Management of severe male infertility with special reference to IVF and ICSI

Background: Until recently the treatment options for couples with severe male factor infertility have been restricted. With the advent of intracytoplasmic sperm injection (ICSI) it has now become possible to offer these couples effective treatment.

Materials and methods: The outcome of treatments with in vitro fertilization (IVF) and ICSI was analysed in men with ejaculation failure due to spinal cord injury (SCI) and in men with infertility, mainly due to ejaculation failure after retroperitoneal Iymph node dissection (RPLND) after testicular cancer in 53 and 21 treatment cycles respectively. In these two groups of men, sperm for IVF and ICSI were mainly retrieved by transrectal electroejaculation (TE), but also by testicular sperm extraction (TESE). In the SCI group sperm were also obtained by penile vibratory stimulation (PVS) in a few cases. The value of microsurgical sperm aspiration (MESA), percutaneous sperm aspiration (PESA) and TESE for recovery of sperm for ICSI in men with obstructive azoospermia was studied in 19 treatment cycles. Sperm recovery and fertilization rates in men with obstructive azoospermia after repeated PESA procedures were analysed in 27 cases. Percutaneous needle biopsies, using 19 and 21G butterfly needles, were compared with conventional open biopsy in the investigation of 22 men with azoospermia.

Results: Sperm quality after TE varied considerably both in the SCI and testicular cancer groups. In the SCI group the fertilization rate (FR) was 43 % using IVF and 57 % using ICSI. There were four cases of fertilization failure with IVF and none with ICSI. The clinical pregnancy rates (PR)/cycle were 11/33 (33 %) and 5/20 (25 %) respectively. In the testicular cancer group the FR was similar for IVF and ICSI (57 % and 55 %) and the clinical PR/cycle were 6/8 (75 %) and 6/13 (46 %) respectively. In the group with obstructive azoospermia spermatozoa for ICSI could be retrieved by MESA/PESA or TESE in all cases and FR was 68 % and with no difference in FR using epididymal and testicular spermatozoa. The clinical PR/cycle was 5/19 (26 %). In the repeated PESA procedures sufficient motile spermatozoa for ICSI were found in a similar proportion of the first two procedures, 91 % and 89 %, respectively, and FR was also similar, 62 % versus 67 %. At the third procedure motile spermatozoa for ICSI were retrieved in 86 %, with FR of 62 %. In the 14 cases where material was obtained with the 19G needle, there was full conformity with open biopsies regarding the presence of mature sperm, whereas with the 21G needle nine of 13 biopsies yielding material were predictive in this respect. For both needle sizes, aspirations correlated poorly with open biopsy regarding evaluation of spermatogenesis.

Conclusions: In men with ejaculation failure due to SCI or RPLND, sperm can be successfully retrieved by TE and used in combination with IVF and ICSI for fertilization. Pregnancy rates obtained in these groups are similar to those groups treated on other indications. When sperm are not obtained by TE or PVS, TESE can be used in combination with ICSI. Sperm from men with obstructive azoospermia can effectively be retrieved by PESA or TESE. PESA can be repeated with a high success rate regarding FR. Percutaneous testicular biopsy using a 19 gauge butterfly needle is a safe and reliable method for assessment of the presence of mature spermatids in men with azoospermia A detailed histopathological evaluation was not possible with use of this size of needle.