ORIGINAL ARTICLE
Correspondence:
Ahmet H. Haliloglu, Ufuk Universitesi Tip Fakultesi, Uroloji A.D. Mevlana Bulvari No. 86–88, Ankara, Turkey. E-mail: [email protected]
Keywords:
infertility, Klinefelter Syndrome, sperm retrieval Received: 28-Dec-2012
Revised: 11-Oct-2013 Accepted: 13-Oct-2013
doi: 10.1111/j.2047-2927.2013.00157.x
Should repeated TESE be performed
following a failed TESE in men with
Klinefelter Syndrome?
1
A. H. Haliloglu,
1S. Tangal,
2O. Gulpinar,
1K. Onal and
3R. Pabuccu
1Department of Urology, Ufuk University School of Medicine,2Department of Urology, Ankara
University School of Medicine, and3Department of Gynecology and Obstetrics, Centrum Clinic
Reproductive Medical Center, Ufuk University School of Medicine, Ankara, Turkey
SUMMARY
The main goal of this study was to evaluate the success rate of repeated Testicular Sperm Extraction (TESE) in Klinefelter Syn-drome (KS). Eighteen patients with the diagnosis of KS who had undergone micro TESE previously were re-evaluated between May 2007 and May 2012. Testes were measured and testicular volume was calculated by orchidometer and by scrotal ultrasonography in all patients All patients underwent repeated micro TESE. Serum follicle stimulating hormone (FSH), luteinizing hormone (LH), tes-tosterone levels and testicular volume of the patients with and without successful sperm retrieval were compared statistically. A p value of less than 0.05 was considered statistically significant. The mean age of the patients was 30.3 years. The mean testicular vol-ume was 2.08 and 2.1 mL for right and left testes respectively. The comparisons of serum FSH, LH, testosterone levels and testicular volume between patients with and without successful sperm retrieval did not show any significant difference. Three of the 18 patients who underwent repeated micro TESE, had successful sperm retrieval and repeated TESE failed in 15 patients. Three patients with successful sperm retrieval underwent intracytoplasmic sperm injection using retrieved testicular spermatozoa. Two embryos for each patient which were determined as healthy were transferred to the wives of the patients. Pregnancy occured in one of them and a healthy female infant was born. We conclude that consideration and hope must be given for a repeated micro TESE in patients with KS, even with a minimal chance of success.
INTRODUCTION
Klinefelter syndrome (KS) is the most common chromosomal abnormality found in humans (1/500–1000 males), and the most frequent genetic cause of azoospermia (Klinefelter et al., 1942; Tuttelman & Gromoll, 2010). About 80–90% of patients with KS have a uniform 47, XXY karyotype (pure KS) in which an extra X chromosome is present in all of the somatic and germ cell compartments (Philip et al., 1976). The remaining 10–20% have the mosaic form (46,XY/47,XXY) in which the presence of spermatozoa in the ejaculate and subsequent paternities have been reported (Ferhi et al., 2009). If and when the diagnosis is made (75% of the expected number of Klinefel-ter men are undiagnosed), it is most often at an adult age when karyotyping is performed because of hypogonadism and/ or infertility (Abramsky & Chapple, 1997). Several reports have been published on successful fertility treatment of men with KS using testicular sperm extraction (TESE) combined with in-tracytoplasmic sperm injection (ICSI), as recently reviewed. In about half (44–55%) of the Klinefelter men, spermatozoa can be retrieved from the testes (Fullerton et al., 2010), with an
average pregnancy rate after ICSI of 20–25% per treatment cycle (Devroey & Van Steirteghem, 2004; Anderson et al., 2008). Ramasamy et al. (2009) reported on 68 men with non-mosaic KS and found that testicular spermatozoa were successfully retrieved in 45 men (66%), representing 62 (68%) attempts. These success rates are similar to those of TESE in azoosper-mic men with other or unknown aetiology (Fullerton et al., 2010).
Clinical parameters such as follicle stimulating hormone (FSH), inhibin B and testicular volume do not have predictive value for sperm retrieval in patients with KS. The mean age of patients with successful sperm retrieval was significantly lower than that of men with unsuccessful results. Sperm extraction in patients with KS should be performed before the critical age of 35 years (Ramasamy et al., 2009). As there are no reliable predic-tive data for repeated TESE, a scientific consensus could not been established about repeated TESE following a failed TESE in patients with KS.
