- Email: [email protected]
Age as a limiting factor for successful sperm retrieval in patients with nonmosaic Klinefelter’s syndrome
Age as a limiting factor for successful sperm retrieval in patients with nonmosaic Klinefelter’s syndrome Hiroshi Okada, M.D., Ph.D.,a Kazumasa Goda, M.D., Ph.D.,b Yasuhisa Yamamoto, M.D., Ph.D.,c Nikolaos Sofikitis, M.D., Ph.D.,d Ikuo Miyagawa, M.D., Ph.D.,c Yasuyuki Mio, M.D., Ph.D.,e Mitsunobu Koshida, M.D., Ph.D.,f and Shigeo Horie, M.D., Ph.D.a a
Department of Urology, Teikyo University School of Medicine, Tokyo, Japan; bDivision of Urology, Department of Organ Therapeutics, Faculty of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan; cDepartment of Urology, Tottori University School of Medicine, Yonago, Japan; dMolecular Urology Laboratory, Department of Urology, Ionannina University School of Medicine, Ionannina, Greece; eMio Fertility Clinic, Yonago, Japan; and fKoshida Clinic, Osaka, Japan
Objective: To determine factors affecting successful sperm retrieval by testicular sperm extraction in patients with nonmosaic Klinefelter’s syndrome. Design: Medical record analysis for nonmosaic Klinefelter’s syndrome patients who underwent testicular sperm extraction. Setting: Three university-based tertiary centers. Patient(s): Fifty-one patients with nonobstructive azoospermia related to nonmosaic Klinefelter’s syndrome. Intervention(s): Testicular sperm extraction. Main Outcome Measure(s): Correlation of patient characteristics; serum concentrations of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone (T); as well as testicular volume with success in testicular sperm extraction. Result(s): We succeeded in obtaining spermatozoa in 26 patients and failed in 25. Levels of LH, FSH, and T and testicular volume did not differ between patient groups defined by success and failure. Median ages for successful and failed testicular sperm extraction were 31 and 38 years, respectively (statistically significant difference). When we analyzed success rates of testicular sperm extraction between two patient groups (⬍35 and ⱖ35 years old), the percentage of successful recovery of spermatozoa decreased after the age of 35 years (statistically significant difference). Conclusion(s): Testicular sperm extraction should be recommended before the critical age of 35 years. (Fertil Steril威 2005;84:1662– 4. ©2005 by American Society for Reproductive Medicine.) Key Words: Klinefelter’s syndrome, testicular sperm extraction, intracytoplasmic sperm injection, success determinants
Intracytoplasmic sperm injection (ICSI) now permits fertilization of eggs with very small numbers of spermatozoa. Improvements in testicular sperm extraction (TESE) techniques have expanded indications from oligozoospermia to nonobstructive azoospermia. Klinefelter’s syndrome, which accounts for 5% of the latter cases, is characterized by sterility caused by lack of spermatogenesis (1). Isolated foci of spermatogenesis have been found in involved testes, explaining the rare cases of sperm production with appearance in the ejaculate. Several institutions perform TESE by using either ordinary testicular biopsy techniques or meticulous microdissection to retrieve spermatozoa for ICSI. The reported success rate for TESE in patients with Klinefelter’s syndrome is 56%, but no predictive factors have been identified, given the paucity of cases in each report (2). We analyzed results of TESE at three university hospitals to elucidate success Received December 8, 2004; revised and accepted May 23, 2005. Reprint requests: Hiroshi Okada, M.D., Department of Urology, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi-ku, Tokyo, Japan, 173-8605 (FAX: ⫹81-3-3964-89349; E-mail: [email protected]. ac.jp).
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determinants for TESE in patients with Klinefelter’s syndrome. MATERIALS AND METHODS Patients Between 1997 and 2003, a total of 51 azoospermic patients were proven to have nonmosaic Klinefelter’s syndrome by cytogenetic analyses of at least 20 peripheral blood lymphocytes using G-banding techniques at Kobe University Hospital, Teikyo University Hospital, and Tottori University Hospital. No patients had been on aromatase inhibitors. Evaluation of Patients All patients were required to complete a questionnaire concerning duration of sterility, medical history, sexual function, and results of gynecologic evaluation of their spouse. Testicular volume was measured bilaterally by ultrasonography. Hormonal analysis included serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH) measured by immunoradiometric assay, as well as testosterone (T) measured by radioimmunoassay. Serum samples were collected between 8 AM and 10 AM and were cryopreserved at ⫺135°C until assayed.
