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Nouveautés dans la prise en charge des azoospermies non obstructives

Nouveautés dans la prise en charge des azoospermies non obstructives. Béatrice Cuzin, Service d’Urologie et de la transplantation, Lyon, France. Micro-TESE:

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Nouveautés dans la prise en charge des azoospermies non obstructives

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  1. Nouveautés dans la prise en charge des azoospermies non obstructives Béatrice Cuzin, Service d’Urologie et de la transplantation, Lyon, France

  2. Micro-TESE: Sous le microscope, jusqu'à un grossissement de 20x, recherche de zones où les tubules séminifères – sont dilatés et donc plus susceptibles de contenir des spermatozoïdes. Ablation de ces zones, et examen en laboratoire Intérêt: petits volumes de tissu testiculaire dans les zones de production de spermatozoïdes actifs ce qui améliore le rendement des spermatozoïdes par rapport aux techniques traditionnelles de biopsie. Qu’en est t’il en 2019 ?

  3. Outcome of microdissection TESEcomparedwithconventional TESE innon-obstructive azoospermia: asystematicreviewY. Deruyver et col 2017 • critère de jugement principal : taux de récupération de sperme (SRR). Critères secondaires : facteurs prédictifs de la récupération de sperme, taux de complications. • Sur 62 articles, sept études au total ont été incluses dans l'analyse finale. • Le RRS global était significativement plus élevé dans le groupe microTESE par rapport au TESE conventionnel dans cinq de ces études : 16,7 à 45% dans le TESE conventionnel contre 42,9 à 63% dans le groupe microTESE. • Sous-analyse du SRR selon l'histologie testiculaire était disponible dans quatre des articles sélectionnés : syndrome de SertoliCellOnly significative, corrélation FSH et volume testiculaire avec résultat positif variable. Moins de complications ont été observés à l’échographie après microTESE, mais pas de différence pour les complications cliniques. • Des études cliniques randomisées comparant microTESE à des traitements conventionnels • TESE manquent toujours à ce jour. Les données prospectives pseudo-randomisées montrent toutefois une récupération plus favorable des spermatozoïdes dans la microTESE, en particulier dans les schémas histologiques de spermatogenèse éparse (SCO. cependant, chez les patients présentant des profils histologiques uniformes tels que l'arrêt de maturation, l'issue de microTESE semble moins favorable.

  4. Predictive value of FSH, testicular volume, and histopathologicalfindings for the spermretrieval rate of microdissection TESE in nonobstructiveazoospermia: a meta‑analysisHao Li et coll 2018 Les trois facteurs étudiés avaient des valeurs prédictives limitées et aucunpourrait être utilisé comme seul facteur prédictif en pratique clinique. Des facteurs tels que l’inhibine B et l’âge pourraint également être utiles pour prédire la probabilité de récupération réussie du sperme, mais des études supplémentaires sont nécessaires. La combinaison de différents paramètres pourrait constituer une nouvelle approche pour prédire le SRR dans la microdissection TESE.

  5. Spermrecovery and ICSI outcomesinKlinefelter syndrome: a systematicreview and meta-analysisJ Corona et coll 2017 BACKGROUND: Specificfactorsunderlyingsuccessfulsurgicalspermretrieval rates (SRR) or pregnancy rates (PR) aftertesticularsperm extraction (TESE) in adult patients with Klinefelter syndrome (KS) have not been completelyclarified. OBJECTIVE AND RATIONALE: The aim of thisreviewwas to meta-analyse the currentlyavailable data fromsubjectswith KS regardingSRRs as the primaryoutcome. In addition, whenavailable, PRs and live birth rates (LBRs) after the ICSI technique werealsoinvestigated as secondaryoutcomes. SEARCH METHODS: An extensive Medline, Embase and Cochrane searchwasperformed. All trials reporting SRR for conventional- TESE (cTESE) or micro-TESE (mTESE) and itsspecificdeterminantswithoutanyarbitrary restriction wereincluded. OUTCOMES: Out of 139 studies, 37 trials wereincluded in the study, enrolling a total of 1248 patients with a meanage of 30.9 ± 5.6years. The majority of the studies (n = 18) appliedmTESE, 13 appliedcTESE and in one case testicularsperm aspiration (TESA) wasused.Additionally, four studiesused a mixed approach and in one study, the methodapplied for spermretrievalwas not specified.

