META-ANALYSIS DEMONSTRATES IMPORTANCE OF TESTICULAR HISTOPATHOLOGY IN DETERMINING THE SUCCESS OF VARICOCELE REPAIR IN PATIENTS WITH NONOBSTRUCTIVE AZOOSPERMIA

THE JOURNAL OF UROLOGY®

Vol. 181, No. 4, Supplement, Wednesday, April 29, 2009

database were reviewed in a retrospective fashion from a single IVF laboratory. The electronic database was queried to identify IVF cycles where cryptozoospermic ejaculated sperm was used for IVF/ICSI. The database was also queried for ICSI cycles utilizing sperm from TESE. Data was collected regarding; female partners age; number of oocytes retrieved per cycle; number oocytes used for ICSI; number of oocytes fertilized; average embryo number and quality; number of embryos transferred, and number of pregnancies. RESULTS: 33 ICSI cycles were identified where only ejaculated sperm were used from cryptozoospermic patients, and compared to 63 ICSI cycles using sperm form TESE. The two groups were similar in age of female partner and number of oocytes retrieved per IVF/ICSI cycle (p=0.853 and p=0.891). The mean fertilization rate for ejaculated sperm was 51.9% vs. 56.9% for the TESE group (p=0.661). Embryo quality was graded 1-5, with one representing poorest embryo quality and five the best embryo quality. The mean embryo quality for each cycle was reported, with the mean being 1.8 for each group. The pregnancy rate for the ejaculated sperm and TESE groups were 30% and 27% respectively (p=0.812). CONCLUSIONS: Several publications have suggested the preferential use of testicular sperm when the density of ejaculated sperm is markedly impaired (cryptozoospermic). However, in the current study, all data examined demonstrates a relative equivalency when comparing outcome utilizing ejaculated sperm from cryptozoospermic men vs. sperm from TESE. Since the functional potential of the cryptozoospermic and testicular sperm appear to be equal, it is reasonable to follow the paradigm of using ejaculated sperm on the day of ICSI with more invasive TESE only as backup. TABLE 1. IVF/ICSI RESULTS Age Of Female Partner

# Oocytes Retrieved Per Cycle

# Oocytes Used For Icsi/Cycle

# Oocytes Fertilized / Cycle

Mean Embryo Quality

Avg. # Of Embryos Transfered

Pregnancies

Cyptozoospermic

33

34.6

13.3

6.9 (51.9%)

1.8

1.7

10 (30%)

Tese

68

34.8

13.0

7.4 (56.9%)

1.8

2.0

17 (27%)

P Value

0.853

0.891

0.892

0.661

0.671

0.426

0.812

Source of Funding: None

2023 META-ANALYSIS DEMONSTRATES IMPORTANCE OF TESTICULAR HISTOPATHOLOGY IN DETERMINING THE SUCCESS OF VARICOCELE REPAIR IN PATIENTS WITH NONOBSTRUCTIVE AZOOSPERMIA John W Weedin*, Richard C Bennett, Jon A Rumohr, Mohit Khera, Larry I Lipshultz, Houston, TX INTRODUCTION AND OBJECTIVE: The first report of pregnancy after varicocele repair in a patient with nonobstructive azoospermia (NOA) was in 1955. Since then, there have been multiple small case series reporting various success. We hypothesized that patients with favorable testicular histopathology on testis biopsy such as maturation arrest (MA) or hypospermatogenesis (HS) would have a higher probability of success after varicocele repair than patients with sertoli-cell only (SCO). METHODS: A review of the literature of varicocele repair in patients with NOA was performed. Varicocele repair was performed either surgically or by internal spermatic vein embolization (IR). 11 case series over the last 20 years were evaluated. 8 publications presented adequate histopathologic data. Histopathology was categorized by SCO, MA, and HS. MA was further categorized by 4 publications. Early MA was defined as maturation ending at the secondary spermatocyte, and late MA as maturation ending at the spermatid without spermatozoa present. Successful varicocele repair was defined as patients having sperm in their ejaculate after the procedure. Statistical analysis was performed using paired student’s t-test and chi-square analysis. RESULTS: 239 patients with NOA who underwent varicocele repair were analyzed from 11 case series. After varicocele repair, 93 (38.9%) patients had sperm in the ejaculate. 14 spontaneous pregnancies

