Khalid Alrabeeah

Sperm retrieval outcomes with microdissection testicular sperm extraction (micro‐TESE) in men with cryptozoospermia

Several studies support of the use of testicular rather than ejaculated spermatozoa for intracytoplasmic sperm injection (ICSI) in couples with virtual azoospermia or cryptozoospermia, although this approach remains controversial. We sought to evaluate sperm retrieval outcomes with microdissection testicular sperm extraction (micro‐TESE) in men with cryptozoospermia. We conducted a retrospective study of 24 consecutive micro‐TESEs in men with cryptozoospermia. We also evaluated the outcomes of seven consecutive TESAs (testicular sperm aspiration) in cryptozoospermic men during the same time period (January 2007 and September 2014). Micro‐TESE and TESA were performed on the day prior to ICSI. Final assessment of sperm recovery (reported on the day of ICSI) was recorded as (i) successful (available spermatozoa for ICSI) or (ii) unsuccessful (no spermatozoa for ICSI). The decision to perform a unilateral or bilateral micro‐TESE was guided by the intra‐operative evaluation of sperm recovery from the first testicle. A unilateral procedure was performed in 87.5% (21/24) and 57% (4/7) of the micro‐TESE and TESA cohorts, respectively. Sperm recovery was successful in 96% (23/24) of the men who underwent micro‐TESE and 43% (3/7) of the men who underwent TESA (p < 0.01). The ICSI pregnancy rates (per embryo transfer) in the micro‐TESE and TESA groups were comparable [33% (6/18) and 50% (1/2), respectively]. The data indicate that micro‐TESE is a highly successful sperm retrieval technique for men with cryptozoospermia and few of these men will require a bilateral procedure. Moreover, sperm retrieval rates are higher with micro‐TESE than TESA in this group of men.

Is ex vivo microdissection testicular sperm extraction indicated for infertile men undergoing radical orchiectomy for testicular cancer? Case report and literature review

OBJECTIVE To report a case of an infertile man with nonobstructive azoospermia who underwent simultaneous radical orchiectomy for testicular cancer and testicular sperm extraction (TESE) for preservation of fertility. DESIGN Case report and literature review. SETTING University teaching hospital. PATIENT(S) A couple being treated for infertility. INTERVENTION(S) Radical orchiectomy with simultaneous TESE. MAIN OUTCOME MEASURE(S) Sperm retrieval, histologic evaluation of archived testicular pathology slides. RESULT(S) We retrieved 20 spermatozoa from the multiple random TESE samples obtained at radical orchiectomy. Histologic evaluation of the archived testicular pathology slides revealed that the testis contained several foci of active spermatogenesis, suggesting that a significantly greater number of spermatozoa would likely have been retrieved had a microdissection TESE been performed instead of the multiple TESEs. CONCLUSION(S) We propose that microdissection TESE should be considered the preferred sperm retrieval technique at the time of radical orchiectomy in men with coexistent nonobstructive azoospermia and testicular cancer.

Testicular Sperm Aspiration for Nonazoospermic Men: Sperm Retrieval and Intracytoplasmic Sperm Injection Outcomes

OBJECTIVE To evaluate testicular sperm aspiration (TESA) sperm retrieval rates and intracytoplasmic sperm injection outcomes in nonazoospermic men. MATERIALS AND METHODS Data were collected retrospectively from 54 consecutive, nonazoospermic, infertile men who underwent TESA between March 2007 and September 2012. Sperm retrieval rates and clinical pregnancy outcomes were recorded. Patients were subgrouped based on clinical diagnosis: group 1, anejaculation (primary, situational); group 2, idiopathic severe oligoasthenozoospermia; and group 3, severe oligoasthenozoospermia after vasovasostomy. RESULTS Mean (± standard deviation) paternal and maternal ages were 39 ± 7 and 35 ± 5 years, respectively. Using TESA, sperm recovery was successful in 94% (51 of 54) of the men overall and in 100% (17 of 17) of the men in group 1, 90% (28 of 31) in group 2, and 100% (6 of 6) in group 3. Overall, 35% of the couples achieved a clinical pregnancy using TESA sperm (with a mean of 1.7 ± 0.9 embryos transferred per cycle). The clinical pregnancy rates were 40% in group 1, 33% in group 2, and 33% in group 3 with no significant difference in paternal or maternal age between groups. CONCLUSION The data indicate that TESA yields high sperm retrieval rates in select groups of nonazoospermic infertile men, and this approach results in acceptable pregnancy rates regardless of the male infertility etiology. Randomized controlled trials comparing ejaculated vs testicular sperm are needed to assess the true benefit of TESA-intracytoplasmic sperm injection in these couples.

