Should primary microsurgical ligation of varicocele be the gold standard approach?

Abstract

Introduction: Varicocele is a common condition affecting over one in 10 men, and in cases with abnormal semen parameters, varicocele is present in about one in four men. Several methods have been used to treat this condition, of which microsurgical treatment has the lowest failure and complication rates. We present a single-centre UK series of microsurgical repair of varicocele.

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THE PLACE OF SPERM DNA FRAGMENTATION TESTING IN CURRENT DAY FERTILITY MANAGEMENT

Abstract

In this debate article, I am going to set out the case that sperm DNA fragmentation testing is essential in current day fertility management because:

  • Our current semen analysis testing is unfit for purpose
  • We need to take a fresh look at the ‘evidence’ against sperm DNA testing
  • Sperm DNA damage testing has strong associations with every fertility check point
  • Sperm DNA damage testing has strong associations with miscarriage
  • Sperm DNA testing can explain ‘unexplained’ infertility
  • There are reasons why sperm with poor DNA are successful in ICSI
  • There are no non-invasive sperm function tests that provide the same information.
  • We need to take a fresh look at the ‘evidence’ against sperm DNA testing

We have no reason to wait. There are benefits for clinics and couples alike.

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Use of surgical sperm retrieval in azoospermic men: A meta-analysis

Objective

To compare the outcomeof intracytoplasmic sperm injection (ICSI) cycles [1] using epididymal and testicular sperm in patients with obstructive azoospermia (OA); [2] using surgically retrieved sperm in patients with OA and nonobstructive azoospermia (NOA); and [3] using fresh and frozen-thawed sperm.

Design

Meta-analysis of published data.

Setting

Assisted conception unit.

Patient(s)

Ten reports (734 cycles: 677 transfers) were identified as suitable to assess source of sperm; 9 reports (1,103 cycles: 998 transfers) to assess etiology; and 17 reports (1,476 cycles: 1,377 transfers) to assess the effect of cryopreservation.

Intervention(s)

Surgical sperm retrieval/ICSI.

Main outcome measure(s)

Fertilization rate (FR), implantation rate (IR), clinical pregnancy rate (CPR), and ongoing pregnancy rate (OPR) per embryo transfer.

Result(s)

Meta-analysis demonstrated no significant difference in any outcome measure between the use of epididymal or testicular sperm in men with OA. Meta-analysis showed a significantly improved FR (relative risk [RR] 1.18; 95% confidence interval [CI]: 1.13–1.23) and CPR (RR 1.36; 95% CI: 1.10–1.69) in men with OA as compared to NOA with a nonsignificant increase in OPR. There was no difference in either IR or miscarriage rate between the two groups. Comparing fresh with frozen-thawed epididymal sperm there was no difference in FR or IR, a significantly higher CPR (RR 1.20; 95% CI: 1.0–1.42), and no difference in OPR. No difference in fertilization or pregnancy outcome was noted when the testicular cycles were analyzed separately, but IR was significantly impaired using frozen-thawed sperm (RR 1.75; 95% CI: 1.10–2.80).

Conclusion(s)

Meta-analysis of published data confirms that etiology of azoospermia and cryopreservation of surgically retrieved sperm impacts on ICSI outcome, and allows us to make several recommendations for clinical practice. Origin of sperm, in men with similar etiology, does not affect outcome.

https://doi.org/10.1016/j.fertnstert.2004.02.116

NOVEL MEASURES OF SPERM DNA DAMAGE INCREASE ITS USEFULNESS TO DIAGNOSE MALE INFERTILITY AND PREDICT LIVE BIRTHS FOLLOWING BOTH IVF AND ICSI

BACKGROUND

• Lister has been using the SpermComet test since 2011
• Initial clinical thresholds seen as a limitation of the test:

– 0-25%– 25-50%– >50%

No significant DNA damage Consider IVF
ICSI recommended

• Majority of clinic results fall in the 25-50% range

• Tighter thresholds would be more clinically useful in guiding treatment selection.

OBJECTIVES

• Determine and compare novel Comet Plot parameters to identify which has the highest ability to predict a live birth following IVF and also ICSI.

• Analyze the relationship between treatment pathway, live birth and sperm DNA damage for clinic patients who have had the SpermComet test.

• Define clinic specific thresholds to better guide the selection of treatment pathway.

