Use Of Testicular Spermatozoa Research Articles

P-012 Euploid and good-quality blastocysts using testicular sperm from men with high sperm DNA fragmentation (SDF), oligozoospermia, and previous failed ICSI with ejaculated sperm

Abstract Study question Are euploid rate and blastocyst quality improved when testicular sperm is used in patients with elevated SDF and poor semen parameters or/and previous ICSI failure? Summary answer The use of testicular spermatozoa in non-azoospermic males does preserve blastocyst ploidy while favoring the proportion of good-quality embryos available for the couple. What is known already Sperm extracted from the testicle has been proposed as a strategy to improve reproductive outcomes in couples with elevated DNA fragmentation in the ejaculate and with severe male infertility or previous ICSI failure. Different studies and meta-analyses show to increase pregnancy and live birth rates, and one of the reasons could be the lower genetic damage of spermatozoa retrieved from the testicle. However, there is little information on the effect on the quality of the embryos generated and their ploidy since the use of testicular sperm tends to have a higher rate of aneuploidy. Study design, size, duration This is a prospective, blinded, randomized, and controlled trial conducted in a private university-affiliated IVF center between October 2020 and June 2023. In each patient (n = 6), oocytes were randomly microinjected by sperm from the testis (T-ICSI) or ejaculate (E-ICSI) assigned in a 1:1 ratio. All males had an SDF>30% (measured by Sperm Chromatin dispersion (SCD) test), severe oligozoospermia, and/or a previous ICSI failure. Participants/materials, setting, methods Males underwent testicular sperm extraction (TESE) to obtain spermatozoa, which were frozen along with an ejaculated semen sample obtained previously on the same day. Women were <38 years old with good ovarian reserve (antral follicle count>10). SDF level was compared between both sources. The primary outcome was the euploid rate (among a total number of biopsied embryos). Secondary outcomes were fertilization rate, blastocyst rate, good-quality blastocyst rate, and ongoing pregnancy rate per embryo transfer (ET). Main results and the role of chance Mean ejaculated SDF was 44.83±16.6 (IC95% 27.5 -62.2), while mean women age was 31.8±2.9 (28.76-34.9). An average of 14.5±5.8 metaphase II oocytes were microinjected per patient. A total of 87 oocytes were randomized to the T-ICSI group (n = 45) or E-ICSI group (n = 42). There was a 14% difference between the SDF of testicular (44.7% (31.3-58.0) and ejaculated sperm (58.5% (37.6-79.4) (p = 0.2). The fertilization rate was slightly lower in the T-ICSI group (53.3% (38.1-68.1) compared to the E-ICSI group (61.9 (61.8-76.0) (p = 0.6). A total of 21 embryos reached the blastocyst stage, being the blastocyst arrival rate per correctly fertilized oocyte 41.7% (10/24) (22.8-63.1) for T-ICSI and 42.3% (11/26) (24.0-62.8) for E-ICSI (p = 1.0). Of them, a higher proportion of good-quality blastocysts was found in the T-ICSI (29.2% (13.4-51.6)) group than in the E-ICSI (19.2% (7.3-40.0)) group, although the difference was not statistically significant. In addition, the euploidy rate was comparable between the T-ICSI (60% (27.4-86.3)) and E-ICSI (63.6% (31.6-87.6)) groups (p = 1.0). Seven embryos were transferred in 6 ET, three in each study group. Only one of the ET in the E-ICSI group resulted in pregnancy (33.3% (1.8-87.5), while the three transfers in the T-ICSI group resulted in an ongoing pregnancy (100% (31.0-100)) (p = 1.0). Limitations, reasons for caution Despite being a randomized controlled trial, the number of subjects recruited is small; it is necessary to increase the number of cases to obtain results with greater statistical power. TESE is a technique that is not risk-free, so its performance should be evaluated in terms of its cost-benefit for patients. Wider implications of the findings The use of less genome-damaged testicular spermatozoa in non-azoospermic males seems to be a reliable strategy for couples with high ejaculated SDF and severe oligospermia and/or previous ICSI failures. However, although we have found an improvement, remains to be statistically confirmed with more cases. Trial registration number NCT04795440

