|Year : 2014 | Volume
| Issue : 6 | Page : 918
Complex and time-consuming laboratory modifications are not always necessary to improve outcome
Department of Reproductive Medicine and Biology, University Hospital of Nantes, Nantes, France
|Date of Web Publication||01-Jul-2014|
Department of Reproductive Medicine and Biology, University Hospital of Nantes, Nantes
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Freour T. Complex and time-consuming laboratory modifications are not always necessary to improve outcome. Asian J Androl 2014;16:918
|How to cite this URL:|
Freour T. Complex and time-consuming laboratory modifications are not always necessary to improve outcome. Asian J Androl [serial online] 2014 [cited 2020 Jun 3];16:918. Available from: http://www.ajandrology.com/text.asp?2014/16/6/918/132473 - DOI: 10.4103/1008-682X.132473
The manuscript by Ozkavukcu et al. provides the demonstration that a simple change in laboratory procedure can lead to a significant improvement in technical outcome, that is, sperm cells extraction from testicular tissue.
The demonstration is basic but relevant: in order to extract as many spermatozoa as possible from minced testicular tissue, one should not lay testicular residual tissue with sperm wash on the density gradient after tissue mincing, but rather only sperm wash, in order to avoid gradient saturation and blockage, and subsequent lower sperm cell retrieval rate. Even if no reference or survey giving an idea of the proportion of laboratories using this technique for sperm extraction can be cited, I have no doubt that such a simple message can lead to a modification in technical procedures in a significant number of andrology teams.
When more and more couples are seeking for IVF throughout the world, with half of them facing with male infertility, alone or in combination with female factors, it is remarkable to notice that sperm extraction and preparation techniques in assisted reproductive technology have little changed since the early 80s. This is both true for ejaculated sperm and surgically retrieved sperm cells. Indeed, in men suffering from azoospermia, whose proportion among men facing with male infertility is far from negligible (up to 5%-10%), surgical retrieval of spermatozoa can be attempted, but this invasive procedure yields various success rates. For patients suffering from nonobstructive azoospermia (NOA) and referred to testicular sperm extraction (TESE), successful sperm extraction rate and subsequent possibility of performing intracytoplasmic sperm injection (ICSI) depends on one hand on residual spermatogenesis and testicular histology, and on the other hand on the capacity of the laboratory to extract live sperm cells from testis biopsy fragments. Unfortunately, this favorable outcome is obtained in only 20%-60% of TESE. 
The issue of sperm quality after TESE and safety of subsequent ICSI should be considered as a first perspective. Ozkavukcu et al. recall in their discussion that testicular spermatozoa retrieved in NOA patients are significantly more likely to be aneuploid  or to have high DNA fragmentation index than ejaculated spermatozoa in fertile men. Although they cite a few references demonstrating that density-gradient can help in lowering the proportion of these poor quality spermatozoa, this proportion still remains significant, and one can obviously not guarantee that the sperm cell used for ICSI is euploid. Moreover, the technics used in these papers suffer from some limitations and standardization is lacking. Finally, despite the wide use of ICSI for nearly two decades, and without questioning its interest in male infertility, there is still some concern about the health of children born after ICSI. Future developments of sperm preparation technics should focus on associating high cellular retrieval rate and selecting competent and high quality sperm for ICSI, in order to improve both the safety and the success rate of NOA care.
Second, and besides these technical considerations, this work raises a few questions on NOA clinical management. First, and prior to performing TESE, NOA patients should obviously be informed on their chances of successful sperm extraction. Unfortunately, the existing noninvasive clinical and biological predictive factors of residual spermatogenesis suffer from relatively poor performance. Age, testicular volume, hormonal markers, such as follicle-stimulating hormone, luteinizing hormone, testosterone, inhibin B, anti-Mullerian hormone have been evaluated, but with limited predictive interest.  Seminal plasma was also tested as a source for noninvasive evaluation of spermatogenesis. Several seminal markers have thus been proposed for evaluating the chance of successful surgical sperm retrieval, but none of these seminal markers was identified as a relevant prognostic marker for TESE in NOA patients, even if recent developments in proteomics might revolutionize this domain. 
Finally, this simple and straightforward paper by Ozkavukcu et al. might lack some clinical perspective, but is really valuable as it highlights that complex and time-consuming laboratory modifications are not always necessary to improve outcome.
| Competing Interests|| |
The author declares no competing interests.
| References|| |
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