SPERM RETRIEVAL AND PREGNANCY OUTCOME FOR AZOOSPERMIC INFERTILE MEN
Background: surgical sperm retrieval and in vitro fertilization using intracytoplasmic sperm injection is the only hope for the infertile men with permanent azoospermia to father a biologic child since its introduction by the Palmero group in 1992.
Aim of the study: To study the testicular sperm retrieval rate of azoospermic infertile men and the pregnancy outcome by intracytoplasmic sperm injection at Azadi infertility center.
Patients and methods: A retrospective study of 220 azoospermic infertile patients were evaluated and dealt with at Azadi infertility center at Duhok, Kurdistan, Iraq, during the period from 2011–2020. They were diagnosed with either obstructive or nonobstructive azoospermia. One hundred forty-three of them were subjected to conventional testicular sperm extraction for sperm retrieval, and the sperms, when detected, were cryopreserved if the surgery was performed in advance. Sixty-one couples accepted the option of intracytoplasmic sperm injection at the Azadi infertility center. Ovarian stimulation performed by the gonadotrophin-releasing hormone agonist and antagonist protocol, and intracytoplasmic sperm injection was performed by the embryologist. The pregnancy result was regarded successful if serum βhCG level is more than 25 mIU/ml two weeks after embryo transfer or miscarriage if serum βhCG level is below 25 mIU/ml or lack of fetal heart beating in trans vaginal ultrasound examination. The pregnancy is then followed regularly through the antenatal care unit. All the completed pregnancies were delivered by the Caesarian section.
Results: Out of 1301 infertile couples, 220 (16.9%) were azoospermic. Testicular sperm extraction was performed for 143 men. One hundred and one men (70.6%) were positive and 42 men (29.3%) were negative for sperm retrieval and 61 of them accepted to proceed for intracytoplasmic sperm injection, 47 (77%) with obstructive azoospermia and 14 (23%) with nonobstructive azoospermia. Freshly extracted sperms were used in 40 (65.6%) ICSI cycles while cryopreserved sperms in 21(34.4%) cycles. The number of ova retrieved ranged from 2-17 with a mean of 8.6. Successful fertilization confirmed in 57 cycles and positive biochemical pregnancy confirmed in 27 (47.3%), miscarriage in 4 out of 27 pregnancies (14.8%) and 16/57 (28%) gave live birth of 11 singletons, 4 twins and one triplet and seven still with ongoing pregnancy. Two birth defects were reported among the delivered babies.
Conclusions: The sperm retrieval rates in obstructive azoospermia were lower than the usual rates using the conventional testicular sperm extraction. Microsurgical testicular sperm extraction is advised for nonobstructive azoospermia. The fertilization rates, biochemical pregnancy, miscarriage and baby take home were within the usual rates no increase in the birth defects rates in ICSI.
2. Borght MV, Wyns C. Fertility and infertility: Definition and epidemiology. Clin Bioch. 2018; 62:2-10. https://www.sciencedirect.com/science/article/pii/S0009912018302200
3. Olmedo SB, Chillik C, Kopelman S. Definition and causes of infertility. Repord Biomed Online.2001;2(1):41-53. https://www.rbmojournal.com/article/S1472-6483(10)62187-6/fulltext
4. Mahnaz A, Robabeh K, Tahereh M Kiandokht K, Fatemeh R, Fatemeh S The pregnancy outcome of singleton in IVF/ICSI cycles: A cross sectional study. int J fert steil. 2007; 1(3): 93-102. http://ijfs.ir/journal/article/abstract/2307
5. Hendriks S, Hessel M, Mochtar MH, Meissner A, Veen FV, Repping S, Dancet EA. Couples with nonobstructive azoospermia are interested in future treatments with artificial gametes. Human Repr. 2016; 31(8): 1738–48. https://academic.oup.com/humrep/article/31/8/1738/2913897
6. Tüttelmann F, Werny F, Cooper TG, Kliesch S, Simoni M, Nieschlag E. Clinical experience with azoospermia: aetiology and chances for spermatozoa detection upon biopsy. Int J Androl. 2011; 34: 291–8. https://doi.org/ 10.1111/j.1365-2605.2010.01087.x
7. Bessonnat J, Brouillet S, Sintzel S, Gillois P, Bergues U, Busquet C, et al. In cryptozoospermia or severe oligozoospermia is sperm freezing useful? Basic and Clin Androl. 2014; 24:15 https://bacandrology.biomedcentral.com/articles/10.1186/2051-4190-24-15
8. The Practice Committee of the American Society for Reproductive Medicine. Management of nonobstructive azoospermia: a committee opinion. Fert and ster. 2018; 110 (7): 1239–45 https://www.fertstert.org/article/S0015-0282(18)32071-5/fulltext
9. International Islamic Fiqh Academy outputs, Amman. In Vitro Fertilization in Islamic perspectives. IIFA j. 1986; 3(1): 423 https://www.iifa-aifi.org/ar/1661.html
10. Tehraninejad ES, Pourmatroud E, Gilani MA, Rakebi M, Neko ZA, Arabipoor A, Comparison of Intracytoplasmic Sperm Injection Outcomes between Oligozoospermic, Obstructive Azoospermic and Nonobstructive Azoospermic Patients. Int J Fer Stril. 2012; 6(1): 13-18 http://ijfs.ir/journal/article/abstract/2938
