RESUMO
INTRODUCTION: Obstructive azoospermia occurs when there is a blockage in the male reproductive tract, leading to a complete absence of sperm in the ejaculate. It constitutes around 40% of all cases of azoospermia (1, 2). Blockages in the male reproductive tract can arise from either congenital or acquired factors, affecting various segments such as the epididymis, vas deferens, and ejaculatory ducts (3). Examples of congenital causes encompass conditions like congenital bilateral absence of the vas deferens and unexplained epididymal blockages (4). Acquired instances of obstructive azoospermia may result from factors like vasectomy, infections, trauma, or unintentional injuries caused by medical procedures (5). This complex condition affecting male fertility, presents two main treatment options: microsurgical reconstruction and surgical extraction of sperm followed by in vitro fertilization (IVF). Microsurgical reconstruction proves to be the most cost-effective option for treating obstructive azoospermia when compared with assisted reproductive techniques (6, 7). However, success rates of reconstruction defined by patency are as high as 99% for vasovasostomy (VV) but decline to around 65% if vasoepididymostomy (VE) is required (8, 9). Thus, continued refinement in technique is necessary in order to attempt to improve patency for patients undergoing VE. In this video, we show a comprehensive demonstration of microsurgical VE, highlighting the innovative epididymal occlusion stitch. The goal of this innovative surgical technique is to improve outcomes for VE. MATERIALS AND METHODS: The patient is a 39-year-old male diagnosed with obstructive azoospermia who presents for surgical reconstruction via VE. His partner is a 37-years-old female with regular menstrual cycles. The comprehensive clinical data encompasses a range of factors, including FSH levels, results from semen analysis, and outcomes from testicular sperm aspiration. This thorough exploration aims to provide a thorough understanding of our innovative surgical technique and its application in addressing complex cases of obstructive azoospermia. RESULTS: The procedure was started on the right, the vas deferens was identified and transected. The abdominal side of the vas was intubated and a vasogram performed, there was no obstruction. There was no fluid visible from the testicular side of the vas for analysis, thus we proceeded with VE. Upon inspection of the epididymis dilated tubules were identified. After selecting a tubule for VE, two 10-0 nylon sutures were placed, and it was incised. Upon inspection of the fluid motile sperm was identified. After VE, we performed a novel epididymal occlusion stitch technique. This was completed distal to the anastomosis by placing a 7-0 prolene through the tunica of the epididymis from the medial to lateral side. This stitch was then tightened down with the goal to largely occlude the epididymis so that sperm will preferentially travel through the anastomosis. The steps were then repeated on the left. At 3-month follow up, the patient had no change in testicular size as compared with preoperative size (18cc), he had no testicular or incisional discomfort, and on semen analysis he had presence of motile sperm. After 3 months post-surgery, the patient had motile sperm seen on semen analysis. DISCUSSION: The introduction of a novel epididymal occlusion stitch demonstrates a targeted strategy to enhance the success of microscopic VE. Encouragingly, a 3-month post-surgery follow-up reveals the presence of motile sperm, reinforcing the potential efficacy of our approach. This is promising given the historical lower patency, delayed time to patency, and higher delayed failure rates that patients who require VE experience (10). In total, 40% of all azoospermia cases can be attributed to obstruction. The conventional treatments for obstructive azoospermia involve microsurgical reconstruction and surgical sperm retrieval followed by IVF. While microsurgical reconstruction has proven to be economically viable, the quest for enhanced success rates has led to the exploration of innovative techniques. Historically, the evolution of VV and VE procedures, initially performed in the early 20th century, laid the foundation for contemporary microsurgical approaches (11). Notably, the microscopic VV demonstrated significant improvements in patency rates and natural pregnancy likelihood, as evidenced by the seminal Vasovastomy Study Group study in 1991 (8). In contemporary literature, success rates particularly for VE remain unchanged for the past three decades since the original published success rates by the Vasectomy Reversal Study Group (12). VE is associated with a longer time to patency as well with patients taking 2.8 to 6.6 months to have sperm return to ejaculate as compared to 1.7 to 4.3 months for those undergoing VV. Additionally, of those patients who successfully have sperm return to the ejaculate after VE up to 50% will have delayed failure compared to 12% for those undergoing VV who are patent. Finally, of those who experience delayed failure after undergoing VE it usually occurs earlier with studies reporting as early as 6 months post-operatively (10). Given the lack of improvement and significantly worsened outcomes with VE further surgical refinement is a constant goal for surgeons performing this procedure. CONCLUSION: In conclusion, this video is both a demonstration and a call to action for commitment to surgical innovation. We aim to raise the bar in VE success rates, ultimately bringing tangible benefits to patients and contributing to the ongoing evolution of reproductive medicine. The novel epididymal occlusion stitch emerges as a beacon of progress, promising not only enhanced safety but also potential reductions in patency time. Surgical excellence and methodological refinement, as exemplified in this video, lay the foundation for a future where male reproductive surgery continues to break new ground.
