Journal of Assisted Reproduction and Genetics

, Volume 33, Issue 10, pp 1319–1335 | Cite as

Novel concepts in male factor infertility: clinical and laboratory perspectives

  • Sandro C. EstevesEmail author
Review meeting


In recent years, the management of male factor infertility has undergone important changes with the introduction of novel concepts, advanced testing, and therapeutic interventions. This review highlights some of these changes and discusses their impact to routine clinical practice. First, we discuss the recent changes in the World Health Organization (WHO) laboratory methods and reference values for the examination of human semen. Second, we examine the role of sperm chromatin integrity tests in light of increasing evidence of the detrimental effect of sperm DNA fragmentation on reproductive outcomes. Third, we summarize the main findings of varicocele-related infertility and the outcomes of microsurgical varicocele repair to different case scenarios. Lastly, we critically discuss the current management of men with nonobstructive azoospermia seeking fertility and the new opportunities that emerged to help these men achieve biological fatherhood.


Andrology Male infertility Microsurgery Nonobstructive azoospermia Semen analysis Sperm DNA fragmentation Varicocele 



The author is grateful to Dr. Hakan Yarali for the invitation to develop this review as a supplementary material to the keynote lecture “Novel concepts in male factor infertility: clinical and laboratory perspectives”,  delivered at the “Excellence in ART: Clinical and Laboratory Perspectives” Meeting, Cappadocia, Turkey April 2016.

Compliance with ethical standards

Conflict of interest

The author declares that he has no conflicts of interest.


  1. 1.
    Esteves SC, Miyaoka R, Agarwal A. An update on the clinical assessment of the infertile male. [corrected]. Clinics (Sao Paulo). 2011;66:691–700. Erratum in: Clinics (Sao Paulo). 2012;67:203.CrossRefGoogle Scholar
  2. 2.
    Brandes M, Hamilton CJ, De Bruin JP, Nelen WL, Kremer JA. The relative contribution of IVF to the total ongoing pregnancy rate in a subfertile cohort. Hum Reprod. 2010;25:118–26.PubMedCrossRefGoogle Scholar
  3. 3.
    Hamada A, Esteves SC, Nizza M, Agarwal A. Unexplained male infertility: diagnosis and management. Int Braz J Urol. 2012;38:576–94.PubMedCrossRefGoogle Scholar
  4. 4.
    Zini A, Bielecki R, Phang D, Zenzes MT. Correlations between two markers of sperm DNA integrity, DNA denaturation and DNA fragmentation, in fertile and infertile men. Fertil Steril. 2001;75:674–77.PubMedCrossRefGoogle Scholar
  5. 5.
    Ahmad G, Moinard N, Esquerre-Lamare C, Mieusset R, Bujan L. Mild induced testicular and epididymal hyperthermia alters sperm chromatin integrity in men. Fertil Steril. 2012;97:546–53.PubMedCrossRefGoogle Scholar
  6. 6.
    Brahem S, Mehdi M, Elghezal H, Saad A. The effects of male aging on semen quality, sperm DNA fragmentation and chromosomal abnormalities in an infertile population. J Assist Reprod Genet. 2011;28:425–32.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Lewis SE. Should sperm DNA fragmentation testing be included in the male infertility work-up? Reprod Biomed Online. 2015;31:134–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Esteves SC, Sharma RK, Gosalvez J, Agarwal A. A translational medicine appraisal of specialized andrology testing in unexplained male infertility. Int Urol Nephrol. 2014;46:1037–52.PubMedCrossRefGoogle Scholar
  9. 9.
    Agarwal A, Esteves SC. Varicocele and male infertility: current concepts and future perspectives. Asian J Androl. 2016;18:161–2.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Cho CL, Esteves SC, Agarwal A. Novel insights into the pathophysiology of varicocele and its association with reactive oxygen species and sperm DNA fragmentation. Asian J Androl. 2016;18:186–93.PubMedCrossRefGoogle Scholar
  11. 11.
