BACKGROUND Estimate that, one per 20 men related to infertility The diagnosis techniques and treatmentsfor female infertility is highly developed, but treatment techniques for male infertility arelimited “Azoospermia” is defined as the absence of sperms in acentrifuged semen sample, the incidence of azoospermia in infertile men is between 5%-13,8% while in the general population, it is about 2% The causes are obstructive or non-obstructive azoospermia characterized by absent of sperm production The advance of intracytoplasmic sperm injection (ICSI) have made it possible to circumvent some case of male factor infertility, especially azoospermia Objectives: Describe features and factors related azoospermia men who were performed percutaneous epididymal sperms aspiration in Assissted Reproductive Technology Center Evaluate the effectiveness and factors affect outcomes of percutaneous epididymal sperm aspiration/intracytoplasmic sperm injection/in-vitro fertilization treatment of obstructive azoospermia cases Practical significance and contributions of the thesis The thesis has found a cut-off of testicular volume, FSH and LH concentration in azoospermia patients in order to rely on that thresholds to offer or not recommendation of PESA for these patients Thesis has humanities when help infertile azoospermia couples have their own sons, before these case were untreated The thesis also demonstrates that PESA is simple,efficient method to retrieve sperms from the epididymis to perform ICSI Epididymal sperms can be frozen, pregnancy rates from frozen semen and fresh semen was equivalent THESIS STRUCTRURE This thesis included 128 pages, chapters, 31 tables, 14 figures, 11 pictures and 181 references Background: pages; Chapter 1: Literature, 38 pages; Chapter 2: materials and method: 11 pages; Chapter 3: Results: 28 pages; 1 Chapter 4: Discussion, 45 pages; Conclussion: pages; Recommendations: page; Further research: page; Related articles; References; Appendix; List of study patients CHAPTER I: LITERATURE 1.1 Difinition of infertility Infertility is commonly defined as the failure of conception after atleast 12 months of unprotected intercourse Primary infertility (infertility I) is woman has never been pregnant before, secondary infertility (infertility II) is the woman has been pregnant at least once before 1.2 Prevalence of infertility in Vietnam and worldwide Oakley (2008-England) survey on 60.000 UK women, 16% have been consulted for infertility, 8% need the treatment to be pregnant Karl(2008), prevalence of infertility in developing countries is between 5% -25.7% In Vietnam, population census in1982, prevalence of infertility was 13% Nguyen Khac Lieu (1993-1997), female infertility was 55,4%, male was 35.6% and unknown was 10% Nguyen Viet Tien (2010) investigated 14.396 couples: incidence of infertility was 7.7%, in which infertility I was 3.9% and II was 3,8% 1.2.1 Obstructive Azoospermia (OA) Intra-testicular obtruction account of 15%, epididymal occupies 30-67%, ejaculate account for 1-3% of cases Epididymis is most common location It may be congenital (CABVD) or acquired (gonorrhea, chlamydia) 1.3 PESA/ICSI/ procedure 1.3.1 Ovarian stimulation, oocyte retrival and oocyte preparation Ovarian stimulation multiple follicular development and maturation Monitor follicular development Oocytes maturation by injecting hCG oocyte retrieval performance 34-36 hours after, oocyte collectionunder stereoscopicmicroscope Denuding preparation for ICSI performance 1.3.2 Percutaneous epididymal sperm aspiration and sperm preparation 2 PESA performed on the oocyte retrival day Washing sperm sample by gradient method or centrifuge if poor concentration 1.3.3 Intra-cytoplasmic sperm injection (ICSI) Palermo, first introduced ICSI in 1992, now