We compared pregnancy outcomes following intracytoplasmic sperm injection for the treatment of male infertility according to the type of azoospermia. First, we analyzed our data from 370 couples who underwent intracytoplasmic sperm injection using sperm from men with obstructive azoospermia and nonobstructive azoospermia, and the outcomes were compared to a group of 465 non-azoospermic infertile males. Then, we performed a systematic review of the published data on pregnancy and neonatal outcomes of children born after sperm injection using sperm from men with obstructive and nonobstructive azoospermia. Live birth rates were significantly lower in the nonobstructive azoospermia group (21.4%) compared with the obstructive azoospermia (37.5%) and ejaculated sperm (32.3%) groups. A total of 326 live births resulted in 427 babies born. Differences were not observed between the groups in gestational age, preterm birth, birth weight and low birth weight, although we noted a tendency towards poorer neonatal outcomes in the azoospermia categories. The overall perinatal death and malformation rates were 2.8% and 1.6%, respectively, and the results did not differ between the groups. We identified 20 published studies that directly compared pregnancy outcomes between obstructive azoospermia and nonobstructive azoospermia. Most of these studies were not designed to detect differences in live birth rates and had lower power to detect differences in less frequent outcomes, and the reporting of neonatal outcomes was unusual. The included studies reported either a decrease or no difference in pregnancy outcomes with intracytoplasmic sperm injection in cases of nonobstructive azoospermia and obstructive azoospermia. In general, no major differences were noted in short-term neonatal outcomes and congenital malformation rates between children from fathers with nonobstructive azoospermia and obstructive azoospermia.

Azoospermia due to obstructive and non-obstructive mechanisms is a common manifestation of male infertility accounting for 10-15% of such cases. Known genetic factors are responsible for approximately 1/3 of cases of azoospermia. Nonetheless, at least 40% of cases are currently categorized as idiopathic and may be linked to unknown genetic abnormalities. It is recommended that various genetic screening tests are performed in azoospermic men, given that their results may play vital role in not only identifying the etiology but also in preventing the iatrogenic transmission of genetic defects to offspring via advanced assisted conception techniques. In the present review, we examine the current genetic information associated with azoospermia based on results from search engines, such as PUBMED, OVID, SCIENCE DIRECT and SCOPUS. We also present a critical appraisal of use of genetic testing in this subset of infertile patients.

The use of non-ejaculated sperm coupled with intracytoplasmic sperm injection has become a globally established procedure for couples with azoospermic male partners who wish to have biological offspring. Surgical methods have been developed to retrieve spermatozoa from the epididymides and the testes of such patients. This article reviews the methods currently available for sperm acquisition in azoospermia, with a particular focus on the perioperative, anesthetic and technical aspects of these procedures. A critical analysis of the advantages and disadvantages of these sperm retrieval methods is provided, including the authors' methods of choice and anesthesia preferences.

Unexplained male infertility is a diagnosis reserved for men in whom routine semen analyses results are within normal values and physical as well as endocrine abnormalities were ruled out. In addition to erectile problems and coital factors, immunologic causes and sperm dysfunction may contribute to such condition. New etiologies of unexplained male infertility include low level leukocytospermia and mitochondrial DNA polymerase gene polymorphism. Contemporary andrology may reveal cellular and sub-cellular sperm dysfunctions which may explain subfertility in such cases, thus aiding the clinician to direct the further work-up, diagnosis and counseling of the infertile male. The objective of this article is to highlight the concept of unexplained male infertility and focuses on the diagnosis and treatment of this condition in the era of modern andrology and assisted reproductive techniques. Extensive literature review was performed using the search engines: Pubmed, Science-direct, Ovid and Scopus.

RESUMO O objetivo desta revisão sistemática é apresentar estudos sobre a associação entre as taxas de gravidez e a presença de fases iniciais de endometriose. Estudos relacionados com a infertilidade e estágios mínimos e leves (estágios I,II, American Society of Reproductive Medicine [ASRM]) foram identificados por busca na base de dados MEDLINE, de 1985 a setembro de 2011. Os seguintes termos foram usados como palavras-chave: endometriose, infertilidade, taxa de gravidez; estágio mínimo; estágio leve de endometriose. Entre janeiro de 1985 e novembro de 2011, 1188 artigos foram recuperados; com base no título, 1038 citações foram excluídas e, finalmente, depois de critérios de inclusão e exclusão, 18 artigos foram selecionados para fazer parte desta revisão sistemática. Várias razões têm sido discutidas na literatura na tentativa de explicar o impacto da endometriose mínima no resultado da fertilidade, tais como: disfunção ovulatória, foliculogênese alterada prejudicada, defeito na implantação, baixa qualidade embrionária, ambiente peritoneal inflamatório e hostil e problemas da fase lútea. Apesar de toda polêmica envolvendo o tópico, o maior ensaio clínico randomizado foi publicado por Marcoux et al. Os autores encontraram uma taxa de gravidez estatisticamente significante após a ressecção de lesões superficiais de endometriose. Estágios iniciais de endometriose desempenham um papel crítico relacionado à infertilidade e, provavelmente proporcionam um impacto negativo nas taxas de gravidez em pacientes com endometriose. Outros estudos envolvendo estágios iniciais de endometriose, especialmente ensaios clínicos randomizados, ainda precisam ser realizados.