    Majzoub A, Esteves SC, Gosálvez J, Agarwal A. Specialized sperm function tests in varicocele and the future of andrology laboratory. Asian J Androl. 2016;18:205–12.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Tiseo BC, Esteves SC, Cocuzza MS. Summary evidence on the effects of varicocele treatment to improve natural fertility in subfertile men. Asian J Androl. 2016;18:239–45.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Esteves SC, Roque M, Agarwal A. Outcome of assisted reproductive technology in men with treated and untreated varicocele: systematic review and meta-analysis. Asian J Androl. 2016;18:254–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Esteves SC. Clinical management of infertile men with nonobstructive azoospermia. Asian J Androl. 2015;17:459–70.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Esteves SC, Agarwal A. The azoospermic male: current knowledge and future perspectives. Clinics. 2013;68 Suppl 1:1–4.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    World Health Organization. WHO laboratory manual for the examination and processing of human semen. 5th ed. Geneva: World Health Organization; 2010. p. 271.Google Scholar
  17. 17.
    Esteves SC. Clinical relevance of routine semen analysis and controversies surrounding the 2010 World Health Organization criteria for semen examination. Int Braz J Urol. 2014;40:443–53.PubMedCrossRefGoogle Scholar
  18. 18.
    Brazil C, Swan SH, Drobnis EZ, Liu F, Wang C, Redmon JB, et al. Standardized methods for semen evaluation in a multicenter research study. J Androl. 2004;25:635–44.PubMedCrossRefGoogle Scholar
  19. 19.
    Iwamoto T, Nozawa S, Yoshiike M, Hoshino T, Baba K, Matsushita T, et al. Semen quality of 324 fertile Japanese men. Hum Reprod. 2006;21:760–5.PubMedCrossRefGoogle Scholar
  20. 20.
    Pompeu C, Feijo C, Esteves S. Comparison between analytical scale and graduated serological pipette for semen volume analysis: a cross sectional study. Hum Reprod. 2015;30 Suppl 1:i331–2.Google Scholar
  21. 21.
    Van Waart J, Kruger TF, Lombard CJ, Ombelet W. Predictive value of normal sperm morphology in intrauterine insemination (IUI): a structured literature review. Hum Reprod Update. 2001;7:495–500.PubMedCrossRefGoogle Scholar
  22. 22.
    Esteves SC, Zini A, Aziz N, Alvarez JG, Sabanegh Jr ES, Agarwal A. Critical appraisal of World Health Organizations new reference values for human semen characteristics and effect on diagnosis and treatment of subfertile men. Urology. 2012;79:16–22.PubMedCrossRefGoogle Scholar
  23. 23.
    Cooper TG, Noonan E, von Eckardstein S, Auger J, Baker HW, Behre HM, et al. World Health Organization reference values for human semen characteristics. Hum Reprod Update. 2010;16:231–45.PubMedCrossRefGoogle Scholar
  24. 24.
    Murray KS, James A, McGeady JB, Reed ML, Kuang WW, Nangia AK. The effect of the new 2010 World Health Organization criteria for semen analyses on male infertility. Fertil Steril. 2012;98:1428–31.PubMedCrossRefGoogle Scholar
  25. 25.
    Esteves SC, Chan P. A systematic review of recent clinical practice guidelines and best practice statements for the evaluation of the infertile male. Int Urol Nephrol. 2015;47:1441–56.PubMedCrossRefGoogle Scholar
  26. 26.
    Agarwal A, Sharma R, Harlev A, Esteves SC. Effect of varicocele on semen characteristics according to the new 2010 World Health Organization criteria: a systematic review and meta-analysis. Asian J Androl. 2016;18:163–70.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Shridharani A, Owen RC, Elkelany OO, Kim ED. The significance of clinical practice guidelines on adult varicocele detection and management. Asian J Androl. 2016;18:269–75.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Sharma R, Harlev A, Agarwal A, Esteves SC. Cigarette smoking and semen quality: a new meta-analysis examining the effect of the 2010 World Health Organization laboratory methods for the examination of human semen. Eur Urol. 2016.Google Scholar
  29. 29.
    Agarwal A, Cho CL, Esteves SC. Should we evaluate and treat sperm DNA fragmentation? Curr Opin Obstet Gynecol. 2016;28:164–71.PubMedCrossRefGoogle Scholar
  30. 30.