Fertility and Sterility姞 Vol. 84, No. 6, December 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/05/$30.00 doi:10.1016/j.fertnstert.2005.05.053
TABLE 1 Potential predictive factors for successful TESE in patients with nonmosaic Klinefelter’s syndrome. Characteristics Age (y) LH (mIU/mL) FSH (mIU/mL) T (ng/mL) Testicular volume (mL)
Successful TESE (n ⴝ 26)
Failed TESE (n ⴝ 25)
P value
31 (25–40) 15.5 (13.3–19.0) 29 (13–61) 2.9 (1.3–5.4) 2.8 (1.6–8)
38 (28–43) 15.6 (13.0–18.5) 27 (14–55) 2.2 (0.9–5.4) 2.7 (1.2–8)
⬍.0001 .89 .45 .43 .62
Note: Data are expressed as median (range). Okada. Age limits success of TESE in KFS. Fertil Steril 2005.
Semen Analysis Semen analysis was performed according to procedures recommended by the World Health Organization in 1992, with slight modification as described elsewhere (3). If we could not identify any spermatozoa, we divided the entire semen sample into several 1-mL aliquots placed in conical tubes. Each aliquot was mixed thoroughly with 10 L of phosphate-buffered saline and then was processed by centrifuge at 600 ⫻ g for 10 minutes at room temperature. The pellet in each tube was suspended in 100 mL of phosphate-buffered saline and then was spread onto glass slides and air-dried. After Papanicolaou staining, slides were examined microscopically at ⫻400. Failure to find a spermatozoon by this method confirmed azoospermia. Testicular Sperm Extraction We counseled patient couples about the TESE-ICSI procedures and genetic risks for the offspring, and we obtained informed consent to perform TESE for possible ICSI. Testicular sperm extraction was performed by a standard testicular biopsy procedure or by a microdissection technique reported to be useful for finding spermatozoa in Sertoli-cell-only syndrome (4). When spermatozoa were obtained successfully, they either were injected immediately into ova from the spouse or cryopreserved in liquid nitrogen for future ICSI. Data Analysis Backgrounds of patients whose testes showed spermatogenesis were compared with those of patients without spermatogenesis to identify factors influencing sperm recovery in TESE. The Mann-Whitney U test was used to compare variables between two groups. Success rates of TESE were compared between two groups (⬍35 years old and ⱖ35 years old) by 2 test. RESULTS We succeeded in obtaining spermatozoa from testicular tissue in 26 patients and failed in 25. Serum LH, FSH, and T concentrations ranged between 13.0 and 19.0 mIU/mL, 14 and 61 mIU/mL, and 1.3 and 6.3 ng/mL, respectively. TesFertility and Sterility姞
ticular volume ranged from 1.2 to 8.0 mL. These parameters did not differ between patient groups defined by success and failure in TESE (Table 1). However, patient age in successful TESE cases (median, 31 years; range, 25 to 40 years) was significantly younger than in failed cases (median, 38 years; range, 28 to 43 years; Table 1). We then analyzed the success rate of TESE for 5-year age brackets ranging from 25 to 44 years. The success rates in TESE were 81% (25 to 29 years); 73% (30 to 34 years); 25% (35 to 39 years); and 22% (40 to 44 years). The rate of successful recovery of spermatozoa in TESE was significantly higher in those younger than 35 years of age than in those older than 35 years of age (P⫽.0002, 2 test; Fig. 1). Although other variables (hormones, testicular volumes) were compared between those groups, no difference was seen. All 26 spouses of patients with successful TESE underwent ICSI using retrieved testicular spermatozoa. Pregnancies were achieved in 12 patient couples and resulted in eight singleton deliveries (3 males, 5 females), two twin births
FIGURE 1 Age-specific success rate of testicular sperm extraction in nonmosaic Klinefelter’s syndrome patients. Vertical axis, percentage of successful testicular sperm extraction (TESE); horizontal axis, 5-year age brackets.
Okada. Age limits success of TESE in KFS. Fertil Steril 2005.