The benefit of medical therapy is not proven. Androgen pro-ducing capacity of the testis and spermatogenic function are 42 Andrology, 2014, 2, 42–44 © 2013 American Society of Andrology and European Academy of Andrology
thought to be interrelated. Normalization of serum testosterone by medical therapy mediates greater potential for spermatogen-esis in some seminiferous tubules. Ramasamy et al. (2009) also reported men with low baseline testosterone who responded to medical therapy with a resultant testosterone of greater than 250 ng/dL had a higher chance of sperm retrieval than men who did not. The aim of this study was to evaluate the success rate of repeated TESE in our patient population.
MATERIALS AND METHODS
We retrospectively evaluated the medical reports of 18 patients with the diagnosis of non-mosaic KS (47XXY) con-firmed by analysis of at least 20 peripheral blood lymphocytes using G- and Q-banding techniques. All patients had a history of unsuccessful micro TESE and underwent repeated micro TESE between May 2007 and May 2012. Histopathological analyses of the initial biopsies were as follows: 12 attempted TESE cases with Sertoli cell-only pattern and four with Leydig cells-only pattern. The histological findings for the other two attempts were not known. None of the patients had a medical therapy before micro TESE. All patients were informed about the low success rate of repeated micro TESE in KS and in patients with a history of unsuccessful micro TESE. Patients were also informed about the possible risks of the procedure. Written informed consent was obtained from all patients. As this was a retrospective study we did not obtain institutional review board approval. The patients underwent a full clinical evaluation and a physical examination. Testes were measured and testicular volume was calculated by orchidometer and by scrotal ultrasonography in all patients. Serum levels of FSH, luteinizing hormone (LH) and total testosterone were noted (Elecsys 2010; Roche, Mannheim, Germany).
The surgical procedure for micro TESE was as follows: sperm retrieval was performed using an open microscopic testicular biopsy technique under general anaesthesia. A transverse inci-sion of approximately 2 cm was made through the skin, dartos and tunica vaginalis of the scrotum; these layers were retracted as the scrotum was squeezed around the testis. The tunica albu-ginea was opened widely along the antimesenteric border, direct exploration of the seminiferous tubules was performed under an operating microscope with optical magnification at 25 power (D.F. Vasconcellos M900, DFV, Sao Paulo, Brazil). In patients with non-mosaic KS, generally show a few seminiferous tubules without sclerotic change and solid brown Leydig cell nodules with predominantly sclerotic tubules. These a very few seminif-erous tubules were expected to show active spermatogenesis. Small samples (1–15 mg) were excised from larger, more opaque tubules. Tubes were treated in an excessively protective manner because of the history of previous micro TESE. Tubes that were not observed plump and shiny were not gathered. Each sample was placed in a Petri dish filled with 0.5–1.0 mL human tubal fluid medium and placing a small droplet of dispersed tissue suspension on a glass slide under a phase contrast microscope at 4009 magnification. The incised segment of tunica albuginea and other layers were closed with sutures of 4/0 vicryl. Three days of antibiotic prophylaxis (Ofloxacine 400 mg 191) and anti-inflammatory therapy (dexketoprofen trometamol 291) were performed after superimposing ice on scrotum for 2 hours post-operatively. Serum FSH, LH, testosterone levels and testicular volume between patients with and without successful sperm
retrieval were compared statistically. A p value of less than 0.05 was considered statistically significant.
RESULTS
Eighteen Klinefelter men (who have experienced unsuccessful micro TESE) were examined. The mean age of the patients was 30.3 years. The mean testicular volume was 2.08 and 2.1 mL for right and left testes respectively (Table 1). Of the 18 patients who underwent repeated micro TESE, three patients (16.7%) had suc-cessful sperm retrieval and TESE was failed in 15 patients (83.3%). Histological analysis of the previous micro TESE was Sertoli cell-only Syndrome in all of the three patients positive for spermatozoa. The comparisons of serum FSH, LH, testosterone levels and testicular volume between patients with and without successful sperm retrieval did not show any significant difference (Table 1).