    Esteves SC, Gosálvez J, López-Fernández C, Núñez-Calonge R, Caballero P, Agarwal A, et al. Diagnostic accuracy of sperm DNA degradation index (DDSi) as a potential noninvasive biomarker to identify men with varicocele-associated infertility. Int Urol Nephrol. 2015;47:1471–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Saleh RA, Agarwal A, Nelson DR, Nada EA, El-Tonsy MH, Alvarez JG, et al. Increased sperm nuclear DNA damage in normozoospermic infertile men: a prospective study. Fertil Steril. 2002;78:313–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Gosalvez J, Lopez-Fernandez C, Fernandez JL, Esteves SC, Johnston SD. Unpacking the mysteries of sperm DNA fragmentation: ten frequently asked questions. J Reprod Biotechnol Fertil. 2015;4:1–16.CrossRefGoogle Scholar
  33. 33.
    Sun JG, Jurisicova A, Casper RF. Detection of deoxyribonucleic acid fragmentation in human sperm: correlation with fertilization in vitro. Biol Reprod. 1997;56:602–7.PubMedCrossRefGoogle Scholar
  34. 34.
    Seli E, Gardner DK, Schoolcraft WB, Moffatt O, Sakkas D. Extent of nuclear DNA damage in ejaculated spermatozoa impacts on blastocyst development after in vitro fertilization. Fertil Steril. 2004;82:378–83.PubMedCrossRefGoogle Scholar
  35. 35.
    Aitken RJ, Krausz C. Oxidative stress, DNA damage and the Y chromosome. Reproduction. 2001;122:497–506.PubMedCrossRefGoogle Scholar
  36. 36.
    Zini A, Boman JM, Belzile E, Ciampi A. Sperm DNA damage is associated with an increased risk of pregnancy loss after IVF and ICSI: systematic review and meta-analysis. Hum Reprod. 2008;23:2663–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Robinson L, Gallos ID, Conner SJ, Rajkhowa M, Miller D, Lewis S, et al. The effect of sperm DNA fragmentation on miscarriage rates: a systematic review and meta-analysis. Hum Reprod. 2012;27:2908–17.PubMedCrossRefGoogle Scholar
  38. 38.
    Feijo CM, Esteves SC. Diagnostic accuracy of sperm chromatin dispersion test to evaluate sperm deoxyribonucleic acid damage in men with unexplained infertility. Fertil Steril. 2014;101:58–63.PubMedCrossRefGoogle Scholar
  39. 39.
    Gosálvez J, Rodríguez-Predreira M, Mosquera A, López-Fernández C, Esteves SC, Agarwal A, et al. Characterisation of a subpopulation of sperm with massive nuclear damage, as recognised with the sperm chromatin dispersion test. Andrologia. 2014;46:602–9.Google Scholar
  40. 40.
    Sharma R, Ahmad G, Esteves SC, Agarwal A. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay using bench top flow cytometer for evaluation of sperm DNA fragmentation in fertility laboratories: protocol, reference values, and quality control. J Assist Reprod Genet. 2016;33:291–300.PubMedCrossRefGoogle Scholar
  41. 41.
    Esteves SC, Sánchez-Martín F, Sánchez-Martín P, Schneider DT, Gosálvez J. Comparison of reproductive outcome in oligozoospermic men with high sperm DNA fragmentation undergoing intracytoplasmic sperm injection with ejaculated and testicular sperm. Fertil Steril. 2015;104:1398–405.PubMedCrossRefGoogle Scholar
  42. 42.
    Agarwal A, Gupta S, Du Plessis S, Sharma R, Esteves SC, Sabanegh E. Abstinence time and its impact on basic and advanced semen parameters. Urology. 2016.Google Scholar
  43. 43.
    Practice Committee of the American Society for Reproductive Medicine. Diagnostic evaluation of the infertile male: a committee opinion. Fertil Steril. 2015;103:e18–25.Google Scholar
  44. 44.
    Agarwal A, Hamada A, Esteves SC. Insight into oxidative stress in varicocele-associated male infertility: part 1. Nat Rev Urol. 2012;9:678–90.PubMedCrossRefGoogle Scholar
  45. 45.
    Hamada A, Esteves SC, Agarwal A. Insight into oxidative stress in varicocele-associated male infertility: part 2. Nat Rev Urol. 2013;10:26–37.PubMedCrossRefGoogle Scholar
  46. 46.
    Miyaoka R, Esteves SC. A critical appraisal on the role of varicocele in male infertility. Adv Urol. 2012;2012:597495.PubMedCrossRefGoogle Scholar
  47. 47.