this technique are widely used and extended it’s indication to male infertility ICSI performed on stereomicroscope equipped with micromanipulator Fix oocyte by holding pipette inferior pole of oocyte touching bottom of dish, polar body is at or 12 hour to ovoid injury spindle Injecting sperm into oolemma of oocyte 1.3.4 Evaluation of fertilization, embryo transfer and monitoring Evaluation of fertilization 18hours after ICSI Evaluation number and size of blastomere Embryo transfer (ET) on day or βhCG dosage > 50 iu > pregnant Clinical pregnancy (CP) if gestational sac or embryo or heart movement in ultrasound CHAPTER 2: MATERIALS AND METHOD Cross-sectional descriptive study and prospective intervention study with sample size and selection criteria are used in this study 2.1 Subjects 2.1.1 Selection criteria 2.1.1.1 For cross-sectional descriptive study Azoospermia (spermogram twice - days, seperated) Agreed to participate in research 2.1.1.2 For prospective interventional study Infertile couples due to azoospermia, PESA diagnosis with sperm Agreed to be treated by PESA/ICSI 3 Wives under or equal 40 year olds Agreed to participate in research 2.1.2 Exclusion criteria For prospective interventional study Infertile wives due to one of following causes: + Infertility due to poor ovarian responder + Ovulation disorder due to hyperprolactinemia + Infertility due to uterus, uterine cavity (fibroid, intra-cavity polype…) + Wives above 40 year olds 2.2 Setting and study time: research covers period 12/2009 to 12/2012, at ART Center of National Hospital of Obstetric and Gynecology 2.3 Sample size 2.3.1 Sample size for cross-sectional descriptive study n = Z (21−α / 2) p.q (ε p) n: sample size, p: incidence of azoospermia in infertile men (15% according to Jarow) q = 1-p; Z (1-α/2)= 1,96: reliability coefficient of probability 95% with α = 0,05.ε.p : desired accuracy; ε: relative deviation ranging from 0,1-0,4.ε = 0,3 n= 245, in fact 249 enrolled 2.3.2 Sample size for prospective interventional study 4  1,96  N ≥  p (1 − p )  m  N: sample size; p: success rate (pregnancy rate) m: constant = 0,1 and p was 34% (Godwin), N =90, in fact 170 enrolled 2.4 Method Cross-sectional descriptive study: study features and factors related to azoospermia Prospective interventional study: evaluation effectiveness of PESA/ICSI for infertile azoospermia couples 2.4.2 Study process Azoospermia men (n = 249) Agreed to participate in research Clinical history Examinations Laboratory Evaluation Percutaneous epididymal sperm aspiration/diagnosis (PESA) Sperm(n = 170) No sperm (n = 79) PESA/ICSI (N =226 ovarian stimualation cycles: 223 embryo transfer cycles + 29 frozen embryo transfer cycles) Evaluation outcomes and affecting factors Finish Results 86 pregnant 84 non-pregnant Freeze (n=26) 5 Figure2.1 Study process 2.6 Data proccessing and analizing Data manipulation and analysis was performed using SPSS 16.0 software Compare % by χ2 test, the average value by T-test ROC curve find threshold of FSH, LH level and testicular volume to predict possibility of sperms aspiration from epididymis CHAPTER 3: RESULTS 3.1 Features and factors related azoospermia men 3.1.1 Features of azoospermia men Figure 3.1 PESA diagnosis 249 azoospermia men were performed PESA 170 cases with sperm (obstructive azoospermia) (68,27%), 79 cases without sperm (non-obstructive azoospermia) (31,73%) Table 3.1 Distribution of age group of azoospermia men Age (year) Obstructive Azoospermia (n; Non-Obstructive Azoospermia (n,%) Total (n,%) 13 (7,6%) 59 (34,7%) 63 (37,1%) 17(10,0%) 18 (10,6%) 170 (100%) (8,9%) 27 (34,2%) 25 (31,6%) 13 (16,5%) (8,9%) 79 (100%) 20 (8%) 86 (34,5%) 88 (35,3%) 30 (12,0%) 25 (10,0%) 249 (100%) %) < 25 26 - 30 31- 35 36 - 40 > 40 Total Trữ lạnh mẫu tinh trùng (n=26) Mean age 32,41 + 5,7 32,28 + 5,7 32,37 + 5,6 Mean age of azoospermia men: 32.37 + 5,6,mean age of OA group was 32.41 + 5.7 and NOA group was 32.28 + 5.7 The difference of age between two groups is not statistically significant, p = 0.869 3.1.2 Factors related azoospermia men Table 3.5 The clinical and laboratoryfeatures of azoospermia men Factors Right testicular size(ml) Left testicular size (ml) FSH (IU/L) LH (IU/L) Testosterone (nmol/L) Obstructive Azoospermia (n = 170) 16,86 + 2,1 16,69 + 2,3 4,76 + 2,7 4,69 + 2,7 19,59 + 6,2 Non-Obstructive Azoospermia (n = 79) 10,57 + 4,5 10,46 + 4,3 16,23 + 10,5 11,35 + 7,6 15,33 + 8,3 p 0,000 0,000 0,000 0,000 0,000 Testicular volume in OA group greater than that in NOA group The difference is statistically significant; p < 0,001.FSH, LH levels in OA group were lower than that in NOA group, the difference is statistically significant; p < 0,001 Table 3.6 Testicular volume and outcomes of PESA in infertile patients Testicular volume (ml) < 10 10 – 14,9 Obstructive Azoospermia (n, %) Right Left (0) (0) 17 (10,1) 26 (15,3) Non-Obstructive Azoospermia (n,%) Right Left 29 (36,7) 29 (36,7) 34 (43,0) 33 (41,8) 15 – 19,9 > 20 Total 126 (74,6) 26 (15,3) 169 (100) 121 (71,2) 23 (13,5) 170 (100) 12 (15,2) (5,1) 79 (100) 13 (16,5) (5,2) 79 (100) 89,9% of right testes and 84,7% of left testes in OA group > 15ml 79,7% of right testes and 78,5% of left testes in NOA group < 15 ml 3.1.3 Threshold of FSH, LH level and testicular volume predict possibility of sperms aspiration 3.1.3.1 Threshold of FSH level predicts possibility of sperms aspiration Figure 3.2 ROC curve of FSH concentration predict possibility of sperms aspiration from epididymis 8 The area under the ROC curve of FSH was 0,866 + 0,02 (with a 95% confidence interval for the area beingbetween 0,811 – 0,921) FSH > 12,4IU/L predicts failure ofsperms retrieval from epididymis with a sensitivity of 62% and a specificity of 100% 3.1.3.2 Threshold of left testicular volume predicts possibility of sperms aspiration Figure 3.3 ROC curve of left testicular volume predicts possibility of sperms aspirationfrom epididymis The area under the ROC curve of left testis was 0,899 ± 0,03 (with a 95% confidence interval for the area being between 0,849 - 0,949) Left testis > 12,5 ml, success of sperms retrieval from epididymis with a sensitivity of 97,6% and a specificity of 72,2% 3.1.3.3 Threshold of right testicular volume predicts possibility of sperms aspiration 9 Figure 3.4 ROC curve of right testicular volume predicts possibility of sperms aspirationfrom epididymis The area under the ROC curve of right testis was 0,906 ± 0,03 (with a 95% confidence interval for the area being between 0,855 - 0,956) Right testis > 13,5 ml, success of sperms retrieval from epididymis with a sensitivity of 97% and a specificity of 75,9% 3.1.3.4 Threshold of LH level predicts possibility sperms aspiration 10 10 Assess testicular size by comparing testicular with standard samples available from to 25ml According to table 3.6, in OA group, 89,9% of right testis and 84,7% left testis > 15ml, no cases of testis size less than 10ml NOA group, 79,7% of right and 78,5% of left testes 12,4IU/L, failure of sperm retrieval from testis with a sensitivity of 62% and a specificity of 100% This threshold was lower than Shyh’s study (2010) was 19,4 IU/L 4.1.3.4 Testicular volume predicts possibility of sperm aspiration Figure 3.3 shows, the area under the ROC curve of left testicular volume was 0,899 + 0,03 (with a 95% confidence interval for the area being between 0,849 – 0,949) and ROC curve of right testicular volume was 0,906 + 0,03 (with a 95% confidence interval for the area being between0,855 – 0,956) Thus, testicular volume can predict ability of sperms aspiration from