Assuntos
Azoospermia , Epididimo , Ducto Deferente , Vasovasostomia , Adulto , Azoospermia/etiologia , Azoospermia/cirurgia , Epididimo/cirurgia , Ducto Deferente/anormalidades , Ducto Deferente/cirurgia , Vasovasostomia/métodos , Técnicas de Sutura , Resultado do Tratamento , Microcirurgia/métodosRESUMO
Azoospermia is defined as absence of spermatozoa and may be secondary to blocked seminal ducts, known as obstructive azoospermia. Semen quality may be impaired due to factors such as sperm cell DNA fragmentation and presence of antisperm antibodies. The objective of this article was to investigate potential differences in outcomes of in vitro fertilisation and intracytoplasmic sperm injection between groups with different obstruction aetiology, as well as between the use of different techniques and sperm cells of different origins. Retrospective, multi-centre analysis of 621 first cycles was carried out between 2008 and 2015: Group I, congenital obstruction, 45 patients and Group 2, vasectomy, 576 patients. Sperm cell retrieval was achieved in all cases. Results were similar for Group I and II fertilisation rates, 70% versus 66.85% (p = .786); pregnancy rates, 42.5% versus 41.46% (p = .896); and live birth rates, 29.73% versus 17.69% (p = .071). According to sperm cell origin (579 epididymal vs. 42 testicular), pregnancy rates, 41.47% versus 43.9% (p = .760); and live birth rates, 18.3% versus 27.78% (p = .163) had no difference. Fertilisation, pregnancy and live birth rates did not differ according to obstruction aetiology. Outcomes did not differ between groups according to sperm cell origin.
Assuntos
Azoospermia/terapia , Injeções de Esperma Intracitoplásmicas , Ducto Deferente/anormalidades , Vasectomia/efeitos adversos , Adulto , Azoospermia/etiologia , Azoospermia/patologia , Coeficiente de Natalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Gravidez , Taxa de Gravidez , Estudos Retrospectivos , Análise do Sêmen , Espermatozoides/patologia , Resultado do Tratamento , Ducto Deferente/cirurgia , Vasovasostomia/efeitos adversosRESUMO
Spino-bulbar muscular atrophy (SBMA) is an X-linked recessive adult progressive disorder affecting motor neurons. It is caused by a poly-glutamine tract expansion in the androgen receptor (AR) which generates protein aggregates that cannot be processed by proteasomes. A secondary mild androgen resistance is developed by AR dysfunction and patients present endocrine abnormalities including gynecomastia and poor function of testosterone in tissues; however, normally they are fertile. In this report we describe a Mexican family with three affected brothers with primary infertility caused by a progressive impairment of spermatogenesis leading to azoospermia before 40 years of age. They presented common features associated to patients affected by SMBA, such as gynecomastia, high level of CPK, muscle cramps, fasciculations, muscle wastage, and impaired swallowing. Two intracytoplasmic sperm injection (ICSI) cycles were performed in one of the patients resulting in fertilization failure. Molecular analysis of AR gene exon 1 revealed 54 CAG repeats in DNA extracted from leukocytes in affected patients and 22 repeats in the fertile non-affected brother. Severe impaired spermatogenesis of rapid progression has not been associated before to SBMA. This is the first report of assisted reproduction techniques indicated by male infertility in patients with this rare disorder. Further studies are required to confirm the unusual result of intracytoplasmic sperm injection cycles. We discuss the implications and possible pathogenesis of these unique features of SBMA in this family.