    Dada R, Shamsi MB, Venkatesh S, Gupta NP, Kumar R. Attenuation of oxidative stress & DNA damage in varicocelectomy: implications in infertility management. Indian J Med Res. 2010;132:728–30.PubMedPubMedCentralGoogle Scholar
  48. 48.
    Wang YJ, Zhang RQ, Lin YJ, Zhang RG, Zhang WL. Relationship between varicocele and sperm DNA damage and the effect of varicocele repair: a meta-analysis. Reprod Biomed Online. 2012;25:307–14.PubMedCrossRefGoogle Scholar
  49. 49.
    Esteves SC, Oliveira FV, Bertolla RP. Clinical outcome of intracytoplasmic sperm injection in infertile men with treated and untreated clinical varicocele. J Urol. 2010;184:1442–6.Google Scholar
  50. 50.
    Bungum M, Humaidan P, Axmon A, Spano M, Bungum L, Erenpreiss J, et al. Sperm DNA integrity assessment in prediction of assisted reproduction technology outcome. Hum Reprod. 2007;22:174–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Duran EH, Morshedi M, Taylor S, Oehninger S. Sperm DNA quality predicts intrauterine insemination outcome: a prospective cohort study. Hum Reprod. 2002;17:3122–8.PubMedCrossRefGoogle Scholar
  52. 52.
    Zhang Z, Zhu L, Jiang H, Chen H, Chen Y, Dai Y. Sperm DNA fragmentation index and pregnancy outcome after IVF or ICSI: a meta-analysis. J Assist Reprod Genet. 2015;32:17–26.PubMedCrossRefGoogle Scholar
  53. 53.
    Osman A, Alsomait H, Seshadri S, El-Toukhy T, Khalaf Y. The effect of sperm DNA fragmentation on live birth rate after IVF or ICSI: a systematic review and meta-analysis. Reprod Biomed Online. 2015;30:120–7.PubMedCrossRefGoogle Scholar
  54. 54.
    Showell MG, Mackenzie-Proctor R, Brown J, et al. Antioxidants for male subfertility. Cochrane Database Syst Rev. 2014;12:CD007411.PubMedGoogle Scholar
  55. 55.
    Sanchez-Martin P, Sanchez-Martin F, Gonzalez-Martinez M, Gosalvez J. Increased pregnancy after reduced male abstinence. Syst Biol Reprod Med. 2013;59:256–60.PubMedCrossRefGoogle Scholar
  56. 56.
    Gosálvez J, González-Martínez M, López-Fernández C, Fernández JL, Sánchez-Martín P. Shorter abstinence decreases sperm deoxyribonucleic acid fragmentation in ejaculate. Fertil Steril. 2011;96:1083–6.PubMedCrossRefGoogle Scholar
  57. 57.
    Parmegiani L, Cognigni GE, Bernardi S, Troilo E, Taraborrelli S, Arnone A, et al. Comparison of two ready-to-use systems designed for sperm-hyaluronic acid binding selection before intracytoplasmic sperm injection: PICSI vs. Sperm Slow: a prospective, randomized trial. Fertil Steril. 2012;98:632–7.PubMedCrossRefGoogle Scholar
  58. 58.
    Said TM, Grunewald S, Paasch U, Rasch M, Agarwal A, Glander HJ. Advantage of combining magnetic cell separation with sperm preparation techniques. Reprod Biomed Online. 2005;10:740–6.PubMedCrossRefGoogle Scholar
  59. 59.
    Teixeira DM, Barbosa MA, Ferriani RA, Navarro PA, Raine-Fenning N, Nastri CO, et al. Regular (ICSI) versus ultra-high magnification (IMSI) sperm selection for assisted reproduction. Cochrane Database Syst Rev. 2013;7:CD010167.PubMedGoogle Scholar
  60. 60.
    Greco E, Scarselli F, Iacobelli M, Rienzi L, Ubaldi F, Ferrero S, et al. Efficient treatment of infertility due to sperm DNA damage by ICSI with testicular spermatozoa. Hum Reprod. 2005;20:226–30.PubMedCrossRefGoogle Scholar
  61. 61.
    Moskovtsev SI, Jarvi K, Mullen JB, Cadesky KI, Hannam T, Lo KC. Testicular spermatozoa have statistically significantly lower DNA damage compared with ejaculated spermatozoa in patients with unsuccessful oral antioxidant treatment. Fertil Steril. 2010;93:1142–6.PubMedCrossRefGoogle Scholar
  62. 62.
