Throughout spermatogenesis multiplication, maturation and differentiation of germ cells results in the formation of the male gamete. The understanding of spermatogenesis needs detailed informations about the organization of the germinal epithelium, the structure and function of different types of germ cells, endocrine and paracrine cells and mechanisms, intratesticular and extratesticular regulation of spermatogenesis. Normal germ cells must be discriminated from malformed, apoptotic and degenerating germ cells and tumor cells. Identification of the border line between normal and disturbed spermatogenesis substantiate the diagnosis of impaired male fertility. The profound knowledge of the complicate process of spermatogenesis and all cells or cell systems involved with is the prerequisite to develop concepts for therapy of male infertility or to handle germ cells in the management of assisted reproduction.

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Understanding spermatogenesis is a prerequisite for treatment

Spermatozoa recovered from testicular biopsies can be used through intracytoplasmic sperm injection (ICSI) to achieve a pregnancy. To assess the likelihood of successful testicular sperm extraction (TESE) in men suffering from severe oligo- or azoospermia, bilateral biopsy specimens were obtained. Following semi-thin sectioning, the morphology of testicular samples was graded according to a modified Johnsen score. TESE was performed in parallel to this histological examination. The number of isolated spermatozoa was assessed in a semiquantitative way. From 103 patients investigated, 64 (62.1%) showed azoospermia in a preceding semen analysis and 29 (28.2%) patients had sperm concentrations between 0.1 and 1 x 10(6)/ml. In 10 patients who had higher sperm counts, most spermatozoa were non-motile. Spermatozoa could be detected after TESE in the testicular tissue of 49 (77%) azoospermic men. When follicle stimulating hormone (FSH) concentration was normal, most patients had detectable spermatozoa after TESE. Nearly one-third of patients with mildly elevated FSH had no spermatozoa. Thirty-nine percent of patients in whom FSH was elevated to more than twice normal and 50% of patients with grossly elevated FSH had no detectable spermatozoa. In all, 82.8% of men with sperm concentrations between 0.1 and 1x10(6)/ml in their ejaculate showed spermatozoa in the tissue sample after TESE. Our data demonstrate that, contrary to previous recommendations, infertile men with azoospermia and high FSH values should be reconsidered for testicular biopsy, provided that tissue samples can be cryopreserved for later TESE/ICSI treatment.

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Successful testicular sperm extraction (TESE) in spite of high serum follicle stimulating hormone and azoospermia: correlation between testicular morphology, TESE results, semen analysis and serum hormone values in 103 infertile men.

BACKGROUND: The objective of this study was to estimate the frequency of Y chromosome microdeletions in the Slovenian population of infertile men and to analyse the consequences of mutation in respect to clinical severity and prognosis. METHODS: In a controlled clinical study at the university-based medical genetics service and infertility clinic, 226 infertile men undergoing ICSI were tested. The main outcome measures included polymerase chain reaction amplification of 16 genes and gene families and 42 sequence-tagged sites in the non-recombining region of the Y chromosome, semen, testicular volume and testicular histological analysis, serum FSH concentrations, fertilization and respective pregnancy rates. RESULTS: The incidence of deletions was 4.4%: 8.6% in men with azoospermia and 1.5% in men with oligoasthenoteratozoospermia. Isolated gene deletions were not identified. No statistically significant differences in clinical outcome measures were found in patients with mutations versus patients without mutations. High fertilization (49%) and pregnancy (43%) rates with sperm of patients with Y chromosome deletions were obtained. CONCLUSIONS: Testing for gene-specific microdeletions does not contribute significantly to the sensitivity of microdeletion test. Fertilization and pregnancy rates obtained using sperm of patients with Y chromosome deletions were comparable with those achieved in conventional IVF.