Endometriosis, a highly prevalent gynecological disease, can lead to infertility in moderate to severe cases. Whether minimal stages are associated with infertility is still unclear. The purpose of this systematic review is to present studies regarding the association between pregnancy rates and the presence of early stages of endometriosis. Studies regarding infertility, minimal (stage I, American Society of Reproductive Medicine [ASRM]) and mild (stage II, ASRM) endometriosis were identified by searching on the MEDLINE database from 1985 to September 2011 using the following MESH terms: endometriosis; infertility; minimal; mild endometriosis; pregnancy rate. 1188 articles published between January of 1985 and November of 2011 were retrieved; based on their titles, 1038 citations were excluded. Finally, after inclusion and exclusion criteria, 16 articles were selected to be part of this systematic review. Several reasons have been discussed in the literature to explain the impact of minimal endometriosis on fertility outcome, such as: ovulatory dysfunction, impaired folliculogenesis, defective implantation, decrease embryo quality, abnormal immunological peritoneal environment, and luteal phase problems. Despite the controversy involving the topic, the largest randomized control trial, published by Marcoux et al. in 1997 found a statistically different pregnancy rate after resection of superficial endometrial lesions. Earlier stages of endometriosis play a critical role in infertility, and most likely negatively impact pregnancy outcomes. Further studies into stage I endometriosis, especially randomized controlled trials, still need to be conducted.

Different surgical methods such as PESA, MESA, TESA, TESE and micro-TESE have been developed to retrieve spermatozoa from either the epididymis or the testis according to the type of azoospermia, i.e., obstructive or non-obstructive. Laboratory techniques are used to remove contaminants, cellular debris, and red blood cells following collection of the epididymal fluid or testicular tissue. Surgically-retrieved spermatozoa may be used for intracytoplasmic sperm injection (ICSI) and/or cryopreservation. In this article, we review the surgical procedures for retrieving spermatozoa from both the epididymis and the testicle and provide technical details of the commonly used methods. A critical analysis of the advantages and limitations of the current surgical methods to retrieve sperm from males with obstructive and non-obstructive azoospermia is presented along with an overview of the laboratory techniques routinely used to process surgically-retrieved sperm. Lastly, we summarize the results from the current literature of sperm retrieval, as well as the clinical outcome of ICSI in the clinical scenario of obstructive and non-obstructive azoospermia.

Cell phones have become a vital part of everyday life. However, the health risks associated with their usage are often overlooked. Recently, evidence from several studies supports a growing claim that cell phone usage may have a detrimental effect on sperm parameters leading to decreased male fertility. Nonetheless, other studies showed no conclusive link between male infertility and cell phone usage. The ambiguity of such results is attributed to the lack of a centralized assay for measuring inflicted damage caused by cell phones. Study design, ethics, and reproducibility are all aspects which must be standardized before any conclusions can be made.

Extraordinary advances have been achieved in the field of male infertility in the last decades. There are new concepts in sperm physiology and several modern tools for the assessment of spermatogenesis kinetics in vivo. New tests using molecular biology and DNA damage assays allow the clinician to correctly diagnose men so far classified as having idiopathic male infertility. In the field of treatment, microsurgery has increased success rates either for reconstruction of the reproductive tract or the retrieval of spermatozoa for assisted conception. Emerging evidence suggests that life-style and environmental conditions are of utmost importance in male fertility and subfertility. This review discusses several concepts that have changed over the last years, such as the duration of the spermatogenic cycle in humans, Y-chromosome infertility, the reproductive potential of non-mosaic Klinefelter syndrome men, the impact of paternal age and sperm DNA in male infertility, the role of antioxidants in the treatment of infertile men, the predictive factors and techniques for sperm retrieval in non-obstructive azoospermia, and the microsurgical treatment of clinical varicoceles. Whenever possible, levels of evidence are provided as suggested by the Oxford Center of Evidence-based Medicine.