epididymis Left testicle > 12,5ml predict epididymal sperms aspiration, 24 24 sensitivity of 97,6% and specificity of 72,2% Right testis > 13,5ml predict ability of sperms aspiration with sensitivity of 97,0% and specificity of 75,9% (figure 3.4) Seyed (2006), testicular volume threshold predict ability sperm aspiration was 9,5 ml 4.1.3.5 LH level predicts possibility sperm aspiration The area under the ROC curve of LH was 0,781 + 0,04 (with a 95% confidence interval for the area being between 0,781 – 0,851) (figure 3.5) Thus, LH level is valuable to predict possibility sperm aspiration from epididymis LH > 9,47IU/L predict possibility sperm aspiration with sensitivity of 58,2% and specificity of 96,5% LH > 16,2IU/L predict possibility sperm aspiration with sensitivity of30,4% and specificity of 100% Small testes, high gonadotropin levels, specially high FSH level in azoospermia patients will predict difficulty of sperms aspiration from epididymis 4.2 Characteristics of wivies treated by PESA/ICSI We discuss characteristics of 170 wives of OA husbands These patients will be stimulated for PESA/ICSI Table 3.7 shows average age was 28,44 + 4,5 years, at this age, ovarian reserve is favorable for ovarian stimulation Age is lower than Mai Quang Trung's study (2010) was 33,1 + 4,95 years and Han Manh Cuong’s was 34,36 +5,5 years The indicators of ovarian reserve include FSH, LH, estradiol was, respectively 6,30 + 1,8IU/L, 4,58 +2,5IU/L and 38,79+ 24,6pmol/ml and antral follicles count was 11,14 + 4,6 follicles (table 3.4), allwere in normal range meaning good ovarian response BMI was 19,94+ 2.3, normal weight so it will get good results when ovaries stimulation (table 3.7) 4.3 Effectiveness and factors affect outcomes of PESA/ICSI 4.3.1 Effectiveness of PESA/ICSI 226 PESA/ICSI cycles, including 125 couples treated cycle, 34 couples treated cycles and 11 couples treated 3cycles (table 3.10) PESA/ICSI is consecutive procedures including PESA, (freeze sperm sample), ovarian 25 25 stimulation, oocyte retrieval, ICSI, embryo culture and transfer Assessment the effectiveness of this method through number of oocyte, embryos, fertilization, implantation rate and clinical pregnancy rate etc 4.3.1.1 Outcomes of PESA Recommendations by American Society for Reproductive Medicine (ASRM), the azoospermia cases can retrieve by: Percutaneous epididymal sperm aspiration (PESA), Microsurgical epididymal sperm extract (MESA), Testicular sperm extraction (TESE) and testicular sperm aspiration (TESA) Table 3.8 indicated, 226 PESA/ICSI cycles, only 207 cycles need to perform PESA, 19 cycles have cryopreserved sperms Among them, 117 patients were performed PESA times, 30 patients performed times and 10 patients aspirated times (figure 3.8) Thus, PESA can be carried out several times on same patient with successful rate This conclusion is consistent with conclusion of Dohle’s (1998), Rosenlund’s (1998), Pasqualotto’s study (2003): PESA can be carried out at least times in same testis Table 3.8 sumary, 226 PESA/ICSI include, 19 cycles with cryopreserved/thawed sperms, account for 8,4% of cycles (in fact 26 cycles but cyclescompletely degenerated and cycles incompletely degenerated) 207 PESA for ICSI with 100% successful retrieval, results (++), (+++), only 19,9% of cases with (+) (table 3.8) Godwin's study (1998) on azoospermia cases were performed PESA diagnosis, the rate of sperm retrieval was 90% lower than that of our’s study Thus, PESA is safe, effective method helping retrieval sperm from epididymis in obstructive azoospermia for ICSI This method can also be perform many times in same patient 4.3.1.2 Effectiveness of freezing PESA sample Table 3.9, 26/226 sperm samples were frozen (11.5%), lower than that of Glina’s (2003) was 37,9% (30/79), of