  6. Overall, a SRR per TESE cycle of 44[39;48]% wasdetected. • SimilarresultswereobservedwhenmTESEwascompared to cTESE (SRR 43[35;50]% vs 45[38;52]% for cTESE vs micro-TESE, respectively; Q = 0.20, P = 0.65). • Meta-regressionanalysisshowedthat none of the parameterstested, includingage, testis volume and FSH, LH and testosterone (T) levels at enrollment, affected the final SRR. • Similarly, no differencewasobservedwhen a bilateralprocedurewascompared to a unilateralapproach. • No sufficient data wereavailable to evaluate the effect of previousTtreatment on SRR. • Information on fertilityoutcomeafter ICSI wasavailable for 29 studies. • Overall a total of 218 biochemicalpregnanciesafter 410 ICSI cycles wereobserved (PR = 43[36;50]%). Similarresultswereobservedwhen LBR wasanalyzed (LBR = 43[34;53]%). Similar to whatwasobserved for SRR, no influence of KS age, mean testis volume, LH, FSH or total Tlevels on either PR and LBR wasobserved. No sufficient data wereavailable to test the effect of the women’sage or otherfemalefertilityproblems on PR and LBR. Finally, nodifference in PR or LBR wasobservedwhen the use of freshspermwascompared to the utilization of cryopreservedsperm. • WIDER IMPLICATIONS: The present data suggestthatperforming TESE/micro-TESE in subjectswith KS results in SRRs of close to50%, and thenPRs and LBRs of close to 50%, with the resultsbeingindependent of anyclinical or biochemicalparameterstested.

  7. AMH is a predictive factor for successfulspermretrieval in non-mosaic Klinefelter syndrome patients Lucie Renault, Sandrine Giscard dʼEstaing, Beatrice Cuzin, Medhi Benchaib, Jacqueline Lornage, Ga.lleSoignon, FrederiqueDijoud,Hervé Lejeune, Ingrid Plotton Context. Klinefelter Syndrome (KS) patients, defined by a 47 XXY karyotype, were long considered infertile. Testicularsperm extraction (TESE) nowallowssome of these patients to accessfatherhood. The predictivefactors for success, however,remainunknown. Patients and methods. Non-mosaic KS patients withazoospermia or severecryptozoospermia on twosemen analyses withoutanyotherspermatogenesisdisorderwereincluded. Theyweresortedintotwoage groups: youths, between 15 and 22 years of age, and adults over 23. Theyhadtwoclinicalexaminations and blood tests beforeconventional TESE and one after. Results. One hundredsixtytwo KS patients wereincludedbetween April 2010 and May 2018: 63 youths and 57 adults. Thirty-six gave up beforebiopsy, 72% of whomwereyouths. Medianage at biopsywas 22 years: 18 years for youths and 31 years for adults. Spermstrawswerefrozen for 50 patients (41.6%): 26 youths (41.3%) and 24 adults (42.1%). Half of the adultswhocryopreservedspermdid at least 1 intra-cytoplasmicsperm injection, leading to 6 pregnancies and 7 livebirths. Clinicalfeatures (BMI, age at diagnosis, testosteronetreatment, Tannerstage, and testis volume) weresimilarbetween patients with and withoutsuccessfulspermretrieval. FSH, LH, total and bioavailabletestosterone, estradiol and inhibin B levelswere not predictive of success. Interestingly, median AMH wassignificantlyhigher in patients withsuccessful TESE, at 13pmol/L [4-31] versus 3pmol/L [0.9-15.3]; p=0.0049. Conclusion. Clinical and biologicalfeatures of a very large cohort of 120 KS patients are described. We show for the first time AMH to be a predictive factor of success for spermretrieval in non-mosaic KS patients.

