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

Human Reproduction 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 0 1 A.Safran 0 1 A.Porat-Katz 0 1 A.Simon 0 1 N.Laufer 0 1 A.Lewin 0 1 0 Hadassah Medical Center , P.O. BOX 12000, Jerusalem 91120 , Israel 1 IVF Unit, Department of Obstetrics and Gynecology, Hadassah Medical Center, Hebrew University , Ein-Kerem, Jerusalem , Israel 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. fine needle aspiration/histology/non-obstructive azoospermia/predictive value/testicular sperm - 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., 1993; Schoysman et al., 1993), later studies reported the successful recovery of mature sperm in patients with non-obstructive azoospermia (Devroey et al., 1995), leading to the first successful pregnancies and deliveries in this latter group of infertile patients (Tournaye et al., 1995; Lewin et al., 1996). 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, 1999). The use of testicular fine needle aspiration (TEFNA) in non-obstructive azoospermia, first introduced by our group (Lewin et al., 1996), was shown to be efficient, safe and well tolerated by the patients (Lewin et al., 1999). Although ICSI using testicular sperm offers men with nonobstructive 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 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 2345 years), and the mean duration of infertility was 7.8 years (range 120), while the mean serum FSH was 19.2 IU/l (range 264 IU/l). All patients were katyotyped prior to the first TEFNA attempt: 44 patients were 46,XY and seven patients were found to Second TEFNA attempt n (%) positive/negative TEFNA attempt. be non-mosaic 47,XXY (Klinefelters 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., 1999). 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 Klinefelters syndrome in seven cases. Results 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 I summarizes the results Table IIa. Histological findings and sperm recovery in 33 patients with a positive first TEFNA undergoing a second TEFNA attempt Table IIb. Hi (...truncated)