News & Updates - MALE INFERTILITY: Assisted reproduction and ICSI

MALE INFERTILITY: Assisted Reproduction and ICSI

Urology 2002 Sep;60(3):497-501
Processed total motile sperm count correlates with pregnancy outcome after intrauterine insemination.
Miller DC, Hollenbeck BK, Smith GD, Randolph JF, Christman GM, Smith YR, Lebovic DI, Ohl DA.
Department of Urology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA.
OBJECTIVES: To determine the impact of processed total motile sperm (PTMS) count on pregnancy after partner intrauterine insemination (IUI). IUI is generally attempted before proceeding to more expensive and invasive assisted-reproductive techniques such as intracytoplasmic sperm injection. Several semen parameters have been shown to correlate with IUI outcome and may be useful when counseling couples. METHODS: Four hundred thirty-eight couples with diverse causes of infertility underwent 1114 cycles of husband IUI during a 39-month period. The clinical and semen parameters were recorded for each couple and each insemination. The parameters were compared between those couples who achieved a pregnancy and those who did not. RESULTS: The total number of pregnancies was 120, resulting in a pregnancy rate per cycle of 10.8% and a couple pregnancy rate of 27.4%. On multivariable logistic regression analysis, the PTMS count was independently associated with fertility after IUI (P = 0.0014). Moreover, the pregnancy rate was significantly lower for couples with less than 10 million PTMS (P <0.05). CONCLUSIONS: The results of this study have demonstrated that the PTMS count independently predicts success with IUI. Cycles with less than 10 million total motile sperm are significantly less likely to result in a pregnancy. If cause-specific therapy has failed, alternatives to IUI should be considered for couples when the PTMS count is less than 10 million.

J Assist Reprod Genet 2002 Feb;19(2):53-9
Intracytoplasmic sperm injection with testicular spermatozoa in men with azoospermia. Windt ML, Coetzee K, Kruger TF, Menkveld R, Van MJ.
Department of Obstetrics and Gynaecology, University of Stellenbosch, Tygerberg Hospital, South Africa. mlw@gerga.sun.ac.za
PURPOSE: The aim of the study was to gain an insight into the optimal management of the infertile couple with the husband suffering from azoospermia. METHODS: One hundred and forty-two intracytoplasmic sperm injection (ICSI) cycles performed with testicular extracted spermatozoa were retrospectively analysed. The following factors were investigated for their possible influence on fertilization, cleavage, damage, pregnancy, and ongoing pregnancy rates: the use of fresh, cryopreserved, and preincubated (24 h) spermatozoa and the etiology of the husbands' azoospermia (obstructive and nonobstructive). All microinjections were performed with apparently normal spermatozoa--a head with a tail of normal length. In 116 cycles at least two embryos were available for transfer. CONCLUSIONS: This study shows that the outcome of fresh and frozen-thawed testicular spermatozoa in ICSI is comparable, obstructive and nonobstructive etiologies perform the same, and that preincubation of testicular spermatozoa results in increased fertilization and pregnancy rates. All testicular biopsies are therefore performed the day before oocyte retrieval, superfluous spermatozoa cryopreserved, and the remaining testicular homogenate preincubated for the 24 h prior to oocyte retrieval. With this regime, most azoospermic patients are treated successfully, irrespective of the use of fresh or frozen-thawed spermatozoa from obstructive or nonobstructive cases.

Acta Obstet Gynecol Scand 2002 Apr;81(4):328-30
Is 24-h sperm motility a useful IVF measure when male infertility is not apparent? Eskandar M.
Department of Obstetrics & Gynecology and Reproductive Medicine, King Khalid University, College of Medicine, Abha, Saudi Arabia. mamdoheskandar@hotmail.com
OBJECTIVE: To examine the relationship of 24-h sperm motility between post insemination and fertilization in vitro, in a population with no apparent semen abnormalities. A retrospective study from July 1998 to June 2000. MATERIAL AND METHODS: Four hundred and seventy-one consecutive in-vitro fertilization (IVF) cycles for which the primary diagnosis was not male infertility (total motility count > 40 x 106) were studied. Linear regression was used to examine the general relation between 24-h sperm motility and IVF. The cohort with 0% 24-h motility was compared with all other cycles using the t-test and the chi2-test. Test quality was assessed using the positive likelihood ratio. RESULTS: Overall fertilization was 58 +/- 16%. There were 45/471 cycles (9.5%) with zero fertilization. Linear regression of percent fertilization vs. 24-h motility showed no relationship (r = 0.01). The cohort with 0% 24-h motility had a lower fertilization rate 29 +/- 19% (P = 0.05), and had a higher incidence of no fertilization 7/21 (P = 0.01). The positive likelihood ratio was 4.6. CONCLUSIONS: Zero 24-h motility indicates occult male infertility, and a positive result indicates a fair to good test. Overall there was no relationship between sperm survival at 24 h post insemination and fertilization in vitro. However, 0% 24-h sperm motility was associated with reduced fertilization

Hum Fertil (Camb) 2002 Feb;5(1 Suppl):S9-S14
Assisted conception in the azoospermic male. Gordon UD.
Centre for Reproductive Medicine, 4 Priory Road, Clifton, Bristol BS8 1TY, UK.
The advent of intracytoplasmic sperm injection (ICSI) has offered new solutions for the management of patients with azoospermia. Surgical sperm recovery combined with ICSI has allowed many men with azoospermia to father their own biological children. Azoospermia can be classified as obstructive and non-obstructive, with investigations, management and success rates varying markedly between the two forms. In certain cases of obstructive azoospermia surgical reconstruction remains a viable option, whereas cases with congenital obstruction need to be screened for mutations of the cystic fibrosis gene. In most cases of obstruction sperm can be retrieved from the epididymis using percutaneous epididymal sperm aspiration (PESA). If PESA is unsuccessful, testicular sperm extraction (TESE) is successful in all cases. With non-obstructive azoospermia, the genetic basis has been investigated intensely. Screening for karyotypic abnormalities as well as Y microdeletions is recommended. Irrespective of the histological diagnosis, focal spermatogenesis can be observed in 40-50% of cases using multiple testicular biopsies.

Hum Fertil (Camb) 2002 Feb;5(1):17-22
Surgical sperm retrieval: a review of current practice. Wood S, Lewis-Jones I, Troup S, Desmond A, Kingsland C.
Reproductive Medicine Unit, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK.
Although pregnancies were achieved after surgical sperm retrieval and in vitro fertilization 8 years before the introduction of intracytoplasmic sperm injection (ICSI), it is the development of ICSI that has led to the rapid expansion of surgical procedures to obtain sperm from azoospermic males for use in assisted conception cycles. The natural desire for couples to achieve a pregnancy using their own gametes and a national shortage of donor sperm have driven the demand for an expansion of this service. Males who have previously been considered unable to father their own genetic child can now be offered treatment, which, in most cases, will lead to the recovery of sperm for use in treatment. This article considers the development of the techniques available to clinicians and provides an overview of the many treatments (and their acronyms) to assist clinicians unfamiliar with the practicalities of surgical sperm retrieval. In reviewing the current published studies, we also offer some guidelines as to the optimization of the potential future provisions of surgical sperm retrieval treatments for azoospermic males, either secondary to obstruction (particularly after vasectomy) or from non-obstructive causes.

