Microdissection testicular spem extraction is currently the optimal sperm retrieval method for non-obstructive azoospermia patients. Research and development of this technique will help clinicians have more tools to collect sperm effectively for non-obstructive azoospermia patients, enabling these patients to have children of their own.
Trang 1STUDY ON THE EFFECTIVENESS OF SPERM RETRIEVAL AND
RELATIONSHIP BETWEEN A NUMBER OF FACTORS AND
SPERM RETRIEVAL ABILITY OF MICRODISSECTION
TESTICULAR SPEM EXTRACTION TECHNIQUE ON NON-OBSTRUCTIVE AZOOSPERMIA PATIENTS
Vu Thi Thu Trang 1 ; Quach Thi Yen 2 ; Nguyen Dinh Tao 3 ; Trinh The Son 3
SUMMARY
Objectives: Microdissection testicular spem extraction is currently the optimal sperm retrieval
method for non-obstructive azoospermia patients Research and development of this technique
will help clinicians have more tools to collect sperm effectively for non-obstructive azoospermia
patients, enabling these patients to have children of their own Subjects and methods: 100
patients with non-obstructive azoospermia who underwent micro TESE from August 2016 to
October 2018 at Military Institute of Clinical Embryology and Histology, Vietnam Military Medical
University Results: The average age of patients was 32.21 ± 4.55; the average duration of
infertility was 4.77 ± 3.37 years; 93% of patients were primary infertility; testicular volume 6.57 ±
2.77 mL; the average concentration of FSH, LH, and testosterone were 20.30 ± 12.63 mIU/mL,
10.83 ± 6.26 mIU/mL amd 4.24 ± 2.40 ng/mL, respectively 19 patients (19%) had gene
abnormalities in AZF region; Sertoli cell-only syndrome accounted for the highest proportion in
the histopathological subgroup (50%); the rate of sperm collection was 37% Surgical testicular
volume, endocrine concentration, AZF gene abnormalities and histopathological lesions related
to sperm collection possibility There was no short complications after surgery Conclusions:
Microdissection testicular spem extraction was a safe sperm retrieval method with a sperm
retrieval rate of 37% Surgical testicular volume, endocrine concentration, AZF gene
abnormalities and histopathological lesions related to sperm retrieval capacity
* Keywords: Non-obstructive azoospermia; Sperm retrieval; Micro-dissection testicular
sperm extraction.
INTRODUCTION
The appearence of intra cytoplasmic
sperm injection (ICSI) method in 1992 and
the success of the ICSI case with sperm
obtained from the epididymis aspiration of
azoospermia patients of Tournaye in 1994
has opened a revolution in the treatment
of male infertility especially with the azoospermia case Since then, there have been many different methods of retrieving sperm, each method has its own advantages and disadvantages,but for non-obstructive azoospermia patients,
2 Vietnam University of Traditional Medicine
3 Vietnam Military Medical University
Corresponding author: Vu Thi Thu Trang (drtrangvu@gmail.com)
Date received: 15/10/2019
Date accepted: 06/12/2019
Trang 2micro-dissection testicular sperm extraction
(micro TESE) is the best method for
sperm retrieval As the first to implement
this technique, Schlege N.P (1999) showed
that the ability to collect sperm was from
42 to 63% [2] This method reduces
damages, reduces the effect of testicular
function by micro-surgical microscopy that
helps to see the sperm ducts and avoid
blood vessels This is a new technique
applied in Vietnam, so the objectives of
the topic were: Determine the sperm
retrieval ability and explore some factors
related to the sperm retrieval ability of
micro TESE method in non-obstructive
azoospermia patients
SUBJECTS AND METHODS
1 Subjects
100 patients with non-obstructive
azoospermia were conducted micro TESE
at Military Institute of Clinical Embryology
and Histology, Vietnam Military Medical
University from August 2016 to October
2018
* Selection criteria: Patients without
sperm in the semen according to WHO
(2010) [3], not retrograde ejaculation;
underwent percutaneuos epididymal sperm
aspiration (PESA) or microsurgical epidymal
sperm aspiration (MESA - Microsurgical
Epidymal Sperm Aspiration) to eliminate
the obstructive azoospermia cases
* Exclusion criteria: Cases of secondary
hypogonadism; cases of acute diseases,
social diseases, endocrine diseases,
taking drugs and chemicals affecting
sperm production
2 Method Prospective, cohort study
RESULTS
1 Some characteristics of research subjects
* Age, infertility type, infertility period of the study subjects:
- The average age of the patient was 32.21 ± 4.55 The highest was 47 years old, the lowest was 21 years old Most in age group of > 30 - 40 years old (57%)
- Primary infertility accounted for 93% Only 7% were secondary infertility
- The average infertility period was 4.77 ± 3.37 years Patients with the longest infertility period were 19 years and the shortest were 1 year Infertility group from 2 - < 5 years was seen the most (52%), followed by group 5 - < 10 years (31%), the lowest was infertility group under 2 years (7%)
* The surgical testicular volume:
The average surgical testicular volume was 6.57 ± 2.77 mL The biggest testicular volume undergoing surgery was
16 mL, the smallest was 2 mL There were 59% testicles with volume from 5 -
< 10 mL; group with volume < 5 mL accounted for 27%; the lowest was the group with volume over 15 mL (1%)
* Concentrations of some hormones of study patients:
The average concentration of FSH, LH and testosterone of the study subjects were 20.30 ± 12.63 mIU/mL, 10.83 ± 6.26 mIU/mL and 4.24 ± 2.40 ng/mL
Trang 3* Results of AZF genetic testing:
Table 1:
Types of AZF gene abnormalities
The amount and
proportion/abnormality AZF gene
Abnormal AZF genes
19% of patients had AZF gene damage Associated lesions were the most common (42.1%), followed by AZFc gene abnormality (36.8%), the lowest was AZFa gene
abnormality (5.3%)
2 Results of retrieving sperm by micro TESE method in study patients
* Percentage of patients retrieving sperm:
Of the 100 patients participating in the study, 37 patients (37%) obtained sperm and
63 patients (63%) did not obtaine sperm
Table 2: Percentage of patients with AZF gene abnormality obtained sperm
Obtaining sperm (n = 7)
Not obtaining sperm (n = 12)
Abnormal AZF genes
(n = 19)
Among19 cases with abnormal AZF genes, abnormality in AZFc gene had the highest sperm retrieval rate (71.4%) The group with abnormality in AZF genes and
associated lesions were unable to find sperm
3 Relationship of some factors with the ability to collecting sperm from micro TESE
* Relationship between age, type of infertility, time/period of infertility, and ability of retrieving sperm:
The test results did not find the relationship between age, type of infertility, time of infertility and the ability of retrieving sperm of the micro TESE method in the study patient (p > 0.05)
Trang 4* Relationship between surgical testicular volume and the ability to retrieve sperm:
Table 3:
Obtaining sperm (n = 37)
Not obtaining sperm (n = 63) Surgical testicular volume
(mL)
p
OR (95%CI)
0.033 2.45 (1.06 - 5.62)
(*: χ2 test)
There was a relationship between testicular volume of ≥ 7 mL with surgery to see
sperm Subjects with testicular volume of ≥ 7 mL were more likely to find sperm 2.45 times higher than those with a testicular volume of less than 7 mL (p < 0.05)
* Relationship between several tests and the ability to obtain sperm:
Table 4: Relationship between FSH, LH, and testosterone concentrations and sperm
retrieval ability
Obtaining sperm (n = 37)
Not obtaining sperm (n = 63)
Hormone level
p
OR (95%CI)
FSH outside the normal value 24 (30.8) 54 (69.2)
0.015*
3.25 (1.22 - 8.63)
0.086**
Testosterone normal (2.2 - 8.0 ng/mL) 35 (43.8) 45 (56.2)
Testosterone outside the normal value 2 (10.0) 18 (90.0)
0.005**
(*: χ2 test; **: Fisher’s exact test)
There was a relationship between FSH concentration in the normal range and
testosterone level in the normal range with the surgery to see sperm (p < 0.05) We did
not find the relationship between normal LH concentration and the surgery to see
sperm (p > 0.05)
Table 5: Relationship between histopathological results and sperm retrieval ability
Histopathological results
Seminiferous tubule hyalinization 1 (9.1) 10 (90.9)
< 0.001**
χ2 = 20.31
(**: Fisher’s exact test)
Trang 5The group with impaired spermatogenesis
was most likely to obtain sperm at the
highest rate (70.4%), followed by the
halfway spermatogenesis group (41.7%)
and the lowest was the hyalinization
spermatomy tube group with the rate of
obtaining sperm of 9.1%
4 Accidents and complications
after surgery
There were no complications after surgery
such as: bleeding, hematoma, infection
DISCUSSION
Through the study results, we realized
that micro TESE method was an effective
method of collecting sperm for
non-obstructive azoospermia patients The
percentage of sperm obtained from
non-obstructive azoospermia patients by this
method reached 37% Micro TESE was
also a safe method, with small volume of
testicle tissue removed, each time only