    Zhao J, Zhang Q, Wang Y, Li Y. Whether sperm deoxyribonucleic acid fragmentation has an effect on pregnancy and miscarriage after in vitro fertilization/intracytoplasmic sperm injection: a systematic review and metaanalysis. Fertil Steril. 2014;102:998–1005.PubMedCrossRefGoogle Scholar
  63. 63.
    Cocuzza M, Alvarenga C, Pagani R. The epidemiology and etiology of azoospermia. Clinics. 2013;68(S1):15–26.PubMedPubMedCentralCrossRefGoogle Scholar
  64. 64.
    Esteves SC, Miyaoka R, Orosz JE, Agarwal A. An update on sperm retrieval techniques for azoospermic male. Clinics. 2013;68(S1):99–110.PubMedPubMedCentralCrossRefGoogle Scholar
  65. 65.
    Schoor RA, Elhanbly S, Niederberger CS, Ross LS. The role of testicular biopsy in the modern management of male infertility. J Urol. 2002;167:197–200.PubMedCrossRefGoogle Scholar
  66. 66.
    Esteves SC, Lee W, Benjamin DJ, Seol B, Verza Jr S, Agarwal A. Reproductive potential of men with obstructive azoospermia undergoing percutaneous sperm retrieval and intracytoplasmic sperm injection according to the cause of obstruction. J Urol. 2013;189:232–7.PubMedCrossRefGoogle Scholar
  67. 67.
    Fraietta R, Zylberstejn DS, Esteves SC. Hypogonadotropic hypogonadism revisited. Clinics (Sao Paulo). 2013;68 Suppl 1:81–8.CrossRefGoogle Scholar
  68. 68.
    Hung AJ, King P, Schlegel PN. Uniform testicular maturation arrest: a unique subset of men with nonobstructive azoospermia. J Urol. 2007;178:608–12.PubMedCrossRefGoogle Scholar
  69. 69.
    Bobjer J, Naumovska M, Giwercman YL, Giwercman A. High prevalence of androgen deficiency and abnormal lipid profile in infertile men with non-obstructive azoospermia. Int J Androl. 2012;35:688–94.PubMedCrossRefGoogle Scholar
  70. 70.
    Monteiro RAC, Pariz JR, Pieri PC, Hallak J. An easy, reproducible and cost-effective method for andrologists to improve the laboratory diagnosis of non-obstructive azoospermia: a novel microcentrifugation technique. Int Braz J Urol. 2016;42:132–8.PubMedPubMedCentralCrossRefGoogle Scholar
  71. 71.
    Aziz N. The importance of semen analysis in the context of azoospermia. Clinics (Sao Paulo). 2013;68 Suppl 1:35–8.CrossRefGoogle Scholar
  72. 72.
    Esteves SC, Agarwal A. Re: sperm retrieval rates and intracytoplasmic sperm injection outcomes for men with non-obstructive azoospermia and the health of resulting offspring. Asian J Androl. 2014;16:642.PubMedCentralCrossRefGoogle Scholar
  73. 73.
    Esteves SC, Miyaoka R, Agarwal A. Sperm retrieval techniques for assisted reproduction. Int Braz J Urol. 2011;37:570–83.PubMedCrossRefGoogle Scholar
  74. 74.
    Esteves SC, Verza Jr S. PESA/TESA/TESE sperm processing. In: Nagy ZP, Varghese AC, Agarwal A, editors. Practical manual of in vitro fertilization. New York: Springer; 2012. p. 207–20.CrossRefGoogle Scholar
  75. 75.
    Verza Jr S, Esteves SC. Microsurgical versus conventional single-biopsy testicular sperm extraction in nonobstructive azoospermia: a prospective controlled study. Fertil Steril. 2011;96(Suppl):S53.CrossRefGoogle Scholar
  76. 76.
    Tournaye H, Verheyen G, Nagy P, Ubaldi F, Goossens A, Silber S, et al. Are there any predictive factors for successful testicular sperm recovery in azoospermic patients? Hum Reprod. 1997;12:80–6.PubMedCrossRefGoogle Scholar
  77. 77.
    Simoni M, Tuttelmann F, Gromoll J, Nieschlag E. Clinical consequences of microdeletions of the Y chromosome: the extended Munster experience. Reprod Biomed Online. 2008;16:289–303.PubMedCrossRefGoogle Scholar
  78. 78.