1663
(each included a male and female), and two spontaneous abortions. DISCUSSION In nonobstructive azoospermia patients such as those with nonmosaic Klinefelter’s syndrome, the only means of possible reproductive success is to obtain spermatozoa from the testes for use in ICSI. This TESE-ICSI procedure has become standard therapy for these patients. Our rate of success in obtaining sperm by TESE in nonmosaic Klinefelter’s syndrome was 51%, which was compatible with that in a previous study in patients with nonobstructive azoospermia (4 – 6). Several attempts have been made to predict presence of spermatozoa in such azoospermic patients and thus avoid unnecessary surgery. Madgar et al. (7) concluded that testicular volume and serum T concentration were predictive of spermatogenesis in Klinefelter’s syndrome patients, but our results did not support these observations. Instead, our data confirmed other previous observations that preoperative variables, including testicular size and serum concentrations of LH, FSH, and T, failed to discriminate patients with successful TESE from those whose procedure was unsuccessful (8 –11). Serum inhibin B concentration was suggested to discriminate between success and failure in TESE (cutoff value, ⬎40 pg/mL; sensitivity, 90%; specificity, 100%) (12), but no data concerning serum inhibin B and sperm recovery rate are available for Klinefelter’s syndrome. Of note was that we found that nonmosaic Klinefelter’s syndrome patients, who were older at the time of TESE, showed less chance of sperm recovery. The present report is the first to show a decline in sperm recovery rate with age in patients with nonmosaic Klinefelter’s syndrome. Testicular biopsy in patients with Klinefelter’s syndrome almost always shows Sertoli-cell tubules or hyalinized tissue with or without focal Leydig cell hyperplasia (13, 14). This indicates that at best, any spermatogenesis is very limited in amount, requiring careful examination of dispersed testicular tissue obtained by TESE. Germ cell depletion, reported in the testes of infants with nonmosaic Klinefelter’s syndrome, progresses rapidly (15). In juvenile cases, focal spermatogenesis has been reported, which suggests that spermatogenesis deteriorates with aging in these patients for presently unknown reasons (16). Lin et al. (17) also described an adult case of Klinefelter’s syndrome in which spermatogenesis declined progressively. According to Japanese government statistics, the average age of marriage for men has increased steadily in the last 2 decades. Among infertile couples seen at our institution, the average age of the male partner at the time of initial semen analysis is 34.5 years. The present results underscore the importance of earlier consultation and assessment to determine the etiology of sterility. If the diagnosis is Klinefelter’s syndrome, TESE should be performed before the critical age of 35 years.
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Okada et al.
Age limits success of TESE in KFS
Acknowledgments: The authors thank Mutsuhiro Nakao, Ph.D. (Department of Hygiene and Public Health, Teikyo University School of Medicine), for statistical analyses, and Tomomoto Ishikawa, M.D., Masato Fujisawa, M.D., Ph.D., and Sadao Kamidono, M.D., Ph.D. (Division of Urology, Department of Organ Therapeutics, Faculty of Medicine, Kobe University Graduate School of Medicine), for technical assistance.
REFERENCES 1. Okada H, Fujioka H, Tatsumi N, Kanzaki M, Okuda Y, Fujisawa M, et al. Klinefelter’s syndrome in the male infertility clinic. Hum Reprod 1999;14:946 –52. 2. Friedler S, Raziel A, Strassburger D, Schachter M, Bern O, Ron-El R. Outcome of ICSI using fresh and cryopreserved-thawed testicular spermatozoa in patients with non-mosaic Klinefelter’s syndrome. Hum Reprod 2001;16:2616 –20. 3. Okada H, Dobashi M, Yamazaki T, Hara I, Fujisawa M, Arakawa S, et al. Conventional versus microdissection testicular sperm extraction for nonobstructive azoospermia. J Urol 2002;168:1063–7. 4. Schlegel PN. Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Hum Reprod 1999;141: 131–5. 5. Tsujimura A, Matsumiya K, Miyagawa Y, Tohda A, Miura H, Nishimura K, et al. Conventional multiple or microdissection testicular sperm extraction: a comparative study. Hum Reprod 2002; 17:2924 –9. 6. Friedler S, Raziel A, Schachter M, Strassburger D, Bern O, Ron-El R. Outcome of first and repeated testicular sperm extraction and ICSI in patients with non-obstructive azoospermia. Hum Reprod 2002; 17:2356 – 61. 7. Madgar I, Dor J, Weissenberg R, Raviv G, Menashe Y, Levron J. Prognostic value of the clinical and laboratory evaluation in patients with nonmosaic Klinefelter syndrome who are receiving assisted reproductive therapy. Fertil Steril 2002;77:1167–9. 8. Tournaye H, Verheyen G, Nagy P, Ubaldi F, Goossens A, Silber S, et al. Are there any predictive factors for successful testicular sperm recovery in azoospermic patients? Hum Reprod 1997;12:80 – 6. 