Patients with successful sperm retrieval underwent ICSI using retrieved testicular spermatozoa. One of the three patients who underwent ICSI did not approve genetic analysis. The embryos of the remaining two patients were genetically analysed. Two embryos for each patient which were determined as healthy were transferred to the wives of the patients. Pregnancy occured in one of them and a healthy female infant was born. No signifi-cant post-operative complication was seen.
The mean serum total testosterone level in patients with KS was below normal ranges before the procedure (1.85 0.4 ng/ mL), and further decrease was established post-operatively (1.6 0.3 ng/mL). However, the difference between pre-opera-tive and post-operapre-opera-tive measurements was not statistically significant (p= 0.08).
DISCUSSION
Approximately 8% of adult men with KS have spermatozoa present in the ejaculate. These men typically have cryptozoosper-mia or severe oligospercryptozoosper-mia, with sperm concentrations lower than 19 106/mL, and impairment in sperm motility and mor-phology (Selice et al., 2010). Successful pregnancies have been achieved using ejaculated spermatozoa and assisted reproductive technologies (Bourne et al., 1997). Successful sperm retrieval in men with KS using TESE was first reported in 1996 (Tournaye et al., 1996). The first pregnancies achieved by using ICSI of ejac-ulated and testicular spermatozoa were reported 2 years later (Palermo et al., 1998). A higher pregnancy rate after ICSI has been reported with the use of freshly retrieved spermatozoa (Seo et al., 2004). However, cryopreserved spermatozoa have been success-fully used by several groups, obviating the need for repeated sur-gical procedures for sperm retrieval (Okada et al., 2005). Table 1 Baseline characteristics of patients (n = 18)
Characteristics Sperm negative group (n = 15) Sperm positive group (n = 3) p-value Age (years) 29.8 (26–34) 33.3 (27–38) FSH (IU/L) 38.3 (20–54) 39.6 (29–44) p = 0.741 LH (IU/L) 21.4 (11–28) 22.3 (8–31) p = 0.654 Testicular volume (mL) (R) 2.06 (1.2–2.9) 2.1 (1.8–2.7) p = 0.856 Testicular volume (mL) (L) 2.1 (1.3–3.0) 2.2 (1.9–2.9) p = 0.752 Testosterone (ng/ mL) 1.9 (0.5–2.9) 1.5 (0.9–2.1) p = 0.699 (R), Right; (L), Left.
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Testicular dissection for sperm extraction has some well-known negative effects on testicular function with a temporary decline in serum testosterone which recovers in 12–18 months post-opera-tively (Ramasamy et al., 2005). Irreversible testicular atrophy and hypogonadism are much less common. In a previous report of outcomes in men with KS who underwent conventional or micro-dissection TESE, a post-operative decline in serum testosterone with no improvement after 12 months was shown (Okada et al., 2004). On the other hand, it has also been reported that serum testosterone levels recover to 50% of baseline in men with KS 12 months after microdissection TESE (Takada et al., 2008).
For the above mentioned reasons, it is highly recommended that all KS patients willing to undergo repeated TESE, must be informed about the possible risk of decrease in serum testoster-one levels and the negative testicular side effects. Success rates of repeated TESE and possible permanent complications should be well explained. KS patients carry the risks of repeated TESE, however, we have seen that there is a slight chance of sperm retrieval and pregnancy achievement. This low possibility must also be explained and discussed with the patient and the decision has to be made in consensus.
Evaluation of whole testis during micro TESE procedure seems to be possible as a result of diminished testicular size in KS patients. However, microdissection of these structures may be difficult and insufficient when performed by inexperienced sur-geons as a result of the histopathological nature of the testis and dense fibrotic structures. In addition, as supported by our study, the success rates of repeated TESE are low in patients who underwent micro TESE previously.
As there is not a well-proven medical treatment that can be applied to KS patients, we believe that consideration and hope must be given for a repeated TESE in patients with unsuccessful TESE, even with a minimal chance of success.
The limited number of patients is the main limitation of our study. Further studies with larger patient populations will help us to make certain statements about repeated micro TESE in KS.
