REPRODUCTIVE MEDICINE

Intracytoplasmic sperm injection outcomes of obstructiveand nonobstructive azoospermic men

Ayse Celikten • Sertac Batioglu • Ayse Nur Cakir Gungor •

Erkan Ozdemir

Received: 4 February 2012 / Accepted: 12 March 2013 / Published online: 23 March 2013

� Springer-Verlag Berlin Heidelberg 2013

Abstract

Purpose We aimed to compare the outcomes of intracy-

toplasmic sperm injection (ICSI) cycles in ostructive and

nonobstructive azoospermic men.

Methods In this retrospective study, we searched the first

ICSI cycle parameters of 211 azoospermic men. Our main

outcomes were the average fertilization rate, implantation

rate, pregnancy and miscarriage rates.

Results The results of this study showed that although the

males with obstructive azoospermia had better fertilization

and biochemical pregnancy rates than the ones with non-

obstructive azoospermia, clinical pregnancy and miscar-

riage rates among the groups were similar.

Conclusion ICSI overcomes the obstacles related to the

sperm in its function as a carrier but it cannot alter the

message carried by the male gamete.

Keywords Obstructive azoospermia � Nonobstructive

azoospermia � Intracytoplasmic sperm injection

Introduction

Azoospermia defined as the absence of spermatozoa in the

ejaculate after the assessment of centrifuged semen on at

least two occasions, and it is observed in 1 % of the general

population and in 10–15 % of infertile men [1]. For a better

pathophysiological understanding of azoospermia, this

condition has been grossly divided into two groups:

obstructive azoospermia (OA) and nonobstructive azoo-

spermia (NOA). Sperm can be retrieved in almost all cases

of OA, but only in 50 % of NOA when no preliminary

selection of patients on the basis of histopathology has been

performed [2].

Although ICSI gives hope to azoospermic men to father

their biological babies, the success rates according to the

etiology of azoospermia is not clarified yet. We aimed to

compare the ICSI success of the first cycles of the OA and

NOA men.

Materials and methods

A retrospective analysis of 211 cases of azoospermia pre-

senting between July 2004 and December 2007 was under-

taken. All males were diagnosed using at least two samples

for semen analysis. Clinical parameters including age, his-

tory of infertility, previous infection, and relevant surgical

procedures were recorded. They were counseled for need of

further workup including genetic testing and histologic

examination. Patients with genetic abnormalities were

excluded. Patients were divided into two groups. Those

(n = 78) in OA group, sperms formed in the testis are unable

to get ejaculated through semen mainly due to obstruction

either in the epididymis, vas deferens or ejaculatory ducts.

Those (n = 133) in NOA group were men with testicular

failure having sertoli cell-only pattern, maturation arrest or

hypospermatogenesis on the testis biopsy.

Percutaneous epididymal sperm aspiration (PESA) or

microepididymal sperm aspiration (MESA) technique was

done, if no spermatozoon was found, testicular sperm

extraction (TESE) was performed under the same local

anesthesia. It has been shown that hormone level and tes-

ticular histology are unable to predict which men with

A. Celikten � S. Batioglu � A. N. C. Gungor (&) � E. Ozdemir

Dr. Zekai Tahir Burak Women Health and Research Hospital,

Ankara, Turkey

e-mail: dr_aysecakir@hotmail.com

123

Arch Gynecol Obstet (2013) 288:683–686

DOI 10.1007/s00404-013-2799-7

azoospermia will have sperm retrieved by PESA or TESE

[3]. PESA was performed under the local anesthesia with a

21-gauge needle and a syringe containing 0.5 ml sperm

preparation medium (MediCult a/s Mollehaven 12,4040

Jyllinge, Denmark). The needle was inserted into the head

of the epididymis, with up to four passes per side and the

aspirate was passed through the needle into a sterile plastic

tube and examined for spermatozoa immediately by the

clinical embryologist. Open TESE was performed through

a transverse scrototomy. Four 3-mm biopsies were taken in

a spiral manner around the testis, the orchiectomies were

closed with 5/0 PDS, and a layered closure was performed

with 3/0 monocryl.