Fertil Steril 2002 Mar;77(3):516-9
Vasectomy reversal performed 15 years or more after vasectomy: correlation of pregnancy outcome with partner age and with pregnancy results of in vitro fertilization with intracytoplasmic sperm injection.
Fuchs EF, Burt RA.
Division of Urology, Department of Surgery, The Oregon Health and Science University, Portland, Oregon 97201, USA. fuchsef@aol.com
OBJECTIVE: To document a contemporary series of vasectomy reversals performed in men 15 years or more after vasectomy and to correlate the results with spousal age and results of ICSI for obstructive azoospermia. SETTING: University referral center for male infertility. DESIGN: Retrospective analysis of a single surgeon's experience compared with reported ICSI results. PARTICIPANT(S): One hundred seventy-three men who had vasectomy reversal 15 years or more after vasectomy. INTERVENTION(S): Reversal of vasectomy by vasovasostomy or epididymovasostomy. MAIN OUTCOME MEASURE(S): Correlation of pregnancy results after vasectomy reversal with spousal age and published ICSI results.
RESULT(S): Pregnancy rates for the intervals of 15-19 years, 20-25 years, and >25 years after vasectomy were 49%, 39%, and 25%, respectively. For spousal age <30 years, 30--35 years, 36-40 years, and >40 years, pregnancy rates were 64%, 49%, 32%, and 28%, respectively. The overall pregnancy rate was 43%, which is similar to the pregnancy rate of 40% for ICSI in obstructive azoospermia. Sixty-two percent of the men required a unilateral or bilateral epididymovasostomy. CONCLUSION(S): Spousal age is an important predictive factor after vasectomy reversal among men who have reversal 15 years or more after vasectomy. Pregnancy rates after vasectomy reversal compare favorably with those obtained with ICSI.

J Med Assoc Thai. 2001 Nov;84(11):1569-75
The outcome of sperm retrieval and intracytoplasmic sperm injection for obstructive azoospermia. Sukcharoen N, Promviengchai S, Boonkasemsanti W, Sithipravej T, Chinpilas V.
Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Thailand.
OBJECTIVES: To study the outcome of sperm retrieval and intracytoplasmic sperm injection (ICSI) from obstructive azoospermic men. METHOD: Overall, 50 sperm retrieval procedures were performed in 45 obstructive azoospermic men, followed by 57 ICSI procedures with fresh epididymal spermatozoa (n=40), fresh testicular spermatozoa (n=4) or frozen-thawed epididymal spermatozoa (n=13). RESULTS: Sperm retrieval was accomplished via percutaneous epididymal sperm aspiration (PESA) in 42 cases, testicular sperm aspiration (TESA) in 1 case and testicular sperm extraction (TESE) in 2 cases. TESA and TESE were only applied when PESA failed to produce enough spermatozoa for simultaneous ICSI. PESA was successful in 92 per cent of cases. Fertilization rate after ICSI was 79.6 per cent of the metaphase II oocytes. Seventy one embryo transfers were performed using both fresh and frozen thawed embryos resulting in clinical pregnancy in 39.4 per cent. Ongoing pregnancy was achieved in 35.2 per cent. CONCLUSION: ICSI has been shown to give a high fertilization and pregnancy rate with epididymal and testicular spermatozoa retrieved from obstructive azoospermic men. PESA is a noninvasive and simple technique for retrieving spermatozoa from obstructive azoospermic men. Therefore, it is suitable as the primary sperm recovery technique in patients with obstructive azoospermia.

Hum Reprod 2002 Jan;17(1):139-42
A high predictive value of the first testicular fine needle aspiration in patients with non-obstructive azoospermia for sperm recovery at the subsequent attempt.
Fasouliotis SJ, Safran A, Porat-Katz A, Simon A, Laufer N, Lewin A.
IVF Unit, Department of Obstetrics and Gynecology, Hadassah Medical Center, Hebrew University, Ein-Kerem, Jerusalem, Israel
BACKGROUND: The objective of this retrospective study, which included 51 men with non-obstructive azoospermia, was to evaluate the predictive value of the results of the first sperm recovery attempt on the probability for sperm recovery in a second attempt. METHODS AND RESULTS: A positive testicular fine needle aspiration (TEFNA) was defined as the recovery of any number of mature sperm. At the first and second TEFNA attempts, mature sperm were recovered in 33 (64.7%) and 25 (49%) of 51 patients respectively. In 23 of the 33 (69.7%) patients with a positive first TEFNA, sperm were recovered at both attempts, whereas in only two of 18 (11.1%) with a negative first TEFNA, sperm were recovered at the second attempt. Our analysis revealed a high predictive value of the first TEFNA for sperm recovery at the subsequent attempt, with a mean positive predictive value of 69.7%, with the highest probability being 90.9% in hypospermatogenesis, 72.7% in Sertoli cell-only pattern, 75% in tubular hyalinization, and the lowest being 28.6% in maturation arrest. The mean negative predictive value was 88.9%, which was high in all categories (80% in Sertoli cell-only pattern and 100% in maturation arrest and tubular hyalinization). CONCLUSION: A second TEFNA attempt should be offered to all non-obstructive azoospermic patients with a positive first TEFNA. Patients with a negative first TEFNA may undergo a repeated attempt, but a donor sperm back-up is strongly advised.

Hum Reprod 2001 Dec;16(12):2621-7
Serial ultrasonography, hormonal profile and antisperm antibody response after testicular sperm aspiration.
Westlander G, Ekerhovd E, Granberg S, Lycke N, Nilsson L, Werner C, Bergh C.
Centre for Reproductive Medicine, Sahlgrenska University Hospital, Goteborg University, Goteborg, Sweden. goran.westlander@medfak.gu.se
BACKGROUND: In many fertility centres, intracytoplasmic sperm injection (ICSI) with epididymal or testicular spermatozoa is a routine treatment for men with azoospermia. In this prospective study, the physiological consequences after testicular sperm aspiration (TESA), using suction and a 19 gauge needle, were evaluated. METHODS AND RESULTS: Thirty-five consecutive men with azoospermia underwent TESA. Testicular ultrasonography with Doppler flow imaging was performed and testicular volumes were evaluated pre-operatively and 3 months after aspiration. If focal testicular lesions were found, further examinations were performed 6 and 9 months after TESA. Serum FSH, testosterone and antisperm antibodies (ASA) were analysed. Focal testicular lesions were seen in four out of 61 testes (6.6%) at the 3 month investigation point. Three lesions were resolved after 6 months and all after 9 months. Testicular echogenicity remained unchanged in 50 cases (82%) 3 months after TESA. Four men (11.4%) reported severe subjective discomfort post-operatively, but only one had a medical consultation where an intratesticular haematoma was diagnosed. There were no significant changes in FSH and testosterone after surgery and testicular volumes were similar after 3 months. There were three borderline cases of ASA in serum, but none was classified as ASA-positive. CONCLUSIONS: The puncture method of testicular sperm aspiration seems to be a safe method for sperm retrieval, with minimal physiological consequences.

