis, Spearman, and Mann-Whitney U test, multiple regression and ROC curve, considering p<0.05 significant. RESULTS: A total of 246 cases was eligible; NOA n=135 (mean age 36.9 yo), SO n=89 (mean age 36.7 yo), MO n=10 (mean age 37.2 yo) and CG n=11. The median level of inhibin B (pg/ml) was 36.8 in NOA, 74.0 in SO, 109.0 in MO and 196.0 in CG (p<0.0001). The correlation between inhibin B and FSH was significant (r=0,701; p<0.0001). In the cyto-histological comparison, the median value of inhibin B was 87.6 in CE, 42.7 in MA and 22.0 in SC (p<0.0001). Patients with inhibin B ≥88,0 have a 73.3% chance of having spermatozoa or spermatid in cyto-histology, and those with inhibin B ≤22.0 have a 76.3% chance of not having these cells (p<0.0001). In the TESE results, the median level of inhibin B was 80.0 in the group with sperm and 27.6 in the group with no sperm. Inhibin B ≥88,0 also has an 85% positive predictive value for having spermatozoa in TESE (p=0.047). CONCLUSIONS: This study shows a cutoff point for inhibin B ≥ 88.0 for a good prognosis of finding sperm in azoospermic individuals for assisted reproduction through TESE. Furthermore, an inhibin B ≤22 points to a bad prognosis, suggesting that the patients look further into infertility treatment alternatives, such as sperm bank. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e346-e347 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Isadora Badalotti-Teloken More articles by this author Mariangela Badalotti More articles by this author Guilherme Santiago More articles by this author Bruna Santos More articles by this author Bruna Araujo More articles by this author Ana Karoline Rosa More articles by this author Alvaro Petracco More articles by this author Claudio Teloken More articles by this author Expand All Advertisement Loading ...

P–038 Clinical outcomes of 77 testicular sperm extraction treatment cycles in non-mosaic Klinefelter syndrome patients

Abstract Study question What are the clinical results of patients with azoospermia and nonmosaic Klinefelter syndrome, using fresh and cryopreserved sperm? Summary answer The results showed a recovery rate of testicular sperm in the order of 40% and a life newborn rate of 52% when using fresh sperm What is known already In Klinefelter syndrome (KS), the rates of successful testicular sperm retrieval were shown to be similar either using conventional TESE or micro-TESE (Corona et al., 2017), which highlights that the variability observed between studies is due to differences in patient characteristics. There are a few works with a large number of KS patients elucidating the clinical outcomes using fresh and cryopreserved testicular sperm. However, these studies revealed contradictory outcomes, either revealing better (Greco et al., 2013; Vicdan et al., 2016) or worst (Madureira et al., 2014) results with cryopreserved testicular sperm, or finding no differences (Chen et al, 2019). Study design, size, duration This study includes all patients up to 2019 presenting azoospermia due to non-mosaic Klinefelter syndrome (n = 76) that went for infertility consultations in a private fertility clinic. Patients were evaluated by the same Urologist. The genetic analysis of the patients was performed at an academic institution. At examination patients did not refer other complaints besides infertility, and referred to have not received any hormone replacement therapy in the past. Participants/materials, setting, methods The 76 azoospermic patients with non-mosaic Klinefelter syndrome (KS) were treated by testicular sperm extraction (TESE) followed by intracytoplasmic sperm injection (ICSI), using fresh and cryopreserved testicular sperm. Most patients used fresh testicular sperm, where others preferred to postpone ICSI treatment cycles and used cryopreserved testicular sperm. Aneuploidy screening in children was performed by prenatal diagnosis and MLPA (Multiplex ligation-dependent probe amplification). Full embryological, clinical and newborn outcomes are provided. Main results and the role of chance Of the 76 patients with non-mosaic Klinefelter syndrome, one repeated the testicular sperm extraction (TESE) procedure. Testicular sperm were recovered in 31/77 (40.3%) of the cases. Comparisons between the 31 cases with successful sperm recover (group–1) and the 46 cases without a successful TESE (group–2) revealed no significant differences regarding age, time of infertility, testicular volume, serum levels of FSH, LH and testosterone, total number of testicular fragments analyzed, and time of search in samples. The mean male age was 34 years. In most of the cases, the testicular volume was reduced (96.1%), the levels of FSH (98.3%) and LH (94.1%) were increased, and the levels of testosterone were normal (77.6%). There were 25 intracytoplasmic sperm injection (ICSI) treatment cycles using fresh testicular sperm and 22 ICSI treatment cycles using frozen testicular sperm. The rates of fertilization (63.5% fresh sperm vs 41.6% frozen sperm), implantation (37% fresh sperm vs 13.2% frozen sperm), clinical pregnancy (60.9% fresh sperm vs 19% frozen sperm), live birth delivery (52.2% fresh sperm vs 19% frozen sperm) and newborn (65.2% fresh sperm vs 23.8% frozen sperm) were higher in the group using fresh testicular sperm. Chromosome analysis of the 21 newborn was normal. Limitations, reasons for caution Although presenting a high number of cases with azoospermic non-mosaic Klinefelter syndrome treated with testicular sperm extraction and intracytoplasmic sperm injection, future studies are needed with a higher number of cycles using frozen testicular sperm, in order to confirm or rebut that the freezing methodology affects negatively the clinical outcomes. Wider implications of the findings: Data adds further information regarding testicular sperm retrieval rates and use of fresh or frozen testicular sperm in Klinefelter syndrome (KS) patients. High newborn rates were obtained only with fresh testicular sperm. Results also reassure KS patients about the safety relative to any abnormal chromosomal transmission to the born children. Trial registration number Not applicable