Ovarian stimulation was achieved using long protocol

with a starting dose depending on the patient’s age and

basal serum hormone levels. Oocytes were collected 36 h

after hCG injection. Cumulus cell removal was achieved by

placing the oocytes briefly in medium (G1, Vitrolife,

Sweden), the remaining cells were removed with a fine

boer pipette. Only oocytes which had extruded a polar body

were selected for ICSI (metaphase II: M2). Microinjection

was carried out on an Olympus inverted microscope. A

single morphologically normal motile sperm was selected,

immobilized, and aspirated into the injection needle. Each

oocyte was firmly attached to the holding pipette with the

polar body at 6 o’clock. The injection needle entered the

oocyte at 3 o’clock and the breakage of the oolemma was

achieved with a gentle aspiration followed by a careful

deposition of the sperm into the cytoplasm.

Fertilization was confirmed 24 h later and the embryo

transfer was performed on day 3 or 5 of ovum pick-up. The

number of embryos transferred was 2–3 per cycle. Only

high quality embryos (grade 1 and 2) were transferred.

Pregnancy was defined as a spontaneous rise in a bhCG

concentration at least 10 days post transfer. Clinical preg-

nancy implied the presence of intrauterine gestational sac

and fetal heart beat on an ultrasound performed at 7 weeks

of gestation.

The Shapiro–Wilk test was used to verify if the data

followed normal distribution. A one-way ANOVA or

Fisher exact test was used to compare the clinical and the

laboratory parameters between groups when appropriate.

The Chi-square test was used to compare the other non

parametric parameters, with P \ 0.05 considered signifi-

cant. Statistical analysis was performed by SPSS software

version 13 (SPSS Inc, Chicago, Ill, USA).

Results

Demographic characteristics of the azoospermic men were

given in Table 1. A total of 211 men underwent their first

microsurgical procedures, those were 66.4 % TESE, 26.1 %

PESA, 6.6 % TESE ? PESA, 0.5 % TESA ? PESA, and

0.5 % MESA procedures. While sperm retrieval was

achieved by TESE in all patients with NOA, majority of the

patients with OA yielded sperm by PESA (70.5 %).

Demographic and clinical characteristics and the average

fertilization rate, implantation rate, pregnancy, and miscar-

riage rates were given in Table 2. Although number of

retrieved mature oocytes, fertilization rates, number of

transferred embryos and biochemical pregnancy rates were

significantly higher in OA group than NOA group, clinical

pregnancy rates and miscarriage rates were similar in two

groups. Fertilization rate, implantation rate, clinical preg-

nancy rate, and miscarriage rates were 59.3, 33.3, 20.5, and

12.8 % for OA group and 49.8, 31.6, 19.5, and 12 % for

NOA group, respectively. When the groups subdivided

according to the sperm retrieval technique, there was no

significant difference on either implantation rates or clinical

pregnancy rates.

Discussion

The development of ICSI and the techniques for sperm

recovery have enabled certain azoospermic males to father

their biological children. OA and NOA are often used to

determine the probability of retrieval, but these can only be

confidently diagnosed with testicular histology [4]. Tes-

ticular biopsy is now rarely performed prior to surgical

sperm retrieval, so the use of this terminology in the

clinical situation can result in inaccuracies when counsel-

ing patients. For giving accurate information azoospermic

males were divided into subgroups based on the clinical

parameters. Sperm retrieval rates were given 50–60 % for

NOA in different studies [1, 2].

De Croo et al. [4] compared 139 OA patients with 54

NOA patients and concluded that fertilization rates were

lower in NOA (67.8 % versus 74.5 % p 0.0167) but

implantation and clinical pregnancy rates were similar in

in-between the groups. In that study, there were significant

differences between the ages of female and male patients.

Table 1 Demographic characteristics of the azoospermic men

Age (years, mean ± SD) 32.8 ± 6.5

Height (cm, mean ± SD) 173.6 ± 6.9

Smoking (n, %) 71 (33.6 %)

Mumps orchitis (n, %) 3 (1.4 %)

Cryptorchitism (n, %) 9 (4.2 %)

Retrograde ejaculation (n, %) 4 (1.9 %)

Varicocele (n, %) 34 (16.1 %)

Unilateral orchiectomy (n, %) 4 (1.9 %)

Inguinal hernia operation (n, %) 5 (2.4 %)

Agenesis of the vas deferens (n, %) 21 (9.9 %)

684 Arch Gynecol Obstet (2013) 288:683–686

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Verza et al. [5] compared 39 OA men with 54 NOA men

and concluded that OA men had significantly better fer-

tilization rates and clinical pregnancy rates.