Esteves’s study (2013) was 26,7% (39/146) This difference is, we conducted freezing sperm sample after study a time Thawing 26 samples, samples degenerated completely (19,2%), samples degenerated imcompletely, need to PESA more (7.,7%) 19 sufficient sperm samples thawing for ICSI (73,1%) Initial results showed that 26 26 sperm samples from epididymal aspiration can freezeand relatively high survival rate after thawing, enough sperm to perform ICSI 4.3.1.3 Outcomes of ovarian stimulation 4.3.1.3.1 Ovarian stimulation protocol Table 3.11 showed the average number of days of ovarian stimulation was 9,65 + 0,9 days with average total dose of FSH was 1943,58 + 663,3IU, similar to results of Bodri (2006), Nguyen Thi Thanh Dung (2012) Evaluation the effectiveness of ovarian stimulation through number of oocytes, and evaluation effectiveness of ICSI through fertilization rate, number of embryos fertilized 4.3.1.3.2 Average oocyte Table 3.11, the average number of oocyte was 8,62 + 4,3, less than Buffat study (2006), was 10,4 ± 6,0 oocytes Average number of oocytes in short protocol group was 6,86 + 4,4 oocytes less than long protocol group, was 9,06 + 4,3 and also antagonist group, was 8,33 + 3,7 oocytes, but similar to study by Hamed (2008) with an average number of oocytes in short protocol group was 5,1 ± 2,4 oocytes, long protocol group was 9,4 ± 3,2 (p = 0,04) 4.3.1.3.3 Premature luteinization during ovarian stimulation During ovarian stimulation, the occurrence of premature luteinization can affect oocyte quality, embryo quality and pregnancy rate The researchs are dosage of progesterone concentration on hCG administration day for diagnosis of this phenomenon In this study we took threshold progesterone > 3,2nmol/L for diagnosis of premature luteinization Table 3.12, in progesterone < 3,2nmol/L group, pregnancy rate was 41,6% compared with 26,1% in progesterone > 3.2 nmol/L group The difference is statistically significant with χ2 = 4.096, p = 0.027 Thus premature luteinization affect pregnancy rate, similar to conclusion of Bosch (2003), Edelstein (1990) and Ozcakir (2004) 4.3.1.4 Effectiveness of ICSI 27 27 4.3.1.4.1 Fertilization rate, mean embryo Fertilization rate is the number of embryos divided by number of oocytes Table 3.14, total 1337 embryos, average number of embryos was 5,92 + 3,4 embryos, with average fertilization rate was 69,16 + 22,4%, higher than that of Tsirigotis’s study (1995) performing ICSI with epididymal sperm was 52,6% (274/521) and of Ho Manh Tuong’s study (2000) performing ICSI with ejaculate sample sperm was 60,8% 4.3.1.4.2 Effectiveness of ICSIwith cryopreserved sperm Table 3.15 showed, fertilization rates in fresh sperm group was 68,86 + 22,3% and in cryopreserved sperm group was 72,45 + 23,4%, clinical pregnancy rate in fresh sperm group was 36,2% and in cryopreserved sperm group was 36,8%, the difference was not statistically significant with p > 0.05 Similar to study of Patrizio (2000), Cayan (2001), Jin (2006) and Ou (2010) (Table 4.2) Table 4.2 Compare fertilization rate, clinical pregnancy rate of ICSI with fresh and cryopreserved epididymal spermatozoidbetween authors Authors Patrizio (2000) Cayan (2001) Jin (2006) Ou L (2010) Ho Sy Hung (2013) Fertilization rate (%) Fresh sperm Frozen sperm 46,0 53,0 58,4 62,0 73,29 84,05 76,49 75,67 68,8 67,4 Clinical pregnancy rate(%) Fresh sperm Frozen sperm 39,0 50,0 31,6 36,8 37,00 53,33 57,22 55,21 36,2 36,8 Table 3.9 showed, 26 frozen semen samples, pregnancy (26,9%) (7/26), if eliminate completely degenarated and incompletely degenarated, pregnancy rate after frozen/thawed was 36,8% (7/19), similar to study of Friedler (1998), Cayan (2001), Nicopoullos (2004), Jin (2006) and Ho Manh Tuong (2000) 28 28 Thus, fertilization rate, pregnancy rate