Hum Reprod 2001 Dec;16(12):2485-90
Should ICSI be the treatment of choice for all cases of in-vitro conception? Considerations of fertilization and embryo development, cost effectiveness and safety.
Ola B, Afnan M, Sharif K, Papaioannou S, Hammadieh N, Barratt CL.
Assisted Conception Unit, Birmingham Women's Hospital, Edgbaston, Birmingham B15 T2G, UK. There is now considerable discussion whether intracytoplasmic sperm injection (ICSI) should be used in all cases of IVF. A critical and balanced view of the current literature is presented. The difficult question is how to identify men with apparently normal semen who are likely to fail to achieve a pregnancy using IVF. In conclusion, from both the safety and scientific viewpoint, ICSI

Arch Androl 2001 Nov-Dec;47(3):161-5
Pregnancy/implantation rates as related to age following transfer of frozen embryos produced by ICSI.
Check ML, Check JH, Summers-Chase D, Swenson K, Yuan W.
The University of Medicine/Dentistry of New Jersey, Robert Wood Johnson Medical School at Camden, USA.
A study has suggested that one drawback of ICSI is that if these embryos are cryopreserved they have lower implantation rates after thawing and transfer as compared to other frozen embryos derived from conventional oocyte insemination. Other studies have not shown such adverse effects on pregnancy rates following frozen embryo transfer (ET) of embryos formed by ICSI. The study presented here evaluated the largest number of frozen ET cycles of embryos following ICSI, which were compared to couples having frozen ET with embryos formed by conventional insemination. In women age 39 and younger, the clinical, viable, pregnancy rates and implantation rates were very similar. Similar rates were reached for the older group. These data convincingly demonstrate that fertilization by ICSI does not adversely effect the implanting capacity of frozen-thawed embryos.

Hum Reprod 2001 Nov;16(11):2298-304
Results of 6139 artificial insemination cycles with donor spermatozoa. Botchan A, Hauser R, Gamzu R, Yogev L, Paz G, Yavetz H.
Institute for the Study of Fertility, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel. amnonbb@inter.net.il
BACKGROUND: Artificial insemination by donor spermatozoa (AID) can prove a valuable treatment for a number of male factor disorders, although its success rate is variable. METHODS: Retrospective analysis of the results of 6139 cycles performed in 1001 women during an 18 year period is presented. Pregnancy rates per cycle are presented as a function of: female fertility history, treatment modalities, medication used for induction of ovulation, female age, year of treatment, consecutive cycle effect and the use of fresh versus frozen-thawed spermatozoa. RESULTS: Overall pregnancy rate of 12.6% and cumulative pregnancy rate after 12 months of treatment of 75% were achieved. Age was found to be the most important determinant for success rate. CONCLUSIONS: Since the establishment of AID treatments, the mean age of the population of women receiving treatment has increased each year. Consequently, success rate did not improve, even with the use of more sophisticated medical modalities.

Hum Reprod 2001 Oct;16(10):2084-92
Incidence of sperm chromosomal abnormalities in a risk population: relationship with sperm quality and ICSI outcome.
Rubio C, Gil-Salom M, Simon C, Vidal F, Rodrigo L, Minguez Y, Remohi J, Pellicer A.
Instituto Valenciano de Infertilidad, Guardia Civil, 23, E-46020 Valencia, Spain.
BACKGROUND: An increased incidence of chromosome abnormalities has been reported in sperm samples of many infertile men by fluorescence in-situ hybridization (FISH). METHODS: Sperm aneuploidy and diploidy rates for chromosomes 13, 18, 21, X and Y were evaluated in 63 patients with normal karyotypes using dual and triple-colour FISH techniques. Indications for sperm FISH analysis were: recurrent miscarriages of unknown aetiology (RM, n = 40), repeated implantation failure after intracytoplasmic sperm injection (ICSI) (IF, n = 19), previous Down's syndrome pregnancies (n = 3), and meiotic abnormalities (MA, n = 1). Nine healthy normozoospermic donors were also evaluated as a control group. RESULTS: A significant increase in the incidence of sex chromosome disomies was found in the RM, IF and MA groups. Oligoasthenoteratozoospermic patients (n = 21) showed significantly higher rates of diploidy and disomies for sex chromosomes and chromosomes 18 and 21 than normozoospermic patients (n = 14). Thirty-one patients with normal and seven with abnormal FISH results had undergone several ICSI treatments (108 and 23 cycles respectively). Couples with abnormal sperm FISH results showed decreased pregnancy and implantation rates and increased miscarriage rates. CONCLUSIONS: Patients with a clinical background of recurrent miscarriages of unknown aetiology or implantation failure after ICSI are at risk of showing sperm chromosomal abnormalities, the incidence of which is higher in oligoasthenoteratozoospermic patients.

Int J Androl 2001 Oct;24(5):306-10
Predictive factors of successful testicular sperm recovery in non-obstructive azoospermia patients. Seo JT, Ko WJ.
Department of Urology, Samsung Cheil Hospital, Sungkyunkwan University School of Medicine, 1-19 Mookjung-Dong, Chung-Ku, Seoul, 100-380 Korea. jtandro@hotmail.com
Recovery of testicular spermatozoa from non-obstructive azoospermic patients for intracytoplasmic sperm injection (ICSI) is a recent advance in the treatment of male infertility. The purpose of this study is to identify predictive factors for sperm recovery in non-obstructive azoospermic patients. A total of 178 men with non-obstructive azoospermia had multiple testicular sperm extraction (TESE) procedures to recover spermatozoa for intracytoplasmic sperm injection (ICSI) from June 1996 to February 1999. Testicular volume, serum follicle stimulating hormone (FSH) level and testicular histology were examined as positive predictive factors for sperm recovery. Testis biopsies were categorized as severe hypospermatogenesis, maturation arrest and Sertoli cell-only syndrome based on the most advanced pattern of spermatogenesis seen on histology. Sperm retrieval success rates for the patients in three histopathological categories were compared. Spermatozoa were successfully recovered in 94 of 178 (52.8%) men. Sperm were retrieved in 13 of 80 (16.3%) with Sertoli cell-only syndrome, 15 of 24 (62.5%) with maturation arrest, and 66 out of 74 (89.2%) with severe hypospermatogenesis. Spermatozoa recovery has no correlation with testicular volume or serum FSH level. When compared against Sertoli cell-only syndrome, the odds of sperm retrieval success rate was 44.3 times higher in severe hypospermatogenesis and 8.4 times in maturation arrest. These results demonstrate meaningful correlation between successful testicular sperm recovery and testis histopathology. Only testicular histopathology can be used as a predictor of successful sperm recovery.