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were achieved, and 10 pregnancies resulted from in-vitro fertilization. Histopathology was analyzed before varicocele repair in 156 patients. Patients with MA or HS had a significantly higher probability of success compared to patients with SCO (p < 0.001 in both groups). Patients with late MA had a higher probability of success than patients with early MA (p = .007). Of the 5 patients with SCO who had success after repair, 4 relapsed into azoospermia. CONCLUSIONS: After varicocele repair, patients with NOA can have improvement in their semen analysis and achieve spontaneous pregnancy. This meta-analysis demonstrates that men with late MA and HS have a higher probability of success after the procedure, and therefore, histopathology should be considered when planning varicocele repair in these patients. References: Matthews GJ 1998, Kim ED 1999, Kadioglu A 2001, Cakan M 2004, Schlegel PN 2004, Esteves SC 2005, Gat Y 2005, Poulakis V 2006, Pasqualotto FF 2006, Ishikawa T 2007, Lee JS 2007. Source of Funding: None

2024 TESTICULAR SPERM RETRIEVED FROM SPINAL CORD INJURED MEN RETAINS EQUAL FECUNDITY TO THAT FROM OBSTRUCTIVE AZOOSPERMIC MEN VIA ICSI IF IT IS FRESHLY USED Satoru Kanto*, Hirofumi Uto, Mayumi Toya, Tetsutaro Ohnuma, Yoichi Arai, Koichi Kyono, Sendai, Japan INTRODUCTION AND OBJECTIVE: Sterility in spinal cord injured (SCI) men is caused by a number of factors such as anejaculation, obstruction of seminal pathways, and impaired spermatogenesis. Even if ejaculated sperm were obtained, they usually exhibit poor motility and viability. Under the hypothesis that testicular sperm is optimal for intracytoplasmic injection (ICSI) in SCI men, we performed a simple testicular sperm extraction (simple TESE) combined with microdissection TESE (MD-TESE) on 22 SCI patients. METHODS: From 1997 to 2007, 22 spinal cord injured men and their partners were referred to our institution. In 18 cases, a simple TESE was scheduled on the day of mature oocyte retrieval following controlled ovarian stimulation. MD-TESE was performed on six men, including two in whom primary simple TESE was unsuccessful. As a control, the outcome of TESE-ICSI from 34 OA patients treated during the same period was examined retrospectively. Motile testicular sperm or non-motile sperm which passed the hypo-osmotic (HOS) test were microinjected into mature oocytes. Fertilization was confirmed by the observation of two pronuclei and two extruded polar bodies 18 hours after ICSI; embryo transfer was conducted at the 4-cell, 8 cell or blastocyst stage. A clinical pregnancy was confirmed by the detection of a fetal heart beat by transvaginal ultrasound. The Chi-square analysis and the Yates Chi-square analysis were used to compare the fertilization rate and pregnancy rate between the groups. RESULTS: Testicular sperm were retrieved from 19 of 22 (86%) SCI patients. ICSI resulted in a fertilization rate of 236/364 (65%). Of 19 couples, 14 couples achieved 18 pregnancies and 22 babies (14 singleton and 4 twin) were born. (pregnancy per couple was 74% and that per ICSI was 54%). There was no significant difference in pregnancy rate at the first ICSI between SCI couples and OA couples (68%: SCI, 68%: OA). However, pregnancy rate per fresh testicular sperm-ICSI was significantly higher than that per frozen/thawed sperm-ICSI in SCI couples (64%: SCI fresh, 25%: SCI frozen/thawed) although no significant difference was seen in OA couples (76%: OA fresh, 63%: OA frozen/thawed). There was no significant difference in pregnancy rate between fresh ET cycle and frozen/thawed ET cycle in SCI couples. CONCLUSIONS: Testicular sperm in SCI men may possess disadvantages in freezing and thawing compared with that in OA men. Fresh testicular sperm-ICSI may offer optimum outcome for SCI couples desirous of pregnancy. Source of Funding: None