with thawed sperm was equal to pregnancy rate with fresh sperm aspirated from epididymis These initial results are evidence to gradually apply this technique routinely in center 4.3.1.5 Embryo transferred outcomes, implantation rate The implantation rate is calculated as the total number of gestational sac divided by total number of embryos transferred Table 3.16, total 783 embryos transferred and 82 pregnancy with 121 gestational sac Implantation rate was 15,45% (121/783), similar to study of Nguyen Thi Thanh Dung (2012) on conventional IVF patients was 14,3% but higher than Buffat’s (2006) was 12,9% 4.3.1.6 Pregnancy rate of PESA/ICSI 4.3.1.6.1 Clinical pregnancy rate As International Committee for Monitoring Assisted Reproductive Technology organized in 2009 Clinical pregnancy a pregnancy diagnosed by ultrasonographic visualization of one or more gestational sacs or definitive clinicalsigns of pregnancy It includes ectopic pregnancy Clinical pregnancy rate is number of clinical pregnancies expressed per 100 initiated cycles, aspiration cycles, or embryo transfer Clinical pregnancy rate was 36,28%/total ovarian stimulation cycles (82/226), similar to study of Esteves (2013), and higher than Mai Quang Trung’s (2010) was 34,1% and Nguyen Thi Thanh Dung’s (2012) was 32,5% Table 4.3 Compare fertilization rate, implantation rate, clinical pregnacy rate between authors Authors Tsirigotis (1996) Shevach (1998) Glina (2003) Lin (2004) Buffat (2006) Ho Sy Hung (2013) 29 Fertilization rate 52,6% 56% 67% 71,6% 58,9% 68,67% Implantation rate 14,2% 10% 14,0% 12,9% 15,45% Pregancy rate 30,5% 31% 38% 40,6% 22,1% 36,3% 29 4.3.1.6.2 Pregnancy rate after each cycle Table 3.17 showed, in first cycle there has been 170 couples treated, 169 patients had embryo stransferred, one patients did not have embryos due to fail fertilization (0.58%) 66 clinical pregnancy account of 38,8% per ovarian stimulation cycles Second cycle: 45 couples continued, 43 patients had embryos transferred, patients cancelled embryo transferred due to ovarian hyper-stimulation syndrom, 13 clinical pregnancy account of 28,9% per ovarian stimulation cycles Third cycle: 11 couples continued treatment, clinical pregnancy account of 27,3% ovarian stimulation cycles Thus 170 couples after cycles of treatment, 82 clinical pregnancy account of 36,28% per ovarian stimulation cycles, higher than Pelinck’s study was 20,8% This difference is due to Pelinck stimulated minimal protocol, using low-dose of FSH to stimulate some follicle Cumulative pregnancy rate per patients was, after treatment cycles 48,24% (82/170) (Figure 3.9), higher than that of Pelinck’s (2006 and 2007)), Marcos’sstudy (2012) (table 4.4) Table 4.4.Compare cumulative pregnancy rate after each cycle with other authors Index Authors Pelinck (2006) Pelinck (2007) Marcos (2012) Ho Sy Hung (2013) n 336 256 75 170 1st cycle 38 (11,3) 27 (10,5) 22 (29,3%) 66 (38,82) Pregnancy rate 2nd cycle 3rd cycle 62 (18,5) 85 (25,3) 47 (18,4) 66 (25,8) 30 (40,0%) 32 (42,67%) 79 (46,47) 82 (48,24) 4.3.1.6.3 Pregnancy rate after frozen embryo transferred 29 patients frozen/thawed embryos transferred, cases of clinical pregnancy rate acount of 13,79% (4/29) (table 3.17), similar to Buffat’s study (2006) was 16,3% (23/136), but lower than Han Manh Cuong's research 30 30 (2010) was 19,5% This difference may be due to author's research on assissted hatching frozen embryos transferred 4.3.1.6.4 The cumulative pregnancy rate after fresh and frozen embryo transferred The cumulative pregnancy rate is pregnancy rate after fresh and frozen embryo transfer in an ovarian stimulation cycles In this study, the cumulative pregnancy rate after fresh and frozen embryo transferred was 38,05% (86/226), similar to Borini’sstudy (2006) (table 3.19) 4.3.1.7 