Am J Obstet Gynecol 2001 Aug;185(2):332-7
Predictors of success with the use of donor sperm. Williams RS, Alderman J.
Department of Obstetrics and Gynecology, University of Florida, Gainesville, FL 32610, USA.
OBJECTIVE: This study was undertaken to assess the effect of multiple factors that influence the success rate and time to conception among couples undergoing donor sperm insemination. STUDY DESIGN: A retrospective analysis of 960 cycles of frozen donor sperm insemination was performed at the University of Florida. Cycle pregnancy rates and cumulative probability of pregnancy were compared using several variables. CONCLUSION: The most significant influence on pregnancy rates in the donor sperm insemination program at the University of Florida was maternal age. Nulligravidity and a diagnosis of mild oligospermia in the man may have a negative impact on pregnancy rates.

J Assist Reprod Genet 2001 Mar;18(3):171-7
Sperm retrieval, fertilization, and pregnancy outcome in repeated testicular sperm aspiration. Westlander G, Rosenlund B, Soderlund B, Wood M, Bergh C.
Center for Reproductive Medicine, Sahlgrenska University Hospital, Goteborg University, S-413 45 Goteborg, Sweden.
PURPOSE: To report the outcome of sperm retrieval and results after ICSI in up to six repeated testicular sperm aspiration procedures. METHODS: Twenty-two men with obstructive and thirty-four men with nonobstructive azoospermia underwent 50 and 91 needle aspirations, respectively. Sufficiency of spermatozoa for ICSI and cryopreservation, fertilization rate, and pregnancy outcome was analyzed retrospectively. RESULTS: No major differences were found in sperm recovery or pregnancy outcome in the repeated cycles. Testicular aspirate containing motile spermatozoa with maintained fertilizing capacity was obtained in up to six repeated procedures in the nonobstructive group. No postoperative complications were reported for any of the participants. CONCLUSIONS: Testicular sperm aspiration is a simple and effective method of sperm retrieval, which can be performed from the same testis up to several times with good recovery of motile spermatozoa for ICSI and maintaining high fertilization and pregnancy rates, in men with both obstructive and nonobstructive azoospermia.

Am J Reprod Immunol 2001 Mar;45(3):161-7
Association between interleukin concentration in follicular fluid and intracytoplasmic sperm injection (ICSI) outcome.
Hammadeh ME, Ertan AK, Baltes S, Braemert B, Georg T, Rosenbaum P, Schmidt W.
Department of Obstetrics and Gynecology, The University of Saarland, Homburg/Saar, Germany. frmham@med-rz.uni-sb.de
PROBLEM: The aim of this study was to determine the presence and concentration of interleukin IL-6, IL-8, and granulocyte-macrophage-colony-stimulating factor (GM-CSF) in pre-ovulatory ovarian follicular fluid (FF) of patients undergoing controlled ovarian hyperstimulation for intracytoplasmic sperm injection (ICSI) therapy on one hand, and to find out whether these cytotokine concentrations could be used as a predictive parameter for ICSI outcome. DESIGN: The levels of IL-6, IL-8, and GM-CSF were measured from women that underwent ICSI therapy and the results were compared between the patients who became pregnant after IC

Semin Reprod Med 2000;18(2):161-9
ICSI and its outcome.
Palermo GD, Neri QV, Hariprashad JJ, Davis OK, Veeck LL, Rosenwaks Z.
Center for Reproductive Medicine and Infertility, New York Presbyterian Hospital-Weill Medical College of Cornell University, 505 East 70th Street, New York, NY 10021-4872, USA. Since its introduction in 1992, intracytoplasmic sperm injection (ICSI) has become a popular assisted fertilization technique proved very efficient in treating male factor infertility. Because of the peculiarity of the technique and the poor characteristics of the spermatozoa used, concern about the safety of ICSI still exist. In this article, we analyze the in vivo development of embryos conceived after ICSI as well as the obstetric outcome, occurrence of chromosomal abnormalities, and rate of congenital malformations in neonates born as a result of this treatment. A total of 2435 couples were studied in whom the male partners were presumed to be the cause of repeated failed attempts at in vitro fertilization (IVF) or had semen parameters that were unacceptable for conventional IVF treatment. Pregnancies resulting from 3573 ICSI cycles were analyzed. The overall clinical pregnancy (fetal heartbeat) rate was 44.8% with a resultant delivery rate of 39.2% per ICSI cycle (n = 1388). In 37 of the 77 miscarriages for which cytogenetic data were available, an autosomal trisomy was found in each and 29 additional pregnancies were terminated because of a chromosomal abnormality revealed by prenatal diagnosis. Of the 2059 neonates resulting from ICSI treatment, 38 (1.8%) presented with congenital abnormalities (22 major and 16 minor). When the frequency of miscarriages and congenital malformations was analyzed in terms of semen origin, the outcome was no different between ICSI and IVF. The course of pregnancies and occurrence of congenital malformations following treatment by ICSI are within the ranges obtained following conventional IVF.

Br Med Bull 2000;56(3):616-29
Male infertility and intracytoplasmic sperm injection (ICSI). Campbell AJ, Irvine DS.
MRC Human Reproductive Sciences Unit, Centre for Reproductive Biology, 37 Chalmers St, Edinburgh EH3 9ET, UK.
Micro-assisted fertilization in the form of intracytoplasmic sperm injection (ICSI) has truly revolutionised the treatment options for couples with impaired semen quality, and those with both obstructive and non-obstructive azoospermia. In general, the major issues which relate to the success of ICSI are those related to the success of conventional IVF, and the high multiple pregnancy rate remains a major cause for concern. There is growing evidence that the short-term health of ICSI offspring is relatively unremarkable, but our growing understanding of the genetic basis of much of male subfertility and of the impaired genomic integrity which characterises the oligozoospermic phenotype indicate a cautious approach to the longer term health of ICSI offspring.

J Assist Reprod Genet 2000 Nov;17(10):586-90
Low-dose aspirin does not increase implantation rates in patients undergoing intracytoplasmic sperm injection: a prospective randomized study.
Urman B, Mercan R, Alatas C, Balaban B, Isiklar A, Nuhoglu A.
Assisted Reproduction Unit, VKV American Hospital of Istanbul, Guzelbahce Sok No. 2, Nisantasi 80200, Istanbul, Turkey.
PURPOSE: The aim was to evaluate the effect of aspirin on pregnancy and implantation rates in an unselected group of patients undergoing intracytoplasmic sperm injection (ICSI). METHODS: Two hundred and seventy-nine patients were randomized to receive 80 mg of aspirin (n = 139) or no treatment (r = 136) starting from the first day of controlled ovarian hyperstimulation. RESULTS: Duration of stimulation, gonadotropin consumption, peak estradiol, number of oocytes retrieved, fertilization rate, cleavage rate, and number of embryos transferred were similar in the two groups. Implantation and clinical pregnancy rates were 15.6% and 39.6% versus 15.1% and 43.4% in aspirin treated and untreated groups, respectively (P > 0.05). CONCLUSIONS: Low-dose aspirin administration does not improve implantation and pregnancy rates in an unselected group of patients undergoing ICSI.

