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.
Journal of military pharmaco-medicine no9-2019 STUDY 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 Trang1; Quach Thi Yen2; Nguyen Dinh Tao3; Trinh The Son3 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, Hung Yen Obstetrics and Pediatric Hospital Vietnam University of Traditional Medicine Vietnam Military Medical University Corresponding author: Vu Thi Thu Trang (drtrangvu@gmail.com) Date received: 15/10/2019 Date accepted: 06/12/2019 216 Journal of military pharmaco-medicine no9-2019 micro-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 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 Method Prospective, cohort study RESULTS 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 year Infertility group from - < years was seen the most (52%), followed by group - < 10 years (31%), the lowest was infertility group under 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 mL There were 59% testicles with volume from < 10 mL; group with volume < 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 217 Journal of military pharmaco-medicine no9-2019 * Results of AZF genetic testing: Table 1: Results of AZF genetic testing Normal AZF genes Types of AZF gene abnormalities Abnormal AZF genes n % 81 81 19 19 100 100 The amount and proportion/abnormality AZF gene AZFa abnormality (5,3) AZFb abnormality (15,8) AZFc abnormality (36,8) Associated lesions (42,1) Total 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%) 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) (n; %) (n; %) AZFa abnormality (0) (1) AZFb abnormality (66,7) (33,3) AZFc abnormality (71,4) (28,6) Associated lesions (0) (100) 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 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) 218 Journal of military pharmaco-medicine no9-2019 * Relationship between surgical testicular volume and the ability to retrieve sperm: Table 3: Obtaining sperm (n = 37) Not obtaining sperm (n = 63) (n; %) (n; %) ≥7 21 (48.8) 22 (51.2) 0.05) Table 5: Relationship between histopathological results and sperm retrieval ability Obtaining sperm Not obtaining sperm (n; %) (n; %) (9.1) 10 (90.9) Sertoli-cell-only syndrome 12 (24.0) 38 (76.0) Maturation arrest (41.7) (58.3) Hypospermatogenesis 19 (70.4) (29.6) Histopathological results Seminiferous tubule hyalinization p < 0.001** χ2 = 20.31 (**: Fisher’s exact test) 219 Journal of military pharmaco-medicine no9-2019 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% 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 nonobstructive azoospermia patients The percentage of sperm obtained from nonobstructive 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 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] 220 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 nonobstructive 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 - 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 Journal of military pharmaco-medicine no9-2019 retrieval 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 nonobstructive azoospermia patients by micro TESE method REFERENCES 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 Schlegel P.N Testicular sperm extraction: Micro-dissection improves sperm yield with minimal tissue excision Hum Reprod 1999, 14, (1), pp.131-135 WHO WHO laboratory manual for the examination and processing of human semen Fifth edition Switzerland 2010 Dabaja A.A, Schlegel N.P Micro-dissection testicular sperm extraction: An update Asian Jourmal of Andrology 2013, 15, pp.35-39 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 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 Bernie M.A, Ramasamy R, Schlegel N.P Predictive factors of successful microdissection testicular sperm extraction Clinical Andrology 2013, 23, p.5 221 ... 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... 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... laboratory manual for the examination and processing of human semen Fifth edition Switzerland 2010 Dabaja A. A, Schlegel N.P Micro-dissection testicular sperm extraction: An update Asian Jourmal