Assuntos
Azoospermia/etiologia , Atrofia Muscular Espinal/complicações , Espermatogênese , Adulto , Azoospermia/genética , DNA , Feminino , Humanos , Masculino , Atrofia Muscular Espinal/genética , Receptores Androgênicos/genética , Sequências Repetitivas de Ácido Nucleico , Irmãos , Injeções de Esperma IntracitoplásmicasRESUMO
The objective of this systemic review was to evaluate the benefit of repairing clinical varicocele in infertile men with nonobstructive azoospermia (NOA). The surgically obtained sperm retrieval rate (SRR) and pregnancy rates following assisted reproductive technology (ART) with the use of retrieved testicular sperm were the primary outcomes. The secondary outcomes included the presence of viable sperm in postoperative ejaculate to avoid the testicular sperm retrieval and pregnancy rates (both assisted and unassisted) using postoperative ejaculated sperm. An electronic search to collect the data was performed using the MEDLINE and EMBASE databases until April 2015. Eighteen studies were included in this systematic review and accounted for 468 patients who were diagnosed with NOA and varicocele. These patients were subjected to either surgical varicocele repair or percutaneous embolization. Three controlled studies evaluating sperm retrieval outcomes indicated that in patients who underwent varicocelectomy, SRR increased compared to those without varicocele repair (OR: 2.65; 95% CI: 1.69-4.14; P< 0.001). Although pregnancy rates with the use of testicular sperm favored the varicocelectomy group, results were not statistically significant (clinical pregnancy rate OR: 2.07; 95% CI: 0.92-4.65; P= 0.08; live birth rate OR: 2.19; 95% CI: 0.99-4.83; P= 0.05). The remaining fifteen studies reported postoperative semen analysis results. In 43.9% of the patients (range: 20.8%-55.0%), sperm were found in postoperative ejaculates. Pregnancy rates for unassisted and assisted (after IVF/ICSI) were 13.6% and 18.9% in the group of men with sperm in postoperative ejaculates, respectively. Our findings indicate that varicocelectomy in patients with NOA and clinical varicocele is associated with improved SRR. In addition, approximately 44% of the treated men will have enough sperm in the ejaculate to avoid sperm retrieval. Limited data on pregnancy outcomes with both postoperative ejaculated sperm and harvested testicular sperm preclude any firm conclusion with regard to the possible increased fertility potential in treated individuals. In conclusion, the results of our study indicate that infertile men with NOA and clinical varicocele benefit from varicocelectomy. âGiven the low/moderate quality of evidence available, it is advisable that doctors discuss with their patients with NOA the risks and benefits of varicocele repair.
Assuntos
Azoospermia/etiologia , Varicocele/complicações , Azoospermia/patologia , Azoospermia/cirurgia , Humanos , Masculino , Técnicas de Reprodução Assistida , Espermatozoides/fisiologia , Testículo/patologia , Resultado do Tratamento , Varicocele/patologia , Varicocele/cirurgiaRESUMO
BACKGROUND: Epidemiological studies treat testicular germ cancer as a single disease, the behavior of the two histological types of cancer; seminoma and nonseminoma have differences in reproductive hormone secretion and impair fertility differently. OBJECTIVE: To demonstrate that the serum concentration of pituitary hormones involved in fertility and spermatogenesis in the affected male is different in the two histological types. METHODS: Were determined by radioimmunoassay or inmunoradiometric assay, luteinizing hormone, follicle stimulating hormone, total testosterone, prolactin, estradiol, human chorionic gonadotropin and alpha fetoprotein in 37 patients with germ cell cancer (15 seminoma and 22 nonseminoma) and 35 controls. We analyzed the semen of patients, and were questioned about paternity before the cancer diagnosis. RESULTS: Age was higher in patients with seminoma cancer, showed decreased luteinizing hormone, follicle stimulating hormone, and testosterone and increased estradiol and prolactin in nonseminoma compared with seminoma. In patients with nonseminoma they had 9 children, 5 were oligozoospermic, 3 azoospermic and 6 normal concentration, 8 did not provide sample, seminoma group they had eight children, only one azoospermic, nine normal concentration, and 5 did not provide sample . CONCLUSIONS: The hormonal behavior is different in men with nonseminoma compared with seminoma, so that the negative impact on the reproductive axis and fertility is higher in cases of non-seminoma.
