Jonathan W.A. Ramsay

Sperm DNA fragmentation in subfertile men: the effect on the outcome of intracytoplasmic sperm injection and correlation with sperm variables.

To present the first UK data on sperm DNA fragmentation levels in subfertile men and fertile controls, the correlation with semen variables, and to assess the effect on the outcome of intracytoplasmic sperm injection (ICSI).

Does the cause of obstructive azoospermia affect the outcome of intracytoplasmic sperm injection: a meta-analysis.

To define whether the outcome of intracytoplasmic sperm injection (ICSI) using sperm surgically retrieved from men with obstructive azoospermia (OA) depends on the cause of obstruction.

Assisted reproduction in the azoospermic couple.

Ten years ago, the use of donor sperm was the only option offering a realistic chance of parenting for the azoospermic or severely oligoasthenoteratozoospermic male. The first pregnancy achieved using assisted reproductive techniques in an azoospermic man was reported in 1985 following epididymal sperm aspiration in a man who had previously undergone a vasectomy. Despite this early success, in vitro fertilisation (IVF) techniques proved to be of limited use in the severely oligospermic male with a significantly reduced chance of fertilisation once the sperm count fell below <5 10/mL. However, over the last decade, the development of micromanipulation techniques and the use of surgically retrieved sperm have revolutionised the management of male factor fertility. Initial techniques, such as partial zona dissection and subzonal sperm injection (SUZI), improved outcome compared with IVF, but fertilisation rates (FR) never exceeded 20–25% and pregnancy outcome remained poor. It was not until the introduction of intracytoplasmic sperm injection (ICSI) by the work of Van Steirteghem and colleagues in Brussels that the management of male factor fertility moved significantly forward. The first pregnancies and live births after ICSI were reported in 1992 in four women who had not benefited from IVF or SUZI, and the results of a controlled comparison of SUZI and ICSI procedures on sibling oocytes showed a substantially higher normal FR with ICSI, 4% and 72%, respectively. The same authors demonstrated high fertilisation (FR) and implantation rates (IR) with ICSI in a series of 150 consecutive treatment cycles in couples previously not accepted for IVF or who had failed fertilisation with IVF. A comparative study of conventional IVF versus ICSI for patients requiring microsurgical epididymal sperm aspiration (MESA) gave overall FRs and pregnancy rates of 45% and 47%, respectively, for ICSI and 6.9% and 4.5%, respectively, for IVF. The ability of ICSI to achieve high fertilisation and pregnancy rates, regardless of semen parameters confirmed the role of ICSI in the management of azoospermic patients. In this article, we review the epidemiology, aetiology and management of azoospermia. Our overall aim is to summarise the increasing amount of published data, often contradictory, on the outcome of assisted reproduction to enable clinicians, both in a general gynaecology clinic and assisted reproduction setting, to counsel couples correctly on management options and chances of success. Epidemiology and aetiology

REVIEW: Assisted reproduction in the azoospermic couple

Ten years ago, the use of donor sperm was the only option offering a realistic chance of parenting for the azoospermic or severely oligoasthenoteratozoospermic male. The first pregnancy achieved using assisted reproductive techniques in an azoospermic man was reported in 1985 following epididymal sperm aspiration in a man who had previously undergone a vasectomy. Despite this early success, in vitro fertilisation (IVF) techniques proved to be of limited use in the severely oligospermic male with a significantly reduced chance of fertilisation once the sperm count fell below <5 10/mL. However, over the last decade, the development of micromanipulation techniques and the use of surgically retrieved sperm have revolutionised the management of male factor fertility. Initial techniques, such as partial zona dissection and subzonal sperm injection (SUZI), improved outcome compared with IVF, but fertilisation rates (FR) never exceeded 20–25% and pregnancy outcome remained poor. It was not until the introduction of intracytoplasmic sperm injection (ICSI) by the work of Van Steirteghem and colleagues in Brussels that the management of male factor fertility moved significantly forward. The first pregnancies and live births after ICSI were reported in 1992 in four women who had not benefited from IVF or SUZI, and the results of a controlled comparison of SUZI and ICSI procedures on sibling oocytes showed a substantially higher normal FR with ICSI, 4% and 72%, respectively. The same authors demonstrated high fertilisation (FR) and implantation rates (IR) with ICSI in a series of 150 consecutive treatment cycles in couples previously not accepted for IVF or who had failed fertilisation with IVF. A comparative study of conventional IVF versus ICSI for patients requiring microsurgical epididymal sperm aspiration (MESA) gave overall FRs and pregnancy rates of 45% and 47%, respectively, for ICSI and 6.9% and 4.5%, respectively, for IVF. The ability of ICSI to achieve high fertilisation and pregnancy rates, regardless of semen parameters confirmed the role of ICSI in the management of azoospermic patients. In this article, we review the epidemiology, aetiology and management of azoospermia. Our overall aim is to summarise the increasing amount of published data, often contradictory, on the outcome of assisted reproduction to enable clinicians, both in a general gynaecology clinic and assisted reproduction setting, to counsel couples correctly on management options and chances of success. Epidemiology and aetiology

Frozen Embryos Generated from Surgically Retrieved Sperm from Azoospermic Men: Are They Clinically Viable?