CONCLUSIONS

All COMET markers highly predictive of male subfertility confirming role for testing in unexplained infertility

IVF Livebirth rate declined sharply once sperm DNA damage exceeded all ROC threshold levels identified with
HCS > 6% the most predictive (38% vs 13%)

ICSI Livebirth rate moderately declined once sperm DNA damage exceeded all ROC threshold levels identified with HCS > 10% the most predictive (43% vs 28%)

SUMMARY

• We have identified clinic-specific thresholds for ACS and novel SpermComet parameters

• Role for testing in Unexplained Subfertility

• Role for prediction of ART outcome / improved treatment pathway

– HCS parameter is most predictive of IVF and ICSI Livebirth

– Recommend IVF over ICSI even with normal semen parameters with COMET scores above identified thresholds

– ICSI livebirth also impacted by COMET scores suggesting role for urological intervention to reduce damage before treatment

– ?Role for testicular retrieval with very high levels / recurrent cycle failures

https://examenlab.com/wp-content/uploads/2018/11/Nicopoullous-BFS.pdf

Use of surgical sperm retrieval in azoospermic men: A meta-analysis

Objective

To compare the outcomeof intracytoplasmic sperm injection (ICSI) cycles [1] using epididymal and testicular sperm in patients with obstructive azoospermia (OA); [2] using surgically retrieved sperm in patients with OA and nonobstructive azoospermia (NOA); and [3] using fresh and frozen-thawed sperm.

Design

Meta-analysis of published data.

Setting

Assisted conception unit.

Patient(s)

Ten reports (734 cycles: 677 transfers) were identified as suitable to assess source of sperm; 9 reports (1,103 cycles: 998 transfers) to assess etiology; and 17 reports (1,476 cycles: 1,377 transfers) to assess the effect of cryopreservation.

Intervention(s)

Surgical sperm retrieval/ICSI.

Main outcome measure(s)

Fertilization rate (FR), implantation rate (IR), clinical pregnancy rate (CPR), and ongoing pregnancy rate (OPR) per embryo transfer.

Result(s)

Meta-analysis demonstrated no significant difference in any outcome measure between the use of epididymal or testicular sperm in men with OA. Meta-analysis showed a significantly improved FR (relative risk [RR] 1.18; 95% confidence interval [CI]: 1.13–1.23) and CPR (RR 1.36; 95% CI: 1.10–1.69) in men with OA as compared to NOA with a nonsignificant increase in OPR. There was no difference in either IR or miscarriage rate between the two groups. Comparing fresh with frozen-thawed epididymal sperm there was no difference in FR or IR, a significantly higher CPR (RR 1.20; 95% CI: 1.0–1.42), and no difference in OPR. No difference in fertilization or pregnancy outcome was noted when the testicular cycles were analyzed separately, but IR was significantly impaired using frozen-thawed sperm (RR 1.75; 95% CI: 1.10–2.80).

Conclusion(s)

Meta-analysis of published data confirms that etiology of azoospermia and cryopreservation of surgically retrieved sperm impacts on ICSI outcome, and allows us to make several recommendations for clinical practice. Origin of sperm, in men with similar etiology, does not affect outcome.

https://doi.org/10.1016/j.fertnstert.2004.02.116

Salvage micro-dissection testicular sperm extraction; outcome in men with non-obstructive azoospermia with previous failed sperm retrievals.

Abstract

OBJECTIVE: To assess the outcome of micro-dissection testicular exploration sperm extraction (m-TESE) as a salvage treatment in men with non-obstructive azoospermia (NOA) in whom no sperm was previously found on single/multiple TESE or testicular sperm aspiration (TESA).

Continue reading “Salvage micro-dissection testicular sperm extraction; outcome in men with non-obstructive azoospermia with previous failed sperm retrievals.”

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?

OBJECTIVES: To assess the outcome of sperm retrieval using micro-dissection-TESE (m-TESE) and simultaneous diagnostic biopsy in NOA to determine if the final definitive histology correlated with the outcome of sperm retrieval by m-TESE in men with NOA. To determine if there was a correlation between FSH levels and positive sperm retrieval rates and assessed the success rate of m-TESE as either a primary or a salvage procedure after previous negative sperm retrieval. The EAU guidelines (2010) recommend that in men with non obstructive azoospermia ‘a testicular biopsy is the best procedure to define the histological diagnosis and the possibility of finding sperm’. However, these guidelines do not identify which patients should have a diagnostic biopsy and if this biopsy should be performed as an isolated procedure or synchronously with sperm retrieval. It is also suggested that there is a correlation between the histological diagnosis and possibility of finding sperm on testis biopsy.

Continue reading “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?”