For prospective interventional study - Infertile couples due to azoospermia, PESA diagnosis with sperm.. Azoospermia men n = 249 Agreed to participate in researchPercutaneous epididymal
Trang 1Estimate that, one per 20 men related to infertility The diagnosis techniques and treatmentsfor femaleinfertility is highly developed, but treatment techniques for male infertility arelimited
“Azoospermia” is defined as the absence of sperms in acentrifuged semen sample, the incidence of
azoospermia in infertile men is between 5%-13,8% while in the general population, it is about 2% The causesare obstructive or non-obstructive azoospermia characterized by absent of sperm production The advance of
intra-cytoplasmic sperm injection (ICSI) have made it possible to circumvent some case of male factor
infertility, especially azoospermia
aspiration/intra-Practical significance and contributions of the thesis
The thesis has found a cut-off of testicular volume, FSH and LH concentration in azoospermia patients inorder to rely on that thresholds to offer or not recommendation of PESA for these patients
Thesis has humanities when help infertile azoospermia couples have their own sons, before these casewere untreated The thesis also demonstrates that PESA is simple,efficient method to retrieve sperms from theepididymis to perform ICSI Epididymal sperms can be frozen, pregnancy rates from frozen semen and freshsemen was equivalent
THESIS STRUCTRURE
This thesis included 128 pages, 4 chapters, 31 tables, 14 figures, 11 pictures and 181 references Background: 2 pages; Chapter 1: Literature, 38 pages; Chapter 2: materials and method: 11 pages; Chapter 3: Results: 28 pages;
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Trang 2Chapter 4: Discussion, 45 pages; Conclussion: 2 pages; Recommendations: 1 page; Further research: 1 page; Related articles; References; Appendix; List of study patients.
CHAPTER I: LITERATURE 1.1 Difinition of infertility
Infertility is commonly defined as the failure of conception after atleast 12 months of unprotected
intercourse Primary infertility (infertility I) is woman has never been pregnant before, secondary infertility (infertility II) is the woman has been pregnant at least once before.
1.2 Prevalence of infertility in Vietnam and worldwide
Oakley (2008-England) survey on 60.000 UK women, 16% have been consulted for infertility, 8% need thetreatment to be pregnant Karl(2008), prevalence of infertility in developing countries is between 5% -25.7%
In Vietnam, population census in1982, prevalence of infertility was 13% Nguyen Khac Lieu (1993-1997),female infertility was 55,4%, male was 35.6% and unknown was 10% Nguyen Viet Tien (2010) investigated14.396 couples: incidence of infertility was 7.7%, in which infertility I was 3.9% and II was 3,8%
1.2.1 Obstructive Azoospermia (OA)
Intra-testicular obtruction account of 15%, epididymal occupies 30-67%, ejaculate account for 1-3% ofcases Epididymis is most common location It may be congenital (CABVD) or acquired (gonorrhea, chlamydia)
1.3 PESA/ICSI/ procedure
1.3.1 Ovarian stimulation, oocyte retrival and oocyte preparation
Ovarian stimulation multiple follicular development and maturation Monitor follicular development.Oocytes maturation by injecting hCG oocyte retrieval performance 34-36 hours after, oocyte collectionunderstereoscopicmicroscope Denuding preparation for ICSI performance
1.3.2 Percutaneous epididymal sperm aspiration and sperm preparation.
PESA performed on the oocyte retrival day Washing sperm sample by gradient method or centrifuge ifpoor concentration
Trang 31.3.3 Intra-cytoplasmic sperm injection (ICSI)
Palermo, first introduced ICSI in 1992, now this technique are widely used and extended it’s indication tomale infertility ICSI performed on stereomicroscope equipped with micromanipulator Fix oocyte by holdingpipette inferior pole of oocyte touching bottom of dish, polar body is at 6 or 12 hour to ovoid injury spindle.Injecting sperm into oolemma of oocyte
1.3.4 Evaluation of fertilization, embryo transfer and monitoring
Evaluation of fertilization 18hours after ICSI Evaluation number and size of blastomere Embryo transfer(ET) on day 2 or 3 hCG dosage > 50 iu > pregnant Clinical pregnancy (CP) if gestational sac or embryo orheart movement in ultrasound
CHAPTER 2: MATERIALS AND METHOD
Cross-sectional descriptive study and prospective intervention study with sample size and selection criteriaare used in this study
2.1 Subjects
2.1.1 Selection criteria
2.1.1.1 For cross-sectional descriptive study
- Azoospermia (spermogram twice 3 - 5 days, seperated).