Reproductive outcomes in patients with high levels of sperm DNA fragmentation using testicular sperm for intracytoplasmic injection: a retrospective analysis

This study aims to compare the embryological and clinical parameters of intracytoplasmic sperm injection (ICSI) cycles using testicular versus ejaculated sperm in male patients with elevated sperm DNA fragmentation (SDF). A total of 73 ICSI cycles were examined in couples where the male partner exhibited high levels of SDF. ICSI was performed using either ejaculated or testicular sperm. The primary outcomes were rates of blastocyst formation, high-quality embryo development, and clinical pregnancy. The DNA fragmentation index (DFI) for testicular sperm (16.81 ± 17.51) was significantly lower than that of ejaculated sperm (56.96 ± 17.56). While the blastocyst formation rate was significantly higher in the testicular sperm group compared to the ejaculated sperm group, no statistically significant differences were noted in fertilization rate (72.15% vs. 77.23%), rate of high-quality embryo formation (47.17% vs. 46.53%), clinical pregnancy (50% vs. 56.52%), Cumulative pregnancy (70.2% vs. 55.6%), or live birth rate (43.75% vs.43.48%). Testicular spermatozoa have no additional advantage over ejaculated spermatozoa except for blastocyst quality in patients with high SDF, the use of testicular spermatozoa for the first ICSI cycle in male infertility patients with high SDF should be undertaken after much consideration at present.

ICSI using testicular spermatozoa after failure of ICSI with ejaculated spermatozoa could be a good choice: A propensity score-matched cohort study.

Ejaculated spermatozoa are considered to possess a higher fertilisation potential than testicular spermatozoa. In selected cases, the use of testicular spermatozoa from non-azoospermic infertile men resulted in a higher implantation and pregnancy rate than the use of ejaculated spermatozoa. The primary objective was to compare the live birth rate and cumulative live birth rate between couples with failed intracytoplasmic sperm injection procedure using ejaculated spermatozoa who subsequently had an intracytoplasmic sperm injection cycle with testicular spermatozoa and those who subsequently had an intracytoplasmic sperm injection cycle with ejaculated spermatozoa. The secondary objective was to determine the indications for the use of testicular spermatozoa after intracytoplasmic sperm injection failure with ejaculated spermatozoa. A retrospective study of matched couples using propensity score matching analysis was performed. After an intracytoplasmic sperm injection failure (cycle_1), intracytoplasmic sperm injection with either ejaculated spermatozoa (ejaculated sperm group), or testicular spermatozoa (testicular sperm group), was performed (cycle_2). The matching was on intracytoplasmic sperm injection performed in cycle_1 according to spermatozoa used (testicular or ejaculated) in cycle_2. Logistic regression was used to evaluate the influence of sperm origin on cumulative live birth rate. Univariate analysis on parameters of cycle_1 was used to identify the prognostic factors to propose an intracytoplasmic sperm injection with testicular spermatozoa in case of cycle_1 failure. The study outcomes were live birth rate and cumulative live birth rate. Among the 6034 couples available, 63 were selected to constitute the testicular sperm group and 63 were selected by propensity score matching to constitute the ejaculated sperm group. After matching, the DNA fragmentation index was higher in the testicular sperm group (13.43%±9.65% vs. 8.93%±4.47%, p=0.013); no significant difference was observed for the fertilisation rate, the number of obtained embryos, blastulation rate and frozen embryo rate. In cycle_2, the live birth rate was higher in the testicular group (22.2% vs. 0.0%, p<0.001), as was the cumulative live birth rate (25.4% vs. 6.3%, p=0.065). The prognostic factors identified for the proposal of intracytoplasmic sperm injection procedure with testicular spermatozoa after intracytoplasmic sperm injection failure with ejaculated spermatozoa were: teratozoospermia, cryptozoospermia and high DNA fragmentation index. According to the present study and current knowledge, the use of testicular spermatozoa after failed intracytoplasmic sperm injection procedure in non-azoospermic men could be proposed instead of sperm donation in case of high sperm DNA fragmentation index, cryptozoospermia and teratozoospermia. A good oocyte response to ovarian stimulation during the previous assisted reproductive technology attempt will increase the chance of success. Although the main limitation of the current study is its retrospective nature, the use of the propensity score matching to perform causal inference study increases its reliability. The present study supports that the use of testicular spermatozoa outside the classical indication of azoospermia is a good option when the indication is well established. However, before proposing a testicular biopsy, an improvement in sperm characteristics should be considered by treating the causes of sperm alteration.

