Intervention Review

Techniques for surgical retrieval of sperm prior to intra-cytoplasmic sperm injection (ICSI) for azoospermia

  1. Michelle Proctor2,
  2. Neil Johnson3,
  3. Arno Maarten van Peperstraten1,*,
  4. Greg Phillipson4

Editorial Group: Cochrane Menstrual Disorders and Subfertility Group

Published Online: 23 APR 2008

Assessed as up-to-date: 10 DEC 2007

DOI: 10.1002/14651858.CD002807.pub3


How to Cite

Proctor M, Johnson N, van Peperstraten AM, Phillipson G. Techniques for surgical retrieval of sperm prior to intra-cytoplasmic sperm injection (ICSI) for azoospermia. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD002807. DOI: 10.1002/14651858.CD002807.pub3.

Author Information

  1. 1

    Department of Obstetrics & Gynecology, nr 791, Nijmegen , Netherlands

  2. 2

    Department of Corrections , Psychological Service , Auckland, New Zealand

  3. 3

    University of Auckland, Department of Obstetrics & Gynaecology, Auckland, New Zealand

  4. 4

    Fertility Centre, New Zealand Centre for Reproductive Medicine, Christchurch, New Zealand

*Arno Maarten van Peperstraten, Department of Obstetrics & Gynecology, nr 791, Geert Grooteplein 10, POBox 9101, Nijmegen , 6500HB, Netherlands. arnovp@gmail.com.

Publication History

  1. Publication Status: Stable (no update expected for reasons given in 'What's new')
  2. Published Online: 23 APR 2008

SEARCH

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Azoospermia, the absence of sperm in ejaculated semen, is the most severe form of male-factor infertility and is present in approximately 5% of all investigated infertile couples. The advent of intra-cytoplasmic sperm injection (ICSI) has transformed treatment of this type of severe male-factor infertility. Sperm can be retrieved for ICSI from either the epididymis or the testis, depending on the type of azoospermia.

Objectives

To evaluate the efficacy of the various surgical retrieval techniques for men with obstructive or non-obstructive azoospermia prior to ICSI.

Search methods

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (November 2007), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 4), MEDLINE (1966 to November 2007), EMBASE (1980 to November 2007), Biological Abstracts (1980 to November 2007), and reference lists of identified articles.

Selection criteria

Randomised controlled trials (RCTs) comparing the effectiveness of different sperm-retrieval techniques in men with azoospermia prior to ICSI. Due to the lack of RCTs, non-randomised trials that used the participants as their own control were also considered in the review but their results were not included in the meta-analysis.

Data collection and analysis

Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

Main results

The search was revised and re-run in November 2007. No new trials were located therefore the results of the updated review remain unchanged from those published in 2006.

Two trials involving 98 men were included. The first small RCT had 59 participants and compared two epididymal techniques. The trial gave limited evidence that microsurgical epididymal sperm aspiration (MESA) achieved a significantly lower pregnancy rate (one pregnancy in 29 procedures compared with seven pregnancies in 30 procedures; OR 0.19, 95% CI 0.04 to 0.83) and fertilisation rate (OR 0.16, 95% CI 0.05 to 0.48) than the micropuncture with perivascular nerve stimulation technique. The other RCT comparing two testicular aspiration techniques (TSA) in 39 participants gave no statistically significant evidence for the superiority of the ultrasound-guided technique compared to the aspiration technique without ultrasound. TSA with ultrasound resulted in pregnancy in three out of 16 participants compared with four out of 23 participants (OR 1.10, 95% CI 0.21 to 5.74).

Authors' conclusions

There is insufficient evidence to recommend any specific sperm retrieval technique for azoospermic men undergoing ICSI. In the absence of evidence to support more invasive or more technically difficult methods, the review authors recommend the least invasive and simplest technique available. Further randomised trials are warranted, preferably multi-centred trials. The classification of azoospermia as obstructive and non-obstructive appears to be relevant to a successful clinical outcome and a distinction according to the cause of azoospermia is important for future clinical trials.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Techniques for surgical retrieval of sperm prior to intra-cytoplasmic sperm injection (ICSI) because of absence of sperm in the semen (azoospermia).

It is not certain whether any particular surgical technique used to remove sperm for ICSI (sperm injection in vitro fertilisation or IVF) is better than another for the men involved or for leading to more pregnancies.

Some men are infertile because they produce sperm but a blockage in the testicle stops the sperm getting into the semen. In vitro fertilisation (IVF) is the only option for helping these men conceive with their own sperm.

