The value of repeat testicular sperm retrieval in azoospermic men To determine the predictive value of a previous testicular biopsy to the chance of sperm retrieval in the next testicular sperm extraction (TESE) procedure, we retrospectively analyzed the outcome of past sperm collection procedures and histopathology diagnoses of patients with nonobstructive azoospermia. Repeated TESE ensured a high recovery rate (96%) when the first recovery procedure had been successful and when hypospermatogenesis was diagnosed (77%); when no spermatozoa were found on the first attempt, a repeat TESE procedure was successful in one-third of the patients. (Fertil Steril 2009;91:1401–3. 2009 by American Society for Reproductive Medicine.)
Since the introduction of testicular sperm extraction (TESE) in 1993 (1, 2), intracytoplasmic sperm injection (ICSI) with testicular sperm has become a routine procedure for patients with azoospermia, both obstructive azoospermia (OA) with normal spermatogenesis and nonobstructive azoospermia (NOA) with testicular failure. In OA, testicular sperm can be retrieved in almost 100% of the cases (3), whereas in patients with NOA, the possibility of finding sperm is only about 50% (3, 4). Repeated TESE may be recommended to patients with a history of successful sperm collection after the exhaustion of the cryopreserved testicular sperm for ICSI, or to those with unsuccessful previous TESE outcome to search for testicular sperm before switching to donor sperm. Because of the possible testicular damage after repeated TESE (5, 6), the outcome of the repetitive procedure is important to adequate counseling. Four studies have investigated the likelihood of finding sperm in repeated testicular biopsies in patients with azoospermia (7–11). In OA it is now acceptable that testicular spermatozoa could be repeatedly collected by TESE (7, 11). In NOA, however, three small-scale studies examined the feasibility of repeating TESE procedures in patients with primarily testicular failure and found that in some patients TESE can be successfully repeated several times. Vernaeve et al. (11) reported in a large-scale study that both OA and NOA patients may benefit from repeated TESE. However, it was unclear from either work whether the previous outcome of the testicular retrieval procedure predicts the outcome of the second TESE. In the present analysis we examined whether the outcome of a previous trial of testicular sperm retrieval and the testicular histopaReceived February 9, 2008; revised April 20, 2008; accepted April 29, 2008; published online August 3, 2008. R.H.-K. has nothing to disclose. F.L. has nothing to disclose. I.N. has nothing to disclose. B.-S.Z. has nothing to disclose. Y.M. has nothing to disclose. D.P. has nothing to disclose. Y.B. has nothing to disclose. A.H. has nothing to disclose. Reprint requests: Ronit Haimov-Kochman, M.D., Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Hadassah Hebrew University Medical Center, Mt. Scopus, P.O.B. 24035, Jerusalem 91240, Israel (FAX: þ972-2-581-4210; E-mail:
[email protected]).
0015-0282/09/$36.00 doi:10.1016/j.fertnstert.2008.04.066
thology are predictive of the chance of sperm retrieval in the next TESE procedure. This was a retrospective analysis of TESE outcome of a subset of azoospermic patients with a history of a previous trial of testicular sperm collection and/or testicular biopsy. All of the patients were diagnosed as azoospermic on the basis of at least two semen analyses, including a centrifugation step at high speed. They all had a clinical work-up including a physical examination, hormonal assessment (FSH, LH, and T), testicular ultrasound, and karyotype analysis. A total of 55 azoospermic men with a history of testicular biopsy had a sperm recovery trial by TESE between January 1, 2000, and December 31, 2007. Sixteen patients had a previous testicular biopsy without an intention to recover spermatozoa, and 38 patients had a former trial of testicular sperm collection by TESE (n ¼ 27) or testicular fine needle aspiration (TEFNA; n ¼ 11) along with a testicular biopsy. The patients were diagnosed as NOA based on histopathology of germ cell aplasia (Sertoli cell–only syndrome), sperm maturation arrest, and tubular sclerosis/atrophy (12). In the case of a mixed histologic pathology, the most prominent pattern was used for classification. Hypospermatogenesis indicates complete but reduced spermatogenic activity and was considered to be a separate subpopulation. Azoospermic patients with histology of normal spermatogenesis were classified as OA. The surgical procedure of TESE and the laboratory handling of the specimen are described elsewhere in length (13). In brief, open excisional testicular biopsies were taken with a view to cryopreservation. An incision of approximately 1 cm was made through the skin and underlying layers. The protruding testicular mass from three distant regions of the testis was resected. The testicular tissue was placed in HEPES medium (IR-90126; Irvine Scientific, Santa Ana, CA) with 4% synthetic serum supplement (SSS; first medium) (IR-99193; Irvine Scientific) and handed to the adjacent laboratory. During surgery, a single randomly taken biopsy of each testis was sent for histologic examination. In the laboratory, the specimens were transfered into new HEPES medium with 4% SSS (later media) and the first media were decanted
Fertility and Sterility Vol. 91, No. 4, Supplement, April 2009 Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc.
