Abstract

Abstract Background

Azoospermia, the absence of sperm in ejaculated semen, is the most severe form of male‐factor infertility and is present in approximately 5% of all investigated infertile couples. The advent of intra‐cytoplasmic sperm injection (ICSI) has transformed treatment of this type of severe male‐factor infertility. Sperm can be retrieved for ICSI from either the epididymis or the testis, depending on the type of azoospermia.

To evaluate the efficacy of the various surgical retrieval techniques for men with obstructive or non‐obstructive azoospermia prior to ICSI.

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (November 2007), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 4), MEDLINE (1966 to November 2007), EMBASE (1980 to November 2007), Biological Abstracts (1980 to November 2007), and reference lists of identified articles.

Randomised controlled trials (RCTs) comparing the effectiveness of different sperm‐retrieval techniques in men with azoospermia prior to ICSI. Due to the lack of RCTs, non‐randomised trials that used the participants as their own control were also considered in the review but their results were not included in the meta‐analysis.

Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

The search was revised and re‐run in November 2007. No new trials were located therefore the results of the updated review remain unchanged from those published in 2006.

Two trials involving 98 men were included. The first small RCT had 59 participants and compared two epididymal techniques. The trial gave limited evidence that microsurgical epididymal sperm aspiration (MESA) achieved a significantly lower pregnancy rate (one pregnancy in 29 procedures compared with seven pregnancies in 30 procedures; OR 0.19, 95% CI 0.04 to 0.83) and fertilisation rate (OR 0.16, 95% CI 0.05 to 0.48) than the micropuncture with perivascular nerve stimulation technique. The other RCT comparing two testicular aspiration techniques (TSA) in 39 participants gave no statistically significant evidence for the superiority of the ultrasound‐guided technique compared to the aspiration technique without ultrasound. TSA with ultrasound resulted in pregnancy in three out of 16 participants compared with four out of 23 participants (OR 1.10, 95% CI 0.21 to 5.74).

There is insufficient evidence to recommend any specific sperm retrieval technique for azoospermic men undergoing ICSI. In the absence of evidence to support more invasive or more technically difficult methods, the review authors recommend the least invasive and simplest technique available. Further randomised trials are warranted, preferably multi‐centred trials. The classification of azoospermia as obstructive and non‐obstructive appears to be relevant to a successful clinical outcome and a distinction according to the cause of azoospermia is important for future clinical trials.

Author(s)

Michelle Proctor, Neil Johnson, Arno Maarten van Peperstraten, Greg Phillipson

Abstract

Plain language summary

Techniques for surgical retrieval of sperm prior to intra‐cytoplasmic sperm injection (ICSI) because of absence of sperm in the semen (azoospermia).

It is not certain whether any particular surgical technique used to remove sperm for ICSI (sperm injection in vitro fertilisation or IVF) is better than another for the men involved or for leading to more pregnancies.

Some men are infertile because they produce sperm but a blockage in the testicle stops the sperm getting into the semen. In vitro fertilisation (IVF) is the only option for helping these men conceive with their own sperm.

The sperm are surgically removed from the testis gland or epididymis (tube leading from the testis towards the penis) and several micro‐surgical and suction techniques through hollow needles can be used for this. Sperm are then injected into an egg, an IVF procedure called ICSI. However, the review found there were too few trials to show which sperm removal technique might be better. Complications associated with surgical sperm‐retrieval techniques are haematoma and fibrosis, identified by ultrasound.

Author(s)

Michelle Proctor, Neil Johnson, Arno Maarten van Peperstraten, Greg Phillipson

Reviewer's Conclusions

Authors' conclusions

Implications for practice

There is insufficient data from randomised trials to recommend any particular surgical sperm‐retrieval techniques for either obstructive or non‐obstructive azoospermia. Non‐obstructive azoospermia is a difficult area to analyse as the physiology of the testis may be very different between individuals. Techniques are modified rapidly and there is much variation between different centres and surgeons. It is logical for the least invasive and simplest technique method for surgical retrieval of sperm to be used, which would be one of the needle retrieval techniques, usually under local anaesthetic, in the absence of evidence to support more invasive or more technically difficult methods. It seems that percutaneous aspiration techniques are now widely used for this reason. The more invasive methods should currently be reserved for situations where sperm cannot be retrieved by a less invasive technique (such as ultrasound‐guided needle aspiration of the epididymis or testis) or for evaluation in the context of a randomised trial.

Implications for research

The onus remains with those in support of the more invasive techniques of surgical retrieval of sperm, which require greater surgical expertise, to demonstrate by performing suitably powered RCTs that these techniques can be justified. Such trials need to have a particular focus upon: 1) a clear definition of the population of men studied in terms of aetiology of azoospermia; 2) use of clinically relevant outcomes, not only clinical pregnancy and live birth rates but also the rate of birth of a normal healthy baby, and certainly not simply the success of retrieval of sperm suitable for ICSI; and 3) cost effectiveness (with inclusion of a cost‐benefit analysis). 
 As the prevalence of azoospermia is low it remains unlikely that a single unit will attain numbers to confer sufficient power to such a trial. Large multi‐centre trials would increase the power and confer generalisability to the results.