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Reviewed research
Authors Vloeberghs V, Verheyen G, Haentjens P, Goossens A, Polyzos NP, Tournaye H.
Review Date June 2015
Citation Human Reproduction 2015: doi:10.1093/humrep/dev139 (online ahead of print)
Update
Since publication of this retrospective cohort study in 2015, the topic of intra-cytoplasmic sperm injection (ICSI) outcomes after testicular sperm extraction (TESE) has been the subject of a systematic review and meta-analysis published in 2019, which found:
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An overall sperm retrieval rate of 47%, with no difference between conventional TESE and micro-TESE techniques
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No effect on sperm retrieval of men’s age or hormonal parameters
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A positive relationship between sperm retrieval rate and testicular size
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A higher pregnancy rate, of 30% per ICSI cycle, for fresh sperm than cryopreserved sperm (20% per ICSI cycle)
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An overall live birth rate of 24% per ICSI cycle, without a statistically significant difference between fresh (30%) or cryopreserved (20%) sperm.
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No effect on pregnancy or live birth rates of meal or female age, testis size or hormonal parameters
Background
Before 1995 the only option for couples where the man has non-obstructive azoospermia (NOA) to have a child was donor sperm or adoption. However, these couples now have the option of testicular sperm extraction (TESE), combined with intracytoplasmic sperm injection (ICSI), to have their own biological child. Despite the considerable time that TESE has been available, the available data only report on either sperm retrieval rates after TESE or on the outcome of ICSI once testicular spermatozoa have been obtained, mostly in selected subpopulations. Data to help counsel men with NOA are needed.
Aim
The aim of this study was to analyse the live birth rate in a consecutive series of patients with a histological diagnosis of NOA having their first TESE procedure followed by ICSI (TESE-ICSI) with frozen or fresh sperm.
Methods
The authors identified all patients with histologically confirmed NOA (all had normal karyotype and absence of Yq deletions), who had their first testicular biopsy between 1994 and 2009. Sperm retrieval was either followed by cryopreservation for later use in ICSI, or ICSI was done on the same day as TESE. Patients were followed longitudinally during consecutive ICSI cycles with testicular sperm.
The primary outcome measure was live birth delivery. The cumulative live birth delivery rate was calculated, based only on ICSI cycles with testicular sperm (fresh and/or frozen) available for injection (maximum 6 cycles). When patients delivered after transfer of supernumerary frozen embryos, this delivery was tallied up to the (unsuccessful) original fresh ICSI cycle. The sperm retrieval rate and pregnancy rate were secondary outcome measures.
Results
This Belgian study included 714 men with NOA (mean age 35 years). Of these men, 40.5% had successful sperm retrieval at their first TESE. If repeated TESE procedures were included the sperm retrieval rate was 49%. In total, 261 couples (mean age female = 31.4 years) had 444 ICSI cycles and 48 frozen embryo transfer cycles, leading to 129 pregnancies and 96 live births and 2 stillborn deliveries. Crude (observed) and expected (those not returning for treatment, i.e. censored, were considered to have same chance of live birth delivery as those continuing treatment) cumulative delivery rates after six ICSI cycles were 37% and 78%, respectively. 13.4% of the original cohort of men with NOA attempting TESE had a livebirth after a maximum of 6 cycles of ICSI.
Multivariable analysis showed male age and calendar year of oocyte retrieval did not have a significant effect on the outcome but female age was independently associated with the outcome (p=0.018).
Conclusion
TESE-ICSI has provided a viable option for men with NOA to have their own biological child. In this study nearly 4 out of 10 (37%) couples having ICSI had a live birth. However, these data suggest that unselected NOA patients should be counselled, before undergoing TESE, that only about one in seven will eventually father their own biological child.
Points to Note
- This study was able to show both the chance of a live birth following ICSI after successful testicular sperm extraction as well as the overall chance of a live birth for a man with non-obstructive azoospermia (NOA) wishing to undergo TESE followed by ICSI.
- Up to 50% of men with NOA had sperm retrieved using TESE.
- The study covered the period 1995 to 2007. The TESE and ICSI procedures may have improved over that time period such that results now may be better than those reported here.
- Belgium had a single embryo transfer policy implemented from 2003 which may have negatively affected the chance of a live birth delivery.
- These data and other similar studies are important to provide realistic expectations for men with azoospermia and their partners with respect to the chances of achieving a live birth within a reasonable number of ICSI cycles.
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