P-013 Testicular spermatozoa for intra-cytoplasmic sperm injection after IVF failure with ejaculated spermatozoa: a propensity score-matched cohort study

Abstract Study question Does the use of testicular spermatozoa from non-azoospermic infertile men after failed IVF with ejaculated spermatozoa increases the pregnancy rate? Summary answer Depending on semen characteristics and obtained embryos number at the previous IVF failure with ejaculated spermatozoa, it seems licit to propose ICSI with testicular spermatozoa. What is known already Ejaculated spermatozoa are generally considered to possess better fertilisation potential than testicular spermatozoa as their maturation has been completed. However, it has been shown that in selected cases, the use of testicular spermatozoa from non-azoospermic infertile men resulted in a higher implantation and pregnancy rate than the use of ejaculated spermatozoa. One of the reasons for this result is a higher DNA fragmentation index (DFI) in ejaculated spermatozoa compared to testicular spermatozoa. This increase in DFI would negatively affect embryo development and implantation. Study design, size, duration A retrospective matched cohort study using propensity score matching (PSM) analysis was performed. After an IFV failure (cycle_1), IVF with ejaculated or testicular spermatozoa was performed (cycle_2). Female age, female BMI, IVF rank, stimulation protocol, gonadotropin total quantity, treatment duration, punctured oocytes number, and mature oocytes punctured were included in PSM. The matching was performed for IVF performed in cycle_1 for cases and controls identified in cycle_2. 26 couples were included between 01/01/2012 and 30/09/2021. Participants/materials, setting, methods Among the 126 couples, for 63 couples, the cycle_2 was performed with ejaculated spermatozoa (controls) and for 63 couples with testicular spermatozoa (cases). Mixed logistic regression was used to compare outcomes of cases versus controls groups. The cycle_1 have allowed finding the prognostic factors to propose a cycle_2 ICSI with testicular spermatozoa in case of cycle_1 IVF failure. The study outcomes were the pregnancy rate (PR) and the cumulative pregnancy rate (CPR). Main results and the role of chance In cycle_1, no difference was observed for the parameters included in PSM. The DFI was higher in case group (13.7% ± 10.5% versus 9.3% ± 4.4%, p &amp;lt; 0.05), no difference was observed for fertilization rate, blastulation rate and frozen embryo rate. However, the PR was higher in case group (22.2% versus 0.0%, p &amp;lt; 0.001), the same result was found for the CPR (25.4% versus 6.3%, p &amp;lt; 0.001). The main prognostics factors to propose a cycle_2 ICSI with testicular spermatozoa after cycle_1 IVF failure with ejaculated spermatozoa: teratozoospermia or cryptozoospermia in cycle_1 (OR = 6.0 [1.2 ; 31.1], p &amp;lt; 0.05), a number of obtained embryos greater than 7 in cycle1 (OR = 5.3 [1.5 ; 18.0], p &amp;lt; 0.01), independently of male age in cycle_1 (OR = 2.3 [0.8 ; 6.5], p &amp;gt; 0.05 Limitations, reasons for caution The main limitations of the current study is being retrospective rather than prospective randomized. However, the used of the propensity score to perform a case-control study allow this study to be more reliable and to obtain results corresponding to real life. Wider implications of the findings This study is in favour of using testicular spermatozoa after IVF failure with ejaculated spermatozoa when the semen morphology is altered or in case of cryptozoospermia, and when at least 8 embryos was obtained in the previous IVF procedure Trial registration number not applicable

Male fertility: summary overview of the publications October – December 2021

The article presents an overview of the most significant publications on the topic of male infertility. The main selection criteria were the practical significance of the article, as well as the impact factor of the journal in which it was published, according to the SCImago Journal Rank. As a result, a list of 10 articles published in the IV quarter (October — December) of 2021 was compiled. The review includes articles on the following topics: genetic causes of male infertility, the effectiveness of antioxidants, the use of testicular spermatozoa in Intra Cytoplasmic Sperm Injection, the impact of DNA fragmentation of spermatozoa on the results of assisted reproductive technology, the relationship of male fertility with physical activity, the consumption of sweetened beverages and vitamin D intake, as well as the prognostic value of blood anti-Mullerian hormone levels before testicular biopsy.