9. Ezeh UI, Taub NA, Moore HD, Cooke ID. Establishment of predictive variables associated with testicular sperm retrieval in men with nonobstructive azoospermia. Hum Reprod 1999;14:1005–12. 10. Westlander G, Ekerhovd E, Granberg S, Hanson L, Hanson C, Bergh C. Testicular ultrasonography and extended chromosome analysis in men with nonmosaic Klinefelter syndrome: a prospective study of possible predictive factors for successful sperm recovery. Fertil Steril 2001;75: 1102–5. 11. Vernaeve V, Staessen C, Verheyen G, Steirteghem AV, Devroey P, Tournaye H. Can biological or clinical parameters predict testicular sperm recovery in 47,XXY Klinefelter’s syndrome patients? Hum Reprod 2004;19:1135–9. 12. Ballesca JL, Balasch J, Calafell JM, Alvarez R, Fabregues F, de Osaba MJ, et al. Serum inhibin B determination is predictive of successful testicular sperm extraction in men with non-obstructive azoospermia. Hum Reprod 2000;15:1734 – 8. 13. Sniffen RC, Howard RP, Simmons FA. The testis III, absence of germ cells, sclerosing tubular degeneration; “male climacteric.” Arch Pathol 1951;51:293–311. 14. Gordon DL, Krmpotic E, Thomas W, Gandy HM, Paulsen CA. Pathologic testicular findings in Klinefelter’s syndrome. 47,XXY vs. 46,XY47,XXY. Arch Intern Med 1972;130:726 –9. 15. Lanfranco F, Kamischke A, Zitzmann M, Nieschlag E. Klinefelter’s syndrome. Lancet 2004;364:273– 83. 16. Damani MN, Mittal R, Oates RD. Testicular tissue extraction in a young male with 47,XXY Klinefelter’s syndrome: potential strategy for preservation of fertility. Fertil Steril 2001;76:1054 – 6. 17. Lin YM, Huang WJ, Lin JSN, Kuo PL. Progressive depletion of germ cells in a man with nonmosaic Klinefelter’s syndrome: optimal time for sperm recovery. Urology 2004;63:380 –1.
Vol. 84, No. 6, December 2005
Department of Urology, Teikyo University School of Medicine, Tokyo, Japan; bDivision of Urology, Department of Organ Therapeutics, Faculty of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan; cDepartment of Urology, Tottori University School of Medicine, Yonago, Japan; dMolecular Urology Laboratory, Department of Urology, Ionannina University School of Medicine, Ionannina, Greece; eMio Fertility Clinic, Yonago, Japan; and fKoshida Clinic, Osaka, Japan
Objective: To determine factors affecting successful sperm retrieval by testicular sperm extraction in patients with nonmosaic Klinefelter’s syndrome. Design: Medical record analysis for nonmosaic Klinefelter’s syndrome patients who underwent testicular sperm extraction. Setting: Three university-based tertiary centers. Patient(s): Fifty-one patients with nonobstructive azoospermia related to nonmosaic Klinefelter’s syndrome. Intervention(s): Testicular sperm extraction. Main Outcome Measure(s): Correlation of patient characteristics; serum concentrations of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone (T); as well as testicular volume with success in testicular sperm extraction. Result(s): We succeeded in obtaining spermatozoa in 26 patients and failed in 25. Levels of LH, FSH, and T and testicular volume did not differ between patient groups defined by success and failure. Median ages for successful and failed testicular sperm extraction were 31 and 38 years, respectively (statistically significant difference). When we analyzed success rates of testicular sperm extraction between two patient groups (⬍35 and ⱖ35 years old), the percentage of successful recovery of spermatozoa decreased after the age of 35 years (statistically significant difference). Conclusion(s): Testicular sperm extraction should be recommended before the critical age of 35 years. (Fertil Steril威 2005;84:1662– 4. ©2005 by American Society for Reproductive Medicine.) Key Words: Klinefelter’s syndrome, testicular sperm extraction, intracytoplasmic sperm injection, success determinants
Intracytoplasmic sperm injection (ICSI) now permits fertilization of eggs with very small numbers of spermatozoa. Improvements in testicular sperm extraction (TESE) techniques have expanded indications from oligozoospermia to nonobstructive azoospermia. Klinefelter’s syndrome, which accounts for 5% of the latter cases, is characterized by sterility caused by lack of spermatogenesis (1). Isolated foci of spermatogenesis have been found in involved testes, explaining the rare cases of sperm production with appearance in the ejaculate. Several institutions perform TESE by using either ordinary testicular biopsy techniques or meticulous microdissection to retrieve spermatozoa for ICSI. The reported success rate for TESE in patients with Klinefelter’s syndrome is 56%, but no predictive factors have been identified, given the paucity of cases in each report (2). We analyzed results of TESE at three university hospitals to elucidate success Received December 8, 2004; revised and accepted May 23, 2005. Reprint requests: Hiroshi Okada, M.D., Department of Urology, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi-ku, Tokyo, Japan, 173-8605 (FAX: ⫹81-3-3964-89349; E-mail: [email protected]. ac.jp).
