Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.
Vita-Salute San Raffaele University, Milan, Italy.
Hum Reprod. 2023 Aug 1;38(8):1464-1472. doi: 10.1093/humrep/dead125.
Is it possible to identify a reliable marker of successful sperm retrieval (+SR) in men with idiopathic non-obstructive azoospermia (iNOA) undergoing microdissection testicular sperm extraction (mTESE)?
A higher likelihood of +SR during mTESE is observed in men with iNOA and lower preoperative serum anti-Müllerian hormone (AMH) levels, with good predictive accuracy achieved using an AMH threshold of <4 ng/ml.
AMH has been previously linked to +SR in men with iNOA undergoing mTESE prior to ART.
STUDY DESIGN, SIZE, DURATION: A multi-centre cross-sectional study was carried out with a cohort of 117 men with iNOA undergoing mTESE at three tertiary-referral centres.
PARTICIPANTS/MATERIALS, SETTING, METHODS: Data from 117 consecutive white-European men with iNOA presenting for primary couple's infertility associated with a pure male factor at three centres were analysed. Descriptive statistics was applied to compare patients with negative (-SR) versus +SR at mTESE. Multivariate logistic regression models were fitted to predict +SR at mTESE, after adjusting for possible confounders. Diagnostic accuracy of the factors associated with +SR was assessed. Decision curve analyses were used to display the clinical benefit.
Overall, 60 (51.3%) men had an -SR and 57 (48.7%) had a +SR at mTESE. Patients with +SR had lower levels of baseline AMH (P = 0.005) and higher levels of estradiol (E2) (P = 0.01). At multivariate logistic regression analysis, lower levels of AMH (odds ratio: 0.79; 95% CI: 0.64-0.93, P = 0.03) were associated with +SR at mTESE, after adjusting for possible confounders (e.g. age, mean testicular volume, FSH, and E2). A threshold of AMH <4 ng/ml achieved the highest accuracy for +SR at mTESE, with an AUC of 70.3% (95% CI: 59.8-80.7). Decision curve analysis displayed the net clinical benefit of using an AMH <4 ng/ml threshold.
LIMITATIONS, REASONS FOR CAUTION: There is a need for external validation in even larger cohorts, across different centres and ethnicities. Systematic reviews and meta-analysis to provide high level of evidence are lacking in the context of AMH and SR rates in men with iNOA.
Current findings suggest that slightly more than one in two men with iNOA had -SR at mTESE. Overall, men with iNOA with lower levels of AMH had a significantly higher percentage of successful SR at surgery. A threshold of <4 ng/ml for circulating AMH ensured satisfactory sensitivity, specificity, and positive predictive values in the context of +SR at mTESE.
STUDY FUNDING/COMPETING INTEREST(S): This work was supported by voluntary donations from the Urological Research Institute (URI). All authors declare no conflict of interest.
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在接受微创睾丸精子提取术（mTESE）的特发性非梗阻性无精子症（iNOA）男性中，是否可以识别出精子提取成功（+SR）的可靠标志物？
在接受 mTESE 的 iNOA 男性中，术前血清抗苗勒管激素（AMH）水平较低的男性，+SR 的可能性更高，使用 AMH 阈值<4ng/ml 可获得良好的预测准确性。
AMH 之前与接受 ART 前 mTESE 的 iNOA 男性的+SR 有关。
研究设计、大小、持续时间：在三个三级转诊中心，对 117 名接受 mTESE 的 iNOA 男性进行了多中心横断面研究。
参与者/材料、地点、方法：对来自三个中心的 117 名连续的白种欧洲男性进行了分析，这些男性患有原发性夫妇不育症，与单纯男性因素有关。应用描述性统计方法比较 mTESE 中阴性（-SR）和阳性（+SR）患者的差异。在调整了可能的混杂因素后，使用多元逻辑回归模型来预测 mTESE 中的+SR。评估与+SR 相关的因素的诊断准确性。决策曲线分析用于显示临床获益。
总体而言，60 名（51.3%）男性的 mTESE 结果为- SR，57 名（48.7%）男性的 mTESE 结果为+ SR。+SR 患者的基线 AMH 水平较低（P=0.005），雌二醇（E2）水平较高（P=0.01）。在多元逻辑回归分析中，调整了可能的混杂因素（如年龄、平均睾丸体积、FSH 和 E2）后，较低的 AMH 水平（比值比：0.79；95%置信区间：0.64-0.93，P=0.03）与 mTESE 中的+ SR 相关。AMH<4ng/ml 的阈值在 mTESE 中实现了最高的准确性，AUC 为 70.3%（95%置信区间：59.8-80.7）。决策曲线分析显示了使用 AMH<4ng/ml 阈值的净临床获益。
局限性、谨慎的原因：需要在更大的队列、不同的中心和种族中进行外部验证。在 AMH 和 iNOA 男性的 SR 率方面，系统评价和荟萃分析缺乏高级别的证据。
目前的研究结果表明，略多于一半的 iNOA 男性在 mTESE 中为-SR。总体而言，AMH 水平较低的 iNOA 男性在手术中成功提取精子的比例显著更高。在 mTESE 中的+ SR 情况下，<4ng/ml 的 AMH 循环阈值可确保满意的敏感性、特异性和阳性预测值。
研究资金/利益冲突：这项工作得到了泌尿生殖研究所（URI）的自愿捐款支持。所有作者均声明不存在利益冲突。
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