Male fertility: a review of the publications from January - March 2021

The article provides an overview of the most significant publications on the topic of male infertility. The main selection criteria were the practical significance of the article, as well as the impact factor of the journal in which it was published, according to the SCImago Journal Rank (SJR). As a result, a list of 10 works published in the first quarter (January - March) of 2021 was formed. The review included articles related to the following issues: sperm DNA fragmentation, the use of testicular spermatozoa in ART programs (assisted reproductive technologies), advanced paternal age, the role of the human papillomavirus for male fertility, hormonal modulation by clomiphene, the risk of birth defects in children in ART programs, andrological examination of patients with CFTR gene mutations. And also, an analysis of the new clinical guidelines of the American Urological Association (AUA) was carried out.

Sperm source does not affect the ICSI outcome of patients with severely compromised spermatogenesis.

Patients with spermatogenic dysfunction may display sperm parameters ranging from extremely severe oligozoospermia (sperm count lower than 2 million/ml) to azoospermia. It has been proposed that, since these patients may have increased sperm DNA damage that could affect their ICSI outcome, the use of surgically retrieved testicular spermatozoa should be preferred to improve their chance of fathering their biological offspring. However, studies in this field have yielded conflicting results. The present study provides an updated assessment of this subject by comparing the ICSI outcome of 762 patients with nonobstructive azoospermia and 419 with sperm count lower than 2 million/ml (median sperm count 300,000/ml). Both groups were homogeneous for the number of retrieved and injected MII oocytes. No difference was seen in terms of fertilisation, clinical pregnancy and cumulative live birth rates. Only the number of injected MII oocytes was found to independently predict the live birth rate, even when adjusted for the number of transferred embryos (OR 1.10 (1.0-1.2, p=0.038)). The results of the present study stand against the use of testicular spermatozoa in patients with extremely severe spermatogenic dysfunction with available spermatozoa in their ejaculate.

An update on clinical and surgical interventions to reduce sperm DNA fragmentation in infertile men

Sperm chromatin integrity is essential for normal embryo development and pregnancy outcome. Sperm DNA fragmentation (SDF) testing constitutes a diagnostic tool to measure the proportion of spermatozoa with damaged chromatin in the ejaculate. SDF is associated with potentially treatable conditions, including varicocele, male accessory gland infections, inadequate lifestyle, and gonadotoxin exposure, thus prompting their treatment as a means of improving sperm DNA quality and the reproductive outcomes. To provide an up-to-date review of the role of clinical and surgical interventions on SDF values in subfertile men. An extensive search of studies examining the relationship between male infertility conditions associated with SDF was performed using PubMed and MEDLINE, with a focus on interventional therapy. The start date for the search was not defined, whereas the end date was March 2019. Randomized and non-randomized controlled trials, observational studies, systematic and narrative reviews, and case series were evaluated. Treating the underlying male infertility factor seems a promising way to alleviate SDF and to increase the likelihood of achieving natural and assisted conception, but data remain limited. The best evidence relates to varicocele repair and hormonal therapy with the follicle-stimulating hormone. Antioxidant therapy and lifestyle changes might alleviate oxidative sperm markers and decrease SDF but their effects on pregnancy outcomes are still unclear. Among men with high SDF undergoing assisted reproductive technology, the use of testicular spermatozoa in preference over ejaculated spermatozoa for intracytoplasmic sperm injection (ICSI) has been shown to improve pregnancy rates possibly owing to the better sperm chromatin quality in testicular spermatozoa than in ejaculated spermatozoa. Current evidence supports interventional therapy as a means to alleviate sperm DNA damage. Identification of the conditions associated with SDF remains important to enable treatment to potentially improve pregnancy outcomes but given the limited data further research is needed to determine the exact role of specific interventional therapy for subfertile men with impaired sperm chromatin.