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determinants for TESE in patients with Klinefelter’s syndrome. MATERIALS AND METHODS Patients Between 1997 and 2003, a total of 51 azoospermic patients were proven to have nonmosaic Klinefelter’s syndrome by cytogenetic analyses of at least 20 peripheral blood lymphocytes using G-banding techniques at Kobe University Hospital, Teikyo University Hospital, and Tottori University Hospital. No patients had been on aromatase inhibitors. Evaluation of Patients All patients were required to complete a questionnaire concerning duration of sterility, medical history, sexual function, and results of gynecologic evaluation of their spouse. Testicular volume was measured bilaterally by ultrasonography. Hormonal analysis included serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH) measured by immunoradiometric assay, as well as testosterone (T) measured by radioimmunoassay. Serum samples were collected between 8 AM and 10 AM and were cryopreserved at ⫺135°C until assayed.
Fertility and Sterility姞 Vol. 84, No. 6, December 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/05/$30.00 doi:10.1016/j.fertnstert.2005.05.053
TABLE 1 Potential predictive factors for successful TESE in patients with nonmosaic Klinefelter’s syndrome. Characteristics Age (y) LH (mIU/mL) FSH (mIU/mL) T (ng/mL) Testicular volume (mL)
Successful TESE (n ⴝ 26)
Failed TESE (n ⴝ 25)
P value
31 (25–40) 15.5 (13.3–19.0) 29 (13–61) 2.9 (1.3–5.4) 2.8 (1.6–8)
38 (28–43) 15.6 (13.0–18.5) 27 (14–55) 2.2 (0.9–5.4) 2.7 (1.2–8)
⬍.0001 .89 .45 .43 .62
Note: Data are expressed as median (range). Okada. Age limits success of TESE in KFS. Fertil Steril 2005.
Semen Analysis Semen analysis was performed according to procedures recommended by the World Health Organization in 1992, with slight modification as described elsewhere (3). If we could not identify any spermatozoa, we divided the entire semen sample into several 1-mL aliquots placed in conical tubes. Each aliquot was mixed thoroughly with 10 L of phosphate-buffered saline and then was processed by centrifuge at 600 ⫻ g for 10 minutes at room temperature. The pellet in each tube was suspended in 100 mL of phosphate-buffered saline and then was spread onto glass slides and air-dried. After Papanicolaou staining, slides were examined microscopically at ⫻400. Failure to find a spermatozoon by this method confirmed azoospermia. Testicular Sperm Extraction We counseled patient couples about the TESE-ICSI procedures and genetic risks for the offspring, and we obtained informed consent to perform TESE for possible ICSI. Testicular sperm extraction was performed by a standard testicular biopsy procedure or by a microdissection technique reported to be useful for finding spermatozoa in Sertoli-cell-only syndrome (4). When spermatozoa were obtained successfully, they either were injected immediately into ova from the spouse or cryopreserved in liquid nitrogen for future ICSI. Data Analysis Backgrounds of patients whose testes showed spermatogenesis were compared with those of patients without spermatogenesis to identify factors influencing sperm recovery in TESE. The Mann-Whitney U test was used to compare variables between two groups. Success rates of TESE were compared between two groups (⬍35 years old and ⱖ35 years old) by 2 test. RESULTS We succeeded in obtaining spermatozoa from testicular tissue in 26 patients and failed in 25. Serum LH, FSH, and T concentrations ranged between 13.0 and 19.0 mIU/mL, 14 and 61 mIU/mL, and 1.3 and 6.3 ng/mL, respectively. TesFertility and Sterility姞