- Agreed to participate in research.
2.1.1.2 For prospective interventional study
- Infertile couples due to azoospermia, PESA diagnosis with sperm.
- Agreed to be treated by PESA/ICSI
- Wives under or equal 40 year olds
- Agreed to participate in research.
2.1.2 Exclusion criteria
For prospective interventional study
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Trang 4- Infertile wives due to one of following causes:
Infertility due to poor ovarian responder
Ovulation disorder due to hyperprolactinemia
Infertility due to uterus, uterine cavity (fibroid, intra-cavity polype…)
Wives above 40 year olds
2.2 Setting and study time: research covers period 12/2009 to 12/2012, at ART Center of National Hospital
of Obstetric and Gynecology
2.3.2 Sample size for prospective interventional study.
N≥(1,96 m )2p (1−p)
N: sample size; p: success rate (pregnancy rate) m: constant = 0,1 and p was 34% (Godwin), N =90, in fact 170enrolled
2.4 Method
- Cross-sectional descriptive study: study features and factors related to azoospermia
- Prospective interventional study: evaluation effectiveness of PESA/ICSI for infertile azoospermia couples.
2.4.2 Study process
Trang 5Azoospermia men (n = 249) Agreed to participate in research
Percutaneous epididymal sperm aspiration/diagnosis (PESA)
PESA/ICSI (N =226 ovarian stimualation cycles: 223 embryo transfer cycles + 29 frozen embryo transfer cycles)
Evaluation outcomes and affecting factors
Finish Results
Freeze (n=26)
Figure2.1 Study process
2.6 Data proccessing and analizing.
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Trang 6Data manipulation and analysis was performed using SPSS 16.0 software Compare % by 2 test, the averagevalue by T-test ROC curve find threshold of FSH, LH level and testicular volume to predict possibility of spermsaspiration from epididymis.
CHAPTER 3: RESULTS 3.1 Features and factors related azoospermia men.
3.1.1 Features of azoospermia men
Obstrucvie Azoo; 68.2731.73
Figure 3.1 PESA diagnosis
249 azoospermia men were performed PESA 170 cases with sperm (obstructive azoospermia) (68,27%), 79 cases without sperm (non-obstructive azoospermia) (31,73%).
Table 3.1 Distribution of age group of azoospermia men
Azoospermia (n;
%)
Non-Obstructive Azoospermia (n,%) Total (n,%)
Trang 73.1.2 Factors related azoospermia men
Table 3.5 The clinical and laboratoryfeatures of azoospermia men
Testicular volume in OA groupgreater than that in NOA group.The difference is statisticallysignificant; p < 0,001.FSH, LH levels
in OA group were lower than that
in NOA group, the difference isstatistically significant; p < 0,001
Table 3.6 Testicular volume and outcomes of PESA in infertile patients
Right testicular size(ml) 16,86 + 2,1 10,57 + 4,5 0,000
Left testicular size (ml) 16,69 + 2,3 10,46 + 4,3 0,000
Testosterone (nmol/L) 19,59 + 6,2 15,33 + 8,3 0,000
Trang 8Total 169 (100) 170 (100) 79 (100) 79 (100)
89,9% of right testes and 84,7% of left testes in OA group > 15ml 79,7% of right testes and 78,5% of left testes
in NOA group < 15 ml
3.1.3 Threshold of FSH, LH level and testicular volume predict possibility of sperms aspiration
3.1.3.1 Threshold of FSH level predicts possibility of sperms aspiration
Figure 3.2 ROC curve of FSH concentration predict possibility of sperms aspiration from epididymis
The area under the ROC curve of FSH was 0,866 + 0,02 (with a 95% confidence interval for the areabeingbetween 0,811 – 0,921) FSH > 12,4IU/L predicts failure ofsperms retrieval from epididymis with asensitivity of 62% and a specificity of 100%
3.1.3.2 Threshold of left testicular volume predicts possibility of sperms aspiration
Trang 9Figure 3.3 ROC curve of left testicular volume predicts possibility of sperms aspirationfrom epididymis