ICSI outcomes using testicular spermatozoa in non-azoospermic couples with recurrent ICSI failure and no previous live births.

The use of testicular over ejaculated spermatozoa for ICSI has been presented as an alternative to overcome infertility in men with poor semen parameters or high levels of sperm DNA fragmentation. To evaluate the efficacy of testicular ICSI outcomes in couples with no previous live birth and recurrent ICSI failure using ejaculated spermatozoa by comparison to the outcomes of couples with similar history of recurrent ICSI using ejaculated spermatozoa only. A total of 145 couples undergoing ejaculated or testicular ICSI cycles with no previous live births and with at least two previous failed ICSI cycles with ejaculated spermatozoa were evaluated retrospectively. ICSI was performed either with ejaculated (E-ICSI) or with testicular (T-ICSI) spermatozoa. Semen parameters and sperm DNA quality were assessed prior to the oocyte collection day. Primary outcomes included cumulative live birth and pregnancy rates. Secondary analysis included percentage of DNA fragmentation in ejaculated spermatozoa (SCSA® and TUNEL). Patients undergoing T-ICSI (n=77) had a significantly higher clinical pregnancy rate/fresh embryo transfer (ET) (27.9%; 17/61) and cumulative live birth rate (23.4%; 15/64) compared to patients using E-ICSI (n=68) (clinical pregnancy rate/fresh ET: 10%; 6/60 and cumulative live birth rate: 11.4%; 7/61). Further, T-ICSI yield significantly better cumulative live birth rates than E-ICSI for men with high TUNEL (≥36%) (T-ICSI: 20%; 3/15 vs. E-ICSI: 0%; 0/7, p<0.025), high SCSA® (≥25%) scores (T-ICSI: 21.7%; 5/23 vs. E-ICSI: 9.1%; 1/11, p<0.01), or abnormal semen parameters (T-ICSI: 28%; 7/25 vs. E-ICSI: 6.7%; 1/15, p<0.01). The use of testicular spermatozoa for ICSI in non-azoospermic couples with no previous live births, recurrent ICSI failure, and high sperm DNA fragmentation yields significantly better live birth outcomes than a separate cohort of couples with similar history of ICSI failure entering a new ICSI cycle with ejaculated spermatozoa.

Testicular versus ejaculated spermatozoa for ICSI in patients without azoospermia: A systematic review.

The use of testicular spermatozoa in men without azoospermia has been proposed as a means to increase the chances of pregnancy following assisted reproductive treatment. The purpose of this systematic review is to assess whether clinical outcomes are better when testicular rather than ejaculated spermatozoa are used for intracytoplasmic sperm injection in patients with abnormal semen parameters without azoospermia. A literature search identified four eligible studies out of 757 initially found. In a prospective study in men with high DNA fragmentation index (DFI) and oligozoospermia, the probability of live birth was significantly higher with testicular compared to ejaculated spermatozoa (risk ratio [RR]: 1.75, 95% confidence interval [CI]: 1.14-2.70). This was not the case in a retrospective study in men with high DFI only (RR: 2.36, 95% CI: 0.98-5.68). Clinical pregnancy rates were similar in a randomized controlled trial in men with asthenozoospermia with or without teratozoospermia (RR: 2.85, 95% CI: 0.76-10.69) and in a retrospective study in men with isolated asthenozoospermia (RR: 1.09, 95% CI: 0.56-2.14). Currently, there is limited, low-quality evidence suggesting that a higher probability of pregnancy might be expected using testicular rather than ejaculated spermatozoa, only in men with high DFI and oligozoospermia.

ICSI outcome in patients with high DNA fragmentation: Testicular versus ejaculated spermatozoa.