Male infertility is directly or indirectly responsible for 60% of cases involving reproductive-age couples with fertility-related issues. Nevertheless, the evaluation of male infertility is often underestimated or postponed. A coordinated evaluation of the infertile male using standardized procedures improves both diagnostic precision and the results of subsequent management in terms of effectiveness, risk and costs. Recent advances in assisted reproductive techniques (ART) have made it possible to identify and overcome previously untreatable causes of male infertility. To properly utilize the available techniques and improve clinical results, it is of the utmost importance that patients are adequately diagnosed and evaluated. Ideally, this initial assessment should also be affordable and accessible. We describe the main aspects of male infertility evaluation in a practical manner to provide information on the judicious use of available diagnostic tools and to better determine the etiology of the most adequate treatment for the existing condition.

Assisted reproductive technology is an evolving area, and several adjuvant procedures have been created to increase a couple's chance of conceiving. For male infertility, the current challenges are to properly accommodate old and new techniques that are both cost-effective and evidence-based. In this context, urologists are expected to diagnose, counsel, provide medical or surgical treatment whenever possible and/or correctly refer male patients for assisted conception. Urologists are sometimes part of a multiprofessional team in an assisted reproduction unit and are responsible for the above-cited tasks as well as the surgical retrieval of sperm from either the epididymides or testicles. We present a comprehensive review of the surgical treatment options for infertile males, including the perioperative planning and prognostic aspects, with an emphasis on the role of microsurgery in the optimization of treatment results. This review also discusses current techniques for sperm retrieval that are used in association with assisted reproductive technology and includes sperm retrieval success rates according to the technique and the type of azoospermia. New insights are provided with regard to each surgical treatment option in view of the availability of assisted conception to overcome male infertility.

PURPOSE: The frequency of testicular cancer and male infertility has been increasing in the past several decades. This article examines the relationship between male infertility and testicular cancer, concentrating particularly on causal links. RESULTS: Both of these disorders are associated with testicular dysgenesis syndrome and have also been traced to mutations in genes involving DNA repair and tumor suppression, as well as environmental exposure. CONCLUSION: The identification and examination of these common points of origin supports the integration of testicular cancer screenings into the routine evaluation of infertile men.

Infertility affects 10-15% of couples who are trying to conceive, and half of the cases are due to male infertility. Intracytoplasmic sperm injection is increasingly being used to overcome multiple sperm deficiencies. Due to its effectiveness, some have proposed ICSI as a solution for all cases of male infertility, regardless of the cause. Hence, even men with potentially treatable causes of infertility have sought the aid of assisted reproductive technology, rather than undergo specific therapies to treat their infertility. Varicoceles are the most frequent physical finding in infertile men; indeed, they may be responsible for nearly one-third of cases of male infertility. Varicocele management, however, has always been a controversial issue because very few randomized, controlled studies have been performed to examine varicocelectomy as an infertility treatment. Significant evidence suggests that varicoceles have a harmful effect on the testis and that varicocelectomy can not only prevent progressive decline in testicular function but also reverse the damage. However, the degree to which varicocele repair improves pregnancy rates and the success of assisted reproductive technology remains controversial.

Oxidative stress (OS) in the reproductive tract is now a real entity and concern due to the potential harmful effects of high levels of reactive oxygen species (ROS) on sperm number, motility, quality, and function including damage to sperm nuclear DNA. Evaluation of OS related damage to non-functional sperm is highly relevant as intracytoplasmic sperm injection (ICSI) technique, an effective therapy for severe male factor infertility, bypasses the majority of reproductive tract deficiencies. Despite the controversial findings in the existing literature, there is now enough evidence to show that sperm DNA damage is detrimental to reproductive outcomes. In addition, spermatozoa of infertile men are suggested to carry more DNA damage than do the spermatozoa from fertile men. Besides impairment of fertility such damage is likely to increase the transmission of genetic diseases during the assisted reproductive procedures. Standardization of protocols to assess reactive oxygen species and DNA damage is very important in introducing these tests in such clinical practice. Thus evaluation of seminal ROS levels and extent of sperm DNA damage especially in an infertile male may help develop new therapeutic strategies and improve success of assisted reproductive techniques (ART).