Endocrine Follow-Up of Men with Non-Obstructive Azoospermia Following Testicular Sperm Extraction.

Testicular sperm extraction (TESE) is a surgical procedure which, combined with intracytoplasmic sperm injection, constitutes the main treatment for achieving biological parenthood for patients with infertility due to non-obstructive azoospermia (NOA). Although it is effective, TESE procedures might cause structural testicular damage leading to Leydig cell dysfunction and, consequently, temporary or even permanent hypogonadism with long-term health consequences. To a lesser extent, the same complications have been reported for microdissection TESE, which is considered less invasive. The resulting hypogonadism is more profound and of longer duration in patients with Klinefelter syndrome compared with other NOA causes. Most studies on serum follicle-stimulating hormone and luteinizing hormone concentrations negatively correlate with total testosterone concentrations, which depends on the underlying histology. As hypogonadism is usually temporary, and a watchful waiting approach for about 12 months postoperative is suggested. In cases where replacement therapy with testosterone is indicated, temporary discontinuation of treatment may promote the expected recovery of testosterone secretion and revise the decision for long-term treatment.

The Assessment of 5 Polymorphisms in the USP9Y Gene in Infertile Patients with Non-obstructive Azoospermia

Background: Male factor infertility that is the cause of about half of the infertility cases, may occur due to azoospermia. Because spermatogenesis defects may lead to non-obstructive azoospermia (NOA), investigating the factors involved in spermatogenesis, including hormones and genes, is one of the most important aspects in understanding the mechanism of NOA in men. Objectives: Male infertility is a complex disorder that affects a large proportion of men, yet many of its causes are unknown. Clarifying its genetic basis may help to identify the causes of infertility and provide effective treatment for patients. Methods: In this case-control study, single nucleotide polymorphisms (SNPs) located in the USP9Y gene were investigated. Accordingly, 100 healthy men and 100 NOA patients were regarded as control and case groups, respectively. Testis tissue samples were taken during the testicular sperm extraction (TESE) procedure, DNA extraction was done, and ARMS PCR was designed and performed. The rs3212292, rs2032597, rs2032604, rs2032598, and rs717268 polymorphisms in the USP9Y gene were analyzed by Tetra-ARMS PCR. Furthermore, the serum levels of sex hormones were assessed by the ELISA technique. Finally, the obtained data were analyzed by SPSS software. Results: According to the obtained results, there was no significant difference in case of genotype frequency of investigated SNPs between the case and control groups (P ≥ 0.05). The mean FSH and LH levels in the control group were relatively lower than the case group (P ≤ 0.05), whereas no significant difference in the mean testosterone level was observed between the two groups (P ≥ 0.05). Conclusions: Polymorphisms of the assessed SNPs showed no effect on the frequency of azoospermia; Thus, polymorphisms did not increase the risk of NOA and also did not have a protective effect against the disease. Also, the results showed that the serum levels of FSH and LH increased in NOA patients.

