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This Presentation about Azoospermia by Dr. Khaled Mokhtar - Assistant Professor of Urology Ain-Shams University - Cairo , Egypt

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  1. 1. History ofAzoospermia in Era of ART Khaled Mokhatr MD Urology Ain Shams University
  2. 2. History of infertility Ancient Egyptian papyri (2000 BC)“Man is the source of life, through his seeds and woman is a reservoir of these seeds”.
  3. 3. History of infertility  Leonardo Da Vinci (1500 AC):  Anatomy of genital systemNetherland MRI 2002 DaVinci 1500
  4. 4. History of infertility Anton Leeuwenhoek (1632-1723), discovered the sperms (Animalcules).I am sending a letter to show my observation, you may consider it as scientific discovery or HOAX.
  5. 5. History of infertility Franzy Leydig, german Zoologist, (1850):discovered Leydig cell
  6. 6. History of infertility Enrico Sertoli, Italin Anatomist, (1865): discovered Sertoli cell
  7. 7. Spermist vs Ovist 1600 till 1700 Spermist  Ovist  ovum is harboring small fetous and it just need to contact the male fluid to be released
  8. 8. Only in 1779 Italian, Lazzaro Spallanzani, Scientific proof that the sperm fertilizes the ovum To produce pregnancy was first available (Spallanzani).
  9. 9. History of infertility Robert Dicknson (BJM, 1921) IUI Stepto& Edward First Test-Tube Baby - Louise Brown (Lancet, 1977) IVF
  10. 10. History of infertility Palermo et al (Lancet, 1992) ICSI. Devroey et al (Hum. Reprod., 1995) TESE/ICSI
  11. 11. “Infertile men, whereverthey live, should have achance to become geneticfathers” Westlander J (Human Reprod. 2000)
  12. 12. Azoospermia 1% of all men 10% of infertile men Azoo spermic Infertile fertile
  13. 13. Introduction Azoospermia is an absolute barrier against spontaneous pregnancy. Until recently, men with azoospermia have little or even no hope to be biologic father. Recent advances in microsurgery and reproductive technology have allowed many azoospermic men to father children. Pregnancy rate is a real reflection of all these advances
  14. 14. ObstructiveAzoospermia
  15. 15. Obstructive Azoospermia Obstructive azoospermia (OA) are potentially correctable with the aid of microsurgery (VE) or endoscopic (TURED). Irreparable OA e.g. CBAVD, requires sperm retrieval (PESA.MESA) combined with IVF/ICSI.
  16. 16. Obstructive Azoospermia: Sperm Retrieval Optionsè Epididymis  MESA (microsurgical epididymal sperm aspiration)  PESA (percutaneous epididymal sperm aspiration)
  17. 17. Obstructive Azoospermia: Sperm Retrieval OptionsTestis TESA (testicular sperm aspiration) TESE (testicular sperm extraction - therapeutic testis biopsy)
  18. 18. Obstructive Azoospermia: Results with IVF/ICSI (Experienced Centres) Epididymal TesticularSperm Retrieval ~100% ~100%Fertilization rates 50-70% 40-70%Clin. Pregnancy rates 30-50% 30-50%Live birth rate 30-40% 20-40% Palermo et al, Hum Reprod 1999 Devroey et al, Hum Reprod 1996 De Croo et al, Hum Reprod 2008
  19. 19. Non ObstructiveAzoospermia..Testicular failureIt is not an absolute failure
  20. 20. NOA Non Obstructive Azoospermia (NOA), recently, have been granted the hope to father their children after testicular extraction and ICSI (Devroey et al, Hum Rprod, 1995) .
  21. 21. New concept. +ve sperm identification in failed testes 20% to 70% of non obstructed azoospermia still harbor foci of active spermatogenesis with mature spermatozoa that could be retrieved and the only way to use it is ICSI
  22. 22. Testicular histology in testicular failure 56454035 20 SCO n=4430 14 Mat. Arrest n=1525 10 Hypo n=820 Mixed n=111510 5 0 NOA
  23. 23. Distribution of spermatogenesis in OA Vs NOA There must be at least 4 sperms per tubule as a minimum quantitative threshold of spermatogenesis to reach the ejaculate. Mapping of spermatogenesis in NOA testes shows that Spermatogenesis is diffuse rather than regional.Silber et al, Hum Reprod 2000
  24. 24. Non-Obstructive Azoospermia: Sperm Retrieval Options TESE (testicular sperm extraction)  Singlevs multiple open biopsies  Microdissection- microTESE TESA (testicular sperm aspiration) is not recommended Silber et al, Hum Reprod 1997 Schlegel et al, Hum Reprod 2004
  25. 25. Non-Obstructive Azoospermia: Sperm Retrieval: Microdissection Small areas of spermatogenesis may be distinguished from areas of Sertoli cell-only by microscopic examination Microdissection enhances sperm yield and reduces volume of tissue excised Schlegel et al, Hum Reprod 1999
  26. 26. Micro. TESE
  27. 27. Doctor patient Minimally invasive procedure Minimally invasive for a Doctor is not Minimally invasive for patients
  28. 28. The only way to use retrieved sperms is via ICSI
  29. 29. Non-Obstructive Azoospermia (NOA): Results with IVF/ICSI (Experienced Centres) NOA OATestic. Sperm Retrieval 20-80% ~100% *Fertilization rates 40-60% 40-70%Clin. Pregnancy rates 30-40% 30-50%Live birth rate 20-30% 20-40% Nagy et al, Fertil Steril 1995 Devroey et al, Hum Reprod 1996 Kahraman et al, Hum Reprod 1996 Palermo et al, Hum Reprod 2002
  30. 30. In Egypt..We are different
  31. 31. In Egypt.. We are different, why? More prevalent of NOA > OA Low incidence of CF mutation gene Misdiagnosis of active spermatogenesis by many pathologists. However, we do not have good statistical reports of true incidence of any of theses
  32. 32. CONCLUSION OA can be effectively and successfully managed with microsurgery. non-constructible OA, (CBAVD) sperm retrieval combined with IVF/ICSI can be highly effective in achieving pregnancy. NOA has been recently revolutionized by successful TESE/ICSI with resultant successful pregnancy. The high cost compared to pregnancy outcome is a considerable limiting factor against the popularization of TESE/IVF-ICSI.
  33. 33. The future In vitro maturation of oocyte (IVM) In vitro spermatogenesis (Tesarik et al.,Lancet, 1998) Tissue culture system fortified with RFSH, T. spermatogenesis could be completed in vitro with an unusual speed, but the resulting gametes are morphologically abnormal.
  34. 34. Design Final Touch:Ahmad Al-Sabbagh March 2012*