The area under the ROC curve of left testis was 0,899 ± 0,03 (with a 95% confidence interval for the area beingbetween 0,849 - 0,949) Left testis > 12,5 ml, success of sperms retrieval from epididymis with a sensitivity of97,6% and a specificity of 72,2%
3.1.3.3 Threshold of right testicular volume predicts possibility of sperms aspiration
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Trang 10Figure 3.4 ROC curve of right testicular volume predicts possibility of sperms aspirationfrom epididymis
The area under the ROC curve of right testis was 0,906 ± 0,03 (with a 95% confidence interval for the areabeing between 0,855 - 0,956) Right testis > 13,5 ml, success of sperms retrieval from epididymis with asensitivity of 97% and a specificity of 75,9%
3.1.3.4 Threshold of LH level predicts possibility sperms aspiration
Trang 11Figure 3.5 ROC curve of LH concentration predicts possibility of sperms aspiration from epididymis
The area under the ROC curve of LH was 0,781 + 0,04 (with a 95% confidence interval for the area beingbetween 0,781 - 0,851) LH > 16,2IU/L, failure of sperms retrieval from epididymis with a sensitivity of 30,4%and a specificity of 100%
3.1.4 Characteristic’s wife whose obstructive azoospermia husband treated by PESA/ICSI
Table 3.7 The indicators of ovarian reserve
0,33 ***
LH (IU/L) 3,39 + 2,5 4,68 + 2,2 5,59 + 3,8 4,58 + 2,5 0,02
* 0,006 **
0,23 ***
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Trang 12(pmol/L) 42,32 + 24,9 36,77 + 16,4 46,11 +51,5 38,79 +24,6
0,20 0,69 **
0,07 ***
AFC 9,27 + 4,1 11,54 + 4,8 11,30 + 3,5 11,14 + 4,6 0,008
* 0,04 **
0,8 ***
BMI 20,09 + 2,4 19,97 + 2,3 19,46 + 2,8 19,94 + 2,3 0,8
* 0,44 **
0,41 ***
Female age
(year) 31,59 + 6,2 27,87 + 3,7 27,56 + 3,8 28,44 + 4,5
0,00 * 0,02 **
0,75 ***
FSH, LH, Estradiol concentration, AFC were in normal range LH concentration, AFC and age of the wives weresignificant difference between short and long protocol; p < 0,05
3.2 Effectiveness and fators affecting outcomes of PESA/ICSI
3.2.1 Effectiveness of PESA/ICSI
3.2.1.1 Effectiveness of PESA
Chọc hút 1 lần Chọc hút 2 lần Chọc hút 3 lần Chọc hút 3 lần 0
10 20 30 40 50 60 70
7.7
68.8
17.6
5.9
Figure 3.8 Number of PESA
13 patients were done PESA 1 time.117 patients were done PESA 2 times (68,8%), 30 patients were done PESA
3 times(17,6%), 10 patients were done PESA 4 times(5,9%) All had sperms
Trang 14Table 3.8 Outcomes of PESA for ICSI
Trang 15Table 3.9 Outcomes and pregnancy rate from frozen sperm sample
Sufficient thawed sperm 7 (26,9%) 12 (46,2%) 19 (73,1%)
3.2.1.2 Effectiveness of ovarian stimulation
Table 3.10 Number of ovarian stimulation cycle
Numbers of cycles Number of
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Trang 160,001 ***
Mean total FSH
dosages (IU) 2227,03 +830,6 1917,75 +592,9 1710,19 +403,2 1943,58+ 633,3
0,03 * 0,004 **
0,02 ***
Mean oocyte 6,86 + 4,4 9,06 + 4,3 8,33 + 3,7 8,62 +4,3 0,006
* 0,16 **
0,41 ***
Endometrium
(mm) 10,87 + 2,6 12,36 + 2,2 12,05 +2,3 12,08 +2,3
0,000 * 0,06 **
0,49 ***
Average day of FSH was 9,65 + 0,9 days, total dose of FSH was 1943,58 + 633,3IU, average number of oocytewas 8,62 + 4,3 Average endometrial thickness was 12,08 + 2,3mm
Trang 17Table 3.12 Progesterone concentration on hCG day related to pregnancy outcomes
3.2.1.3 Effectiveness of ICSI and embryo culture
Table 3.14 Results of ICSI
0,68 ***
Mean embryo 4,24 + 2,7 6,30 + 3,4 5,89 + 3,5 5,92 +3,4 0,001
* 0,04 **
0,56 ***
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Trang 18Notes: ( ): between short and long protocol; ( ): short and antagonist protocol; ( ): long and antagonist protocol
Average number of oocytes was 5,92 + 3,4 Fertilization rate was 69,16%, fertilization rate in short protocolgroup was 63,24%, long protocol group was 70,59% and antagonist group was 68,72% Difference offertilization rate between groups is not statistically significant with p > 0.05