ticular volume ranged from 1.2 to 8.0 mL. These parameters did not differ between patient groups defined by success and failure in TESE (Table 1). However, patient age in successful TESE cases (median, 31 years; range, 25 to 40 years) was significantly younger than in failed cases (median, 38 years; range, 28 to 43 years; Table 1). We then analyzed the success rate of TESE for 5-year age brackets ranging from 25 to 44 years. The success rates in TESE were 81% (25 to 29 years); 73% (30 to 34 years); 25% (35 to 39 years); and 22% (40 to 44 years). The rate of successful recovery of spermatozoa in TESE was significantly higher in those younger than 35 years of age than in those older than 35 years of age (P⫽.0002, 2 test; Fig. 1). Although other variables (hormones, testicular volumes) were compared between those groups, no difference was seen. All 26 spouses of patients with successful TESE underwent ICSI using retrieved testicular spermatozoa. Pregnancies were achieved in 12 patient couples and resulted in eight singleton deliveries (3 males, 5 females), two twin births
FIGURE 1 Age-specific success rate of testicular sperm extraction in nonmosaic Klinefelter’s syndrome patients. Vertical axis, percentage of successful testicular sperm extraction (TESE); horizontal axis, 5-year age brackets.
Okada. Age limits success of TESE in KFS. Fertil Steril 2005.
1663
(each included a male and female), and two spontaneous abortions. DISCUSSION In nonobstructive azoospermia patients such as those with nonmosaic Klinefelter’s syndrome, the only means of possible reproductive success is to obtain spermatozoa from the testes for use in ICSI. This TESE-ICSI procedure has become standard therapy for these patients. Our rate of success in obtaining sperm by TESE in nonmosaic Klinefelter’s syndrome was 51%, which was compatible with that in a previous study in patients with nonobstructive azoospermia (4 – 6). Several attempts have been made to predict presence of spermatozoa in such azoospermic patients and thus avoid unnecessary surgery. Madgar et al. (7) concluded that testicular volume and serum T concentration were predictive of spermatogenesis in Klinefelter’s syndrome patients, but our results did not support these observations. Instead, our data confirmed other previous observations that preoperative variables, including testicular size and serum concentrations of LH, FSH, and T, failed to discriminate patients with successful TESE from those whose procedure was unsuccessful (8 –11). Serum inhibin B concentration was suggested to discriminate between success and failure in TESE (cutoff value, ⬎40 pg/mL; sensitivity, 90%; specificity, 100%) (12), but no data concerning serum inhibin B and sperm recovery rate are available for Klinefelter’s syndrome. Of note was that we found that nonmosaic Klinefelter’s syndrome patients, who were older at the time of TESE, showed less chance of sperm recovery. The present report is the first to show a decline in sperm recovery rate with age in patients with nonmosaic Klinefelter’s syndrome. Testicular biopsy in patients with Klinefelter’s syndrome almost always shows Sertoli-cell tubules or hyalinized tissue with or without focal Leydig cell hyperplasia (13, 14). This indicates that at best, any spermatogenesis is very limited in amount, requiring careful examination of dispersed testicular tissue obtained by TESE. Germ cell depletion, reported in the testes of infants with nonmosaic Klinefelter’s syndrome, progresses rapidly (15). In juvenile cases, focal spermatogenesis has been reported, which suggests that spermatogenesis deteriorates with aging in these patients for presently unknown reasons (16). Lin et al. (17) also described an adult case of Klinefelter’s syndrome in which spermatogenesis declined progressively. According to Japanese government statistics, the average age of marriage for men has increased steadily in the last 2 decades. Among infertile couples seen at our institution, the average age of the male partner at the time of initial semen analysis is 34.5 years. The present results underscore the importance of earlier consultation and assessment to determine the etiology of sterility. If the diagnosis is Klinefelter’s syndrome, TESE should be performed before the critical age of 35 years.
1664
Okada et al.