CONCLUSION
As KS patients have limited testicular volumes, repeated TESE procedure can be a risk factor for the functionality of testicular tissues and for the possible future stem cell treatment. However, when patients are fully aware of the process, are provided with the needed medical information and if the required approvals are obtained, then repeated TESE can be performed. Neverthe-less, careful attention should be paid for minimal traumatization of the tissues.
REFERENCES
Abramsky L & Chapple J. (1997) 47, XXY (Klinefelter syndrome) and, 47, XYY: estimated rates of and indication for postnatal diagnosis with implications for prenatal counselling. Prenat Diagn 17, 363–368.
Anderson AN, Goossens V, Ferraretti AP, Bhattacharya S, Felberbaum R, de Mouzon J et al. (2008) Assisted reproductive technology in Europe, 2004: results generated from European registers by ESHRE. Hum Reprod 23, 756–771.
Bourne H, Stern K, Clarke G, Pertile M, Speirs A & Baker HW. (1997) Delivery of normal twins following the intracytoplasmic injection of spermatozoa from a patient with 47, XXY Klinefelter’s syndrome. Hum Reprod 12, 2447–2450.
Devroey P & Van Steirteghem A. (2004) A review of ten years experience of ICSI. Hum Reprod Update 10, 19–28.
Ferhi K, Avakian R, Griveau JF & Guille F. (2009) Age as only predictive factor for successful sperm recovery in patients with Klinefelter’s syndrome. Andrologia 41, 84–87.
Fullerton G, Hamilton M & Maheshwari A. (2010) Should non-mosaic Klinefelter syndrome men be labelled as infertile in 2009? Hum Reprod 25, 588–597.
Klinefelter HF, Reifenstein EC & Albright F. (1942) Syndrome characterised by gynecomastia, aspermatogenesis without
a-leydigism, and increased excretion of follicle-stimulation hormone. J Clin Endocrinol 2, 615–627.
Okada H, Shirakawa T, Ishikawa T, Goda K, Fujisava M & Kamidono S. (2004) Serum testosterone levels in patients with nonmosaic Klinefelter syndrome after testicular sperm extraction for intracytoplasmic sperm injection. Fertil Steril 82, 237–238. Okada H, Goda K, Muto S, Maruyama O, Koshida M & Horie S. (2005)
Four pregnancies in nonmosaic Klinefelter’s syndrome using cryopreserved-thawed testicular spermatozoa. Fertil Steril 84, 1508.
Palermo GD, Schlegel PN, Sills ES, Veeck LL, Zaninovic N, Menendez S et al. (1998) Births after intracytoplasmic injection of sperm obtained by testicular extraction from men with nonmosaic Klinefelter’s syndrome. N Eng J Med 338, 588–590.
Philip J, Lundsteen C, Owen D & Hirschlom K. (1976) The frequency of chromosome aberration in tall men with special reference to 47, XYY and 47, XXY. Am J Hum Genet 28, 404–411.
Ramasamy R, Yagan N & Schlegel PN. (2005) Structural and functional changes to the testis after conventional versus microdissection testicular sperm extraction. Urology 65, 1190–1194.
Ramasamy R, Ricci JA, Palermo GD, Gosden LV, Rosenwaks Z & Schlegel PN. (2009) Successful fertility treatment for Klinefelter’s syndrome. J Urol 182, 1108–1113.
Selice R, Di Mambro A, Garolla A & Ficarra V. (2010) lafrate M, Ferlin A, et al. Spermatogenesis in klinefelter syndrome. J Endocrinol Invest 33, 789–793.
Seo JT, Park YS & Lee JS. (2004) Successful testicular sperm extraction in Korean Klinefelter syndrome. Urology 64, 1208–1211.
Takada S, Tsujimura A, Ueda T, Matsuoka Y, Takao T, Miyagawa Y et al. (2008) Androgen decline in patients with nonobstructive azoospermia after microdissection testicular sperm extraction. Urology 72, 114–118.
Tournaye H, Staessen C, Liebaers I, Van Assche E, Devroey P, Bonduelle M et al. (1996) Testicular sperm recovery in nine 47, XXY Klinefelter patients. Hum Reprod 11, 1644–1649.
Tuttelman F & Gromoll J. (2010) Novel genetic aspects of Klinefelter’s syndrome. Mol Hum Reprod 16, 386–395.
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