Testicular sperm aspiration (TESA) for infertile couples with severe or complete asthenozoospermia

The aim of the study was to evaluate reproductive outcomes in a cohort of infertile couples with severe and complete asthenozoospermia undergoing TESA (testicular sperm aspiration) with ICSI. We conducted a retrospective study of 28 couples with complete or severe asthenozoospermia who underwent TESA between January 2010 and December 2015. We compared TESA‐ICSI outcomes of these couples to ejaculate ICSI outcomes of 40 couples with severe asthenozoospermia treated during the same time period at our institution. Couples with female factor infertility and/or female aged ≥39 were excluded. Sperm retrieval rates and ICSI outcomes [(MII oocytes, fertilization rate, good embryo rate (transferred and frozen), couples with embryo transfer (per cycle started), clinical pregnancy (per embryo transfer)] were recorded. Patients were grouped based on whether they had ejaculated (Ej‐group) or testicular (TESA‐group) spermatozoa used. Testicular sperm patients were further classified based on whether they had complete asthenozoospermia (0% total motility) (Tc‐group) or severe asthenozoospermia (≤1% progressive motility) (Ts‐group). Mean (±SD) male and female ages were 36 ± 6 and 32 ± 4, respectively. Sperm recovery by testicular sperm aspiration (TESA) was successful in 100% (28/28) of the men. The overall clinical pregnancy rate (CPR) per cycle started was 34% (23/68) with a mean of 1.1 ± 0.4 embryos transferred per transfer. Fertilization rates were significantly lower in TESA‐group compared to Ej‐group (52% vs. 67%, respectively; p = 0.001), while male age was significantly higher in TESA‐group compared to Ej‐group (34 ± 6 vs. 37 ± 6, respectively; p = 0.03). Moreover, female age was significantly higher in Tc‐group compared to Ts‐group (30 ± 4 vs. 33 ± 3, respectively; p = 0.0285). However, there were no significant difference in clinical pregnancy rate per embryo transfer in the Tc‐group, Ts‐group, and Ej‐group (50% vs. 45% vs. 57%, respectively; p = 0.8219). The data suggest that testicular sperm‐ICSI is no better than ejaculated sperm‐ICSI in couples with severe or complete asthenozoospermia. Randomized, controlled trials comparing ejaculated vs. testicular spermatozoa are needed to assess the true benefit of TESA‐ICSI in these couples.

Update on Testosterone Replacement Therapy in Hypogonadal Men

Late-onset male hypogonadism has long been recognized as a treatable medical condition; however, misconceptions about the use of testosterone replacement therapy (TRT) have often led urologists away from its more mainstream use. This paper aims to bring the reader up-to-date on the current understanding of TRT, starting with when and who to treat. Various formulations of TRT, each with its own risks and benefits, are also detailed. Finally, a comprehensive analysis of the current literature’s views into the various controversies of TRT including its impact on prostate health, sexual health, cardiovascular health, frailty, and mood is discussed.

Is varicocelectomy beneficial in men previously deemed subfertile but with normal semen parameters based on the new guidelines? A retrospective study.

OBJECTIVE To determine whether using the 2010 World Health Organization (WHO) semen parameter reference values to select varicocelectomy candidates may exclude infertile men who can potentially benefit from this treatment. With the application of the 2010 WHO semen parameter thresholds, some men previously considered to have abnormal semen parameters would now be considered normozoospermic. METHODS We conducted a retrospective review of infertile men with varicocele and identified those with abnormal semen parameters according to WHO 1992 or 1999 standards but normozoospermic by WHO 2010 standards. We compared outcomes (semen parameters and spontaneous pregnancy) of couples undergoing varicocelectomy with those choosing observation. RESULTS We identified 445 infertile men with varicocele and abnormal semen parameters by WHO 1992 or 1999 standards. Fifty-six of 445 men (13%) were normozoospermic by WHO 2010. Thirty-two of 56 (57%) of these normozoospermic men elected to have varicocelectomy, and 24 of 56 men (43%) choosing observation. In these normozoospermic men (by WHO 2010), varicocelectomy was associated with a significant increase in sperm concentration (50 ± 35 × 10(6)/mL [postsurgery] vs. 32 ± 23 × 10(6)/mL [presurgery]; P = .003). Although not statistically significant, the clinical pregnancy rate was higher in the varicocelectomy group compared with the observation group (52% vs. 38%; P = .37). CONCLUSION Varicocelectomy may be beneficial in those men with clinical varicocele and abnormal semen parameters by WHO 1992 or 1999 standards but now normozoospermic by WHO 2010 standards. Applying the 2010 WHO semen parameter reference values into practice may result in missed opportunities to correct treatable causes of male infertility.

