Testicular sperm retrieval by fine needle aspiration and ICSI treatment for infertile men with azoospermia: Results of a two- years experience at Prince Rashed Hospital Dr. Hussein. S. Qublan- Al-Hammad Jordanian Board in Obstet &Gynecology European Board in Obstet & Gynecology Subspecialty in IVF and Andrology

INTRODUCTION It has been demonstrated that ICSI can achieve normal fertilization and ongoing pregnancy rates in severe male factor infertility where traditional IVF-ET has failed. (Van Steirteghem et al, 1993) The utilization for ICSI of spermatozoa extracted from the testes was first reported in 1993 by Craft and his colleagues. Several procedures were performed to retrieve sperms from the infertile men with obstructive and non-obstructive azoospermia. These include: MESA (Microsurgical epididymal sperm aspiration, Silber et al, 1994) TESE (Testicular sperm extraction, Devroey et al, 1994) TESA (Testicular sperm aspiration, Tsirigotis and Craft, 1995) PESA (Percutaneous epipidymal sperm aspiration- Craft et al, 1994) PSFNA (Percutaneous sperm fine needle aspiration, Tournaye et al, 1998)

INTRODUCTION It has been found that ICSI with testicular spermatozoa recovered by FNA yields results comparable to those obtained with spermatozoa recovered by open biopsy in azoospermic patients. (Tournaye et al., 1998) The pregnancy rate was reported to range between 27% and 50%. (Silber et al., 1995; Friedler et al., 1997; Tournaye et al.,m 1998; Mercan et al., 2000).

OBJECTIVE To assess the pregnancy rate and outcome in women who underwent ICSI treatment after testicular sperm retrieval by testicular FNA.

Methods Period: Between Aug 2005 and December 2007 Number of patients: 55 infertile couples Ages: Women ( years) Men (25-71 years) Obstructive azoospermia: 12 (21.2%) Non-obstructive AZ: 43 (78.8%) - All males underwent testicular FNA before commencing the ICSI cycle to confirm the presence of sperms

Methods Treatment: ICSI treatment due male factor (azoospermia). Duration of infertility ranged from 2 to 17 years. The demographic, hormonal and treatment data of both male and female partner along with the reproductive outcome were analyzed.

Methods Procedure: TEFNA By using 21 gouge butterfly needles attached to a 20 ml plastic syringe serving as an aspiration device. While holding the testicle between the index finger and thumb, 3-5 different entries were made in each testicle after passing directly through the scrotal skin into the testis, moved up and down at various sites. Following each aspiration, the aspirate was deposited in tubes containing special media with heparin. Then the aspirates were immediately examined under the microscope at X200 and X400 magnification to detect the presence of sperms The aspirate was collected and transferred to a 6 ml conical tubes and centrifuged at 300 g for 10 min

Methods Treatment characteristics: - ICSI - The best quality embryos (1-4) transferred - Luteal support: progesterone - b-HCG: 12 days after transfer - Clinical pregnancy: Visualization of intrauterine gestational sac with positive fetal heart activity

Results The outcome of testicular sperm FNA and ICSI of the study group No. of ICSI cycles No of oocytes retrieved No of oocytes fertilized No of embryos transferred Implantation rate (%) Pregnancy rate / ET (%) -Multiple PR -Abortion rate -Delivery of alive babies -Ongoing pregnancy /179 (20.1) 28/55 (50.9) 6/28 (21.4) 4/28 (14.3) 15/28 (53.6) 9/28 (32)

Discussion Friedler et al (29%) Tournaye et al (19.6%) Mercan et al (46%) - 37 patients with NOA -- No previous TEFNA -- No female data patients with OA -- No female data patients with NOA -- Previous TEFNA in 50 patients -- female data were available

Conclusion (s) Testicular fine needle aspiration is a simple, non-invasive procedure that can retrieve sperms from azoospermic men for ICSI treatment.. TEFNA to confirm the presence of sperms shortly before commencing treatment is mandatory to increase the chances of success of the ICSI procedure. With efficient laboratory and proper management of patients, pregnancy can be achieved almost in half of cases.

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