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RHG Congress 2018 - Rene Woderich

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Testicular versus ejaculated sperm should be used for ICSI in cases of failed fertilisation. Presentation from the RHG Congress 2018.

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RHG Congress 2018 - Rene Woderich

  1. 1. Testicular versus ejaculated sperm should be used for ICSI in cases of failed fertilisation René Woderich Consultant Urologist Warrington
  2. 2. “Insanity Is Doing the Same Thing Over and Over Again and Expecting Different Results” Misappropriated to A. Einstein
  3. 3. “in cases of failed fertilisation” 1) Failed natural fertilisation Analyse/ address/ treat underlying causes and persevere with natural conception? 2) Failed AFT with ejaculated sperm What about poor quality of ejaculated sperm? How many attempts? Is testicular (epididymal) sperm superior?
  4. 4. Overview • Infertility with poor sperm quality • Reversible obstructive azoospermia • Medical treatment of ‘mild’ male factor infertility • Meta-analysis ejaculated vs. testicular sperm
  5. 5. 23.8 28.2 23.4 25.3 0 10 20 30 40 50 60 70 80 90 100 Ejaculate (2160) Epididymal (43) Testicular fresh (122) Testicular frozen (106) Transfers Deliveries per transfer ICSI RESULTS AND ORIGIN OF SPERM A. Van Steirteghem, 2004
  6. 6. Infertility Definition Failure to conceive after 1 year 10% couples 5% men 30% cause not identified - ideopathic
  7. 7. Relative incidence of causes of Infertility 25% female factor alone 25% male factor alone 25% male and female factor 25% unexplained
  8. 8. % Chance Conception within 1 year Trying time (months) Motile sperm (million/ ml) <12 24 48 96 0 0 0 0 0 0.5 16 12 9 6 1 25 19 14 9 2 34 26 19 13 5 36 28 21 14 >10 37 28 21 14
  9. 9. % Ovarian Reserve by Age Average ♀ age at ICSI
  10. 10. Normal Fertility Depends on: ♂ Spermatogenesis ♂ Maturation in epididymis ♂♀ Coitus ♀ Transport through female genital tract ♀ Fertilisation ♀ Implantation
  11. 11. Semen Analysis WHO minimum standard Volume 1-5 ml Density 20 million/ ml Motility > 50% Forward progression > 2% Morphology > 15% normal
  12. 12. Severe Male Factor Infertility Number < 1 million/ ejaculate Motility < 20% Progression < 2% (4%) Abnormal forms > 85%
  13. 13. Mild Male Factor Infertility Two or more semen analyses that have one or more variables which fall below the 5th centile as defined by the World Health Organization. (NICE 2013)
  14. 14. Definitions Aspermia – patient produces no semen Azoospermia – semen contains no sperm Oligo(zoo)spermia – sperm concentration <20 mill/ ml Astheno(zoo)spermia – <50% sperm are active Terato(zoo)spermia - >85% sperm abnormally shaped OATS (Oligo-Astheno-Terato-Spermia) – all of the above Crypto(zoo)spermia – isolated sperm in ejaculate, detected only after extensive microscopic search (+/- centrifugation) Necro(zoo)spermia – all sperm are dead Pyospermia / Leucospermia – large numbers of WBC
  15. 15. Causes of Oligospermia Idiopathic Cryptorchidism Varicoceles Drugs/ gonadotoxins Chemotherapy Radiotherapy Genito-urinary infections Endocrinopathy Partial ejaculatory duct obstruction Unilateral vasal obstruction Hypospermatogenesis Genetic
  16. 16. NICE Guidelines 2013 “Unless there is azoospermia, the predictive value of subnormal semen variables is limited. No functional test has yet been established that can unequivocally predict the fertilising capacity of spermatozoa. Sperm function tests such as computer-assisted semen analysis have not been found to be more predictive. Reliable sperm function tests are urgently required.”
  17. 17. NICE guidelines 2013 “Primary testicular failure is the most common cause of male infertility due to oligozoospermia… ; however, in the majority of cases (66%) the cause is unknown. ... There is no effective treatment to restore fertility in primary testicular failure.”