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into new tubes. The first media and the specimens in the later media were processed separately as previously described (13). A successful biopsy was defined as the detection of at least one spermatozoon in the biopsy specimen. The sperm-containing suspensions were frozen for later use or saved for histopathology confirmation if no spermatozoa were found. We used chi-squared test to compare categoric variables for statistical significance. Kappa test was used to assess the association between the first and second histopathology diagnoses of testicular biopsies. Mean and standard deviation were calculated, and P<.05 was considered to be significant. All statistical analyses were performed using SAS 8.2 (SAS Institute, Cary, NC). Sperm was successfully recovered in 62% of TESE procedures (n ¼ 34). Mean FSH SEM levels differed significantly between successful and unsuccessful sperm retrieval groups (14.4 11.9 vs. 25.7 15.2, respectively; P¼.008) (Table 1). Normal spermatogenesis was diagnosed in 38% of sperm-positive biopsies and in none of sperm-negative biopsies (P¼0.0012), and germ cell aplasia was recorded in 62% of sperm-negative biopsies vs. 24% of sperm-positive biopsies (P¼.0044). The percentage of histopathology diagnoses of hypospermatogenesis and spermatogenic maturation arrest did not differ between sperm-positive and sperm-negative biopsies. The mean interval between the last TESE to the previous procedure was 4.6 years (range 3 months to 21 years). Six patients had more than a single former procedure, four had two previous TESE, and two had three past TESE. Testicular sperm was detected in 96% (25 of 26) of azoospermic men with a history of sperm-positive procedure. Testicular sperm was also found in 33% (4 of 12) of azoospermic patients with past sperm-negative procedure (P<.0001; Table 1). The success rate of recovering spermatozoa from positive frozen-thawed TESE samples was 100%. In the group with past sperm-negative testicular biopsy (n ¼ 12), there was no significant difference in FSH
levels, testicular histology, site of the former procedure, or type of the previous procedure (TESE or TEFNA) between the patients with next successful (n ¼ 4) versus unsuccessful sperm retrieval (n ¼ 8). The prediction of the present TESE outcome by the last procedure outcome is 89% specific and 86% sensitive, with a false positive rate of 4% and false negative rate of 33%. Additionally, we analyzed the present TESE outcome by the former testicular histopathology. The chance of successful testicular sperm retrieval was 33% for germ cell aplasia, 33% for spermatogenic maturation arrest, and 77% for the histology of hypospermatogenesis (P¼.01; Table 1). The accordance among the histopathologic diagnoses of the first and second testicular biopsies was variable. Full agreement was noted only regarding 12 patients who were primarily diagnosed as germ cell aplasia, whereas only 45% of patients formerly diagnosed with spermatogenic maturation arrest and 32% of patients previously diagnosed with hypospermatogenesis kept that diagnosis. This study summarizing our 8 years’ experience of repeated TESE in azoospermic men was intended to assist the physician in consulting with an azoospermic patient after a testicular biopsy based on his previous procedure’s outcome and testicular histopathology. To our knowledge, only a few studies investigated the issue of repeated procedure for testicular sperm collection. All reported that repeated TESE ensured a high sperm recovery rate even in patients with NOA (7–11). Prediction of the likelihood of testicular sperm detection was specifically addressed by several authors. The success rate of repeated TESE ranged from 88.8% to 91.5% in patients with a history of sperm-positive procedure (8, 10). Only one successful TESE was reported after previous failed procedure in a single patient out of four patients (8). Fasouliotis et al. (9) found that 69.7% (23 of 33) of patients with a positive first TEFNA had a successful second attempt, whereas only 2 cases out of 18 (11.1%) with
TABLE 1 Prediction of TESE outcome by FSH serum level, outcome, and histopathology diagnosis of previous testicular sperm retrieval procedure.
FSH (mU/mL), mean SEM Previous sperm retrieval procedure Sperm-positive biopsies Sperm-negative biopsies Previous histopathology diagnosis Hypospermatogenesis Germ cell aplasia Spermatogenic maturation arrest
Failed TESE
Successful TESE
P value
25.7 15.2
14.4 11.9
.008 .0001
1/26 (4%) 8/12 (67%)
25/26 (96%) 4/12 (33%)
5/22 (23%) 8/12 (67%) 6/9 (67%)
17/22 (77%) 4/12 (33%) 3/9 (33%)
.01
Note: TESE ¼ testicular sperm extraction. Haimov-Kochman. Repeat TESE for azoospermia. Fertil Steril 2009.