Antecedentes: los estudios epidemiológicos tratan al cáncer germinal de testículo como una sola patología, el comportamiento de los dos tipos histológicos: el seminoma y no seminoma tienen diferencias en la secreción de hormonas reproductivas y alteran la fertilidad de forma diferente. Objetivo: demostrar que la concentración sérica de las hormonas hipofisarias que intervienen en la fertilidad y espermatogénesis en el varón afectado es diferente en los dos tipos histológicos. Material y métodos: estudio clínico, prospectivo, transversal, comparativo de tres grupos de pacientes. Por medio de radioinmunoensayo o ensayo inmunorradiométrico se determinaron las concentraciones de: hormona luteinizante, hormona folículo estimulante, testosterona total, prolactina, estradiol, gonadotropina coriónica humana y alfa feto proteína en suero de 37 pacientes (15 seminoma, y 22 no seminoma) y 35 controles. Se analizó el semen de los pacientes y se les interrogó acerca de su satisfacción de paternidad antes del diagnóstico de cáncer. Resultados: los pacientes con cáncer tipo seminoma fueron de mayor edad, se encontró disminución de: hormona luteinizante, hormona folículo estimulante y testosterona; aumento de: estradiol y prolactina en cáncer no seminoma, en comparación con seminoma. En los pacientes con no seminoma 9 ya tenían hijos, 5 eran oligozoospérmicos, 3 azoospérmicos y 6 con concentración normal 8 no proporcionaron muestra; en el grupo de seminona, 8 ya tenían hijos, sólo 1 azoospérmico; 9 concentración normal, y 5 no proporcionaron muestra. Conclusiones: el comportamiento hormonal es diferente en los hombres con cáncer no seminoma en comparación con los de seminoma, por lo que la repercusión negativa en el eje reproductor y fertilidad es mayor en los casos de no seminoma.
Assuntos
Hormônios Esteroides Gonadais/sangue , Gonadotropinas Hipofisárias/sangue , Infertilidade Masculina/etiologia , Neoplasias Embrionárias de Células Germinativas/sangue , Neoplasias Testiculares/sangue , alfa-Fetoproteínas/análise , Adulto , Azoospermia/sangue , Azoospermia/etiologia , Estudos Transversais , Humanos , Infertilidade Masculina/sangue , Masculino , Neoplasias Embrionárias de Células Germinativas/complicações , Estudos Prospectivos , Seminoma/sangue , Seminoma/complicações , Espermatogênese , Neoplasias Testiculares/complicações , Adulto JovemRESUMO
The prevalence of microdeletions of azoospermia factor (AZF) among azoospermic Klinefelter's syndrome (KFS) patients shows conflicting data. We aimed to detect this frequency in a Northeast Chinese population, and to investigate the possible association between AZF microdeletions and KFS by comparison with previous conflicting reports. Eighty men affected with KFS and a random healthy control group comprising 60 fertile men and women were recruited. AZF microdeletions were detected by multiplex polymerase chain reaction using 9 specific sequence-tagged sites. Karyotype analyses were performed on peripheral blood lymphocytes using standard G-banding. Finally, azoospermia was confirmed in 77 men affected with KFS and no AZF microdeletions were found. Karyotype analysis revealed 1 patient with karyotype 47,XXY,inv (9) (p11, q13), and 2 with mosaic karyotypes (46,XX/47,XXY and 46,XY/47,XXY). All other patients had karyotype 47,XXY. Review of the literature showed that these results were similar to those of other regions of Northeast Asia, but differed from those obtained from Caucasian populations. Our results supported the proposal that AZF microdeletions and KFS result from separate genetic defects. The prevalence of AZF in azoospermic KFS patients varies among populations, and it might result from genetic drift or selective pressure. These results suggest that routine screening for classical AZF microdeletions among infertile azoospermic men with a 47,XXY karyotype might not be necessary in Northeast Chinese individuals. However, it remains imperative for patients considering assisted reproductive treatments, particularly for those with mosaic karyotypes.
