Nikita Abhyankar

Implications of Sperm Source on ICSI Outcome: Assessment of TESE and Other Surgical Sperm Retrieval Methods

This chapter addresses the options for sperm origin for couples requiring intracytoplasmic sperm injection (ICSI) for advanced fertility treatment. Sperm from various sources have been shown to have differing properties, which are thought to affect ICSI outcomes. One of these key differences is in the DNA fragmentation index (DFI). It has been postulated that sperm DFI increases during transit through the male genital tract and that this may impact fertilization and pregnancy rates. Sperm may be either ejaculated or surgically retrieved from the testicle, vas deferens, or epididymis. Various retrieval methods exist. In men with azoospermia, epididymal and testicular sperm have been utilized for ICSI with varied results; therefore, a conclusive superior source cannot be identified. In men with cryptozoospermia, ejaculated sperm or surgically retrieved sperm can be used. Comparing testicular and ejaculated sperm, combining all studies no statistically significant difference in pregnancy or fertilization rates have been seen.

PD68-08 EFFICACY OF ANASTROZOLE IN OLIGOZOOSPERMIC HYPOANDROGENIC SUBFERTILE MEN – THE SIGNIFICANCE OF POST TREATMENT TESTOSTERONE TO ESTRADIOL RATIO

INTRODUCTION AND OBJECTIVES: We aim to determine the effect of anastrazole on hormonal and seminal parameters in hypoandrogenic subfertile men. We also aim to assess whether seminal parameter changes are correlated to the magnitude of increase in testosterone to estrogen ratio in men responding to treatment. METHODS: A retrospective review was performed of all hypogonadal subfertile men attending a male infertility clinic and treated with anastrazole. Hormone analysis before treatment, 2 weeks after starting treatment and 4 months after were performed. Hormone analysis included measurements of total testosterone, estradiol, sex-hormone binding globulin, albumin, FSH and LH, and bioavailable testosterone was calculated. Semen analyses before treatment and 4 months after treatment were recorded. Total motile sperm count was calculated from the semen analysis. For statistical analysis, variables are presented as median interquartile range or mean standard error. A matched pairs analysis estimated significance of change in laboratory values and semen analyses with treatment. A sub-group analysis was performed of men with baseline oligozoospermia. In this group, we used linear regression to identify correlations between changes in hormone concentrations and increase in semen parameters. RESULTS: The study group consisted of 86 subfertile hypoandrogenic men with low testosterone to estradiol ratio (n1⁄478) or a prior aversive reaction to clomiphene citrate (n1⁄48). 95.3% of patients had an increased serum testosterone and decreased serum estradiol following treatment with anastrozole. Sperm concentration and total motile counts improved in 18 out of 21 subfertile hypoandrogenic oligozoospermic men treated with anastrozole. In these men, the magnitude of total motile count increase was significantly correlated with the change in the testosterone to estradiol ratio. None of the men with azoospermia or cryptozoospermia experienced an improvement in sperm in the ejaculate and microTESE recovery rates were 72.7% in these men. CONCLUSIONS: Approximately 95% of men with hypoandrogenism responded with improved endocrine parameters, and a subset of oligozoospermic men (approximately 25% of all patients) displayed significantly improved sperm parameters. In that subset, increase in sperm parameters was correlated with the change in the testosterone to estradiol ratio, which argues for a physiological effect of treatment.