Sperm DNA fragmentation (SDF) has emerged as an important biomarker in the assessment of male fertility potential with contradictory results regarding its effect on ICSI. The aim of this study was to evaluate intracytoplasmic sperm injection (ICSI) outcomes in male patients with high SDF using testicular versus ejaculated spermatozoa. This is a prospective study on 36 men with high-SDF levels who had a previous ICSI cycle from their ejaculates. A subsequent ICSI cycle was performed using spermatozoa retrieved through testicular sperm aspiration. Results of the prior ejaculate ICSI were compared with those of the TESA-ICSI. The mean (SD) SDF level was 56.36% (15.3%). Overall, there was no difference in the fertilization rate and embryo grading using ejaculate and testicular spermatozoa (46.4% vs. 47.8%, 50.2% vs. 53.4% respectively). However, clinical pregnancy was significantly higher in TESA group compared to ejaculated group (38.89% [14 of 36] vs. 13.8% [five of 36]). Moreover, 17 live births were documented in TESA group, and only three live births were documented in ejaculate group (p<.0001). We concluded that the use of testicular spermatozoa for ICSI significantly increases clinical pregnancy rate as well as live-birth rate in patients with high SDF.

A sperm viability test using SYBR-14/propidium iodide flow cytometry as a tool for rapid screening of primary ciliary dyskinesia patients and for choosing sperm sources for intracytoplasmic sperm injection

Spermatozoa viability tests based on dual-color flow cytometry after staining with Sybr-14/propidium iodide were performed on 44 men with complete asthenospermia for primary ciliary dyskinesia (PCD) screening, and seven were identified with PCD by electron microscopy of ultrastructural ciliary defects. Six PCD patients underwent eight intracytoplasmic sperm injection therapy cycles using ejaculated sperm or testicular sperm, obtaining a mean fertilization rate of 46.6%, with three healthy babies born and one in utero at the time of writing.

Phosphatidylserine translocation in human spermatozoa from impaired spermatogenesis

The aim of the present study was to evaluate phosphatidylserine translocation in specific patient groups and compare the rates of apoptosis between ejaculated and testicular spermatozoa. Fifty-six patients undergoing infertility treatments were included in the present study. Semen samples (n = 37) were obtained from cases with normozoospermia (n = 9) and abnormal semen parameters (n = 28). Testicular biopsy was performed in 19 patients, eight with obstructive and six with non-obstructive (hypospermatogenesis) azoospermia, and in five patients without azoospermia (anejaculation and oligozoospermia). Phosphatidylserine externalization was assessed using annexin-V binding and fluorescence microscopy, and propidium iodide exclusion tests were used to distinguish live from dead cells. In semen, oligoasthenoteratozoospermia showed significantly increased rates of sperm apoptosis (60.3 +/- 12.9) than normozoospermia (47.5 +/- 10.2). In testis, hypospermatogenesis (63.3 +/- 10.3) and obstructive azoospermia (63.6 +/- 15.1) showed significantly increased rates of sperm apoptosis than non-azoospermic patients (49.6 +/- 25.5). Comparisons between semen and testis showed that oligozoospermia had significantly higher rates of sperm apoptosis in semen (57.9 +/- 11.9) than in testis (29.4 +/- 1.1). The results suggest the presence of a post-testicular apoptotic induction factor and the potential beneficial use of testicular spermatozoa in clinical treatments.

Pregnancies and live births following ICSI with testicular spermatozoa after repeated implantation failure using ejaculated spermatozoa

The use of testicular spermatozoa for IVF/intracytoplasmic sperm injection (ICSI) is currently indicated exclusively for patients with azoospermia, since a favourable outcome is expected even when very few spermatozoa are present in the ejaculate. Here, a series of four couples with long-standing male factor infertility and multiple failed IVF/ICSI cycles are described. In all couples, the use of ejaculated spermatozoa for ICSI resulted in poor embryo quality and repeated implantation failure. Testicular sperm aspiration was performed in subsequent cycles, and testicular spermatozoa were used for ICSI. Embryo implantation and ongoing pregnancies/deliveries were achieved in all four couples. It is postulated that spermatozoa are subjected to post-testicular damage during sperm transport between the seminiferous tubules and epididymis, with the injection of damaged spermatozoa being the cause for repetitive IVF/ICSI failures. In selected patients, the use of testicular spermatozoa for IVF/ICSI should be considered, even when motile spermatozoa can be identified in the ejaculate.