The sperm are surgically removed from the testis gland or epididymis (tube leading from the testis towards the penis) and several micro-surgical and suction techniques through hollow needles can be used for this. Sperm are then injected into an egg, an IVF procedure called ICSI. However, the review found there were too few trials to show which sperm removal technique might be better. Complications associated with surgical sperm-retrieval techniques are haematoma and fibrosis, identified by ultrasound.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

針對無精子症而言,在實施卵細胞質內精蟲注射之前,為了進行外科取精而使用的技術

如果在射出的精液當中沒有精子的話,就是無精子症,而且這在男性因素所造成的不孕症當中,是最嚴重的類型,對於所有被涵蓋在研究範圍內的不孕症夫妻們而言,大約有5% 的比率會發生這種情況。然而,因為卵細胞質內精蟲注射(ICSI)這項技術的問世,已經使得這種嚴重之男性因素所造成的不孕症類型,在治療方面產生了改變。為了實施卵細胞質內精蟲注射,我們可以按照無精子症的類型,然後從附睪或是睪丸的其中1項當中取出精子。

目標

在進行卵細胞質內精蟲注射之前,針對患有阻塞性或是非阻塞性之無精子症的男性而言,要評估不同之外科取樣技術的功效。

搜尋策略

在進行卵細胞質內精蟲注射之前,對於患有無精子症的男性而言,這些隨機對照試驗(RCTs)比較了各項精子取樣技術的效用。因為缺乏隨機對照試驗的關係,在某些非隨機化的試驗當中,曾經使用了這些參與者來當作它們本身的對照組,而在本篇回顧當中也會將這些非隨機化試驗列入考慮,但是並不會將它們收集在統合分析之中。

選擇標準

我們搜尋 Cochrane Menstrual Disorders以及Subfertility Group Trials Register (searched 12 Jan 2005) 、 Cochrane Central Register of Controlled Trials (Cochrane Library Issue 4, 2004) 、 MEDLINE (1966年2004年11月) 、 EMBASE (1980年2004年12月) 、以及Biological Abstracts (1980年2004年11月) 以及文章的參考資料清單.

資料收集與分析

有2位審稿者獨立地評估了試驗的品質,並且擷取出資料。針對額外的更多資訊,我們曾經連繫過研究的作者。

主要結論

當中共收集了包含98名男性在內的2份試驗。在第1份小型的隨機對照試驗中,共有59名參與者,並且曾經將2項附睪方面的技術加以比較。跟微穿刺搭配血管周圍的神經刺激技術比較起來,顯微外科的附睪精子抽吸術(MESA)明顯地只能達到比較低的懷孕比率(在29道過程之中,有1次懷孕,相較於在30道過程之中,有7次懷孕, OR 0.19,95% CI 0.04到0.83)以及受精比率(OR 0.16, 95% CI 0.05到0.48),但是這份試驗所提供的相關證據卻是有限的。在另外1份隨機對照試驗當中,曾經在39名參與者身上比較了2種睪丸方面的技術,但是跟沒有使用超音波導引的抽吸技術比較起來,關於超音波導引式的抽吸技術所帶來的優點,在試驗中並沒有提供任何統計學方面的顯著證據。對於這16名參與者當中的3名而言,搭配上超音波的睪丸精子抽吸術確實帶來了懷孕的結果,至於不搭配超音波而睪丸精子抽吸術的時候,則是在23名參與者當中帶來了4件懷孕的案例(OR 1.10,95% CI 0.21到5.74)。

作者結論

對於正在接受卵細胞質內精蟲注射且患有無精子症的男性來說,若是要推薦任何1種特定的精子取樣技術,目前都沒有足夠的證據。對於更加具有侵入性或是技術方面更為困難的方法而言,因為欠缺證據可以用來支持它們,這些審稿者便在手邊可以取得的對象之中,推薦了侵入性最低且又最簡單的方法。還是有必要進行更深入的隨機化試驗,而且最好是採用多中心式的試驗。臨床的預後和阻塞性及非阻塞性無精子症有關,所以,找出無精症的原因,對於未來的臨床試驗就很重要。

翻譯人

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

因為在精液中缺乏精子(無精子症)的緣故,在實施卵細胞質內的精蟲注射(ICSI)之前,為了進行外科取精而使用的技術。對於卵細胞質內的精蟲注射(精子注射型的體外受精或是試管嬰兒)而言,跟其他種用於相關男性的技術比較起來,若是就造成更多懷孕案例的觀點來看,是否有任何1種取出精子的特定外科技術會比較占有優勢,目前還不確定。某些男性之所以會患有不孕症,是因為他們雖然會製造精子,但是卻在睪丸裡面發生了某種阻塞的現象,因而阻擋了精子到達精液裡面。若是想要幫助這些男性可以使用他們自身的精子來達到懷孕的目的,體外受精(IVF)就是唯一的選擇。醫師們可以從睪丸腺體或是附睪(從睪丸前端通往陰莖的管子)當中,以手術的方式將精子搬移出來,而且針對這樣的目的,有好幾種顯微手術與透過空心針的抽吸技術都可以使用。然後,就可以將精子注射到某個卵子當中,而這就是1種被稱作卵細胞質內精蟲注射的體外受精過程。然而,本篇回顧卻發現,只有少數幾份試驗可以顯示哪1種移除精子的技術可能會比較理想。因為外科的精子取樣技術而造成的併發症,包括了血腫與纖維化,而這些都是經由超音波所確認的結果。