  18. 18. Anti-sperm antibodies (persist even if causes are addressed or reversed) Ductal obstruction acquired or congenital unilateral or bilateral Vasectomy Epididymitis, Orchitis Trauma, torsion Cryptorchidism Varicoceles “Screening for antisperm antibodies should not be offered because there is no evidence of effective treatment to improve fertility. [NICE Guidelines 2013]
  19. 19. Seminal fluid analysis Motility % sperm moving in 10 hpf Forward progression 0 non-motile 1 sluggish 2 slow 3 moderate 4 excellent Agglutination
  20. 20. Contribution of accessory sex glands to semen volume Volume (ml) Seminal vesicles 2.0 Prostate 0.5 Cowper’s glands 0.1
  21. 21. Main biochemical constituents of seminal plasma Acid phosphatase L-carnitine Citric acid Fructose Glucosidase Glycerophosphocholine Magnesium Prostaglandins Zinc
  22. 22.
  23. 23. Spermcell with release of cytoplasm round spermatid Sertoli-cell B spermatogonium cytoplasmic bridge spermatocyt tight-junction Spermatogenesis
  24. 24. Johnsen score count 10 Complete spermatogenesis organised epithelium 9 many spermatozoa disorganised epithelium 8 < 10 spermatozoa 7 many spermatids 6 < 10 spermatids 5 many spermatocytes 4 < 10 spermatocytes 3 Spermatogonia 2 Sertoli cells only 1 No cells, tubular fibrosis
  25. 25. Relationship Between Johnsen Score and Testicular Size in 388 Testicular Biopsies from Azoospermic Men 2 cm 3 cm 4 cm 5 cm < 2 2.1-7.9 > 8.0
  26. 26. Essential Genetic Investigations Karyotype all ICSI patients X-linked genetic defects Kallman’s Syndome Androgen insensitivity Sex chromosome aneuploidy Klinefelters (XXY) Autosomal defects CFTR gene Vasal aplasia Y chromosome microdelitions Hypospermatogenesis (DNA fragmentation ? Role)
  27. 27. Vincent et al. J. of Andrology, 2002 azoospermia oligozoospermia Obstructive Non-obstructive <5x106/ml 5-10 >10-20 total N° of subjects 144 648 648 628 583 % Anomalies 3 9.7 4.316.7 2651 9.7 4.3 7.70.5 % in the General population 0.4-0.6 INCIDENCE OF CHROMOSOMAL ANOMALIES
  28. 28. GENETIC CAUSES OF SPERMATO/SPERMIOGENESIS FAILURE Gene Anomalies Chromosomal Anomalies >1000 genes involved in human spermatogenesiS (Hochstenbach and Hackstein 2000)
  29. 29. Yp Yq 1 2 3 4 5 6 Centromere 7 USP9Y -DBY -UTYAZFa AZFb CDY2 XKRY HSF2-L SMCY eIF-1AY RBMY1 AZFc PRY TTY2 DAZ BPY2 PRY CDY1 >1200 PATIENTS tested: ONE ISOLATED GENE DELETION FOUND SEARCH FOR ISOLATED GENE DELETIONS
  30. 30. Type of deletions Frequency AZFa complete 2,5% partial 2,5% AZFb complete 2,5% AZFb partial 14% AZFc 63% AZFb complete +AZFc 10,5% AZFb partial +AZFc 2,5% AZFa+b+c 2,5% 39 PATIENTS WITH DELETIONS / TOTAL 449 PATIENTS ANALYSED 1 2 3 4 5 6 7 AZFa AZFc AZFb Krausz et al. 1999 Hum. Reprod ; 1999 JCEM;2001 JCEM
  31. 31. Azoospermia <1x106 <5x106 >5x106 Indications for routine screening 8-10x106 Phenotype number of deleted pat. / frequency totale pat. AZOOSPERMIA 26/175 14,8% <5 millions/ml 12/184 6,5% 5-20 millions/ml 1/59 1,6% Krausz et al. 1999 Hum. Reprod ; 1999 JCEM;2001 JCEM
  32. 32. Y chromosome microdeletions • 7% unselected infertile men • 16% men with severe oligospermia • 25% with azoospermia • Y chromosome 11q position • AZF a – b – c (order of severity) • Genes RBW, DAZ, DBY, XXX • Commonest AZFc (Daz gene) • No phenotype abnormality • All male offspring have Y deletions • Obstructive azoospermia – no deletions