Management options for the treatment of benign prostatic hyperplasia with or without erectile dysfunction: a focus on tadalafil and patient considerations.

Lower urinary tract symptoms (LUTS) and erectile dysfunction increase with age. Several studies have identified a true association between these two disorders. Basic research studies have shown a significant decrease in the nitric oxide/cyclic guanosine monophosphate pathway with age that leads to decreased relaxation of the bladder wall and prostate and worsening LUTS. In this review article, we will focus on the potential use and clinical significance of phosphodiesterase-5 inhibitors in the treatment of LUTS secondary to benign prostate hyperplasia.

Mini-incision microdissection testicular sperm extraction: a useful technique for men with cryptozoospermia.

Microdissection testicular sperm extraction (micro‐TESE) was developed to minimize the testicular injury associated with multiple open TESEs. We sought to evaluate a mini‐incision micro‐TESE in men with cryptozoospermia and non‐obstructive azoospermia (NOA). We conducted a retrospective study of 26 consecutive men with NOA and cryptozoospermia who underwent a primary (first) micro‐TESE between March 2015 and August 2015. Final assessment of sperm recovery (reported on the day of intra‐cytoplasmic sperm injection (ICSI)) was recorded as (i) successful (available spermatozoa for ICSI) or (ii) unsuccessful (no spermatozoa for ICSI). The decision to perform a mini‐incision micro‐TESE (with limited unilateral micro‐dissection) or standard/extensive (with unilateral or bilateral micro‐dissection) was guided by the intra‐operative identification of sperm recovery (≥5 spermatozoa) from the first testicle. Overall, sperm recovery was successful in 77% (20/26) of the men. In 37% of the men (8/26), the mini‐incision micro‐TESE was successful (positive sperm recovery). The remaining 18 men required a standard (extensive) microdissection: 61% (11/18) underwent a unilateral and 39% (7/18) a bilateral micro‐TESE. We found that 90% (9/10) of the men with cryptozoospermia and 63% (10/16) of the men with NOA underwent a unilateral (mini or standard micro‐TESE). The mini‐incision micro‐TESE allowed for successful sperm recovery in 60% (6/10) of the men with cryptozoospermia and 13% (2/16) of the men with NOA. The data demonstrate that a mini‐incision micro‐TESE together with rapid intra‐operative assessment and identification of spermatozoa recovery can be useful in men undergoing microTESE, particularly, men with cryptozoospermia.

Can the rapid identification of mature spermatozoa during microdissection testicular sperm extraction guide operative planning

The minimum sperm count and quality that must be identified during microdissection testicular sperm extraction (micro‐TESE) to deem the procedure successful remains to be established. We conducted a retrospective study of 81 consecutive men with non‐obstructive azoospermia who underwent a primary (first) micro‐TESE between March 2007 and October 2013. Final assessment of sperm recovery [reported on the day of (intracytoplasmic sperm injection) ICSI] was recorded as (i) successful (available spermatozoa for ICSI) or (ii) unsuccessful (no spermatozoa for ICSI). The decision to perform a unilateral (with limited or complete microdissection) or bilateral micro‐TESE was guided by the intra‐operative identification of sperm recovery (≥5 motile or non‐motile sperm) from the first testicle. Overall, sperm recovery was successful in 56% (45/81) of the men. A unilateral micro‐TESE was performed in 47% (38/81) of the men (based on intra‐operative identification of sperm) and in 100% (38/38) of these men, spermatozoa was found on final assessment. In 42% (16/38) of the unilateral cases, a limited microdissection was performed (owing to the rapid intra‐operative identification of sperm). The remaining 43 men underwent a bilateral micro‐TESE and 16% (7/43) of these men had sperm identified on final assessment. The cumulative ICSI pregnancy rates (per cycle started and per embryo transfer) were 47% (21/45) and 60% (21/35), respectively, with a mean (±SD) of 1.9 ± 1.0 embryos transferred. The data demonstrate that intra‐operative assessment of sperm recovery can correctly identify those men that require a unilateral micro‐TESE. Moreover, the rapid identification of sperm recovery can allow some men to undergo a limited unilateral micro‐TESE and avoid the need for complete testicular microdissection.

Robotic-assisted radical nephrectomy for renal angiomyolipoma with inferior vena cava thrombus extension

Renal angiomyolipoma with inferior vena caval venous extension is rare with only 40 cases reported in the literature. We report a case of a 35-year-old lady with angiomyolipoma with inferior vena caval thrombus that was managed surgically with robotic-assisted radical nephrectomy.