Center for Reproductive Medicine, Dutch-speaking Brussels Free University, Brussels, Belgium
1 To whom correspondence should be addressed. e-mail: osmanagaoglu{at}hotmail.com
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Abstract |
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Key words: cumulative pregnancy rates/life-table/non-obstructive azoospermia/obstructive azoospermia/TESE-ICSI
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Introduction |
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Although significant progress has been recorded in reproductive medicine, multiple assisted reproductive technique (ART) cycles are still necessary (Kolibianakis et al., 2002) in order to achieve a live birth. For this reason, the need to inform the patients about the chances of delivery following consecutive cycles is evident.
Cumulative delivery rates after ICSI using freshly ejaculated sperm have already been reported in patients younger (Osmanagaoglu et al., 1999) or older than 37 years (Osmanagaoglu et al., 2002
). Success rates for the TESE technique have been reported per ICSI cycle, but so far no cumulative success rates are available for cumulative delivery rates after ICSI with surgically retrieved sperm, making appropriate counselling rather difficult. The few data available in this respect do not discriminate between obstructive and non-obstructive azoospermia.
This study aims to assess the cumulative delivery rates in patients with non-obstructive and obstructive azoospermia following treatment by ICSI using freshly retrieved testicular sperm. We aimed to analyse the efficiency of consecutive interventions for testicular sperm retrieval in an assisted reproduction programme.
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Materials and methods |
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Female age was recorded on the first day of the initial ICSI cycle treatment. Only those cycles which reached the stage of oocyte retrieval and in which testicular sperm was used were included in the analysis.
Ovarian stimulation was performed using hMG. Down-regulation was carried out with GnRH agonist.
Assessment and handling of sperm/oocyte as well as the embryo transfer policy followed have been described extensively elsewhere (Van Steirteghem et al., 1996; Adonakis et al., 1997
). For luteal-phase supplementation, micronized progesterone (600 mg per day) was administered intravaginally in three separate doses with or without additional hCG, three times 1500 IU, or 5000 IU single dose (Staessen et al., 1995
).
The main outcome measure was delivery beyond 25 gestational weeks. Pregnancy follow-up was documented by our prospective follow-up programme for ICSI (Bonduelle et al., 1999).
The obstructive azoospermia group consisted of patients with congenital bilateral absence of vas deferens, post-infectious obstruction of vas deferens or failed vaso-vasostomy with normal spermatogenesis. The non-obstructive azoospermia group consisted of patients with histopathologically proven maturation arrest, atrophic sclerosis or germ cell aplasia (Sertoli cell-only syndrome). Klinefelter patients were excluded from the study. Patients with hypospermatogenesis were identified as a different clinical entity but were not included in the analysis of cumulative delivery rates in TESEICSI cycles, since the number of cycles performed was too small to permit meaningful conclusions.
Testicular sperm recovery
Open excisional testicular biopsies were performed under general or local anaesthesia. Experienced staff members of our institute performed the surgery. A 0.51 cm incision was made through the skin and the underlying layers. After incision of the tunica albuginea, gentle pressure was applied to the testicular mass and a small specimen (maximum 0.05 ml) of the testicular mass which protruded was removed by a pair of curved scissors. The testicular tissue was placed in a Petri dish containing HEPES-buffered modified Earles medium and transported to the adjacent laboratory. In the laboratory, the testicular tissue was teased apart with microscopic glass slides on the warmed stage of a stereomicroscope at x40 magnification. Under an inverted microscope (x400 magnification), the shredded tissue was then checked for the presence of spermatozoa. If no spermatozoa were observed, another biopsy specimen was taken. Surgery was terminated when spermatozoa were found or when the whole testicular mass had been bilaterally sampled at random. In obstructive azoospermia patients, the procedure was terminated after one biopsy while in non-obstructive azoospermia patients 510 biopsies were performed for each testis. During surgery, a randomly taken biopsy was sent for histopathological examination (Tournaye et al., 1997). Levins histopathological criteria were used for the classification of patients in different groups (Levin, 1979
).
Statistical analysis
Cumulative delivery rates were estimated by life-table analysis using the KaplanMeier product limit procedure (Kaplan and Meier, 1958), and differences between groups were assessed by the log-rank test. Cumulative delivery rates were expressed as cumulative percentage probabilities with 95% confidence intervals (95% CIs). These computational procedures were run on SPSS for Windows version 10 (SPSS Inc., Chicago, IL, USA).
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Results |
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The cumulative delivery rate and life-table analysis for obstructive azoospermia are shown in Table I. The expected cumulative delivery rate increased in the first six cycles, after which it reached a plateau (79%).
Four triplets and 31 twin pregnancies were recorded. In addition two stillbirths occurred at term. No information could be obtained for six (1.6%) couples from abroad and these were assumed not to be pregnant for the purpose of this analysis.