    Hamada AJ, Esteves SC, Agarwal A. A comprehensive review of genetics and genetic testing in azoospermia. Clinics (Sao Paulo). 2013;68 Suppl 1:39–60.CrossRefGoogle Scholar
  79. 79.
    Krausz C, Hoefsloot L, Simoni M, Tüttelmann F. EAA/EMQN best practice guidelines for molecular diagnosis of Y-chromosomal microdeletions: state-of-the-art 2013. Andrology. 2014;2:5–19.PubMedCrossRefGoogle Scholar
  80. 80.
    Peterlin B, Kunej T, Sinkovec J, Gligorievska N, Zorn B. Screening for Y chromosome microdeletions in 226 Slovenian subfertile men. Hum Reprod. 2002;17:17–24.PubMedCrossRefGoogle Scholar
  81. 81.
    Navarro-Costa P, Plancha CE, Gonçalves J. Genetic dissection of the AZF regions of the human Y chromosome: thriller or filler for male (in)fertility? J Biomed Biotechnol. 2010;2010:936569.PubMedPubMedCentralCrossRefGoogle Scholar
  82. 82.
    Patsalis PC, Sismani C, Quintana-Murci L, Taleb-Bekkouche F, Krausz C, McElreavey K. Effects of transmission of Y chromosome AZFc deletions. Lancet. 2000;360:1222–4.CrossRefGoogle Scholar
  83. 83.
    Siffroi JP, Le Bourhis C, Krausz C, Barbaux S, Quintana-Murci L, Kanafani S, et al. Sex chromosome mosaicism in males carrying Y chromosome long arm deletions. Hum Reprod. 2000;15:2559–62.PubMedCrossRefGoogle Scholar
  84. 84.
    Rajpert-De Meyts E, Ottesen AM, Garn ID, Aksglaede L, Juul A. Deletions of the Y chromosome are associated with sex chromosome aneuploidy but not with Klinefelter syndrome. Acta Paed. 2011;100:900–2.CrossRefGoogle Scholar
  85. 85.
    Coviello AD, Bremner WJ, Matsumoto AM, Herbst KL, Amory JK, Anawalt BD, et al. Intratesticular testosterone concentrations comparable with serum levels are not sufficient to maintain normal sperm production in men receiving a hormonal contraceptive regimen. J Androl. 2004;25:931–8.PubMedCrossRefGoogle Scholar
  86. 86.
    Kato Y, Shiraishi K, Matsuyama H. Expression of testicular androgen receptor in non-obstructive azoospermia and its change after hormonal therapy. Andrology. 2014;2:734–40.PubMedCrossRefGoogle Scholar
  87. 87.
    Kumar R. Medical management of non-obstructive azoospermia. Clinics. 2013;68(S1):75–9.PubMedPubMedCentralCrossRefGoogle Scholar
  88. 88.
    Shinjo E, Shiraishi K, Matsuyama H. The effect of human chorionic gonadotropin-based hormonal therapy on intratesticular testosterone levels and spermatogonial DNA synthesis in men with non-obstructive azoospermia. Andrology. 2013;1:929–35.PubMedCrossRefGoogle Scholar
  89. 89.
    Shiraishi K, Ohmi C, Shimabukuro T, Matsuyama H. Human chorionic gonadotrophin treatment prior to microdissection testicular sperm extraction in non-obstructive azoospermia. Hum Reprod. 2012;27:331–9.PubMedCrossRefGoogle Scholar
  90. 90.
    Hussein A, Ozgok Y, Ross L, Rao P, Niederberger C. Optimization of spermatogenesis-regulating hormones in patients with non-obstructive azoospermia and its impact on sperm retrieval: a multicentre study. BJU Int. 2013;111(3, pt. B):E110–4.PubMedCrossRefGoogle Scholar
  91. 91.
    Reifsnyder JE, Ramasamy R, Husseini J, Schlegel PN. Role of optimizing testosterone before microdissection testicular sperm extraction in men with nonobstructive azoospermia. J Urol. 2012;188:532–6.PubMedCrossRefGoogle Scholar
  92. 92.
    Weedin JW, Khera M, Lipshultz LI. Varicocele repair in patients with nonobstructive azoospermia: a meta-analysis. J Urol. 2010;183:2309–15.PubMedCrossRefGoogle Scholar
  93. 93.