  8. Infertility in Patients WithKlinefelterSyndrome: Optimal Timing for Spermand Testicular Tissue CryopreservationDorota J. Hawksworth et coll 2018

  9. Salvage micro-dissectiontesticularspermextraction; outcome in men with non-obstructiveazoospermiawithpreviousfailedspermretrievalsJas J Kalsi et coll 2014

  10. Klinefelter syndrome: an argument for earlyaggressive hormonal and fertility management.Mehta A et coll 2012 Abstract OBJECTIVE:  To investigate the impact of early hormone replacement therapy (HT) on spermretrieval rates in patients withKlinefeltersyndrome (KS). DESIGN:  A systematicreview of the relevant literatureusing the PubMed NLM database. RESULT(S):  There are no randomizedcontrolled trials evaluating the impact of HT on spermretrieval or reproductive outcomes in men with KS. On average, surgicalspermretrieval rates in men with KS are around 51%, with a range of 28%-69%. Young patient ageis the most consistent positive predictor of spermretrieval. Lowerretrieval rates have been reported in a smallsubset of KS adultswhopreviouslyreceivedexogenousT, although the nature, duration, and reason for suchtherapy in these patient subsets are unknown. CONCLUSION(S):  Early HT isrecommended in patients with KS, but itseffect on fertilitypotential has not been definitivelystudied. Largerstudies are needed to betteranswerthis question. Cryopreservation of sperm-containingsemen or testicular tissue from a significant proportion of affected adolescents is possible, evenwhencontainingverylownumbers of spermatozoa, and shouldbeconsidered to maximize future fertilitypotential.

  11. Predictors for successfulspermretrieval of salvagemicrodissection testicularsperm extraction (TESE) followingfailed TESE in nonobstructiveazoospermia patientsTao Xu et coll 2016 Summary The purpose of thisstudywas to observe the clinical utility and the possible determinants in predictingspermretrieval of salvage microdissection testicularsperm extraction (mTESE) for nonobstructiveazoospermia (NOA) patients withfailedconventional TESE at their first attempts. A total of 52 NOA males underwent salvage mTESEwererecruited in thisstudy. Related data, includingage, BMI, the presence of Klinefelter’s syndrome and varicocele, cryptorchidism, meantesticular volume, hormonal profile (total testosterone (TT), follicle-stimulating hormone (FSH), luteinising hormone (LH), inhibin B (INHB)), testicularhistology and surgical duration, werecollected and analysed. A multivariatelogisticregressionwithlikelihood ratio test revealed the followingpredictors of spermretrieval: TT and testicularhistology (chi-square of likelihood ratio = 26.42, df = 4, p < .005). A formula wasalsoestablishedusingmultivariateregressionanalysis in predictingspermretrievalprobability. A predictedprobability of more than 71% wasdetermined of the formula as the cut-off value in predictingspermretrievalusingreceiver operating characteristics (ROC) analysiswith a sensitivity and specificity 78.0% and 72.4% respectively. In conclusion, salvage mTESEis of clinicalvalue in NOA males withfailed TESE attempts, whereas the established formula couldbeuseful in determining the proper salvage mTESE candidates.

  12. Reproductive outcomes of testicular versus ejaculatedsperm forintracytoplasmicsperminjectionamong men with high levels of DNAfragmentation in semen: systematicreview and meta-analysisSC Esteves et coll 2017

  13. Interêt de la MicroTESE: systématiques ? Échec prélèvement classique • Changement dans la prise en charge des syndrome de Klinefelter • (Biopsies dans certains cas ciblés de fragmentation élévée) • Recherche: • PHRC: protocole deuxièmes biopsies après Clomid (H Lejeune) • Biologicaltherapy for non-obstructive azoospermia. Sarah C. Vij, Edmund Sabanegh Jr & AshokAgarwal 2018

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