Mol Cell Endocrinol 2000 Nov 27;169(1-2):11-4
Cryopreservation of epididymal sperm. Patrizio P.
University of Pennsylvania Medical Center Department of Obstetrics and Gynecology Male Infertily Program, Phiadelphia 19104-4183, USA. ppatrizio@obgyn.upenn.edu
There are two methods to retrieve epididymal sperm: microsurgical epididymal sperm aspiration (MESA) and percutaneous epididymal sperm aspiration (PESA). There are no data on cryopreservation and ICSI with epididymal sperm collected with PESA technique. In summary, these data show that epididymal sperm obtained by PESA can be successfully cryopreserved; pregnancy rates are similar between fresh and cryopreserved epididymal sperm. The transfer of frozen embryos obtained with either fresh or frozen thawed epididymal sperm leads to the same pregnancy and delivery rate.

Hum Reprod 2001 Jan;16(1):125-129
Blastocyst transfer following intracytoplasmic injection of ejaculated, epididymal or testicular spermatozoa.
Balaban B, Urman B, Isiklar A, Alatas C, Mercan R, Aksoy S, Nuhoglu A.
Assisted Reproduction Unit, American Hospital of Istanbul, Turkey. Recent studies indicate a strong paternal influence on embryo development and progression of the embryo to the blastocyst stage. The aim of this study was to compare, during extended culture, the in-vitro development of embryos resulting from intracytoplasmic sperm injection (ICSI) of ejaculated spermatozoa (group 1, n = 347), epididymal (group 2, n = 22) or testicular (group 3, n = 18) spermatozoa from obstructive azoospermic and testicular spermatozoa from non-obstructive azoospermic (group 4, n = 31) subjects. Fertilization and blastocyst formation rates were significantly lower in group 4 (P < 0.05). The incidence of expanded and hatching blastocysts was significantly lower in group 4 (P < 0.05). Overall in 93.2% ejaculate ICSI cycles, blastocysts were transferred on day 5. This was significantly higher than the 62% day 5 transfers in the non-obstructive azoospermic group (P < 0.05). Implantation rate per embryo was significantly higher in the ejaculate ICSI group compared with the other groups (P < 0.05). Clinical pregnancy per transfer was similar between groups; however, significantly fewer multiple pregnancies were encountered in the non-obstructive azoospermic group (P < 0.01). In conclusion, the source of the spermatozoa, most likely to be indicative of the severity of spermatogenic disorder, affects the rate of blastocyst formation and blastocyst implantation. Spermatozoa from non-obstructive azoospermic subjects, when utilized for ICSI, result in embryos that progress to the blastocyst stage at a lower and slower rate and implant less efficiently.

Arch Androl 2000 Nov-Dec;45(3):125-30
ICSI as an effective therapy for male factor with antisperm antibodies. Check ML, Check JH, Katsoff D, Summers-Chase D.
The University of Medicine/Dentistry of New Jersey, Robert Wood Johnson Medical School at Camden, USA.
This study was conducted to evaluate if in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) is an effective treatment for infertility complicated by the presence in the male partner of sperm autoantibodies. Over a 1-year study period comparisons of fertilization, pregnancy, and implantation rates were made in couples where the male partner was negative or weakly positive for sperm autoantibodies (<50%) (gr 1); autoantibodies were strongly positive (>80%) (gr 2); or autoantibodies were moderately positive (50-80%) (gr 3). Only patients having oocytes fertilized by ICSI were included. The fertilization, clinical pregnancy, implantation, and miscarriage rate for group 1 (n = 67) was 56, 43, 21, and 14%. Comparable values for group 2 (n = 20) were 55, 40, 23, and 25%, and for group 3 (n = 6) were 63, 33, 23, and 0%. IVF with ICSI demonstrates comparable fertilization, pregnancy, implantation, and miscarriage rates in female partners of males with and without sperm autoantibodies.

Hum Reprod 2000 Nov;15(11):2415-7
Cystic fibrosis in infertility: screening before assisted reproduction: opinion. Lewis-Jones DI, Gazvani MR, Mountford R.
Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS and University of Aberdeen, Aberdeen Maternity Hospital, Foresterhill, Aberdeen AB25 2ZD, UK. Cystic fibrosis (CF) is the most common autosomal recessive disease in Caucasians. In 97-98% of men with CF, bilateral congenital absence of the vas deferens (CBAVD) blocks the transport of spermatozoa resulting in azoospermia. Abnormalities in sperm parameters have also been identified in males with CF. To date, over 800 disease-causing mutations of the CF transmembrane conductance regulator (CFTR) gene have been identified (also called ABCC7). Current legislation suggests that prior to intracytoplasmic sperm injection (ICSI) treatment, men with CBAVD or unexplained oligozoospermia should be considered for screening. If the male is negative with routine screening then the female partner is not screened. This is fundamentally wrong because if the female is screened and is found to be CF positive on routine testing, her partner would then need the fullest possible investigation of the CFTR gene. It is ideal to screen both partners in cases of oligozoospermia. However, if the resources are stretched, then only the female needs to be routinely screened because if she is negative, then the couple's residual risk of having a CF or CBAVD child will be reduced to 1:960. Only when the female is found to be a carrier does the male partner need routine screening followed by full testing for known mutations.

Chest. 2000 Oct;118(4):893-4.
Fertility in men with cystic fibrosis: an update on current surgical practices and outcomes. McCallum TJ, Milunsky JM, Cunningham DL, Harris DH, Maher TA, Oates RD.
Department of Urology, and the Center for Human Genetics, Boston University School of Medicine, Boston, USA.
BACKGROUND: Men with cystic fibrosis (CF) have bilateral absence of the vas deferens causing an obstructive azoospermia that is not amenable to surgical correction. Advances in the field of reproductive medicine allow for the procurement of viable sperm and facilitate fertilization and pregnancy in couples where the man has CF. OBJECTIVES: To describe patient anatomy and semen characteristics and to determine the pregnancy rates of couples in whom the male partner has CF and who have undergone microsurgical epididymal sperm aspiration coupled with in vitro technology, specifically intracytoplasmic sperm injection (ICSI). DESIGN: Retrospective analysis. SETTING: Clinical department of urology and two reproductive medicine units. PATIENTS: Thirteen married men with CF who were referred for infertility. INTERVENTIONS: History, physical examination, semen analysis, transrectal and renal ultrasonography, CF mutation analysis, and microsurgical sperm aspiration coupled with ICSI. RESULTS: All 13 men had low-volume azoospermia, absent vasa, and aplasia/hypoplasia of the seminal vesicles. CF mutation analysis was carried out in 11 of 13 men, and 9 of 11 were DeltaF508 homozygous. Eight men underwent microsurgical sperm aspiration, and their partners underwent one or more cycles of ICSI. Five couples (62.5%) achieved a pregnancy, with four couples delivering (three sets of twins and one singleton). CONCLUSIONS: CF in men is accompanied by bilateral vasal aplasia. The resultant obstructive azoospermia can be treated quite successfully with a combination of sperm aspiration and ICSI. It is important for physicians involved in the care of men with CF to convey the message that prospects for fatherhood are excellent with current technology.