Assuntos
Infertilidade Masculina/epidemiologia , Infertilidade Masculina/etiologia , Cariótipo Anormal , Azoospermia/epidemiologia , Azoospermia/etiologia , China/epidemiologia , Bandeamento Cromossômico , Deleção Cromossômica , Cromossomos Humanos Y , Humanos , Síndrome de Klinefelter/complicações , Síndrome de Klinefelter/genética , MasculinoRESUMO
This special issue is fully dedicated to the topic of azoospermia and contains the seminal work of renowned scientists and clinicians from seven countries on three continents. In seventeen chapters, a comprehensive review of the epidemiology, genetics, physiopathology, diagnosis, and management of azoospermia addresses our current knowledge on the topic. The clinical results of assisted reproductive techniques applied to this category of male infertility and the health of offspring originating from such fathers are critically analyzed. In addition, the challenges and the future biotechnological perspectives for the treatment of azoospermic males seeking fertility are discussed.
Assuntos
Azoospermia , Técnicas de Reprodução Assistida , Azoospermia/diagnóstico , Azoospermia/etiologia , Azoospermia/terapia , Humanos , MasculinoRESUMO
The misconception that infertility is typically associated with the female is commonly faced in the management of infertile men. It is uncommon for a patient to present for an infertility evaluation with an abnormal semen analysis report before an extensive female partner workup has been performed. Additionally, a man is usually considered fertile based only on seminal parameters without a physical exam. This behavior may lead to a delay in both the exact diagnosis and in possible specific infertility treatment. Moreover, male factor infertility can result from an underlying medical condition that is often treatable but could possibly be life-threatening. The responsibility of male factor in couple's infertility has been exponentially rising in recent years due to a comprehensive evaluation of reproductive male function and improved diagnostic tools. Despite this improvement in diagnosis, azoospermia is always the most challenging topic associated with infertility treatment. Several conditions that interfere with spermatogenesis and reduce sperm production and quality can lead to azoospermia. Azoospermia may also occur because of a reproductive tract obstruction. Optimal management of patients with azoospermia requires a full understanding of the disease etiology. This review will discuss in detail the epidemiology and etiology of azoospermia. A thorough literature survey was performed using the Medline, EMBASE, BIOSIS, and Cochrane databases. We restricted the survey to clinical publications that were relevant to male infertility and azoospermia. Many of the recommendations included are not based on controlled studies.
Assuntos
Azoospermia/epidemiologia , Azoospermia/etiologia , Azoospermia/classificação , Azoospermia/diagnóstico , Humanos , Infertilidade Masculina/diagnóstico , Infertilidade Masculina/epidemiologia , Infertilidade Masculina/etiologia , Masculino , Análise do SêmenRESUMO
Non-obstructive azoospermia is diagnosed in approximately 10% of infertile men. It represents a failure of spermatogenesis within the testis and, from a management standpoint, is due to either a lack of appropriate stimulation by gonadotropins or an intrinsic testicular impairment. The former category of patients has hypogonadotropic hypogonadism and benefits from specific hormonal therapy. These men show a remarkable recovery of spermatogenic function with exogenously administered gonadotropins or gonadotropin-releasing hormone. This category of patients also includes some individuals whose spermatogenic potential has been suppressed by excess androgens or steroids, and they also benefit from medical management. The other, larger category of non-obstructive azoospermia consists of men with an intrinsic testicular impairment where empirical medical therapy yields little benefit. The primary role of medical management in these men is to improve the quantity and quality of sperm retrieved from their testis for in vitro fertilization. Gonadotropins and aromatase inhibitors show promise in achieving this end point.
Assuntos
Inibidores da Aromatase/uso terapêutico , Azoospermia/tratamento farmacológico , Gonadotropina Coriônica/uso terapêutico , Azoospermia/classificação , Azoospermia/etiologia , Hormônio Liberador de Gonadotropina/uso terapêutico , Humanos , Hipogonadismo/classificação , Hipogonadismo/complicações , Hipogonadismo/tratamento farmacológico , Masculino , Espermatogênese , Testosterona/deficiênciaRESUMO
Obstructive azoospermia is a common cause of male infertility and can result from infection, congenital anomalies, or iatrogenic injury. Microsurgical vasal reconstruction is a suitable treatment for many cases of obstructive azoospermia, although some couples will require sperm retrieval paired with in-vitro fertilization. The various causes of obstructive azoospermia and recommended treatments will be examined. Microsurgical vasovasostomy and vasoepididymostomy will be discussed in detail. The postoperative patency and pregnancy rates for surgical reconstruction of obstructive azoospermia and the impact of etiology, obstructive interval, sperm granuloma, age, and previous reconstruction on patency and pregnancy will be reviewed.