Table 3.15 Compare outcomes of ICSI between fresh and frozen/thawed sperms from epididymis
p > 0.05
3.2.1.4 Embryo transfer results
Table 3.16 Embryo transfer results
0,34 ***
Trang 19No of gestational sac 11 104 6 121
Implatation rate
0,04 * 0,316 **
0,00 ***
Implatation rate was 15,45% Avarage transfered embryos were 3,5 + 1,2
3.2.1.5 Pregnancy outcomes
Table 3.17 Pregnancy rate after each ovarian stimulation cycle
Clinical pregnancy (n ;%) Total
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Trang 201st cycle 2nd cycle 3rd cycle
Figure 3.11 Cumulative pregnancy rate/patients after 3 cycles
1st cycle: 66 pregnancies (38,8%/total patient) 2nd cycle: 79 pregnancies (46,47%/total patient) 3rd cycle: 82pregnancies (48,24%/total patient)
Table 3.18 Evolution of pregnancy
52 ongoing pregnancies (60,5%), 22 live births (25,6%), 12 abortions (13,9%)
3.2.2 Factors affecting outcomes of PESA/ICSI
3.2.2.1 Male factors
Table 3.19 Male fators affecting pregnancy outcome
Factors Pregnant (n = 82) Non-pregnant (n =
Age (year) 31,67 + 5,5 32,81+ 5,8 0,151
Trang 21Testosterone 20,93+5,9 19,46+5,8 0,074
Right testicular volume
0,120
Left testicular volume (ml) 16,30+ 1,8 17,08+ 2,4 0,155
No significant difference of mean age, FSH, LH and testosteronbetween pregnant and non-pregnant groups; p >0,05
3.2.2.2 Female factors
Table 3.20 Female fators affecting pregnancy outcome
Factors Pregnant(n = 82) Non-pregnant(n =
No significant difference of female mean age, infertility duration between pregnant and non-pregnant groups; p
> 0,05 Differences of endometrial thickness and numbers of embryo transfered between pregnant and pregnant groups are statistically significant with p < 0,05
non-3.2.2.2.3 Relation between endometrium and pregnancy rate
Table 3.24 Relation between endometrial features and pregnancy rate
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Trang 22Pregnancy rate in triple-layer endometrium was 52,5%, hyperechoic endometrium was 19,1% and 4 patients
in heterogeneous endometrium was non-pregnant Difference is statistically significant with 2 = 29,54; p =0,000
3.2.2.2.4 Relation between quantity and quality of embryos and pregnancy rate
Table 3.25 Relation between quantity and quality of embryos and pregnancy outcomes
0 good quality embryo 2,5 (1/40)
1 good quality embryo 32,3 (10/31)
Trang 232 good quality embryo 31,8 (14/44)
> 3 good quality
embryo (57/108)52,8
good quality embryos.
Difference of pregnancy rate between 1 good quality embryo transfer group and 0 good quality embryotransfer group is statistically significant with 2 = 11,81; OR = 18,57; CI (2,2-155,2) Difference of pregnancyrate between > 3 good quality embryo transfer group and 2 good quality embryo transfer group with 2 = 5,52;
OR = 2,4; CI (1,1 – 5,0)
CHAPTER 4: DISSCUSSION
249 azoospermia men were performed PESA 170/249obstructive azoospermia (68,27%) 79 obstructive azoospermia (31,73%) (figure 3.1) 170 obstructive azoospermiacouples were treated byPESA/ICSI Total 226 PESA/ICSI cycles, in which 125 couples treated 1 cycle, 34 couples were treated 2 cyclesand 11 couples were treated 3 cycles (table 3.10) 82 clinical pregnant cases after 223 fresh embryo transfercycles and 4 clinical pregnant cases after 29 frozen embryo transfer cycles
non-4.1 Discussion of features and laboratory indicators of azoospermia patients.
4.1.1 Outcomes of diagnosis PESA
Percutaneous epididymal sperm aspirationprocedure to identify sperm in epididymis (PESA diagnosis) is
an important step before PESA/ICSI cycle for sure having available sperm before deciding ovarian stimulation
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