Age limits success of TESE in KFS
Acknowledgments: The authors thank Mutsuhiro Nakao, Ph.D. (Department of Hygiene and Public Health, Teikyo University School of Medicine), for statistical analyses, and Tomomoto Ishikawa, M.D., Masato Fujisawa, M.D., Ph.D., and Sadao Kamidono, M.D., Ph.D. (Division of Urology, Department of Organ Therapeutics, Faculty of Medicine, Kobe University Graduate School of Medicine), for technical assistance.
REFERENCES 1. Okada H, Fujioka H, Tatsumi N, Kanzaki M, Okuda Y, Fujisawa M, et al. Klinefelter’s syndrome in the male infertility clinic. Hum Reprod 1999;14:946 –52. 2. Friedler S, Raziel A, Strassburger D, Schachter M, Bern O, Ron-El R. Outcome of ICSI using fresh and cryopreserved-thawed testicular spermatozoa in patients with non-mosaic Klinefelter’s syndrome. Hum Reprod 2001;16:2616 –20. 3. Okada H, Dobashi M, Yamazaki T, Hara I, Fujisawa M, Arakawa S, et al. Conventional versus microdissection testicular sperm extraction for nonobstructive azoospermia. J Urol 2002;168:1063–7. 4. Schlegel PN. Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Hum Reprod 1999;141: 131–5. 5. Tsujimura A, Matsumiya K, Miyagawa Y, Tohda A, Miura H, Nishimura K, et al. Conventional multiple or microdissection testicular sperm extraction: a comparative study. Hum Reprod 2002; 17:2924 –9. 6. Friedler S, Raziel A, Schachter M, Strassburger D, Bern O, Ron-El R. Outcome of first and repeated testicular sperm extraction and ICSI in patients with non-obstructive azoospermia. Hum Reprod 2002; 17:2356 – 61. 7. Madgar I, Dor J, Weissenberg R, Raviv G, Menashe Y, Levron J. Prognostic value of the clinical and laboratory evaluation in patients with nonmosaic Klinefelter syndrome who are receiving assisted reproductive therapy. Fertil Steril 2002;77:1167–9. 8. Tournaye H, Verheyen G, Nagy P, Ubaldi F, Goossens A, Silber S, et al. Are there any predictive factors for successful testicular sperm recovery in azoospermic patients? Hum Reprod 1997;12:80 – 6. 9. Ezeh UI, Taub NA, Moore HD, Cooke ID. Establishment of predictive variables associated with testicular sperm retrieval in men with nonobstructive azoospermia. Hum Reprod 1999;14:1005–12. 10. Westlander G, Ekerhovd E, Granberg S, Hanson L, Hanson C, Bergh C. Testicular ultrasonography and extended chromosome analysis in men with nonmosaic Klinefelter syndrome: a prospective study of possible predictive factors for successful sperm recovery. Fertil Steril 2001;75: 1102–5. 11. Vernaeve V, Staessen C, Verheyen G, Steirteghem AV, Devroey P, Tournaye H. Can biological or clinical parameters predict testicular sperm recovery in 47,XXY Klinefelter’s syndrome patients? Hum Reprod 2004;19:1135–9. 12. Ballesca JL, Balasch J, Calafell JM, Alvarez R, Fabregues F, de Osaba MJ, et al. Serum inhibin B determination is predictive of successful testicular sperm extraction in men with non-obstructive azoospermia. Hum Reprod 2000;15:1734 – 8. 13. Sniffen RC, Howard RP, Simmons FA. The testis III, absence of germ cells, sclerosing tubular degeneration; “male climacteric.” Arch Pathol 1951;51:293–311. 14. Gordon DL, Krmpotic E, Thomas W, Gandy HM, Paulsen CA. Pathologic testicular findings in Klinefelter’s syndrome. 47,XXY vs. 46,XY47,XXY. Arch Intern Med 1972;130:726 –9. 15. Lanfranco F, Kamischke A, Zitzmann M, Nieschlag E. Klinefelter’s syndrome. Lancet 2004;364:273– 83. 16. Damani MN, Mittal R, Oates RD. Testicular tissue extraction in a young male with 47,XXY Klinefelter’s syndrome: potential strategy for preservation of fertility. Fertil Steril 2001;76:1054 – 6. 17. Lin YM, Huang WJ, Lin JSN, Kuo PL. Progressive depletion of germ cells in a man with nonmosaic Klinefelter’s syndrome: optimal time for sperm recovery. Urology 2004;63:380 –1.
Vol. 84, No. 6, December 2005