A meta-analysis evaluated 9 reports comparing OA and

NOA and concluded that although fertilization and clinical

pregnancy rates were significantly lower in NOA group,

the live birth rates did not differ significantly in in-between

groups [6].

Our results indicate that sperm from men with severely

altered spermatogenesis, such as testicular sperm in NOA,

have decreased the fertility potential after ICSI. Lower

fertilization rates, as observed in our study for the testicular

sperm from NOA men, are explained by the early paternal

effects which include alterations in the spermatic cytosolic

factor and are responsible for the completion of the oocyte

meiotic division as well as alterations on the sperm cen-

triole, which participate in the formation of embryo mitotic

fuses in early cellular divisions [7].

Similar to the previous studies, this study showed that

although biochemical pregnancy rates in NOA group were

lower significantly there was no significant difference in

the clinical pregnancy and miscarriage rates following ICSI

in OA and NOA men.

Most studies evaluating ICSI and azoospermia regard

only the sperm source but not the type of azoospermia. These

studies tend to have a better outcome when epididymal

spermatozoa are used, but these findings can be justified by

the fact that epididymal sperm are always from obstructive

azoospermia, while the testicular sperm can be from both

types of azoospermia [8, 9].TESE is currently the most fre-

quently used technique in azoospermic men. A single

extended incision or multiple incisions can be made for

TESE. Similar mean weights of testicular tissue removed and

sperm retrieval rates were comparable between both tech-

niques [10].

Naru et al. [11] also compared PESA, TESE, and ejac-

ulated sperm cycles. They evaluated 69 PESA cycles of 53

couples, 47 TESE cycles of 43 couples and 437 ejaculated

sperm cycles of 421 oligospermic men and found that there

was no significant difference among groups on pregnancy

and miscarriage rates.

It has been shown that the age of the female partner has

an influence on the success of the ICSI treatment. Some

researchers reported low delivery rate in woman aged more

than 37 [12], others older than 40 [13, 14]. Of the other

factors considered for the prediction of successful ICSI

cycles are hormone profile, testicular volume, and histo-

pathology findings; few studies have reported that these

parameters are unable to predict which procedure would be

successful in azoospermic men [11].

Adequate fertilization, cleavage and pregnancy rates are

to be expected when ICSI is performed to azoospermic

men with a normal sperm production, such as OA ones.

However, lower fertilization rates are achieved when ICSI

performed with sperm from men with NOA. Although ICSI

overcomes the obstacles related to the sperm in its function

as a carrier, it cannot alter the message carried by the male

gamete.

Conflict of interest We declare that we have no conflict of interest.

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Table 2 ICSI cycle properties

and outcomes of study groupsOA (n = 78) NOA (n = 133) p

Female age 29.2 ± 5.4 28.2 ± 5.2 0.168

Male age 33.5 ± 6.7 32.4 ± 6.3 0.245

Infertility duration 8.5 ± 5.7 7.1 ± 4.6 0.061

Basal FSH (mIU/ml) 6.2 ± 1.7 7 ± 3.6 0.055

Basal LH (mIU/ml) 4.5 ± 2.3 5.2 ± 2 0.022

Basal E2 (pg/ml) 44.3 ± 17.5 44.5 ± 16.1 0.923

Basal PRL (ng/ml) 19.7 ± 8.4 19.6 ± 9.3 0.900

Ovulation E2 (pg/ml) 2,453 ± 1,259 2,507 ± 1,135 0.745

Ovulation progesterone (pg/ml) 0.85 ± 0.36 0.89 ± 0.40 0.448

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Fertilization rate 59.3 % 49.8 % 0.026

Biochemical pregnancy rate 26 (33.3 %) 42 (31.6 %) 0.01

Clinical pregnancy rate 16 (20.5 %) 26 (19.5 %) 0.966

Miscarriage 10 (12.8 %) 16 (12 %) 0.899

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