ICSI outcomes in obstructive azoospermia: influence of the origin of surgically retrieved spermatozoa and the cause of obstruction

Spermatozoa can be retrieved from the testis and epididymis of men with obstructive azoospermia (OA) and used for ICSI. However, it is unknown whether the outcome of ICSI depends on the cause of obstruction or the origin of surgically retrieved spermatozoa. A cohort of 171 men with OA and normal spermatogenesis were included in this retrospective study. They were divided into three groups according to the site and origin of obstruction: 83 men had congenital bilateral absence of vas deferens; 55 and 33 had acquired epididymal and deferent duct obstructions, respectively. The outcome of 368 ICSI cycles was determined and compared according to the origin of spermatozoa: epididymal (n = 253) or testicular (n = 115). Fertilization and clinical pregnancy rates did not differ between spermatozoa of different origin (58.9% versus 51.9% and 22.1% versus 24.3% with epididymal and testicular spermatozoa, respectively). However, the miscarriage rate was significantly higher for testicular spermatozoa (35.7% versus. 12.5% P < 0.05, chi2 test). Findings were similar whatever the aetiology of the OA. This study suggests that the use of testicular spermatozoa, even those generated during normal spermatogenesis, alters embryonic development and that epididymal spermatozoa should be preferentially used, irrespective of the aetiology of OA.

Testicular sperm results in elevated miscarriage rates compared to epididymal sperm in azoospermic patients.

Several sperm retrieval techniques are available for use on azoospeermic men. Comparisons between spermatozoa retrieved from the testicles and epididymis in relation to pregnancy and miscarriage rates are not well established. To compare pregnancy and miscarriage rates using sperm retrieved from the testes and epididymis using intracytoplasmic sperm injection. Furthermore, we evaluated the fertilization and pregnancy rates according to the status of the spermatozoa retrieved (motile or immotile). Retrospective study. A private center for assisted fertilization. One hundred and eight consecutive patients who presented with azoospermia were included in our study, on whom a total of 144 retrieval procedures were performed. Of the 144 retrieval procedures, 104 were testicular sperm aspirations (TESA) and 40 were epididymal sperm aspirations (PESA). PESA was the first approach in obstructive patients (n = 68), whereas TESA was used when the former failed. For non-obstructive patients (n = 40), TESA was the method of retrieval. Pregnancy and miscarriage rates according to spermatozoa characteristics (motile or immotile). The number of cycles performed using spermatozoa retrieved from the testicles and epididymis was 81 and 30, respectively. Motile spermatozoa had higher fertilization (2PN) and pregnancy rates compared to immotile spermatozoa (p < 0.05). Also, motile spermatozoa had lower miscarriage rates compared to immotile spermatozoa (p < 0.0001). No differences were seen in pregnancy rates with testicular spermatozoa (n = 28) compared to epididymal spermatozoa (n = 13) (p = 0.1). However, the miscarriages rates were higher in spermatozoa retrieved from the testicles (n = 12) compared to epididymis retrievals (n = 1) (p = 0.01). Although pregnancy rates were similar when the intracytoplasmic sperm injection was performed with spermatozoa retrieved from the testicles and epididymis, the use of testicular spermatozoa yields a significantly higher miscarriage rate. It is possible that the higher miscarriage rate seen in patients using spermatozoa retrieved from the testicles is linked to high genetic sperm abnormalities.