    Esteves SC, Glina S. Recovery of spermatogenesis after microsurgical subinguinal varicocele repair in azoospermic men based on testicular histology. Int Braz J Urol. 2005;31:541–8.PubMedCrossRefGoogle Scholar
  94. 94.
    Esteves SC, Miyaoka R, Roque M, Agarwal A. Outcome of varicocele repair in men with nonobstructive azoospermia: systematic review and meta-analysis. Asian J Androl. 2016;18:246–53.PubMedCrossRefGoogle Scholar
  95. 95.
    Schlegel PN, Su LM. Physiological consequences of testicular sperm extraction. Hum Reprod. 1997;12:1688–92.PubMedCrossRefGoogle Scholar
  96. 96.
    Deruyver Y, Vanderschueren D, Van der Aa F. Outcome of microdissection TESE compared with conventional TESE in non-obstructive azoospermia: a systematic review. Andrologia. 2014;2:20–4.CrossRefGoogle Scholar
  97. 97.
    Bernie AM, Mata DA, Ramasamy R, Schlegel PN. Comparison of microdissection testicular sperm extraction, conventional testicular sperm extraction, and testicular sperm aspiration for nonobstructive azoospermia: a systematic review and meta-analysis. Fertil Steril. 2015;104:1099–103.PubMedCrossRefGoogle Scholar
  98. 98.
    Esteves SC. Microdissection testicular sperm extraction (micro-TESE) as a sperm acquisition method for men with nonobstructive azoospermia seeking fertility: operative and laboratory aspects. Int Braz J Urol. 2013;39:440–1.PubMedCrossRefGoogle Scholar
  99. 99.
    Ashraf MC, Singh S, Raj D, Ramakrishnan S, Esteves SC. Micro-dissection testicular sperm extraction as an alternative for sperm acquisition in the most difficult cases of azoospermia: technique and preliminary results in India. J Hum Reprod Sci. 2013;6:111–23.PubMedPubMedCentralCrossRefGoogle Scholar
  100. 100.
    Esteves SC, Agarwal A. Reproductive outcomes, including neonatal data, following sperm injection in men with obstructive and nonobstructive azoospermia: case series and systematic review. Clinics (Sao Paulo). 2013;68 Suppl 1:141–50.CrossRefGoogle Scholar
  101. 101.
    Schlegel PN. Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Hum Reprod. 1999;14:131–5.PubMedCrossRefGoogle Scholar
  102. 102.
    Esteves SC, Varghese AC. Laboratory handling of epididymal and testicular spermatozoa: what can be done to improve sperm injections outcome. J Hum Reprod Sci. 2012;5:233–43.PubMedPubMedCentralCrossRefGoogle Scholar
  103. 103.
    Meseguer M, Santiso R, Garrido N, Gil-Salom M, Remohí J, Fernandez JL. Sperm DNA fragmentation levels in testicular sperm samples from azoospermic males as assessed by the sperm chromatin dispersion test. Fertil Steril. 2009;92:1638–45.PubMedCrossRefGoogle Scholar
  104. 104.
    Vozdova M, Heracek J, Sobotka V, Rubes J. Testicular sperm aneuploidy in non-obstructive azoospermic patients. Hum Reprod. 2012;27:2233–9.PubMedCrossRefGoogle Scholar
  105. 105.
    Verza Jr S, Esteves SC. Sperm defect severity rather than sperm source is associated with lower fertilization rates after intracytoplasmic sperm injection. Int Braz J Urol. 2008;34:49–56.PubMedCrossRefGoogle Scholar
  106. 106.
    Esteves SC, Prudencio C, Seol B, Verza S, Knoedler C, Agarwal A. Comparison of sperm retrieval and reproductive outcome in azoospermic men with testicular failure and obstructive azoospermia treated for infertility. Asian J Androl. 2014;16:602–6.PubMedPubMedCentralCrossRefGoogle Scholar
  107. 107.
    Aydos K, Demirel LC, Baltaci V, Unlü C. Enzymatic digestion plus mechanical searching improves testicular sperm retrieval in non-obstructive azoospermia cases. Eur J Obstet Gynecol Reprod Biol. 2005;120:80–6.PubMedCrossRefGoogle Scholar
  108. 108.
