Training Program in Assisted Reproductive Technology 2011 Cleveland Clinic Reproductive Research CenterSandro Esteves, MD, PhDDirector, ANDROFERTCenter for Male Reproduction and InfertilityCampinas, BRAZIL
Learning Objectives Understand the difference between obstructive and non-obstructive azoospermia Overview the sperm retrieval techniques and laboratory processing methods for retrieved sperm Learn the success rates of sperm retrieval in obstructive and non-obstructive azoospermia Understand what is the reproductive potential of azoospermic men undergoing assisted conceptionEsteves, 2
Azoospermia • It is not a synonymous of sterility Non-Obstructive obstructive• Normal sperm production • Sperm production deficient or absent• Mechanical blockage • Cryptorchidism, Orchitis, Ra• Vasectomy, Post- diation, Chemotherapy, Trau infectious, Congenital ma, Genetic, Varicocele, Go nadotoxins, Unexplained
Sperm Retrieval Techniques Technique Acronym Indications Percutaneous epididymal PESA OA cases only sperm aspiration Microsurgical epididymal MESA OA cases only sperm aspiration Testicular sperm aspiration TESA; TEFNA1 Failed PESA in OA Epididymal agenesis in CAVD cases Favorable testicular histopathology2 in NOA Previous successful TESA attempt in NOA Testicular sperm extraction TESE Failed PESA or TESA in OA (single or multiple NOA cases biopsies) Microsurgical testicular Micro-TESE NOA cases only sperm extraction Esteves SC et al. Sperm Retrieval Techniques for Assisted Reproduction. Int Braz J Urol 2011, in press.Esteves, 4
Obstructive Azoospermia Sperm • Epididymis • Testicle Retrieval • Simple and for ART effective Esteves SC & Agarwal A. Sperm Retrieval Techniques; In: Gardner D et al (Eds.), Human Assisted Reproductive Technology. Cambridge University Press, pp. 41-53, 2011.Esteves, 5
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Laboratory Sperm ProcessingVerza Jr & Esteves, Atlas of Human Reproduction, in press
PERCUTANEOUS RETRIEVALEsteves SC, Verza S, Prudencio C, Seol B. Success of percutaneous spermretrieval and intracytoplasmic sperm injection (ICSI) in obstructive azoospermic (OA)men according to the cause of obstruction. Fertil Steril. 2010;94 (Suppl):S233.
Non-obstructive Azoospermia 10-20% of infertile men attending ART Clinics 60-70% of azoospermic men Causes are: Male Infertility • Pre-testicular: HH Diagnosis • Testicular causes 7.7 • Genetic 19.5 Y chromosome microdeletion Klinefelter syndrome 72.8 Varicocele Cryptorchidism Other Chemotherapy/Radiation Non-obstructive azoospermia Infection Obstructive azoospermia Idiopathic Source: ANDROFERT, Brazil
Non-obstructive Azoospermia Sperm • Sperm productionUntreatable reduced or absent Retrieval • Geographic location condition for ART unpredictableTESATESE
Non-obstructive Azoospermia TESA vs. TESEControlled studies Needle Open Biopsyfor NOA men AspirationFriedler et al., 4/37 (11%) 16/37 (43%)Human Reprod 12:1488, 1997Ezeh et al. 5/35 (14%) 22/35 (63%)Human Reprod 13:3075, 1998
Conventional TESE (open biopsy) in NOA Number of patients 25 20 15 10 5 0 1 2 3 4 7 8 9 10 14 Number of testicular fragments excised Ostad et al., Urology 52:692, 1998.Esteves, 12
Non-obstructive Azoospermia Testicular microdissection - micro-TESE• Method to identify site(s) of production – Based on the diameter of seminiferous tubules• Microsurgical approach – Identify site of production – Preserve vasculature of testis – Small quantity of tissue excised Schlegel PN. Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Hum Reprod. 1999;14:131-135.
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TESE/TESA Sperm Processing Verza Jr & Esteves, Atlas of Human Reproduction, in pressEsteves, 15
Micro-TESE vs TESE Success Rates in Controlled Series Study N Micro-TESE TESESchlegel 1999 27 63% 41%Amer et al. 2000 100 45% 30%Okada et al. 2002 98 45% 17%Okubu et al. 2002 17 48% 24%Tsujimura et al. 2002 93 43% 35%Ramon et al. 2003 321 62% 58%Esteves et al. 2011 60 45% 25% Total 716 53% 41% Microdissection provides sperm retrieval for 1/5 of men who fail standard TESE
Can We Predict Sperm Retrieval Success in NOA? Important because: 1. Can minimize emotional and financial cost of IVF cycles. 2. Can minimize trauma/ damage to testis during sperm harvesting.Esteves, 18
Predictive Values of Noninvasive Tests for Sperm Retrieval in NOAMarker Sensitivity % Specificity % Overall Predictive Value %Testicular Volume 7.6-50 6.7-71FSH 9-71 40-90Inhibin B 44.6 63.4FSH, Testosteron 71 71.4e, Inhibin BTesticular Volume 80.8+ HormonesDoppler US 47.3 89 Carpi. Controversies in nonobstructive azoospermia. Fertil Steril 2009.