Coding and Non-Coding RNAs, as Male Fertility and Infertility Biomarkers.

Semen analysis is usually the first step in the assessment of male fertility. Although analyzes provide valuable information about male fertility, success of cytoplasmic sperm injection using this method is not predictable. In the recent years, studies have shown that sperm quality assessment helps clinicians predict male fertility status based on the expression of biomarkers. To write this article, a comprehensive study was conducted on several RNA transcripts by searching related words on medical information databases by 2018. According to the literature, spermatogenesis based disorders in male infertility have a significant relationship with the expression level of some RNA molecules (like DAZ and PRM1/PRM2 ratio) in semen and testicular tissue. Thus, they might be used as predictor biomarkers to evaluate success rate of testicular sperm extraction (TESE) procedure, but confirmation of this hypothesis requires more extensive research. By comparing the number of RNAs attributed to each fertility disorder in men, it is possible to trace the causes of disease or return fertility to some infertile patients by regulating the mentioned molecules. Further researches can provide a better understanding of the use of RNA expression profiles in the diagnosis and treatment of male infertility.

Nfertilite Tedavisinde TESE Başarısını Etkileyen Faktörler: Tek Merkez Deneyimi Ön Sonuçları

Objective: Today, infertility is a health problem with increasing treatment seeking. Testicular sperm extraction (TESE) is the only possible procedure to offer genetic parenting to men with nonobstructive azoospermia (NOA). Our aim in this study is to present our clinical experiences that affect the success of sperm retrieval in men with NOA in the light of the literature. Materials and Methods: In our study, patients who underwent TESE with a diagnosis of NOA between 2017-2020 were retrospectively analyzed. According to the TESE procedure; the patients were divided into two groups as conventional TESE and TESE performed under microscopic magnification (micro-TESE). Medical histories, hormone values, and physical examination findings of all patients were recorded. Results: Our micro-TESE success rate was found to be 100%. A positive correlation (rho 0.714, p = 0.009) was found between the factors affecting sperm retrieval , and the application of micro-TESE, and a negative correlation was detected with FSH levels (rho -0.759, p = 0.004). Conclusion: The success of sperm retrieval increases with the micro-TESE procedure. As FSH levels increase, sperm retrieval success rates decrease.

Testicular immune cells and vasculature in Klinefelter syndrome from childhood up to adulthood.

Is the distribution of immune cells and the testicular vasculature altered in testicular biopsies from patients with Klinefelter syndrome (KS)? Increased numbers of macrophages and mast cells, an increased expression of decorin and an increased blood vessel density were found in KS samples compared to controls. Most KS patients are infertile due to an early germ cell loss. From puberty onwards, testicular fibrosis can be detected. How this fibrotic process is initiated remains unknown. In this study, the number of macrophages, mast cells and their secretory products were evaluated in KS, Sertoli cell only (SCO) and control patient samples. The association between immune cell numbers and level of fibrosis in KS tissue was examined. In addition, the vascularization within these testicular tissue biopsies was studied. For immunohistochemical evaluation, KS patients at different stages of testicular development were included: prepubertal (aged 4-7 years; n = 4), peripubertal (aged 11-17 years; n = 21) and adult (aged >18 years; n = 37) patients. In addition, testicular tissue biopsies of adult SCO (n = 33) and control samples for the three KS age groups (prepubertal n = 9; peripubertal n = 5; adult n = 25) were analysed. Gene expression analysis was performed on adult testicular tissue from KS (n = 5), SCO (n = 5) and control (n = 5) patients. Adult (>18 years) KS, SCO and control testicular tissue biopsies were obtained during a testicular sperm extraction procedure. KS peripubertal (11-18 years), prepubertal (<11 years) and age-matched control biopsies were obtained from the biobank of the university hospital. Immunohistochemistry was used to determine the tubular structure (H/PAS), the number of spermatogonia (MAGE-A4), macrophages (CD68) and mast cells (tryptase) and the blood vessel density (Von Willebrand factor). In addition, quantitative real-time polymerase chain reaction was used to determine the expression of secretory products of macrophages and mast cells (tryptase, tumour necrosis factor alpha and decorin). A significant increase in the number of macrophages (P < 0.0001) and mast cells (P = 0.0008) was found in the peritubular compartment of testes of adult KS patients compared to control samples. However, no association between the number of immune cells and the degree of fibrosis was observed. In adult SCO samples, a significant increase was seen for peritubular macrophage (P < 0.0001) and mast cell (P < 0.0001) numbers compared to control samples. In the interstitial compartment, a significant increase in mast cell number was found in adult SCO samples compared to KS (P < 0.0001) and control (P < 0.0001) tissue. A significant difference (P = 0.0431) in decorin expression could be detected in adult KS compared to control patients. Decorin expression was mostly seen in the walls of the seminiferous tubules. When comparing the vascularization between KS patients and age-matched controls, a significant increase (P = 0.0081) in blood vessel density could be observed only in prepubertal KS testicular tissue. N/A. As controls for this study, testicular tissue biopsies of men who underwent a vasectomy reversal or orchiectomy were used, but these men may not represent fertile controls. In addition, a high variability in immune cell numbers, secretory products expression and number of blood vessels could be observed amongst all patient samples. Increased numbers of macrophages and mast cells have previously been described in non-KS infertile men. Our results show that these increased numbers can also be detected in KS testicular tissue. However, no association between the number of macrophages or mast cells and the degree of fibrosis in KS samples could be detected. Decorin has previously been described in relation to fibrosis, but it has not yet been associated with testicular fibrosis in KS. Our results suggest a role for this proteoglycan in the fibrotic process since an increased expression was observed in adult KS tissue compared to controls. Impaired vascularization in KS men was suggested to be responsible for the KS-related disturbed hormone levels. Our results show a significant difference in blood vessel density, especially for the smallest blood vessels, between prepubertal KS samples and age-matched controls. This is the first study to report differences between KS and control testicular tissue at prepubertal age. The project was funded by grants from the Vrije Universiteit Brussel (E.G.) and the scientific Fund Willy Gepts from the UZ Brussel (D.V.S.). D.V.S. is a post-doctoral fellow of the Fonds voor Wetenschappelijk Onderzoek (FWO; 12M2819N). No conflict of interest is declared for this research project.