Purpose: To assess the viability of frozen-thawed embryos derived from intracytoplasmic sperm injection (ICSI) in azoospermic men.Methods: Retrospective analysis of 154 consecutive ICSI cycles using surgically retrieved sperm from azoospermic men and case-control comparison of subsequent frozen transfer cycles with those using embryos generated from ejaculated sperm.Results: Patient and fresh cycle characteristics were similar in both groups. There were no differences between the two groups in the proportion of pronucleate (54% and 62%), and cleavage-stage embryos thawed (46% and 38%), post-thaw survival rates (retrievals: 69%; ejaculated: 73%) or quality of frozen embryos subsequently transferred. Implantation was significantly lower in frozen cycles where embryos were generated from surgically retrieved sperm (0% versus 11.5%; p=0.03). Both clinical pregnancy rate (5% versus 21%) and livebirth rate (0% versus 21%) were lower in this group, but only the difference in LBR reached borderline statistical difference (p=0.10).Conclusion: This small series demonstrates a significant impairment in implantation in FET cycles using embryos generated from surgically retrieved sperm and a trend towards a poorer pregnancy outcome.

Male-factor infertility: do we really need urologists? A gynaecological view

The Royal College of Obstetricians and Gynaecologists state that male factor infertility is responsible for up to 25% of all cases of infertility and may contribute in a further 25%. Where the role of the urologist ends and gynaecologist begins in these couples is a matter of debate. We therefore discuss the management of these couples and the need for a multidisciplinary approach.

Primary uretero-iliac fistula: the unusual source of haematuria.

Uretero-iliac fistula is a rare cause of frank haematuria. The aetiology of such fistula is commonly iatrogenic. We present a unique case of a primary aorto-iliac fistula in the absence of an aneurysm or arteriovenous malformation. The diagnosis was demonstrated by ureteroscopy and real-time retrograde ureterogram. Multiple arterial embolisation of the fistula had failed, and the patient underwent a successful ureterolysis and ligation of fistula. We demonstrate the diagnostic difficulties and treatment dilemma of such rare cause of haematuria.

REVIEW: Assisted reproduction in the azoospermic couple: REVIEW

Ten years ago, the use of donor sperm was the only option offering a realistic chance of parenting for the azoospermic or severely oligoasthenoteratozoospermic male. The first pregnancy achieved using assisted reproductive techniques in an azoospermic man was reported in 1985 following epididymal sperm aspiration in a man who had previously undergone a vasectomy. Despite this early success, in vitro fertilisation (IVF) techniques proved to be of limited use in the severely oligospermic male with a significantly reduced chance of fertilisation once the sperm count fell below <5 10/mL. However, over the last decade, the development of micromanipulation techniques and the use of surgically retrieved sperm have revolutionised the management of male factor fertility. Initial techniques, such as partial zona dissection and subzonal sperm injection (SUZI), improved outcome compared with IVF, but fertilisation rates (FR) never exceeded 20–25% and pregnancy outcome remained poor. It was not until the introduction of intracytoplasmic sperm injection (ICSI) by the work of Van Steirteghem and colleagues in Brussels that the management of male factor fertility moved significantly forward. The first pregnancies and live births after ICSI were reported in 1992 in four women who had not benefited from IVF or SUZI, and the results of a controlled comparison of SUZI and ICSI procedures on sibling oocytes showed a substantially higher normal FR with ICSI, 4% and 72%, respectively. The same authors demonstrated high fertilisation (FR) and implantation rates (IR) with ICSI in a series of 150 consecutive treatment cycles in couples previously not accepted for IVF or who had failed fertilisation with IVF. A comparative study of conventional IVF versus ICSI for patients requiring microsurgical epididymal sperm aspiration (MESA) gave overall FRs and pregnancy rates of 45% and 47%, respectively, for ICSI and 6.9% and 4.5%, respectively, for IVF. The ability of ICSI to achieve high fertilisation and pregnancy rates, regardless of semen parameters confirmed the role of ICSI in the management of azoospermic patients. In this article, we review the epidemiology, aetiology and management of azoospermia. Our overall aim is to summarise the increasing amount of published data, often contradictory, on the outcome of assisted reproduction to enable clinicians, both in a general gynaecology clinic and assisted reproduction setting, to counsel couples correctly on management options and chances of success. Epidemiology and aetiology