Assuntos
Azoospermia/cirurgia , Microcirurgia/métodos , Vasovasostomia/métodos , Azoospermia/etiologia , Epididimo/cirurgia , Humanos , Masculino , Ducto Deferente/cirurgiaRESUMO
Obstructive azoospermia is a relatively common male infertility condition. The main etiologies of obstructive azoospermia include congenital, surgical-derived, traumatic and post-infectious cases. Although seminal tract reconstruction is a cost-effective treatment in most cases, this approach may not be feasible or desired in some cases. In such cases, assisted reproduction techniques offer a method for achieving pregnancy, notably via sperm retrieval and intracytoplasmic sperm injection. This process requires several considerations and decisions to be made, including the cause and duration of obstruction, which sperm retrieval technique to use, and whether to use fresh or frozen-thawed sperm. We present a review of obstructive azoospermia and assisted reproduction techniques, highlighting the most relevant aspects of the decision-making process for use in clinical practice.
Assuntos
Azoospermia/etiologia , Recuperação Espermática , Azoospermia/terapia , Criopreservação , Humanos , Masculino , Preservação do Sêmen , Injeções de Esperma Intracitoplásmicas/métodosRESUMO
There are two main reasons why sperm may be absent from semen. Obstructive azoospermia is the result of a blockage in the male reproductive tract; in this case, sperm are produced in the testicle but are trapped in the epididymis. Non-obstructive azoospermia is the result of severely impaired or non-existent sperm production. There are three different sperm-harvesting procedures that obstructive azoospermic males can undergo, namely MESA (microsurgical epididymal sperm aspiration), PESA (percutaneous epididymal sperm aspiration), and TESA (testicular sperm aspiration). These three procedures are performed by fine-gauge needle aspiration of epididymal fluid that is examined by an embryologist. Additionally, one technique, called TESE (testicular sperm extraction), is offered for males with non-obstructive azoospermia. In this procedure, a urologist extracts a piece of tissue from the testis. Then, an embryologist minces the tissue and uses a microscope to locate sperm. Finding sperm in the testicular tissue can be a laborious 2- to 3-hour process depending on the degree of sperm production and the etiology of testicular failure. Sperm are freed from within the seminiferous tubules and then dissected from the surrounding testicular tissue. It is specifically these situations that require advanced reproductive techniques, such as ICSI, to establish a pregnancy. This review describes eight different lab processing techniques that an embryologist can use to harvest sperm. Additionally, sperm cryopreservation, which allows patients to undergo multiple ICSI cycles without the need for additional surgeries, will also be discussed.
Assuntos
Azoospermia/cirurgia , Epididimo , Injeções de Esperma Intracitoplásmicas/métodos , Recuperação Espermática , Azoospermia/etiologia , Biópsia por Agulha Fina , Humanos , Masculino , Injeções de Esperma Intracitoplásmicas/classificação , Recuperação Espermática/classificaçãoRESUMO
PURPOSE: We evaluated the retrieval rates and reproductive outcomes of percutaneous sperm retrieval according to the cause of obstructive azoospermia. MATERIALS AND METHODS: We retrospectively studied the records of 146 men with obstructive azoospermia who underwent sperm retrieval for intracytoplasmic sperm injection. Patients were grouped by the cause of obstruction, including 32 with congenital bilateral absence of the vas deferens, 59 with vasectomy and 55 with obstruction due to post-infection disease. Sperm were retrieved percutaneously from the epididymis or testis. We compared retrieval rates and intracytoplasmic sperm injection outcomes, including neonatal results, in the groups of men with obstructive azoospermia. RESULTS: The success of sperm retrieval was similar among the etiology groups, including 100% for congenital bilateral absence of the vas deferens, 96.6% for vasectomy and 96.3% for previous infection. Significantly fewer men in the congenital bilateral absence of the vas deferens group needed testicular aspiration compared to those in the post-infection and vasectomy groups (3.1% vs 23.6% and 30.5%, respectively, p <0.001). Sperm cryopreservation was possible in 26.7% of the cases and did not significantly differ among the groups. Live birth rates after sperm injection were similar in the congenital (34.4%), vasectomy (32.2%) and previous infection (36.4%) groups. Birth parameters, prematurity and low birth weight rates were comparable among the groups. CONCLUSIONS: Percutaneous sperm retrieval is an effective method to retrieve sperm in men with obstructive azoospermia irrespective of the cause of obstruction. The chance of achieving a live birth and the profile of neonates born after sperm injection do not seem to be related to the cause of obstruction.