SAT-043 Utility of Ultrasensitive Inhibin B Measurement for the Management of Men with Non-Obstructive Azoospermia

Inhibin B measurement by conventional assay(s) may be useful in the assessment of spermatogenesis in infertile male patients, especially in cases of azoospermia. Indeed, numerous previous studies have shown that Inhibin B could be helpful to predict a positive testicular sperm extraction (TESE). However, an undetectable Inhibin B concentration (<10pg/mL) does not predict a TESE failure in all cases. These findings explained that most medical centers have precluded the use of Inhibin B assay in the pre-operative hormonal assessment of azoospermic men. Recently, an ultrasensitive Inhibin B assay has been developed allowing the measurement of concentrations below 10pg/mL. The current study aims to assess the clinical relevance of this new assay in men with azoospermia with undetectable Inhibin B levels by conventional assay(s).Methods: This retrospective study included 71 non-obstructive azoospermic men who had undetectable Inhibin B levels (i.e. <10pg/mL by Gen II ELISA from Beckman Coulter, USA) and who underwent a TESE procedure between 2013 and 2019 in the Lille University Hospital. Serum LH, FSH and testosterone levels were systematically measured by routine immunoassays. Cryopreserved serum samples were used to perform ultrasensitive Inhibin B assay (Ultrasensitive Inhibin B, AL-195, Ansh Labs, USA). Additional hormonal assays including Inhibin A, Activin B and Activin A were performed on available subset of samples.Results: The TESE was successful, allowing sperm cryopreservation in 32.5 % (25/71) of the cases. No significant statistical difference was found in FSH, LH, or testosterone levels between patients with positive or negative TESE. By contrast, men with positive TESE had more than twice higher serum ultrasensitive Inhibin B levels (median 5.03pg/mL [1.93-8.5] vs. 2.19pg/mL [0.2-4.72], p=0.006). An ultrasensitive Inhibin B serum level >3.67 pg/mL (determined by ROC analysis) was associated with increased odds ratio (OR= 4.82; 95% CI: 1.647-12.93) for positive TESE. Inhibin A, Activin B and Activin A serum concentrations did not differ significantly between the two groups.Conclusion: FSH measurement which is routinely performed in men with azoospermia was not predictive of successful TESE whereas, Inhibin B was found to be a valuable marker in predicting TESE success in this population using ultrasensitive Inhibin B assay.