from 5 to 10 mg of testicular tissue, thus
less affecting the testicular function after
surgery In the study, after the testicular
tissue sample was obtained under a
micro-surgical microscope, a sample of
collagenase type IA was added at a
concentration of 0.8 mg/mL, so that the
sperm cell line was separated from the
wall of the spermatogenesis tube This is
the first procedure implemented in
Vietnam instead of studying testicular
tissue with two prism or two obtuse
needles Dabaja A.A et al (2013)
recommended the use of enzymes to
process testicular tissue samples to
increase the chances of sperm retrieval
from tissue samples obtained [4]
However, compared to results published
by some authors in the world, our success rate was still lower Schlege N.P (1999) announced that the percentage of sperm collection by micro TESE method was about 42 - 63%; Bryon F.C (2014) showed that this rate reached 50 - 60% [2, 5] This difference may be due to patient selection criteria, the sample size, and it also depends on the surgical base and surgeon's experience
Compared with the sperm collection rate from testicles of non-obstructive azoospermia patients by TESE in Vietnam published by Trinh The Son et al (2015), the micro TESE method was the method
of collecting sperm from testicles much more effective than other methods (37% compared to 23.3%) [1] Thus, with the success of the micro-TESE, it has contributed to improving the quality and effectiveness of infertility treatment in general and male infertility in particular and providing opportunities for non-obstructive azoospermia patients to have their own baby
In the study, the AZFc gene abnormality
group had a higher sperm collection rate
than the other AZF gene abnormalities
that contributed to the counseling and prognosis for patients
The average FSH concentration of the study patients was 20.30 ± 12.63 mIU/m, much higher than the normal index of about 2 - 10 mIU/mL In this study, FSH and testosterone levels were correlated
with sperm retrieval ability (table 4) However,
some other authors, such as Kalsi J et al (2012) found that FSH concentrations did not have a prognostic value of sperm
Trang 6retrieval ability of micro TESE method [6];
Bermie M.A (2013), Bryson F.C (2014)
supposed that there was no single factor
that can assess the sperm retrieval ability
of micro TESE, so it is necessary to
combine all factors/elements to predict
[5, 7] This difference may be due to
differences in sample size and subjects
Among the histopathologic lesions, the
group with impaired spermatogenesis was
most likely to obtain sperm at the highest
rate (70.4%), followed by the halfway
spermatogenesis group (41.7%) and the
lowest was the hyalinization spermatomy
tube group with the rate of obtaining sperm
of 9.1% (table 5) Thus, histopathology
was a valuable factor in the prognosis of
sperm retrieval ability of micro TESE
CONCLUSION
Micro TESE is a method to collect
sperm from the testicle safely, effectively
in patients with non-obstructive azoospermia,
the sperm collection rate reacheed 37%
Testicular volumes, FSH concentration,
testosterone, AZF gene abnormalities,
histopathological lesions had a prognostic
value of sperm retrieval ability in
non-obstructive azoospermia patients by micro
TESE method
REFERENCES
1 Trinh The Son, Vu Van Tam. Evaluation
of results of percutaneuos epididymal sperm aspiration (PESA) and testicular spem extraction (TESE) on azoospermia patients in Haiphong Obstetrics and Gynecology Hospital Journal of Military Medicine 2015
2 Schlegel P.N Testicular sperm extraction: Micro-dissection improves sperm yield with minimal tissue excision Hum Reprod 1999,
14, (1), pp.131-135
3 WHO. WHO laboratory manual for the examination and processing of human semen Fifth edition Switzerland 2010
4 Dabaja A.A, Schlegel N.P Micro-dissection testicular sperm extraction: An update Asian Jourmal of Andrology 2013, 15, pp.35-39
5 Bryson F.C, Ramasamy R, Sheehan M, Palermo D.G, Rosenwaks Z, Schlegel N.P
Severe testicular atrophy does not affect the success of micro-dessection testicular sperm extraction J Urol 2014, 191 (1), pp.175-178
6 Kalsi J, Thum Y.M, Muneer A, Abdullah
H, Minhas S. In the era of micro-dissection sperm retrieval (m-TESE) is an isolated testicular biopsy necessary in the management
of men with non-obstructive azoospermia BJU 2012, 109 (3), pp 418-424
7 Bernie M.A, Ramasamy R, Schlegel
micro-dissection testicular sperm extraction Clinical Andrology 2013, 23, p.5