MP89-12 EFFICACY OF TREATMENT WITH PSEUDOEPHEDRINE IN MEN WITH RETROGRADE EJACULATION

INTRODUCTION AND OBJECTIVES: Microdissection testicular sperm extraction (Micro-TESE) is the standard treatment for nonobstructive azoospermia (NOA). However, the amount of tissue that should be extracted has not been reported. This study investigated the relationship between sample volume and sperm retrieval rate in Micro-TESE. METHODS: The subjects were 208 Asian patients with NOA (mean age: 35.1 5.4 years) who had undergone Micro-TESE at Nagoya City University Hospital or affiliated facilities between July 2007 and December 2014. In this study, testicular volume was measured with a ruler before albugineotomy and after testicular ligature, and the difference in values was set as the sample volume. The subjects were assigned to groups based on sample volume: less than 1.5 mL (group A: n1⁄417), 1.5 mL to 3.0 mL (group B: n1⁄456), 3.0 mL to 4.5 mL (group C: n1⁄491), and more than 4.5 mL (group D: n1⁄444); the groups were then compared. Subjects were also divided into groups based on sampling rate (sample volume/testicular volume before surgery): less than 15% (group a: n1⁄446), 15% to 30% (group b: n1⁄470), 30% to 45% (group c: n1⁄445), and more than 45% (group d: n1⁄437); the groups were again compared. RESULTS: Sperm extraction rates in groups A, B, C, and D were 39.3%, 17.1%, 20.0%, and 27.0%, respectively (Figure 1). Sperm retrieval rate in group A was significantly higher (p<0.05) than that in group B. No significant differences were noted between the other groups. Sperm retrieval rates in groups a, b, c, and d were 58.3%, 30.3%, 18.6%, and 22.7%, respectively (Figure 2). Sperm retrieval rate in group a was significantly higher than that in groups c and d (p<0.05). No significant differences were noted among the other groups. CONCLUSIONS: In Micro-TESE, the sperm retrieval rate in the group with a low sample volume was significantly higher, possibly because seminiferous tubules containing sperms are easily identified during microsurgery. The findings suggest that if sperms cannot be seen in a low sample volume, there will be no change in the sperm retrieval rate if the sample volume is increased. Source of Funding: none

Efficacy of treatment with pseudoephedrine in men with retrograde ejaculation

The use of pseudoephedrine, an alpha agonist, for the treatment of retrograde ejaculation is well‐known, however, there is no clear consensus from the literature regarding its efficacy and treatment protocol. We evaluated the efficacy of pseudoephedrine treatment in patients with retrograde ejaculation, utilizing a yet undescribed short‐period treatment protocol. Twenty men were medically treated with pseudoephedrine for retrograde ejaculation between January 2010 and May 2016 (12 with complete retrograde ejaculation and 8 with partial retrograde ejaculation). All patients had a semen analysis and post‐ejaculatory urinalysis before and after treatment. The treatment protocol consisted of 60 mg of pseudoephedrine every 6 h on the day before semen analysis and two more 60 mg doses on the day of the semen analysis. Diabetes was the most common etiology for complete retrograde ejaculation (60%), whereas an idiopathic cause was the most common etiology for partial retrograde ejaculation (82%). Of the 12 complete retrograde ejaculation patients treated with pseudoephedrine prior to semen analysis, 7 (58.3%) recovered spermatozoa in the antegrade ejaculate, with a mean total sperm count of 273.5 ± 172.5 million. Of the eight patients with partial retrograde ejaculation, five (62.5%) had a ≥50% increase in the antegrade total sperm count. In this group, the mean total sperm count increased from 26.9 ± 8.5 million before treatment to 84.2 ± 24.6 million after treatment, whereas the percentage of spermatozoa in the urine declined from 43.2 ± 9% to 17 ± 10%, respectively (both p < 0.05). Overall, in men with retrograde ejaculation treated with a pseudoephedrine regimen prior to ejaculation, some improvement in seminal parameters occurred in 14 (70%) patients, with 10 patients (38.5% of all patients) achieving antegrade total sperm counts over 39 million.

Using Advanced Imaging Including MRI to Detect Voiding Dysfunction in Neurogenic Bladder and Fowler Syndrome

Purpose of ReviewThe diagnosis of neurogenic bladder typically involves invasive urodynamic testing; however, recent literature has shown the utility in advanced functional brain imaging. These imaging modalities have proposed neural circuitry pathways for both healthy micturition and pathologic states.Recent FindingsAdvanced imaging including fMRI, PET, SPECT, and near infrared spectroscopy have identified cortical, subcortical, and spinal relationships to micturition, as well as changes that occur with neurogenic bladder patients.SummaryImaging studies support both efferent control of micturition via the nucleus within the pons and afferent regulation of bladder storage via the periaqueductal gray area. These regulatory centers are controlled by both cortical activation and inhibition. Identifying the pathologic networks may create specific targets for physical, pharmaceutical, or neuromodulation of pathways including newer treatment modalities like deep brain stimulation.