Non-obstructive azoospermia
A total of 235 couples underwent 303 fresh TESEICSI treatment cycles, leading to 42 deliveries. The mean female age was 31.7 years (95% CI, 30.632.8), while that of the males undergoing testicular sperm recovery was 37.1 (95% CI, 35.638.6). The average number of cycles performed per patient was 1.3 and the average number of cycles required per patient for delivery was 7.2. The mean interval between consecutive TESE attempts was 9.4 months (95% CI, 7.311.5).
Life-table analysis overall and cumulative delivery rates according to histopathological classification in non-obstructive azoospermia are shown in Table II. The mean number of cycles required to achieve a delivery in patients with germ cell aplasia (Sertoli cell-only syndrome), those with maturation arrest and those with tubular sclerosis and atrophy were 5.8, 8.6 and 20 respectively. Four (1.7%) couples could not be contacted and these were assumed not to be pregnant for the purposes of this analysis.
The expected cumulative delivery rate increased in the first three cycles, after which it reached a plateau (31%).
The mean number of embryos replaced for obstructive azoospermia patients was 2.7 (range: 14) and for non-obstructive azoospermia patients was 2.8 (range: 14). Three triplets and eight twin pregnancies were recorded, while one stillbirth occurred at term.
A significant difference was apparent (P < 0.001) in the survival distributions observed in obstructive and non-obstructive azoospermia patients (Figure 1).
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Discussion |
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Our data showed that after a few cycles, the delivery rate per cycle decreases compared with the first two cycles in patients with obstructive and non-obstructive azoospermia (Tables I and II). We observe the same trend in consecutive ICSI cycles with freshly ejaculated sperm (Osmanagaoglu et al., 1999, 2002). The delivery rate per cycle that is observed here is different from that in a recently published report (Shulman et al., 2002
). The difference probably originates from not distinguishing between obstructive and non-obstructive azoo spermia and from the definition of non-obstructive azoospermia. However, expected cumulative pregnancy rates after five consecutive cycles are comparable.
In patients with non-obstructive azoospermia, a higher crude cumulative delivery rate after three TESEICSI cycles was observed for patients with Sertoli cell-only syndrome than for patients with maturation arrest and tubular sclerosis (22% versus 14 and 7%, respectively).
It has been shown that repetitive testicular biopsies within 36 months might decrease the possibility of sperm retrieval and harm testicular tissue due to permanent devascularization (Schlegel and Su, 1997; Westlander et al., 2001
). In the current study, the mean time interval between consecutive TESE attempts was 9.6 and 9.4 months in patients with obstructive and non-obstructive azoospermia, respectively, and thus its potential influence on the results obtained is probably negligible.
A high dropout rate in couples with both non-obstructive and obstructive azoospermia was observed (Tables I and II), although this may be attributed to the fact that no cryopreserved TESEICSI cycles were included in the analysis. Only 8.5% (51/599) of the couples in the present study underwent both fresh and frozen TESEICSI cycles. Moreover, by including only patients in whom sperm was recovered, the dropout rate would be expected to be small. Probably the most important reason for discontinuing ICSI treatment was the fact that most of the patients were non-Belgian residents. In the beginning of the TESEICSI treatment era, they were referred to our centre for what was a novel treatment, but because of the rapid spread of the treatment worldwide, they continued their treatment in their home countries when no pregnancy ensued. Moreover, it is not possible to know whether these couples used the option of donor sperm since they could not be reached subsequently, rendering further follow-up inaccurate.
The other possible reasons for stopping ICSI treatment are: restricted numbers of cycles planned, treatment which is psychologically wearing, a financial cost that is too high, fertilization or cleavage problems, other medical problems, too advanced maternal age, divorce, death and other various reasons connected with work, relationships, transport or adoption (Osmanagaoglu et al., 1999). In our previous study (Osmanagaoglu et al., 1999
), we included only Belgian residents and limited the time period of the initial cycles started, so as to ensure a long follow-up and a limited dropout. In the current study, all cycles with surgically retrieved testicular sperm were included without reference to residency, in order to have enough statistical power for the purposes of analysis.
The decision not to include those TESEICSI cycles in which sperm was cryopreserved in the life-table analysis was taken in order to avoid potential bias due to the fact that such cycles might be related to a deteriorating reproductive outcome (Palermo et al., 1999).
It is expected that the wider application of TESEICSI will allow a larger population of patients to be analysed and thus lead to conclusions for specific subgroups of male patients and/or extend the analysis to cover several parameters such as female age, female diagnosis, number of oocytes retrieved and embryos yielded, and the method of sperm retrieval.
At present, however, couples in whom the male partner is diagnosed with obstructive azoospermia may be counselled that their chances of achieving delivery within three ICSI cycles with freshly retrieved testicular sperm are 48%. In addition, couples with non-obstructive azoospermia have an expected delivery rate after two cycles of 19% and after three cycles of 31%.
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Acknowledgements |
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References |
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Submitted on June 12, 2002; accepted on May 9, 2003.