Assuntos
Injeções de Esperma Intracitoplásmicas , Recuperação Espermática/estatística & dados numéricos , Adulto , Azoospermia/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Gravidez/estatística & dados numéricos , Resultado da Gravidez , Estudos RetrospectivosRESUMO
The misconception that infertility is typically associated with the female is commonly faced in the management of infertile men. It is uncommon for a patient to present for an infertility evaluation with an abnormal semen analysis report before an extensive female partner workup has been performed. Additionally, a man is usually considered fertile based only on seminal parameters without a physical exam. This behavior may lead to a delay in both the exact diagnosis and in possible specific infertility treatment. Moreover, male factor infertility can result from an underlying medical condition that is often treatable but could possibly be life-threatening. The responsibility of male factor in couple's infertility has been exponentially rising in recent years due to a comprehensive evaluation of reproductive male function and improved diagnostic tools. Despite this improvement in diagnosis, azoospermia is always the most challenging topic associated with infertility treatment. Several conditions that interfere with spermatogenesis and reduce sperm production and quality can lead to azoospermia. Azoospermia may also occur because of a reproductive tract obstruction. Optimal management of patients with azoospermia requires a full understanding of the disease etiology. This review will discuss in detail the epidemiology and etiology of azoospermia. A thorough literature survey was performed using the Medline, EMBASE, BIOSIS, and Cochrane databases. We restricted the survey to clinical publications that were relevant to male infertility and azoospermia. Many of the recommendations included are not based on controlled studies.
Assuntos
Humanos , Masculino , Azoospermia/epidemiologia , Azoospermia/etiologia , Azoospermia/classificação , Azoospermia/diagnóstico , Infertilidade Masculina/diagnóstico , Infertilidade Masculina/epidemiologia , Infertilidade Masculina/etiologia , Análise do SêmenRESUMO
Obstructive azoospermia is a common cause of male infertility and can result from infection, congenital anomalies, or iatrogenic injury. Microsurgical vasal reconstruction is a suitable treatment for many cases of obstructive azoospermia, although some couples will require sperm retrieval paired with in-vitro fertilization. The various causes of obstructive azoospermia and recommended treatments will be examined. Microsurgical vasovasostomy and vasoepididymostomy will be discussed in detail. The postoperative patency and pregnancy rates for surgical reconstruction of obstructive azoospermia and the impact of etiology, obstructive interval, sperm granuloma, age, and previous reconstruction on patency and pregnancy will be reviewed.
Assuntos
Humanos , Masculino , Azoospermia/cirurgia , Microcirurgia/métodos , Vasovasostomia/métodos , Azoospermia/etiologia , Epididimo/cirurgia , Ducto Deferente/cirurgiaRESUMO
Non-obstructive azoospermia is diagnosed in approximately 10% of infertile men. It represents a failure of spermatogenesis within the testis and, from a management standpoint, is due to either a lack of appropriate stimulation by gonadotropins or an intrinsic testicular impairment. The former category of patients has hypogonadotropic hypogonadism and benefits from specific hormonal therapy. These men show a remarkable recovery of spermatogenic function with exogenously administered gonadotropins or gonadotropin-releasing hormone. This category of patients also includes some individuals whose spermatogenic potential has been suppressed by excess androgens or steroids, and they also benefit from medical management. The other, larger category of non-obstructive azoospermia consists of men with an intrinsic testicular impairment where empirical medical therapy yields little benefit. The primary role of medical management in these men is to improve the quantity and quality of sperm retrieved from their testis for in vitro fertilization. Gonadotropins and aromatase inhibitors show promise in achieving this end point.