Predictive Values of Noninvasive Tests for Sperm Retrieval in NOA Chance of finding sperm is dependent on the most advanced site of spermatogenesis within the testis. Markers reflect global spermatogenic function but not the most advanced site of sperm production in a dysfunctional testis. Esteves, Miyaoka & Agarwal: An update on the initial assessment of the infertile male. CLINICS 2011; 66:1-10.
Chance of Sperm Retrieval by NOA Diagnosis Cryptorchidism 52-74% Varicocele 63-68% Post-infection (mumps, etc.) 67% Torsion >50% Post-radiation/chemotherapy 55-75% Genetic (Klinefelter, Y microdeletion) 0-75% Idiopathic 50-60% Esteves et al., Fertil Steril 94; 2010; Raman and Schlegel. J Urol.170; 2003; Hopps et al. Hum Reprod. 180, 2003; Damani et al. JCO. 15; 2002
Predictive Values of Noninvasive Tests for Sperm Retrieval in NOA Y Chromosome Microdeletion AZFb deletion Absence of retrievable sperm Esteves SC & Agarwal A. Novel concepts in male infertility.Esteves, 22 Int Braz J Urol 2011; 37:5-15.
Predictive Values of Invasive Tests for Sperm Retrieval in NOA Testicular Histopathology Esteves, Miyaoka & Agarwal. Surgical Treatment of Male Infertility in the ICSI Era. CLINICS 2011; 66:1463-77.Esteves, 23
Microsurgical vs Single-Biopsy TESE in NOA: a prospective controlled study Verza Jr S & Esteves SC; ASRM 2011 (O-178) Single Large Second Biopsy Micro-TESE Open-Biopsy Fragment • Sperm Search • Sperm Search • HistologyEsteves, 24
Microsurgical vs Single-Biopsy TESE in Non-obstructive Azoospermia• Controlled series of 60 patients Sperm Retrieval Success Rates Micro-TESE single-biopsy TESE 93% P=0.02 64% 64% 45% 25% 20% 9% 6% Overall Hypospermatogenesis Maturation Arrest Sertoli-cell Only Verza Jr & Esteves, O-178, ASRM 2011
Sperm Retrieval Techniques Advantages DisadvantagesPESA Fast and low cost; No surgery Few sperm retrieved; Cryopreservation limited Minimal morbidity, repeatable Fibrosis and obstruction at aspiration site Risk of hematoma/spermatoceleMESA Large number of sperm retrieved Increased cost and time-demanding Sperm cryopreservation Microsurgical instruments and expertise Reduced risk of hematoma Postoperative discomfortTESA Fast and low cost; No surgery Low success rate/few sperm retrieved in NOA Repeatable Cryopreservation limited Minimal/mild postop discomfort Risk of hematoma/testicular atrophyTESE No microsurgical expertise Low success rate/few sperm retrieved in NOA Fast and repeatable Risk of testicular atrophy (multiple biopsies) Postoperative discomfortMicro-TESE Higher success rates in NOA Increased cost and time-demanding Larger number of sperm Microsurgical instruments and expertise retrieved Postoperative discomfort Esteves, Miyaoka & Agarwal. Sperm Retrieval Techniques for Assisted Conception. Int Braz J Urol in press
Reproductive Potential of Azoospermic Men undergoing ARTEsteves, 27
Intracytoplasmic Sperm Injection Outcomes Using Surgically-retrieved Sperm from Obstructive Azoospermic Men Epididymis Testicle p Female Age (years) 31.5 7.7 36.3 5.1 Mature Oocytes Injected (n) 9.4 5.8 9.4 4.9 Embryo Transfer (n) 3.3 1.3 3.7 1.5 2PN Fertilization (%) 74.7% 21.2% 69.1% ± 19.6% NS TQE day 3 (%) 44.6% 30.5% 52.7% ± 29.6% Clinical Pregnancy (%) 51.6% 50.0% Miscarriage (%) 18.8% 25.0% 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.Esteves, 28
Intracytoplasmic Sperm Injection Outcomes Using Ejaculates vs. Surgically-retrieved Sperm from Obstructive Azoospermic Men Ejaculate Epididymis/Testicle 70 73 48 46 51 NS 43 20 12 Fertilization rate %TQE Pregnancy (%) Miscarriage (%) (%) 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.