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Correspondence
Vol. 91, No. 4, Supplement, April 2009
negative first TEFNA were successful the second time. Recently, Ramasamy and Schlegel (14) reported a sperm recovery rate of 51% by microdissection TESE in NOA patients with a prior biopsy. In 20 subjects who underwent a former unsuccessful TESE, the sperm recovery rate was 45%. In accordance with these reports, we found that former successful testicular sperm retrieval almost entirely ensured the success of the next procedure. Successful TESE may also be expected in a third of patients with a prior spermnegative testicular biopsy. Additionally, we investigated the predictive value of the first histopathology diagnosis to the chance of testicular sperm detection in the subsequent procedure. We found that hypospermatogenesis was the most favorable testicular histopathology diagnosis, predicting sperm detection in about three-fourths of future sperm retrieval procedures. However, apart from the diagnosis of germ cell aplasia (Sertoli cell only) poor correlation existed between the first and second histopathology testicular diagnoses. This observation could be explained by interobserver differences as well as the patchy appearance of testicular pathology. Given the possible focality of the histologic patterns and the chance of a single sampling from each testis in the previous biopsy, some patients might have been misclassified. Based on the histology discordance found between the previous and present biopsies, we suspect that only the consistent pathology of germ cell aplasia could be regarded as predictive, whereas the variable histology diagnoses of hypospermatogenesis lowered its predictive value. Our analysis has several weaknesses, partly as a result of its retrospective nature. 1) The number of subjects in our analysis is relatively small as a result of the infrequency of repeated TESE. 2) The study was unblinded. The surgeon was aware of the initial outcome, so that an expectation bias may exist. However, the embryology laboratory personnel were blind to the sperm recovery potential based on the patient’s history. Furthermore, the pathologist was blinded to the initial histopathology diagnosis and to whether sperm was ever retrieved. And 3) During the surgical procedure, inconsistent testicular specimen mass was excised, which may account for some discrepancy between sperm retrieval and the histopathology result. The present data suggest that repeated TESE ensures a high recovery rate when a previous recovery procedure has been successful and when the hypospermatogenesis was diagnosed previously on histopathology. The data also show that even when no spermatozoa were found on the first attempt, a subsequent TESE procedure can be scheduled with hope for successful sperm retrieval in onethird of the patients. Acknowledgments: The authors thank the administrative and nursing staff of the IVF unit of Hadassah Mt. Scopus.
Fertility and Sterility
Ronit Haimov-Kochman, M.D.a Francine Lossos, B.Sc.a Iris Nefesh, M.Sc.a Bat-Sheva Zentner, M.Sc.a Yulia Moz, Ph.D.a Diana Prus, M.D.b Yuval Bdolah, M.D.a Arye Hurwitz, M.D.a a In Vitro Fertilization Unit, Department of Obstetrics and Gynecology, and b Department of Pathology, Hadassah Hebrew University Hospital, Mt. Scopus, Jerusalem, Israel REFERENCES 1. Craft I, Bennett V, Nicholson N. Fertilising ability of testicular spermatozoa:[letter]. Lancet 1993;342:864. 2. Schoysman R, Vanderzwalmen P, Nijs M, Segal L, Segal-Bertin G, Geerts L, et al. Pregnancy after fertilization with human testicular spermatozoa. Lancet 1993;342:1237. 3. Tournaye H, Camus C, Vandervorst M, Nagy Z, Joris H, Van Steirteghem A, et al. Surgical sperm retrieval for intracytoplasmic sperm injection. Int J Androl 1997;20(Suppl 3):69–73. 4. Tournaye H, Verheyen G, Nagy P, Goossens A, Ubaldi F, Silber S, et al. Are there any predictive factors for successful testicular sperm recovery in azoospermic patients? Hum Reprod 1997;12: 80–6. 5. Schlegel P, Su L. Physiological consequences of testicular sperm extraction. Hum Reprod 1997;12:1688–92. 6. Ron-El R, Strauss S, Friedler S, Strassburger D, Komarovsky D, Raziel A. Serial sonography and colour flow Doppler imaging following testicular and epididymal sperm extraction. Hum Reprod 1998;13: 3390–3. 7. Westlander G, Rosenlund B, Soderlund B, Wood M, Bergh C. Sperm retrieval, fertilization, and pregnancy outcome in repeated testicular sperm aspiration. J Assist Reprod Genet 2001;18: 171–7. 8. 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 nonobstructive azoospermia. Hum Reprod 2002;17: 2356–61. 9. Fasouliotis SJ, Safran A, Porat-Katz A, Simon A, Laufer N, Lewin A. A high predictive value of the first testicular fine needle aspiration in patients with nonobstructive azoospermia for sperm recovery at the subsequent attempt. Hum Reprod 2002;17:139–42. 10. Kamal A, Fahmy I, Mansour R, Abou-Setta A, Serour G, Aboulghar M. Outcome of repeated testicular sperm extraction and ICSI in patients with nonobstructive azoospermia. MEFSJ 2004;9:42–6. 11. Vernaeve V, Verheyen G, Goossens A, Van Steirteghem A, Devroey P, Tournaye H. How successful is repeat testicular sperm extraction in patients with azoospermia? Hum Reprod 2006;21: 1551–4. 12. Matsumiya K, Namiki M, Takahara S, Kondoh N, Takada S, Kiyohara H, et al. Clinical study of azoospermia. Int J Androl 1994;17:140–2. 13. Haimov-Kochman R, Imbar T, Lossos F, Nefesh I, Zentner B, Moz Y, et al. Technical modification of testicular sperm extraction expedites testicular sperm retrieval. Fertil Steril. Published online 13 February, 2008 [Epub ahead of print]. 14. Ramasamy R, Schlegel PN. Microdissection testicular sperm extraction: effect of prior biopsy on success of sperm retrieval. J Urol 2007;177:1447–9.
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