A high predictive value of the first testicular fine needle aspiration in patients with non-obstructive azoospermia for sperm recovery at the subsequent attempt

S.J. Fasouliotis, A. Safran, A. Porat-Katz, A. Simon, N. Laufer and A. Lewin,1

IVF Unit, Department of Obstetrics and Gynecology, Hadassah Medical Center, Hebrew University, Ein-Kerem, Jerusalem, Israel


    Abstract
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 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
BACKGROUND: The objective of this retrospective study, which included 51 men with non-obstructive azoospermia, was to evaluate the predictive value of the results of the first sperm recovery attempt on the probability for sperm recovery in a second attempt. METHODS AND RESULTS: A positive testicular fine needle aspiration (TEFNA) was defined as the recovery of any number of mature sperm. At the first and second TEFNA attempts, mature sperm were recovered in 33 (64.7%) and 25 (49%) of 51 patients respectively. In 23 of the 33 (69.7%) patients with a positive first TEFNA, sperm were recovered at both attempts, whereas in only two of 18 (11.1%) with a negative first TEFNA, sperm were recovered at the second attempt. Our analysis revealed a high predictive value of the first TEFNA for sperm recovery at the subsequent attempt, with a mean positive predictive value of 69.7%, with the highest probability being 90.9% in hypospermatogenesis, 72.7% in Sertoli cell-only pattern, 75% in tubular hyalinization, and the lowest being 28.6% in maturation arrest. The mean negative predictive value was 88.9%, which was high in all categories (80% in Sertoli cell-only pattern and 100% in maturation arrest and tubular hyalinization). CONCLUSION: A second TEFNA attempt should be offered to all non-obstructive azoospermic patients with a positive first TEFNA. Patients with a negative first TEFNA may undergo a repeated attempt, but a donor sperm back-up is strongly advised.

Key words: fine needle aspiration/histology/non-obstructive azoospermia/predictive value/testicular sperm


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Recent advances in the treatment of male infertility enabled the recovery of testicular sperm from azoospermic patients for ICSI. While initially this type of treatment was limited to patients with obstructive azoospermia (Craft et al., 1993Go; Schoysman et al., 1993Go), later studies reported the successful recovery of mature sperm in patients with non-obstructive azoospermia (Devroey et al., 1995Go), leading to the first successful pregnancies and deliveries in this latter group of infertile patients (Tournaye et al., 1995Go; Lewin et al., 1996Go). These initial successes with surgically retrieved sperm were followed by the development of several methods for recovering sperm, each technique having its drawbacks and advantages (Tournaye, 1999Go). The use of testicular fine needle aspiration (TEFNA) in non-obstructive azoospermia, first introduced by our group (Lewin et al., 1996Go), was shown to be efficient, safe and well tolerated by the patients (Lewin et al., 1999Go).

Although ICSI using testicular sperm offers men with non-obstructive azoospermia the possibility of fathering their own genetic children, the recovery of sperm may not always be successful in these patients, an event that encompasses important emotional and financial implications. Despite that, before turning to the alternative treatment with donor sperm, many couples request the performance of a repeated sperm recovery attempt. Determining factors which may predict the outcome of such a repeated TEFNA attempt allow objective counselling, offering thus realistic expectations for both the couple and the physician. This study aims to analyse the predictive value of the first TEFNA attempt in patients with non-obstructive azoospermia for sperm recovery in the subsequent attempt.


    Materials and methods
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 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Patients
A total of 51 men diagnosed as suffering from non-obstructive azoospermia who underwent two TEFNA attempts were included in this retrospective study. The second TEFNA attempt was performed for repeated sperm recovery following either a successful prior TEFNA procedure in 33 patients or previous failure in retrieving sperm in 18 patients. The mean age of the patients was 31.8 years (range 23–45 years), and the mean duration of infertility was 7.8 years (range 1–20), while the mean serum FSH was 19.2 IU/l (range 2–64 IU/l). All patients were katyotyped prior to the first TEFNA attempt: 44 patients were 46,XY and seven patients were found to be non-mosaic 47,XXY (Klinefelter's syndrome), and thus were offered genetic counselling and the possibility of undergoing preimplantation genetic diagnosis.

Methods
The pretreatment evaluation comprised karyotyping, sonographic and physical examination of the testes, serum FSH and testosterone, testicular biopsy, as well as repeated semen analysis following high velocity centrifugation (1800 g for 5 min). In all patients, TEFNA was used for the recovery of testicular sperm as previously described (Lewin et al., 1999Go). A positive TEFNA was defined as the recovery of any number of mature sperm. In order to rule out testicular malignancy and corroborate the pretreatment histological evaluation, after searching for the presence of sperm, tissue specimens retrieved from each TEFNA attempt were sent for histopathological examination. Based on testicular histology as determined in the pretreatment testicular biopsy, patients were classified as having Sertoli cell-only (germ cell aplasia) in 21 cases, maturation (spermatogenic) arrest in 12 cases, hypospermatogenesis (germ cell hypoplasia) in 11 cases, and tubular hyalinization due to non-mosaic Klinefelter's syndrome in seven cases.