Intracytoplasmic Sperm Injection Outcomes Using Surgically-retrieved Sperm Obstructive Non-obstructive Azoospermia Azoospermia 2PN Fertilization Rate 73.6% 52.2%* TQE transfer day 46.3% 35.7%* Clinical Pregnancy Rate 51.3% 25.9%* Miscarriage Rate 20.0% 14.3% * 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.Esteves, 30
Sperm Defect Severity Rather Than Sperm Source Is Associated With Lower Fertilization Rates After Intracytoplasmic Sperm Injection Verza Jr S & Esteves SC; Int Braz J Urol 2008; 34 ICSI Ejaculated Sperm (n=220) Testicular/ Epididymal Sperm Sperm Defect (n=93) Normal Single Double Triple OA NOA2PN Fertilization (%) 71.3 73.2 72.1 63.4* 73.6 52.2*TQE on Day 3 (%) 48.4 50.5 46.9 48.3 46.3 35.7*Clinical Pregnancy (%) 40.9 36.6 44.4 51.0 51.3 25.9*Miscarriage (%) 14.9 9.1 12.5 12.0 20.0 14.3 * P<0.05 Esteves, Androfert
Sperm Retrieval Rates and ReproductivePotential of Azoospermic Men undergoing ICSI Obstructive (N=142) Non-obstructive (N=172) 97.9% 55.2% 38.2% 25.0% Successful Sperm Retrieval Live Birth rate Odds-ratio 43.0 1.86 95% CI 10.3 – 179.5 1.03 – 2.89 p <0.01 0.03 Prudencio C, Seoul B, Esteves SC. Reproductive potential of azoospermic men undergoing intracytoplasmic sperm injection is dependent on the type of azoospermia. Fertil Steril 2010; 94(4):S232-3.
Sperm Retrieval Techniques Obstructive Azoospermia• Sperm retrieval and lab processing simple• Sperm obtained in virtually all cases• Chance of Retrieval and ICSI Outcomes: • Independent on obstruction etiology • Independent on retrieval technique • Independent on sperm source • Results similar or better than ejaculated sperm
Sperm Retrieval Techniques Non-obstructive Azoospermia• Sperm production deficient or absent• Overall, retrieval rates ~50%• Labor-intensive lab sperm processing• Retrieval rates dependent on technique • Micro-TESE yields better SRR • Predictive factors: testis histology & Y-chromosome• Reproductive potential by ICSI lower than OA and non-azoospermic men
MCQ 1 Azoospermic males presenting with: a) obstructive azoospermia (OA) have normal spermatogenesis and a mechanical block somewhere between the epididymis and the ejaculatory duct. Common causes of OA include vasectomy, post- infectious diseases and congenital conditions. b) nonobstructive azoospermia (NOA) have extremely deficient or absent sperm production within the testicles. Common causes of NOA include cryptorchidism, orquitis, radio/chemotherapy, use of gonadotoxic medication and steroids, and genetic origin. c) nonobstructive azoospermia have retrieval rates dependent on the method of collection. Testicular histopathology results and Y- chromosome microdeletion testing are useful tools to predict the likelihood of sperm retrieval. d) obstructive azoospermia have virtually 100% successful retrievals. Retrieval rates and ICSI outcomes are neither dependent on the method of collection nor on the origin of sperm for ICSI (epididymal or testicular).
MCQ 2 The following techniques can be used to retrieve sperm in men with nonobstructive azoospermia: a) PESA (percutaneous epididymal sperm aspiration). b) Micro-TESE (microdissection testicular sperm extraction). c) TESA (testicular sperm aspiration). d) Conventional TESE (testicular sperm extraction) using single or multiple biopsies.
MCQ 3 The following statements apply to sperm retrieval techniques: a) Micro-TESE yields higher sperm retrieval success rates than conventional TESE or TESA. b) PESA is a fast, effective and safe method to retrieve sperm in obstructive azoospermia. Expertise in microsurgery is required for PESA. c) TESA is safe and effective in cases of failed PESA. No expertise in microsurgery is required for TESA. d) MESA is indicated in obstructive azoospermia. Sperm retrieval rates are comparable to PESA although higher sperm number is obtained.
MCQ 4 Overall, sperm retrieval success and pregnancy rates by ICSI (using retrieved sperm) in men with obstructive (OA) and nonobstructive (NOA) azoospermia are: a) 50% and 30%, 70% and 25%, respectively. b) >90% and 50%, 40% and 25%, respectively. c) 50% and 30%, respectively, and rates are not dependent on the type of azoospermia being obstructive or nonobstructive. d) 100% and 50% in OA men with vasectomy, and 0% in NOA men with testicular histology showing germ cell aplasia (Sertoli cell-only).