OBJECTIVE: In this study, we evaluated whether the hypo-osmotic swelling test (HOST) can be used as a vital marker in combination with peanut agglutinin (PNA) - labeling in fresh and cryopreserved spermatozoa. MATERIALS AND METHODS: Human sperm populations were exposed to a hypo-osmotic medium for 60 minutes, and then incubated in a 1 µg/mL solution of the fluorescent dye Hoescht 33258 (H33258) for 10 minutes. Excess stain was removed by washing in phosphate-buffered saline (PBS) solution, and the pellet was resuspended in 100 µL of culture medium. Twenty microliters of this solution were subsequently smeared on a microscope slide, and fixed in ice-cold methanol to permeabilize the sperm membranes. The fixed smears were finally incubated in a 40-µg/mL FITC-PNA solution for 20 minutes. Simultaneous assessment of acrosome and viability scores was done in a fluorescent microscope equipped with appropriate filters and phase contrast illumination. The same slide was examined for FITC-PNA labeling, tail swelling, and for Hoechst-33258 staining by interchanging the filters and phase contrast optics. RESULTS: In fresh specimens, HOST was found to provide viability assessments comparable to those obtained using the H33258 method (r = 0.95). However, the results of HOST and H33258 were not correlated in cryopreserved specimens (r = 0.22). There was no alteration of PNA-labeling due to the HOST or H33258. CONCLUSIONS: FITC-PNA labeling in conjunction with the visualization of the morphological change induced by exposure to hypo-osmotic solution provides a simple but effective method for establishing the state of acrosomal membrane and viability in fresh human spermatozoa, but this technique is not reliable for cryopreserved ones.

OBJETIVO: Determinar se pacientes portadores do fator de infertilidade masculina podem ser precisamente identificados através do cálculo de um novo escore de qualidade de sêmen e pela medida de espécies reativas de oxigênio durante uma avaliação rotineira de infertilidade. MÉTODOS: Amostras de sêmen de 133 pacientes e de 91 doadores saudáveis foram avaliadas através de análise manual e computadorizada de sêmen. Um modelo de análise do componente principal foi empregado para calcular o escore de qualidade de sêmen, utilizando logaritmos base 10, multiplicados por ponderações variáveis de 9 parâmetros espermáticos. Os níveis de espécies reativas de oxigênio foram medidos através de testes de quimiluminescência. RESULTADOS: O escore de qualidade de sêmen apresentou sensibilidade de 80.45% e precisão de 77% para um "cutoff" de 93.1 na identificação do fator de infertilidade masculina. A área sob a curva "receiver operating characteristic" para o escore de qualidade de sêmen foi de 84.28% (95% intervalo de confiança: 65.22%-100%). Os níveis de espécies reativas de oxigênio [log10 (espécies reativas de oxigênio +1)] foram siginificativamente mais elevados nos pacientes portadores de fator de infertilidade masculina. A medica de espécies reativas de oxigênio apresentou sensibilidade de 83.47% e especificidade de 60.52% com uma precisão (definida como pacientes portadores do fator de infertilidade masculina com diagnóstico positivo e doadores corretamente excluídos) de 75% para um "cutoff" de 1.25 na identificação de pacientes portadores do fator de infertilidade masculina. A área sob a curva "receiver operating characteristic" para níveis de espécies reativas de oxigênio foi de 78.92% (95% intervalo de confiança: 72.60%-85.23%). Os escores de qualidade de sêmen correlacionaram negativamente com os níveis de espécies reativas de oxigênio tanto nos doadores e nos pacientes portadores do fator de infertilidade masculina. CONCLUSÕES: O escore de qualidade de sêmen e os níveis espécies reativas de oxigênio nas amostras de sêmen parecem associar-se fortemente com o fator de infertilidade masculina. Na medida em que os dois parâmetros mostraram-se mais sensíveis que parâmetros espermáticos individuais na identificação do fator de infertilidade masculina, deveriam ser incluídos na avaliação rotineira de infertilidade.

PURPOSE: To determine whether patients with male factor infertility can be accurately identified by calculating a novel semen quality score and measuring levels of reactive oxygen species during routine infertility screening. METHODS: Semen samples from 133 patients and 91 healthy donors were evaluated with manual and computer-assisted semen analysis. A principal component analysis model was employed to calculate a semen quality score. In brief, this score was calculated by base 10 logarithms multiplied by varying weights given to 9 sperm parameters. Reactive oxygen species levels were measured using chemiluminescence assay. RESULTS: The semen quality score had a sensitivity of 80.45% and accuracy of 77% at a cutoff of 93.1 in identifying patients with male factor infertility. The area under the receiver operating characteristic curves for the semen quality score was 84.28% (95% CI: 65.22%-100%). Reactive oxygen species levels [log10 (reactive oxygen species +1)] were significantly higher in male factor infertility patients. Reactive oxygen species had a sensitivity of 83.47% and specificity of 60.52% with an accuracy of 75% at a cutoff of 1.25 in identifying male factor infertility patients. The area under the receiver operating characteristic curve for reactive oxygen species levels was 78.92% (95% CI: 72.60%-85.23%). semen quality scores were significantly and negatively correlated with reactive oxygen species levels in the donors and the male factor infertility patients. CONCLUSIONS: The semen quality score and reactive oxygen species levels in semen samples appear to be strongly associated with male factor infertility. Because both of these parameters are more sensitive than individual sperm parameters in identifying male factor infertility, they should be included in routine infertility screening.