Assuntos
Humanos , Masculino , Inibidores da Aromatase/uso terapêutico , Azoospermia/tratamento farmacológico , Gonadotropina Coriônica/uso terapêutico , Azoospermia/classificação , Azoospermia/etiologia , Hormônio Liberador de Gonadotropina/uso terapêutico , Hipogonadismo/classificação , Hipogonadismo/complicações , Hipogonadismo/tratamento farmacológico , Espermatogênese , Testosterona/deficiênciaRESUMO
Obstructive azoospermia is a relatively common male infertility condition. The main etiologies of obstructive azoospermia include congenital, surgical-derived, traumatic and post-infectious cases. Although seminal tract reconstruction is a cost-effective treatment in most cases, this approach may not be feasible or desired in some cases. In such cases, assisted reproduction techniques offer a method for achieving pregnancy, notably via sperm retrieval and intracytoplasmic sperm injection. This process requires several considerations and decisions to be made, including the cause and duration of obstruction, which sperm retrieval technique to use, and whether to use fresh or frozen-thawed sperm. We present a review of obstructive azoospermia and assisted reproduction techniques, highlighting the most relevant aspects of the decision-making process for use in clinical practice.
Assuntos
Humanos , Masculino , Azoospermia/etiologia , Recuperação Espermática , Azoospermia/terapia , Criopreservação , Preservação do Sêmen , Injeções de Esperma Intracitoplásmicas/métodosRESUMO
There are two main reasons why sperm may be absent from semen. Obstructive azoospermia is the result of a blockage in the male reproductive tract; in this case, sperm are produced in the testicle but are trapped in the epididymis. Non-obstructive azoospermia is the result of severely impaired or non-existent sperm production. There are three different sperm-harvesting procedures that obstructive azoospermic males can undergo, namely MESA (microsurgical epididymal sperm aspiration), PESA (percutaneous epididymal sperm aspiration), and TESA (testicular sperm aspiration). These three procedures are performed by fine-gauge needle aspiration of epididymal fluid that is examined by an embryologist. Additionally, one technique, called TESE (testicular sperm extraction), is offered for males with non-obstructive azoospermia. In this procedure, a urologist extracts a piece of tissue from the testis. Then, an embryologist minces the tissue and uses a microscope to locate sperm. Finding sperm in the testicular tissue can be a laborious 2- to 3-hour process depending on the degree of sperm production and the etiology of testicular failure. Sperm are freed from within the seminiferous tubules and then dissected from the surrounding testicular tissue. It is specifically these situations that require advanced reproductive techniques, such as ICSI, to establish a pregnancy. This review describes eight different lab processing techniques that an embryologist can use to harvest sperm. Additionally, sperm cryopreservation, which allows patients to undergo multiple ICSI cycles without the need for additional surgeries, will also be discussed.
Assuntos
Humanos , Masculino , Azoospermia/cirurgia , Epididimo , Recuperação Espermática , Injeções de Esperma Intracitoplásmicas/métodos , Azoospermia/etiologia , Biópsia por Agulha Fina , Injeções de Esperma Intracitoplásmicas/classificação , Recuperação Espermática/classificaçãoRESUMO
INTRODUCTION: Damage of testicles is frequent in lepromatous leprosy and worsened by the presence of erythema nodosum leprosum. Objective. A patient is presented who developed lepromatous leprosy and erythema nodosum leprosum with major testicular compromise. MATERIAL AND METHODS: The 28-year-old male patient had lepromatous leprosy since age 22. During a polychemotherapy treatment for the lepromatous leprosy, he presented chronic erythema nodosum leprosum that affected both testicles; he did not respond to the conventional treatment. A left orchidectomy was performed to treat the persistent pain. RESULTS: The extracted testis evidenced the following: tubular atrophy, extensive fibrosis, cumulus of foamy macrophages without rods, focal Leydig cell hyperplasia, linfocitary and granulomatous arteritis and endarteritis of small and medium size vessels. These changes were also observed in the epididymis. Two years after the polychemoterapy and the orchidectomy, the patient exhibited azoospermy, normal total testosterone, slightly diminished free testosterone and elevated levels of luteinizing hormone and follicle-stimulating hormone. No loss of libido or sexual activity was reported. General concepts of erythema nodosum leprosum were reviewed, as well as the pathologic changes produced by leprosy in the testis. CONCLUSION: Lepromatous leprosy may lead to hypogonadism. This condition is recommended for inclusion in leprosy diagnostic programs in order to detect and treat the consequences of the possible hypogonadism.