Birth of two infants with normal karyotype after intracytoplasmic injection of sperm obtained by testicular extraction from two men with nonmosaic Klinefelter’s syndrome

Objective: To report two births of a healthy male and a healthy female baby after use of testicular spermatozoa from two patients with nonmosaic Klinefelter’s syndrome. Design: Case report. Setting: General academic hospital with IVF center and university institute of human genetics. Patient(s): Two couples with primary infertility in which the men had secretory azoospermia and nonmosaic 47,XXY karyotype. Both women had a normal karyotype and no gynecologic abnormalities. Intervention(s): ICSI was performed using testicular spermatozoa after ovarian stimulation and transvaginal ultrasonography–guided oocyte pick-up. Main Outcome Measure(s): Normal fertilization, embryo cleavage, clinical pregnancy outcome, and peripheral blood karyotype of the newborn. Result(s): In each case, 13 metaphase II oocytes were injected, of which 7 fertilized normally. Three good-quality embryos (4-cell stage) were transferred into the uterine cavity. Both women conceived, and normal pregnancies followed. Genetic analysis of the neonates revealed normal 46,XX and 46,XY karyotypes. Conclusion(s): These case reports reaffirm that patients with nonmosaic Klinefelter’s syndrome produce normal spermatozoa with fertilization potential. Although it is premature to make conclusions about the rate of transmission of this aneuploidy because of the low number of the published cases, this report substantiates the idea that rates of transmission of this gonosomal aneuploidy are low.

Biological aspects of testicular sperm extraction

Since the first reports of successful pregnancies after treatment with intra cytoplasmic sperm injection (ICSI) in humans, intensive investigations focused on the use of testicular spermatozoa and immature sperm cells in the treatment of azoopsermic patients. Several studies explore the technical development of the preparation, isolation and cryo storage of testicular germ cells. Other studies focus on ICSI itself and try to identify the biochemical and biophysical processes involved in fertilisation after injection of a testicular sperm cell into a human oocyte. Indications for azoospermic patients to whom this first line treatment can be offered are becoming more defined. But one of the major concerns is of course the safety of the technique, especially, for the health and reproductive life of the babies born after application of ICSI with testicular germ cells. An evaluation of ICSI with testicular germ cells is presented in this manuscript.

Oocyte insemination with spermatozoa precursors.

Since the use of testicular spermatozoa in programs of assisted fertilization proved very successful, attention was focussed on the use of spermatids also carrying 23 chromosomes. Several difficulties became obvious; the first one concerned the recognition of round spermatids. This is a problem which does not concern elongating and elongated cells. The intra-cytoplasmic injection of elongated spermatids resulted in several pregnancies but this is not so for the round ones. Although, in the group of patients in whom only round spermatids are found at the time of the attempt, is to be divided into two categories; patients in whom previous research allowed to find spermatozoa, however few, and patients who never produced spermatozoa at all. This last group is no longer an indication for intracytoplasmic sperm injection procedure unless in the future new culture media allow a maturation into elongated forms.

Birth of twin males with normal karyotype after intracytoplasmic sperm injection with use of testicular spermatozoa from a nonmosaic patient with Klinefelter’s syndrome

Objective: To report the birth of healthy twin males after the use of testicular spermatozoa from a nonmosaic patient with Klinefelter’s syndrome. Design: Case report. Setting: Private reproduction center with university affiliation. Patient(s): A couple undergoing intracytoplasmic sperm injection (ICSI) combined with testicular sperm extraction because of the husband’s secretory azoospermia and a nonmosaic 47,XXY peripheral blood karyotype. The wife, a healthy female, presented with a history of oligomenorrhea. Intervention(s): ICSI was performed using testicular spermatozoa; 3 mM pentoxifylline solution was used to induce sperm motility because the spermatozoa recovered were all immotile. Main Outcome Measure(s): Normal fertilization, embryo cleavage, pregnancy outcome, and peripheral blood karyotype of the newborns. Result(s): Thirteen metaphase II oocytes were injected. Seven of them fertilized normally and six did not fertilize. Three good-quality embryos (4-cell stage class III) were transferred, and four were cryopreserved at the two-cell and four-cell stages using a slow freezing protocol. Twelve days after ET, a β-hCG determination was positive. Ultrasonographic examination revealed three intrauterine fetal sacs, but one of them showed a fetal pole without cardiac activity and vanished in subsequent ultrasonographic examinations. The patient delivered twins with normal male peripheral blood karyotypes. Conclusion(s): Normal outcome after the use of testicular sperm extraction and ICSI in a nonmosaic patient with Klinefelter’s syndrome reaffirms the notion of low transmission risk of this gonosomal aneuploidy.