Ongoing pregnancy, live birth rate, abortion and preterm delivery Table 3:18, there were 22 live birth (25,6%) According Nicopoullos (2004) live birth rate was 18.4% pregnant 52 ongoing pregnancy (60,5%), 12 miscarriage accounted for 13,9%, equal to study of Buffat (2006) miscarriage rate was 12.5% (7/56), Naru's research (2008) was 16.7% (5/30), but higher than Woldringh’s study (2011) rate of miscarriageafter PESA/ICSI was 4.0%, Nguyen Thi Thanh Dung (2012) in oocyte donner was 5,7% (7/123) 4.3.2 Factors affect outcomes of PESA/ICSI treatment of obstructive azoospermia cases 4.3.2.1 Male factors No difference of average age of husband, of FSH, LH and testosterone levels as well as testicular volume between pregnant and non-pregnant groups with p > 0,05 (table 3.19), similar to study of Friedler (2002), Mai Quang Trung’s (2010) Fertilization rate of non-pregnant group was 67,78% (747/1102) similar to 69,91% pregnant group (567/811) (table 3.20) 4.3.2.2 Female factors 4.3.2.2.1 Age and duration of infertility The average age of wives of pregnant group was 27,96 + 4,1 years and non-pregnant group was 28,72 + 4,7 years Difference of wife’s age between two groups is not statistically significant with p> 0.05 (table 3.20) The results of this study is similar to Mai Quang Trung's study but different Friedler’s (2002) and Zorn’s (2009) 31 31 Pregnancy rate in under 25 years group was 38,9% and 26-34 years group was 38,4% compared with 21,7% in over 35years group The difference was not statistically significant with χ2 = 2.497, p> 0.05 (figure 4,2) Average duration of infertility in pregnant group was 3,63 + 2,9 years and in non-pregnant group was 4,48 + 4,0 years, the difference was not statistically significant with p = 0,09 (table 3.20) Pregnancy rates in over 10 years of infertility group is lower than those in under 10 years group Pregnancy rates in group under years and 5-10 years of infertility group were respectively 39,4% and 35,4% compared with 13,3% in over 10 years group, this difference is not statistically significant with χ2 = 4,049, p> 0,05 (figure 4.2) Figure 4.2 Pregnancy rate decreases with female age and duration of infertility Thus, pregnancy rate decreases with female age and duration of infertility, though the reduction did not differ much 4.3.2.2.2 Endometrium related to pregnancy rate Table 3.20 shows the thickness of endometrium in pregnant group was 12,47 + 1,9mm compared with 11,86 + 2,5mm in non-pregnant group with p < 0.05, consistent with conclusions of Ahlam (2008), Mai Quang Trung (2010) Pregnancy rates in group if 8,0 to 10mm was 20%, 10,1mm -12mm was 39,2%, and 12,1 - 14mm was 52,7% and > 14mm was 34,3% patients with endometrium < 8mm were not pregnant The difference is statistically significant with χ2 = 14.698, p = 0.005 (table 3.23) Pregnancy rates in triple – layers group was 52,5%, in hyperechoic group was 19,1% and no cases pregnancy in heterogenous endometrium group The difference is statistically significant with χ2 = 29.54, p < 0.001 (table 3:24) Thus, thickness and features of endometrium affects pregnancy rates 4.3.2.2.3 Quantity and quality of transferred embryos related to pregnancy outcomes Average number of transferredembryos in pregnant group was 3,8 + 0,9 embryos higher than non-pregnant group was 3,34 + 1,3 embryos (Table 3.20) Table 3.27, pregnancy rate in good quality embryo transferred group 32 32 was 32,3% higher than no good embryo transferred group was 2,5% with χ2 = 11.81, OR = 18,57, CI (2,2 -155,2) Similarly, pregnancy rate in good embryos transferred group was 31,8% lower than that of at least good embryos transferred was 52,8% with χ2 = 5,52, OR = 2.4, CI (1,1-5,0) So if there is one good embryo to transfer the chance of pregnancy increase 18,57 times compare with