Obstet Gynecol Clin North Am 2000 Sep;27(3):517-27
Advances in assisted reproductive technologies. Thornton KL.
kimthornton@bostonivf.com
Several clinical advances in the field of assisted reproductive technology have improved the success rates of IVF. These advances include improvements in ovulation induction protocols, the introduction of recombinant gonadotropins, GnRH agonists, and, most recently, GnRH antagonists. ICSI has proved to be the most successful technique for the treatment of male infertility. The micromanipulation techniques developed in the embryology laboratory have facilitated advances in the field of preimplantation genetic diagnosis. Years of research in embryology laboratories have enabled the successful culture of embryos to the blastocyst stage. In the future, blastocyst transfer may have even more impact on overall success rates of IVF and multiple pregnancy rates. The field of assisted reproductive technologies has come a long way since the first successful IVF pregnancy. Future developments are expected to be equally

Ann N Y Acad Sci 2000;900:336-44
Intracytoplasmic sperm injection. Survey of world results.
Tarlatzis BC, Bili H.
1st Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Greece. The widespread application of intracytoplasmic sperm injection (ICSI) has raised concern about the efficacy and safety of this novel technique. The European Society of Human Reproduction and Embryology (ESHRE) has established an ICSI Task Force to collect annually the clinical results. Over a 3-year span (1993-1995), the number of centers increased from 35 to 101, and the total number of ICSI cycles per year rose from 3,157 to 23,932. The incidence of oocytes damaged by the procedure remained low (< 10%), whereas the fertilization rates obtained with ejaculated, epididymal, and testicular spermatozoa for 1995 were 64%, 62%, and 52%, respectively. Thus, 86-90% of the couples had embryo transfer, and the viable pregnancy rate was 21% for ejaculated, 22% for epididymal, and 19% for testicular sperm, while the incidence of multiple gestations was 29%, 30%, and 38%, respectively. Furthermore, 3,149 transfers of frozen-thawed embryos after ICSI with ejaculated, epididymal, or testicular sperm were performed, and in 11%, 9%, and 7% of them, respectively, a viable pregnancy was achieved. The ICSI results were similar during this 3-year period, irrespective of the origin of the sperm. The perinatal outcome of children born after ICSI was not different from that after in vitro fertilization or natural conception and was only affected by multiplicity. Moreover, the incidence of major or minor malformations was not increased, but the chromosomal, especially the sex chromosomal, aberration rate was slightly elevated (approximately 2%). Therefore, ICSI has opened new horizons in the treatment of male infertility. The procedure seems to be safe, but further follow-up of the children is necessary to more accurately assess its safety.

J Obstet Gynaecol Res 2000 Feb;26(1):55-60
Clinical usefulness of basal FSH as a prognostic factor in patients undergoing intracytoplasmic sperm injection.
Chae HD, Kim CH, Kang BM, Chang YS.
Department of Obstetrics and Gynecology, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea.
OBJECTIVE: To determine if basal serum follicle stimulating hormone (FSH) level could be a prognostic factor of the clinical outcome in intracytoplasmic sperm injection (ICSI) cycles in the couples with male factor infertility. MATERIALS AND METHODS: From December 1995 to March 1998, total 118 patients underwent in vitro fertilization and embryo transfer (IVF-ET) with ICSI due to male factor infertility were included in this study. Patients were allocated to the low basal FSH group (< 8.5 mIU/ml) and the high basal FSH group (> or = 8.5 mIU/ml). The basal levels of FSH were measured in the 3rd day of menstrual cycle preceding ovarian stimulation cycle in total IVF cycles by immunoradiometric assay (IRMA). Statistical analysis was performed using Student's t-test, Fisher's exact test, and chi 2 test as appropriate. Statistical significance was defined as p < 0.05. RESULTS: The total dose of exogeneous gonadotropin required in the high basal FSH group was significantly higher than that in the low basal FSH group. The numbers of retrieved oocytes and oocytes with grade I, II were significantly higher in the low basal FSH group. The clinical pregnancy rate per cycle in the low basal FSH group (16.2%) was significantly higher than that in the high basal FSH group (4.0%). CONCLUSION: These results suggested that the basal serum FSH levels could be predictive of pregnancy outcome and the results of controlled ovarian hyperstimulation (COH) in ICSI cycles.

Andrologia 2002 Sep;34(4):248-54
Five years experiences with microinjection of testicular spermatozoa into oocytes in Hungary. Matyas S, Rajczy K, Papp G, Bernard A, Korponai E, Kovacs T, Krizsa F, Kulin S, Menyhart R, Szmatona G, Kopa Z, Erdei E, Balogh I, Gati I, Egyed J, Kaali SG.
Kaali Institute SEETK Department of Andrology Krio Institute SEETK Department of Obstetrics and Gynecology, Budapest, Hungary.
The aim of the study was to summarize our five years experience (1996-2000) of testicular spermatozoa for intracytoplasmic sperm injection in Hungary. The influence of sperm count, maternal age, number of transferred embryos, and application of assisted hatching on outcome was investigated. Testicular spermatozoa were retrieved by microsurgical testicular sperm extraction. Samples were classified depending on the number of spermatozoa. Indication for testicular sperm extraction in conjunction with intracytoplasmic sperm injection was severe azoospermia or azoospermia combined with tubal origin infertility. Ovarian stimulation was carried out using an ultrashort protocol with GnRH agonist and gonadotrophin. Intracytoplasmic sperm injection was performed without PVP. Embryos were cultured for 48 or 72 h before embryo transfer. Indications for assisted hatching included elevated maternal age, increased zona thickness or at least two previous unsuccessful IVF cycles. Testicular spermatozoa were successfully retrieved in 218 out of 273 cases. Extreme low sperm count was found more frequently in cases of nonobstructive azoospermia. No significant differences were observed in fertilization rate (61.1% vs. 51.7%) or clinical pregnancy rate (29.0% vs. 26.7%) between patients with obstructive or nonobstructive azoospermia. Maternal age, number of transferred embryos and application of assisted hatching had a significant effect on outcome. It is concluded that testicular sperm extraction is an efficient way of obtaining testicular spermatozoa, allowing not only successful fertilization by ICSI, but also freezing of testicular spermatozoa for use in subsequent cycles.

Di Yi Jun Yi Da Xue Xue Bao 2001;21(11):862-864
Study on embryo morphology and clinical result of intracytoplasmic sperm injection for infertility. Huang MZ, Chen SL, Xing FQ.
Center for Assisted Reproduction, Department of Obstetrics and Gynecology, Nanfang Hospital, First Military Medical University, Guangzhou 510515, China.
OBJECTIVE: To explore the relevance of the embryo morphology with the clinical result of intracytoplasmic sperm injection (ISCI) for infertility treatment. METHODS: A retrospective analysis was conducted of 291 ISCI and 352 in vitro fertility (IVF) cycles collected during the period from January, 1999 to March, 2001. RESULTS: Significant difference was not found in the fertility rates between the 2 groups (75.7% vs 73.2%, P=0.5738), nor in the oocyte lysis rates (10.6% vs 7.9%, P=0.238). The rates of the embryos with more than 20% fragments were similar between the 2 groups (41.2% vs 55.8%, P=0.137), but ICSI group had a significantly lower rate of blastocyst formation (43.1% vs 55.8%, P<0.001). The clinical pregnancy rates and miscarriage rates did not vary significantly between the 2 groups (34.7% vs 39.9%, P=0.189; 8.9% vs 13.4%, P=0.079). CONCLUSIONS: ISCI is an effective treatment for male infertility to achieve uneventful clinical pregnancy.