Statistical analysis
Positive predictive value (the probability that sperm will be recovered) and negative predictive value (the probability that sperm will not be found) were calculated.


    Results
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 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Mature sperm were recovered in the first and second TEFNA attempts from 33 (64.7%) and 25 (49%) of 51 patients respectively. In 13 of the 33 patients (39.4%) with successful sperm recovery in the first TEFNA attempt (two with maturation arrest, seven with hypospermatogenesis and four with Sertoli cell-only) sperm were recovered in enough numbers (>10 sperm) to allow their cryopreservation for use in subsequent ICSI treatment. In these patients the second TEFNA attempt was performed following the exhaustion of the cryopreserved tissue, whereas in the remaining 20 patients with a positive first TEFNA attempt, sperm were recovered in smaller numbers (<10 sperm), enough only for a single ICSI treatment. Following the second TEFNA attempt, in eight of the 25 patients (32%) with successful sperm recovery (one with maturation arrest, five with hypospermatogenesis, two with Sertoli cell-only), sperm were found in numbers allowing cryopreservation for future ICSI treatment, whereas in the remaining 17 patients, sperm were found in numbers allowing only a single ICSI treatment. Table IGo summarizes the results of the first TEFNA attempt in comparison with the second TEFNA attempt. In 23 of the 33 (69.7%) patients with a positive first TEFNA attempt, mature sperm were recovered in both attempts, whereas in only two of 18 (11.1%) patients with a negative first TEFNA, mature sperm were recovered in the second attempt.


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Table I. Predictive value for sperm recovery by testicular fine needle aspiration (TEFNA) attempt in 51 patients with non-obstructive azoospermia
 
The sperm recovery rates using testicular histology in the first and second TEFNA attempts respectively were 11/21 (52.4%) and 10/21 (47.6%) of patients with Sertoli cell-only, 11/11 (100%) and 10/11 (90.9%) of patients with hypospermatogenesis, 7/12 (58.3%) and 2/12 (16.7%) of patients with maturation arrest and 4/7 (57.1%) and 3/7 (42.9%) of patients with tubular hyalinization due to non-mosaic Klinefelter's syndrome.

The sperm recovery results of the second TEFNA attempt performed in patients with either positive or negative first TEFNA classified by the histological findings are summarized in Table IIaGo and bGo. In the 33 patients with a positive first TEFNA, sperm recovery rates in the second TEFNA attempt by testicular histology were respectively 10/11 (90.9%) in hypospermatogenic patients, 8/11 (72.7%) in Sertoli cell-only patients, 2/7 (28.6%) in patients with maturation arrest and 3/4 (75%) in patients with tubular hyalinization. In the 18 patients with a negative first TEFNA, the second attempt succeeded in retrieving sperm in only 2/10 (20%) of patients with Sertoli cell-only, whereas no sperm were recovered in the five patients with maturation arrest and the three patients with tubular hyalinization. The predictive value of the first to the second TEFNA attempt for sperm recovery by testicular histology is shown in Figure IGo.


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Table IIa. Histological findings and sperm recovery in 33 patients with a positive first TEFNA undergoing a second TEFNA attempt
 

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Table IIb. Histological findings and sperm recovery in 18 patients with a negative first TEFNA undergoing a second TEFNA attempt
 


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Figure I. The predictive value for sperm recovery by testicular histology at the subsequent TEFNA attempt. HYP = hypospermatogenesis; SCO = Sertoli cell-only; MA = maturation arrest; TH = tubular hyalinization; PPV = positive predictive value; NPV = negative predictive value

 

    Discussion
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 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
The introduction of ICSI offered the opportunity partially to alleviate male factor infertility due to non-obstructive azoospermia by the use of testicular sperm. The fantastic possibility of achieving a pregnancy with even only one available spermatozoon led to the evolution of a number of methods aiming to obtain sperm from testicular tissue (Tournaye, 1999Go). However, studies have shown that independently of the method used, patients with hypospermatogenesis have an invariably high recovery rate, whereas in patients with maturation arrest, Sertoli cell-only, or tubular hyalinization, recovery rates range from 11–70% (Tournaye et al., 1996Go; Friedler et al., 1997Go; Ezeh et al., 1998Go; Lewin et al., 1999Go; Tournaye, 1999Go).

Considering the reported average sperm recovery rate is <50% in patients with testicular failure, and the fact that testicular biopsy is an invasive procedure that may be associated with significant complications (Harrington et al., 1996Go), the need to restrict testicular sperm search to those with a high chance of yielding testicular sperm was widely acknowledged. As a result, several, mainly retrospective, studies examined possible predictive factors for successful testicular sperm recovery in azoospermic patients (Tournaye et al., 1996Go; Ezeh et al., 1998Go; Jezek et al., 1998Go). Although the roles of various parameters as predictors were previously evaluated, including testicular volume, serum FSH, serum inhibin B, the presence of at least one single spermatozoon in any preliminary semen analysis, and the histological results of testicular biopsy, studies failed to show any strong predictors except for testicular histopathology for successful testicular sperm recovery (Tournaye et al., 1997Go; Schultze et al., 1999Go).

