In this study (May 1 until August 31, 1994) a total of 15 azoospermic patients suffering from testicular failure were treated with a combination of testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI). Spermatozoa were available for ICSI in 13 of the patients. Out of 182 metaphase II injected oocytes, two-pronuclear fertilization was observed in 87 (47.80%); 57 embryos (65.51%) were obtained for either transfer or cryopreservation. Three ongoing pregnancies out of 12 replacements (25%) were established, including one singleton, one twin and one triplet gestation. The ongoing implantation rate was 18% (six fetal hearts out of 32 embryos replaced).

A comprehensive study is presented of a series of 124 infertile men undergoing testicular sperm retrieval for intracytoplasmic sperm injection (ICSI). In this study we correlated the histological changes observed in the testicular tissue with the results of the wet preparation and the outcome after ICSI using testicular spermatozoa. In all patients with normal spermatogenesis and hypospermatogenesis spermatozoa were recovered from the wet preparation. The sperm recovery rate as 84% in patients with incomplete germ-cell-aplasia and maturation arrest, while in patients with complete germ-cell aplasia or maturation arrest this figure was 76%. In these patients more specimens were sampled and fewer spermatozoa were recovered. Since no spermatozoa were recovered in only 10 patients, ICSI with testicular sperm was performed in the remaining 114 couples (91.9%). The normal fertilization rate was 57. 8%. The fertilization rate was significantly lower in couples among whom the husband showed germ-cell aplasia and maturation arrest. Overall, 55.2% of normally fertilized oocytes developed into embryos showing <=50% of anucleate fragments. There were no major differences between the different histological categories in terms of embryonic development in vitro. The overall pregnancy rates per testicular sperm extraction (TESE) procedure, per ICSI procedure and per transfer were respectively 36.3, 39.5 and 43.7%. The overall implantation rate per embryo (sacs/embryos replaced) was 20.3%. A lower implantation rate was observed in couples among whom the husband had maturation arrest (not statistically significant). The above data show that testicular biopsies may have an important therapeutic role in the management of infertility in azoospermic patients.

Testicular biopsy has been widely used for the diagnosis of male infertility. Since the introduction of intracytoplasmic sperm injection (ICSI), spermatozoa recovered from a testicular biopsy specimen can be successfully used for establishing pregnancies. A few spermatozoa may be recovered from a wet preparation of a testicular biopsy, not only in obstructive azoospermic patients, but also in many patients with non-obstructive azoospermia. In 36 out of 38 non-obstructive azoospermic patients sperm cells were recovered from a testicular biopsy specimen. However in two patients, spermatozoa could not be found after further preparation of the biopsy specimens for ICSI. In the remaining 32 patients, a normal fertilization rate of 56.8% per successfully injected oocyte was obtained after ICSI of testicular spermatozoa. In 84% of patients, embryos were replaced with an overall pregnancy rate of 28.9% per testicular biopsy or 34.3% per embryo transfer. The results clearly indicate that at present an excisional testicular biopsy should be offered to all azoospermic patient, irrespective of concentration of follicle stimulating hormone, testicular size or medical history.

Loss of weight was limited after prophylactic gastrostomy placement and early tube feeding. Moreover, the complication rate was low. In 82% of the NED patients the PEG could eventually be removed.

Recovery of testicular spermatozoa from azoospermic patients with testicular failure, followed by intracytoplasmic sperm injection (ICSI) is a recent advance in the treatment of male infertility. In most cases, free spermatozoa are recovered from testicular tissue after mechanical mincing of multiple biopsies. Testicular sperm retrieval, however, remains unsuccessful in 30-50% of male patients suffering from Sertoli cell-only syndrome and maturation arrest. In this study, a strategy was developed in order to maximize the chance of sperm retrieval in difficult cases of testicular failure. The ultimate step was the use of enzymatic procedures (collagenase type IV) to dissociate the testicular tissue completely. Testicular tissue of 41 patients for whom no spermatozoa were found after mechanical mincing of the testicular tissue was investigated. In 14 out of the 41 cases (34%), enough spermatozoa for ICSI were found after fine mincing of multiple biopsies and several hours' search in the cell suspension treated with the erythrocyte-lysing buffer (ELB). In 27 out of the 41 patients, no spermatozoa were found even after the use of ELB. In seven out of these 27 failures (26%), spermatozoa for ICSI were retrieved after enzymatic dissociation of the residual minced tissue pieces, thus making ICSI possible despite failure to find spermatozoa with conventional mincing. From this study, we may conclude that enzymatic digestion of testicular tissue is easy to perform, is not time-consuming and constitutes a successful method in reducing the sperm recovery failures in patients with non-obstructive azoospermia.