Arch Androl 2002 Sep-Oct;48(5):329-36
The scheduled ovarian hyperstimulation method makes it easy to perform ICSI with fresh testicular sperm (ICSI/TESE).
Nakagawa K, Yamano S, Tsutsumi Y, Matsumoto M, Hinokio K, Irahara M, Aono T, Naroda T, Kagawa S.
Department of Obstetrics and Gynecology, School of Medicine, University of Tokushima, Tokushima, Japan.
The authors evaluated whether scheduled ovarian stimulation makes it easy to perform ICSI with fresh testicular sperm. Scheduled ovarian hyperstimulation was applied for testicular sperm extraction and ICSI with fresh testicular spermatozoa. Fifteen cycles in 10 couples were included in the present study; all couples were azoospermic, 5 were obstructive, and the remaining 5 were nonobstructive. No cycles were canceled, and all oocyte retrievals were performed on the scheduled day. Testicular sperm were obtained in 14 treatment cycles (93%). The mean numbers of retrieved and injected oocytes were 9.4 and 6.4, respectively. The fertilization and cleavage rates were 47 and 91%, respectively. Embryo transfers were performed in 12 cycles except 2 cycles that had no embryos. The number of transferred embryos was 2.3. Two clinical pregnancies were obtained. This scheduled ovarian hyperstimulation was applicable for ICSI with fresh testicular sperm.

Fertil Steril 2002 Sep;78(3):520-8
Efficacy and safety of highly purified menotropin versus recombinant follicle-stimulating hormone in in vitro fertilization/intracytoplasmic sperm injection cycles: a randomized, comparative trial. The European and Israeli Study Group on Highly Purified Menotropin versus Recombinant Follicle-Stimulating Hormone.
Kiel, Augsburg, Germany.1
OBJECTIVE: To demonstrate that highly purified human menopausal gonadotropin (HP-hMG) is as efficient and safe as recombinant FSH in females undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment cycles.DESIGN: Multinational, open label, randomized, parallel group, comparative phase III trial.SETTING: In 22 centers across six countries; Belgium (1 center), Germany (6 centers), Israel (6 centers), The Netherlands (2 centers), Switzerland (1 center) and the United Kingdom (6 centers).PATIENT(S): A total of 781 women were enrolled between May 1999 and November 2000.INTERVENTION(S): In the all-patients-treated population, 373 patients received HP-hMG and 354 received recombinant FSH. A long protocol GnRH agonist regimen was used.MAIN OUTCOME MEASURE(S): The primary end point was ongoing pregnancy rate following one IVF/ICSI treatment cycle. Safety was assessed as a secondary end point.RESULT(S): Ongoing pregnancy rates 10 weeks after ovum pickup in the per-protocol population were 25% (n = 85/344) in the HP-hMG group and 22% (n = 71/317) in the recombinant FSH group. The incidence of ovarian hyperstimulation syndrome, miscarriage, adverse events, and injection site reactions (tolerability) were similar in both treatment groups.CONCLUSION(S): We found HP-hMG to be as effective as recombinant FSH in terms of ongoing clinical pregnancy. Both treatments have a similar safety/tolerability profile.

BJU Int 2002 Aug;90(3):277-81
Surgical sperm retrieval after previous vasectomy and failed reversal: clinical implications for in vitro fertilization.
Wood S, Vang E, Troup S, Kingsland CR, Lewis-Jones DI.
Liverpool, UK. simon_j.wood@virgen.net
OBJECTIVE: To investigate the effect of the interval between previous vasectomy reversal on retrieval rates of epididymal and testicular spermatozoa using percutaneous epididymal sperm aspiration (PESA), or testicular sperm extraction (TESE), and the subsequent reproductive potential of these gametes in intracytoplasmic sperm injection (ICSI) cycles. RESULTS: All 66 patients had sperm retrieved successfully; the success rates for PESA were not significantly affected by previous failed reversal when compared with patients who had not had a reversal, at 14 of 54 (26%) vs five of 12 (P=0.3). The interval since vasectomy did not affect PESA retrieval rates but there was a significantly poorer retrieval rate for PESA in the presence of palpable epididymal cysts, at seven of 35 (20%) vs 12 of 23 (52%) (P=0.012). Fertilization rates were significantly lower using cryopreserved spermatozoa retrieved from either the epididymis or testis (50% vs 70%, P=0.007), although subsequent implantation and pregnancy rates were not significantly different. CONCLUSION: Surgical sperm retrieval is successful in all cases of azoospermia secondary to vasectomy, either by PESA or TESE. There are no clinical markers to indicate which patients will have successful PESA after vasectomy, although the presence of epididymal cysts is associated with significantly lower retrieval rates. The reduction in fertilising ability of cryopreserved spermatozoa does not affect clinical pregnancy rates in ICSI cycles.

Asian J Androl 2002 Mar;4(1):9-15
Testicular sperm extraction in azoospermic patients with gonadal germ cell tumors prior to chemotherapy--a new therapy option.
Schrader M, Muller M, Straub B, Miller K.
Department of Urology, University Hospital Benjamin Franklin, Freie University Berlin, Germany. schrader@medizin.fu-berlin.de
BACKGROUND: In view of the high cure rates in patients with testicular germ cell tumors (TGCT), increasing clinical importance is attached to protection of fertility. Long-term infertility due to cytostatic therapy may be expected in more than 50% of the patients at a cumulative dose of cisplatin > 0.6 g/m2. The standard procedure for fertility protection in cancer patients includes cryopreservation of ejaculated spermatozoa. Considering that some patients have tumor-induced azoospermia, we examined the usefulness of testicular sperm extraction before therapy. METHOD: A survey of the literature served as a basis for investigating biological and clinical aspects of the impact of chemotherapy on male fertility. A study of our patient population also enabled us to explore the option of extracting sperm from the contralateral healthy testis prior to treatment in 14 azoospermic patients with testicular germ cell tumors. RESULTS: We were able to successfully recover haploid germ cells in 6/14 testicular biopsies from azoospermic patients with testicular germ cell cancer prior to treatment. Maturation arrest was found in 3/14 cases and Sertoli-cell-only syndrome in the rest. None of the patients had secondary healing or a treatment delay because of the testicular biopsy. CONCLUSION: Since the post-therapeutic fertility status is difficult to predict in cancer patients, we think that TESE should be regarded as a general option prior to cancer treatment and offered to azoospermic cancer patients. New guidelines should be established in this connection.