The correlation between testicular histology and successful testicular sperm recovery was corroborated by others (Jow et al., 1993Go), who reported testicular sperm retrieval to be successful in seven out of 11 (64%) patients with hypospermatogenesis, two out of nine (22.2%) patients with maturation arrest and none of nine patients with Sertoli cell-only. On the other hand, high sperm retrieval rates for all histological categories in obstructive and non-obstructive azoospermia patients were reported (Tournaye, 1999Go), although showing that the number of testicular sperm retrieved decreases as the histological pattern changes from normal spermatogenesis (100%) to different degrees of maturation arrest (48–62%) and Sertoli cell-only patterns (19–86%). Ezeh et al. similarly reported testicular sperm retrieval in all patients with hypospermatogenesis, 91% of patients with focal spermatogenesis, none of the patients with maturation arrest and 67% of patients with Sertoli cell-only pattern (Ezeh et al., 1998Go).

Thus far, to our knowledge, the possible predictive value of the results of the first testicular biopsy in counselling patients interested in undergoing a second attempt has not been evaluated by any study. This study was performed in an effort to offer appropriate counselling to patients suffering from non-obstructive azoospermia turning to our IVF clinic for a second TEFNA attempt. In accordance with the results of previous studies showing testicular histopathology to be the only valid predictor for successful testicular sperm recovery by testicular biopsies (Tournaye et al, 1997Go; Schultze et al., 1999Go), the parameters used in this study for evaluation included only the sperm recovery and the testicular histopathological classification. In examining the relationship between the results of the first and second TEFNA attempt, a high predictive value of the first TEFNA attempt has been found in patients with non-obstructive azoospermia for sperm recovery at the subsequent attempt, with a mean positive predictive value (PPV) of 69.7%, with the highest probability being 90.9% in patients with hypospermatogenesis, 72.7% in patients with Sertoli cell-only, 75% in patients with tubular hyalinization, and the lowest being 28.6% in patients with maturation arrest. The negative predictive value (NPV) was found to be high in all categories (80% in Sertoli cell-only, 100% in maturation arrest and 100% in tubular hyalinization), with the mean NPV being 88.9%. None of the patients with hypospermatogenesis had two subsequent negative TEFNA attempts.

Our results corroborate those reported by others (Tournaye et al., 1997Go), in which a positive histopathology of a preliminary single-specimen testicular biopsy would correctly predict successful testicular sperm recovery in 83.3% of cases, whereas a negative result would predict recovery failure in 68.7% of cases. Furthermore, in the study by Tournaye et al. (1997), similar to our results, the probability that sperm would be recovered was 86% with focal hypospermatogenesis, whereas the probability that sperm would not be recovered was as high as 80% with Sertoli cell-only. For complete and incomplete maturation arrest the results were less encouraging for successful sperm recovery and included 52.5 and 66.6% respectively.

One of the primary considerations regarding repeated TEFNA attempts might be the possible consequences on testicular function. While several studies evaluating the effects of testicular sperm extraction (TESE) on the testis reported possible side-effects, which in the majority were transient and resolving within 6 months (Schlegel and Su, 1997Go), our experience with TEFNA in over 110 attempts has shown a very low rate of minor complaints, and has been proven thus far to be safe and well tolerated by all patients (Lewin et al., 1999Go).

In conclusion, considering the important psychological and financial implications of a subsequent TEFNA/ICSI treatment, some guidelines for patient counselling may be proposed. At present, we therefore suggest that repeated TEFNA may be offered to all non-obstructive azoospermic patients with a positive first TEFNA. In view of the poor (11%) prognosis of sperm recovery following a negative result, patients are strongly advised to use donor back-up if a second attempt is planned, but such an attempt should not be denied should the patient decide not to use donor sperm and face the consequences of a negative result.


    Notes
 
1 To whom correspondence should be addressed at: IVF Unit, Department of Obstetrics and Gynecology, Hebrew University, Hadassah Medical Center, P.O. BOX 12000, Jerusalem 91120, Israel. E-mail: lewin{at}md2.huji.ac.il Back


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 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Craft, I., Bennett, V. and Nicholson, N. (1993) Fertilising ability of testicular sperm (letter). Lancet, 342, 864.

Devroey, P., Liu, J., Nagy, Z. et al. (1995) Pregnancies after testicular sperm extraction and intracytoplasmic sperm injection in non-obstructive azoospermia. Hum. Reprod., 10, 1457–1460.[Abstract]

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Friedler, S., Raziel, A., Strassburger, D. et al. (1997) Testicular sperm retrieval by percutaneous fine needle aspiration compared with testicular sperm extraction by open biopsy in men with non-obstructive azoospermia. Hum. Reprod., 12, 1488–1493.[Abstract]

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Submitted on April 9, 2001; accepted on September 4, 2001.