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Screening for Y chromosome microdeletions in 226 Slovenian subfertile men

Although testicular biopsy for sperm extraction is a procedure with a potential for complications, sperm retrieval is successful in 30-70% of patients with non-obstructive azoospermia. In order to predict the probability of retrieving at least one testicular spermatozoon we conducted a prospective study of a set of variables in 40 patients with non-obstructive azoospermia. Using the receiver operating characteristic curves, we determined the probability estimates of testicular volume, plasma follicle stimulating hormone (FSH) concentration, Johnsen score and visualization of testicular spermatids in discriminating between patients with successful and failed testicular sperm extraction. Visualization of testicular spermatids provided the best estimate of success of testicular sperm extraction. Of the factors studied using logistic-regression analysis (age, maternal and paternal age at birth, body mass index, luteinizing hormone, testosterone, FSH, testicular volume, the presence of testicular spermatids and Johnsen score), only the presence of spermatids and Johnsen score were independent variables able to predict the success of testicular sperm extraction. The visualization of the presence of spermatids gave a correct prediction of 77% and Johnsen score of 71%. The diagnostic model derived from these independent predictors when validated in 40 patients using the Jackknife technique gave a correct overall prediction of 87%. The probability of successful testicular sperm extraction in patients with non-obstructive azoospermia could be objectively predicted on the basis of simple histopathological criteria represented by the visualization of testicular spermatids and Johnsen score.

Establishment of predictive variables associated with testicular sperm retrieval in men with non-obstructive azoospermia.

The purpose of this chapter is to provide a comprehensive overview of spermatogenesis and the various steps involved in the development of the male gamete, including cellular processes and nuclear transformations that occur during spermatogenesis, to provide a clear understanding of one of the most complex cellular metamorphosis that occurs in the human body. Spermatogenesis is a highly complex temporal event during which a relatively undifferentiated diploid cell called spermatogonium slowly evolves into a highly specialized haploid cell called spermatozoon. The goal of spermatogenesis is to produce a genetically unique male gamete that can fertilize an ovum and produce offspring. It involves a series of intricate, cellular, proliferative, and developmental phases. Spermatogenesis is initiated through the neurological axis by the hypothalamus, which releases gonadotropin-releasing hormone, which in turn signals follicle-stimulating hormone (FSH) and luteinizing hormone (LH) to be transmitted to the reproductive tract. LH interacts with the Leydig cells to produce testosterone, and FSH interacts with the Sertoli cells that provide support and nutrition for sperm proliferation and development. Spermatogenesis involves a series of cell phases and divisions by which the diploid spermatogonial cells develop into primary spermatocytes via mitosis. Primary spermatocytes in the basal compartment of Sertoli cells undergo meiosis to produce haploid secondary spermatocytes in the ­adluminal compartment of Sertoli cells in a process called spermatocytogenesis. This process gives the cells a unique genetic identity within the population of secondary spermatocytes and subsequent developing cells. After spermatocytogenesis, spermatids elongate to form spermatozoa by spermiogenesis, a morphological development phase in which the nuclear transformations involving chromatin remodeling and compaction occur. Spermatozoa then leave the Sertoli cells through the lumen of the seminiferous tubules, exit through the rete testis, and enter the epididymis for final maturation. This is where spermatozoa acquire motility and acrosomal function. Spermatogenesis in the human male takes about 74 days. Spermatogenesis is regulated by intrinsic and extrinsic factors. Not all spermatogonia mature into spermatozoa – most are eliminated and phagocytosed in a process called apoptosis. The overall goals of spermatogenesis are (1) to enable the male to transfer genetically recombined DNA by contributing to half of the offspring’s genome and (2) to equip the spermatozoa to effectively navigate through the female reproductive tract and deliver the genetic material to the ovum. In the following sections, the complex transformation of the simple single diploid cell into a fully functional haploid cell is described.

Spermatogenesis: An Overview

Male fertility can usually be assessed by careful examination of testicular size and consistency, evaluation of semen analysis and hormone levels, especially follicle-stimulating hormone (FSH). Further information may be obtained by detailed light and transmission electron microscopical examination of spermatozoa but this is not always feasible and is impossible in men with azoospermia. In such circumstances, only a testicular biopsy can give an accurate assessment of spermatogenic activity and this remains the standard investigation against which all indirect methods must be compared.

A. F. Holstein

Papers

Histopathology of Human Testicular and Epididymal Tissue