11. Sherins RJ, Thoresell LP, Dorfmann A, Lagos LD, Calvo LP, Krysa L. Intracytoplasmic Sperm Injection Facilitates Fertilization Even in the Most Severe Form of Male Infertility: Pregnancy Outcome Correlates With Maternal Age and Number of Eggs Available. Fertil Steril. 1995; 64(2): 369-75. https://www.fertstert.org/article/S0015-0282(16)57737-1/fulltext
12. Palermo G, Joris H, Devroey P, Van Steirteghem A. Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. Lancet. 1992; 340(8810): 17–18. https://doi.org/10.1016/0140- 6736(92)92425-F
13. Dieke AC, Mehta A, Kissin DM, Nangia AK, Warner L, Boulet SL.Intracytoplasmic sperm injection use in states with and without insurance coverage mandates for infertility treatment, United States, 2000–2015. Fertil Steril. 2018; 109(4): 691–697 https://www.fertstert.org/article/S0015-0282(17)32174-X/fulltext
14. Naredi N, Agrawal A. Testicular Sperm Extraction: Can we Combat Both Obstructive and Non Obstructive Azoospermia? Endocrinol Metab Syndr. 2016;5(1):1-3. https://www.longdom.org/archive/ems-volume-5-issue-1-year-2016.htm
15. Girardi S.K., Schlegel P.N. Micromanipulation of the Male Gamete. In: Hellstrom W.J.G. (eds) Male Infertility and Sexual Dysfunction. Springer, New York, NY. 1997; 258-275. https://link.springer.com/chapter/10.1007/978-1-4612-1848-7_17
16. Erdem E , Karacan M , Çebi Z , Uluğ M, Arvas A, Çamlıbel T . Results of intracytoplasmic sperm injection performed with sperm retrieved by microscopic testicular sperm extraction in azoospermic patients. Turk J Urol. 2018; 44: 462-466. https://turkishjournalofurology.com/EN/november-2018-00176
17. Vloeberghs V, Verheyen G, Haentjens P, Goossens A, Polyzos NP, Tournaye H. How successful in TESE-ICSI in couples with nonobstructive azoospermia. Hum Reprod. 2015; 30: 1790-6. https://academic.oup.com/humrep/article/30/8/1790/951272
18. Bernie AM, Mata DA, Ramasamy R, Schlegel PN. Comparison of microdissection testicular sperm extraction, conventional testicular sperm extraction, and testicular sperm aspiration for nonobstructive azoospermia: a systematic review and meta-analysis. Fertil Steril. 2015; 104: 1099-103. https://www.fertstert.org/article/S0015-0282(15)01647-7/fulltext
19. Turunc T, Gul U, Haydardedeoglu B, Bal N, Kuzgunbay B, Peskircioglu L, Ozkardes H. Conventional testicular sperm extraction combined with the microdissection technique in nonobstructive azoospermic patients: a prospective comparative study. Fertil steril. 2010; 94(6):2157–60. https://www.fertstert.org/article/S0015-0282(10)00068-3
20. Habermann H, Seo R, Cieslak J, Niederberger C, Prins GS, Ross L. In vitro fertilization outcomes after intracytoplasmic sperm injection with fresh or frozen-thawed testicular spermatozoa. Fertil Steril. 2000; 73(5): 955-60. https://doi.org/10.1016/S0015-0282 (00)00416-7
21. Ohlander S, Hotaling J, Kirshenbaum E, Niederberger C, Eisenberg ML. Impact of fresh versus cryopreserved testicular sperm upon intracytoplasmic sperm injection pregnancy outcomes in men with azoospermia due to spermatogenic dysfunction: a meta-analysis. Fertil Steril. 2014; 101(2): 344-9. https://doi.org/10.1016/j.fertnstert.2013.10.012
22. Basukarno A, Birowo P, Rasyid N. Success Rate of Pregnancy after PESA/TESE and ICSI in Jakarta. ASPIRE. KnE medicine, 2016;133-139. https://knepublishing.com/index.php/KnE-Medicine/article/view/548
23. Gunby J, Bissonnette F, Librach C, Cowan L. Assisted reproductive technologies (ART) in Canada: 2006 results from the Canadian ART Register. Fertil Steril. 2010; 93(7): 2189–201. https://www.fertstert.org/article/S0015-0282(09)00772-9/fulltext
24. Tummers P, De Sutter P, Dhont M. Risk of spontaneous abortion in singleton and twin pregnancies after IVF/ICSI. Human Reproduction. 2003; 18(8): 1720–23. https:// doi.org/10.1093/humrep/deg308
25. Esteves SC, Roque M, Bradley CK, Garrido N. Reproductive outcomes of testicular versus ejaculated sperm for intracytoplasmic sperm injection among men with high levels of DNA fragmentation in semen: systematic review and meta-analysis. Fertil Steril. 2017; 108: 456–67. https:// www.fertstert.org/article/S0015-0282 (17)30471-5/pdf
26. Stahl PJ. Testicular sperm retrieval for intracytoplasmic sperm injection in non-azoospermic men: when should we pull the trigger? Fertil Steril. 2017; 108(3): 442–3. https:// www.fertstert.org/article/S0015-0282(17)30499-5/fulltext
27. Bassiouny YA, Bayoumi YA, Gouda HM, Hassan AA. Is intracytoplasmic sperm injection (ICSI) associated with higher incidence of congenital anomalies? A single center prospective controlled study in Egypt. J Matern Fetal Neonatal Med. 2014; 27(3): 279–82. https://www.tandfonline.com/doi/full/10.3109/14767058.2013.814633
28. Yu H, Yang Q, Sun X, Cai R, Guo H, Wang C, et al. Association of birth defects with the mode of assisted reproductive technology in a Chinese data-linkage cohort. Fertil Steril. 2018; 109(5): 849-56. https://doi.org/10.1016/j.fertnstert.2018.01.012