Hum Fertil (Camb) 2002 Feb;5(1 Suppl):S9-S14
Assisted conception in the azoospermic male.
Gordon UD.
Centre for Reproductive Medicine, 4 Priory Road, Clifton, Bristol BS8 1TY, UK. The advent of intracytoplasmic sperm injection (ICSI) has offered new solutions for the management of patients with azoospermia. Surgical sperm recovery combined with ICSI has allowed many men with azoospermia to father their own biological children. Azoospermia can be classified as obstructive and non-obstructive, with investigations, management and success rates varying markedly between the two forms. In certain cases of obstructive azoospermia surgical reconstruction remains a viable option, whereas cases with congenital obstruction need to be screened for mutations of the cystic fibrosis gene. In most cases of obstruction sperm can be retrieved from the epididymis using percutaneous epididymal sperm aspiration (PESA). If PESA is unsuccessful, testicular sperm extraction (TESE) is successful in all cases. With non-obstructive azoospermia, the genetic basis has been investigated intensely. Screening for karyotypic abnormalities as well as Y microdeletions is recommended. Irrespective of the histological diagnosis, focal spermatogenesis can be observed in 40-50% of cases using multiple testicular biopsies.

Hum Fertil (Camb) 2002 Feb;5(1):17-22
Surgical sperm retrieval: a review of current practice.
Wood S, Lewis-Jones I, Troup S, Desmond A, Kingsland C.
Reproductive Medicine Unit, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK. Although pregnancies were achieved after surgical sperm retrieval and in vitro fertilization 8 years before the introduction of intracytoplasmic sperm injection (ICSI), it is the development of ICSI that has led to the rapid expansion of surgical procedures to obtain sperm from azoospermic males for use in assisted conception cycles. The natural desire for couples to achieve a pregnancy using their own gametes and a national shortage of donor sperm have driven the demand for an expansion of this service. Males who have previously been considered unable to father their own genetic child can now be offered treatment, which, in most cases, will lead to the recovery of sperm for use in treatment. This article considers the development of the techniques available to clinicians and provides an overview of the many treatments (and their acronyms) to assist clinicians unfamiliar with the practicalities of surgical sperm retrieval. In reviewing the current published studies, we also offer some guidelines as to the optimization of the potential future provisions of surgical sperm retrieval treatments for azoospermic males, either secondary to obstruction (particularly after vasectomy) or from non-obstructive causes.

Med Assoc Thai 2001 Nov;84(11):1569-75
The outcome of sperm retrieval and intracytoplasmic sperm injection for obstructive azoospermia. Sukcharoen N, Promviengchai S, Boonkasemsanti W, Sithipravej T, Chinpilas V.
Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Thailand.
OBJECTIVES: To study the outcome of sperm retrieval and intracytoplasmic sperm injection (ICSI) from obstructive azoospermic men. METHOD: Overall, 50 sperm retrieval procedures were performed in 45 obstructive azoospermic men, followed by 57 ICSI procedures with fresh epididymal spermatozoa (n=40), fresh testicular spermatozoa (n=4) or frozen-thawed epididymal spermatozoa (n=13). RESULTS: Sperm retrieval was accomplished via percutaneous epididymal sperm aspiration (PESA) in 42 cases, testicular sperm aspiration (TESA) in 1 case and testicular sperm extraction (TESE) in 2 cases. TESA and TESE were only applied when PESA failed to produce enough spermatozoa for simultaneous ICSI. PESA was successful in 92 per cent of cases. Fertilization rate after ICSI was 79.6 per cent of the metaphase II oocytes. Seventy one embryo transfers were performed using both fresh and frozen thawed embryos resulting in clinical pregnancy in 39.4 per cent. Ongoing pregnancy was achieved in 35.2 per cent. CONCLUSION: ICSI has been shown to give a high fertilization and pregnancy rate with epididymal and testicular spermatozoa retrieved from obstructive azoospermic men. PESA is a noninvasive and simple technique for retrieving spermatozoa from obstructive azoospermic men. Therefore, it is suitable as the primary sperm recovery technique in patients with obstructive azoospermia.

Hum Reprod 2002 Jan;17(1):157-60
The value of sperm pooling and cryopreservation in patients with transient azoospermia or severe oligoasthenoteratozoospermia.
Lahav-Baratz S, Rothschild E, Grach B, Koifman M, Shiloh H, Ishai D, Dirnfeld M.
IVF Unit, Department of Obstetrics and Gynecology, Carmel Medical Center and the Technion Faculty of Medicine, Haifa, Israel.
BACKGROUND: A transient state of azoospermia may occur due to toxic, environmental, infectious or iatrogenic conditions. Finding sperm in the ejaculate of such patients is often unpredictable and may be critical in IVF treatment. In the present study, the approach of pooling and cryopreservation of sperm is evaluated. Cryopreservation was performed in a unique group of patients in whom no sperm had been found in at least one previous sperm examination and in patients diagnosed as suffering from non-obstructive azoospermia in whom, occasionally, sperm were found. METHODS: A total of 157 semen pooling and cryopreservation procedures in 53 patients was performed between January 1998 and December 2000 in our centre. Forty five of these patients underwent an IVF-ICSI treatment during the study period. In 32 patients, fresh sperm were used to perform ICSI. In 13 patients no sperm were available, and the previously frozen sperm were used. RESULTS: Using our pooling system, 13 IVF-ICSI cycles were rescued. In seven patients with a previous testicular biopsy due to azoospermia, sperm cryopreservation was possible. Overall, 13 pregnancies (10 deliveries, two ongoing pregnancies and one missed abortion) were achieved. CONCLUSION: The introduction of semen banking for patients with transient azoospermia may increase the chance of pregnancy using their own sperm.

Hum Reprod 2002 Jan;17(1):139-42
A high predictive value of the first testicular fine needle aspiration in patients with non-obstructive azoospermia for sperm recovery at the subsequent attempt.
Fasouliotis SJ, Safran A, Porat-Katz A, Simon A, Laufer N, Lewin A.
IVF Unit, Department of Obstetrics and Gynecology, Hadassah Medical Center, Hebrew University, Ein-Kerem, Jerusalem, Israel.
BACKGROUND: The objective of this retrospective study, which included 51 men with non-obstructive azoospermia, was to evaluate the predictive value of the results of the first sperm recovery attempt on the probability for sperm recovery in a second attempt. METHODS AND RESULTS: A positive testicular fine needle aspiration (TEFNA) was defined as the recovery of any number of mature sperm. At the first and second TEFNA attempts, mature sperm were recovered in 33 (64.7%) and 25 (49%) of 51 patients respectively. In 23 of the 33 (69.7%) patients with a positive first TEFNA, sperm were recovered at both attempts, whereas in only two of 18 (11.1%) with a negative first TEFNA, sperm were recovered at the second attempt. Our analysis revealed a high predictive value of the first TEFNA for sperm recovery at the subsequent attempt, with a mean positive predictive value of 69.7%, with the highest probability being 90.9% in hypospermatogenesis, 72.7% in Sertoli cell-only pattern, 75% in tubular hyalinization, and the lowest being 28.6% in maturation arrest. The mean negative predictive value was 88.9%, which was high in all categories (80% in Sertoli cell-only pattern and 100% in maturation arrest and tubular hyalinization). CONCLUSION: A second TEFNA attempt should be offered to all non-obstructive azoospermic patients with a positive first TEFNA. Patients with a negative first TEFNA may undergo a repeated attempt, but a donor sperm back-up is strongly advised.

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