    Baukloh V. Retrospective multicentre study on mechanic and enzymatic preparation of fresh and cryopreserved testicular biopsies. Hum Reprod. 2002;17:1788–94.PubMedCrossRefGoogle Scholar
  109. 109.
    Ozkavukcu S, Ibis E, Kizil S, Isbacar S, Aydos K. A laboratory modification to testicular sperm preparation technique improves spermatogenic cell yield. Asian J Androl. 2014;16:852–7.PubMedPubMedCentralCrossRefGoogle Scholar
  110. 110.
    Popal W, Nagy ZP. Laboratory processing and intracytoplasmic sperm injection using epididymal and testicular spermatozoa: what can be done to improve outcomes. Clinics. 2013;68(S1):125–30.PubMedPubMedCentralCrossRefGoogle Scholar
  111. 111.
    Esteves SC, Bento FC. Implementation of cleanroom technology in reproductive laboratories: the question is not why but how. Reprod Biomed Online. 2016;32(1):9–11.PubMedCrossRefGoogle Scholar
  112. 112.
    Esteves SC, Bento FC. Air quality control in the ART laboratory is a major determinant of IVF success. Asian J Androl. 2015;18:596–9.Google Scholar
  113. 113.
    Esteves SC, Bento FC. Implementation of air quality control in reproductive laboratories in full compliance with the Brazilian Cells and Germinative Tissue Directive. Reprod Biomed Online. 2013;26:9–21.PubMedCrossRefGoogle Scholar
  114. 114.
    Endo Y, Fujii Y, Shintani K, Seo M, Motoyama H, Fu H. Simple vitrification for small numbers of human spermatozoa. Reprod Biomed Online. 2012;24:301–7.PubMedCrossRefGoogle Scholar
  115. 115.
    Coetzee K, Ozgur K, Berkkanoglu M, Bulut H, Isikli A. Reliable single sperm cryopreservation in Cell Sleepers for azoospermia management. Andrologia. 2016;48:203–10.PubMedCrossRefGoogle Scholar
  116. 116.
    He X, Cao Y, Zhang Z, Zhao J, Wei Z, Zhao J, et al. Spermatogenesis affects the outcome of ICSI for azoospermic patients rather than sperm retrieval method. Syst Biol Reprod Med. 2010;56:457–64.PubMedCrossRefGoogle Scholar
  117. 117.
    Fedder J, Gabrielsen A, Humaidan P, Erb K, Ernst E, Loft A. Malformation rate and sex ratio in 412 children conceived with epididymal or testicular sperm. Hum Reprod. 2007;22:1080–5.PubMedCrossRefGoogle Scholar
  118. 118.
    Belva F, De Schrijver F, Tournaye H, Liebaers I, Devroey P, Haentjens P, et al. Neonatal outcome of 724 children born after ICSI using non-ejaculated sperm. Hum Reprod. 2011;26:1752–8.PubMedCrossRefGoogle Scholar
  119. 119.
    Aponte PM, Schlatt S, Franca LR. Biotechnological approaches to the treatment of aspermatogenic men. Clinics (Sao Paulo). 2013;68 Suppl 1:157–67.CrossRefGoogle Scholar
  120. 120.
    Vloeberghs V, Verheyen G, Tournaye H. Intracytoplasmic spermatid injection and in vitro maturation: fact or fiction? Clinics (Sao Paulo). 2013;68 Suppl 1:151–6.CrossRefGoogle Scholar
  121. 121.
    Kumar M, Kumar K, Jain S, Hassan T, Dada R. Novel insights into the genetic and epigenetic paternal contribution to the human embryo. Clinics (Sao Paulo). 2013;68 Suppl 1:5–14.PubMedCentralCrossRefGoogle Scholar
  122. 122.
    Sato T, Katagiri K, Gohbara A, Inoue K, Ogonuki N, Ogura A, et al. In vitro production of functional sperm in cultured neonatal mouse testes. Nature. 2011;471:504–7.PubMedCrossRefGoogle Scholar
  123. 123.
    Lee DR, Kim KS, Yang YH, Oh HS, Lee SH, Chung TG, et al. Isolation of male germ stem cell-like cells from testicular tissue of non-obstructive azoospermic patients and differentiation into haploid male germ cells in vitro. Hum Reprod. 2006;21:471–6.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  1. 1.ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male ReproductionCampinasBrazil

Personalised recommendations