no good embryos transferred and at least good embryos transferred, the chance off pregnancy increased by 2,4 times compared with good embryos transferred CONCLUSIONS Features and factors related azoospermia men − Testicular volume in OA patients was greater than that in NOA patients and testicular volume can predict results of epididymalsperms aspiration + Right testicular volume >13,5ml predicts success of sperms aspiration from epididymis with sensitivity of 97% and specificity of 75,9% + Left testicular volume > 12,5ml predicts success of sperms aspiration from epididymis with sensitivity of 97,6% and specificity of 72,2% − FSH and LH level in OA patients were lower than that in NOA patients and these hormons can predict results of epididymal sperms aspiration + FSH >12,4IU/L predicts failure of sperms aspiration from epididymis with sensitivity of 62% and specificity of100% + LH > 16,2IU/L predicts failure of sperms aspiration from epididymis with sensitivity of 30,4% and specificity of 100% Effectiveness and factors affect outcomes of percutaneous epididymal sperm aspiration/intracytoplasmic sperm injection/in-vitro fertilization treatment of obstructive azoospermia cases − PESA for ICSI is safe, effective method and can perform many times in same patients 33 33 − The success rate of PESA/ICSI is similar to ICSI ưith sperm from ejaculate sample + Fertilization rate of PESA/ICSI was 69,16%; implantation rate was 15,45% Clinical pregnancy rate per ovarian stimulation cycles was 36,28% and per total patients was 48,24% + At the end, 86 pregnancy in which 60,5% ongoing pregnancy, 25,6% live birthand 13.9% miscarriage − Initial results showed that epididymal sperms can be frozen and when thawing for ICSI, success rate is equivalent to fresh epididymal sperms + Fertilization rate of PESA/ICSI with frozen/thawed sperm was 72,45%, implantation rate was 13,16%, clinical pregnancy rate was 36,8% − Age, FSH, testosterone leveland testicular volume of husband did not affect clinical pregnancy rate − Pregnancy rates decrease as the age of the wife and duration of infertilityincreased − Pregnancy rate depends on thickness and features of endometrium Highest clinical pregnancy rate in endometrium from 12,1 to 14mm and triple-layers image and there were no cases of pregnancy in endometrial thickness under 8mm, heterogenous image group − Pregnancy rate depends on quantity and quality of embryos transferred When transfer at least one good quality embryo pregnancy rate increased 18,57 times compared to transfer no good quality embryo RECOMMENDATIONS Advice for couples to seek early examination and early diagnosis and treatment will be highly successful results Examination of boths, especially the husbands because simple tests The initial success of cryopreservation of epididymal sperm, this technique would be applied in routine to limit the number of epididymal aspiration Azoospermia men with FSH levels above 12,4IU/L and testicular volume is less than 12,5ml should not epididymal aspiration 34 34 In case of embryo transfer if endometrium under 8mm, it should not transfer embryos But embryo cryopreservation and embryo transfer in next cycle 35 35 ... (35,3%) 30 (12,0%) 25 (10,0%) 249 (100%) %) < 25 26 - 30 31- 35 36 - 40 > 40 Total Trữ lạnh mẫu tinh trùng (n=26) Mean age 32,41 + 5,7 32,28 + 5,7 32,37 + 5,6 Mean age of azoospermia men: 32.37... ovarian stimulation Age is lower than Mai Quang Trung''s study (2010) was 33,1 + 4,95 years and Han Manh Cuong’s was 34,36 +5,5 years The indicators of ovarian reserve include FSH, LH, estradiol was,... average total dose of FSH was 1943,58 + 663,3IU, similar to results of Bodri (2006), Nguyen Thi Thanh Dung (2012) Evaluation the effectiveness of ovarian stimulation through number of oocytes, and