  33. 33. AZFa, AZFb, AZFc Micro-deletion AZFa – Sertoli cell only Micro-deletion AZFb – Maturation arrest Micro-deletion AZFc – Severe olgospermia Vogt et al 1996
  34. 34. Human Studies • 200 fertile vs. 200 infertile men • Y deletion on PCR 2% vs. 7% • Most infertile men with deletion were azoospermic Pryor JL N Engl J Med 1997 • 20% azoospermic and 13% oligospermic men undergoing TESE for ICSI had AZFc deletions • Y deletion had no effect on fertilisation and implantations rates Silber SJ, Hum Rep
  35. 35. Surgery for infertility Ethical considerations Natural pregnancy: Cheaper Less stressful Age of partner ICSI: Both require surgery Cost Safety
  36. 36. Surgery for infertility Varicoceles Obstruction
  37. 37.  Altered spermatogenesis  Reflux of toxic metabolites  Disturbed hormonal status  Abnormal temperature regulation Varicocele Sperm DNA damage  Increased ROS  Elevated temperature Saleh RA et al Evaluation of nuclear DNA damage in spermatozoa from infertile men with varicocele. Fertil Steril 2003;80(6):1431-6
  38. 38. pre-operative post-operative 0 10 20 30 40 meanDFI(%) 38 33 .079 DNA Fragmentation Index pre – post Varicocelectomy
  39. 39. Randomised Controlled Trials of Varicocele Treatment Study Treated Untreated Semen Quality Number Pregnant Number Pregnant Nilsson 1979 57 4 (8%) 45 8 (18%) No change Breznik 1993 38 13 (34%) 41 22 (54%) No sig. change Madgar 1995 25 8 (32%) 20 2 (10%) Improvement Yamamoto 1996 45 3 (7%) 47 4 (8.5%) Improvement Nieschlag 1998 62 18 (29%) 63 16(25%) Improvement WHO 1998 135 47(35%) 113 19(17%) Improvement ALL 27% 22% OR 1.32(0.9 1.96)
  40. 40. Randomised Controlled Trials of Varicocele Treatment In Oligozoospermia Study Treated Untreated Semen Quality Number Pregnant Number Pregnant Madgar 1995 25 8 (32%) 20 2 (10%) Improvement Nieschlag 1998 62 18 (29%) 63 16(25%) Improvement WHO 1998 135 47(35%) 113 19(17%) Improvement ALL 29% 19% OR 2.26(1.4 –3.6)
  41. 41. NICE Guidelines 2013 Recommendation 88 “Men should not be offered surgery for varicoceles as a form of fertility treatment because it does not improve pregnancy rates.” Research recommendation 15 “Randomised controlled trials are needed to compare the effectiveness of surgery for varicocele and in vitro fertilisation treatment in men with abnormal semen quality.”
  42. 42. Surgery for infertility Varicoceles Obstruction
  43. 43. Reconstructive options: obstruction Vaso-vasostomy (vasectomy reversal) Vaso-epididymostomy Transurethral incision of ejaculatory ducts
  44. 44. Cause of Obstructive Azoospermia in 321 Men Site of obstruction n % Intra-testicular 47 16 Epididymal 163 51 Bilateral vasal aplasia 58 18 Unilateral vasal aplasia 39 12 Ejaculatory duct 3 1
  45. 45. Vaso-epididymostomy Patency rate 39-100% Pregnancy rate 18-30% Depending on: Cause of obstruction Microsurgical skills Age of spouse
  46. 46. NICE Guidelines 2013 Recommendation 87 “Where appropriate expertise is available, men with obstructive azoospermia should be offered surgical correction of epididymal blockage because it is likely to restore patency of the duct and improve fertility. Surgical correction should be considered as an alternative to surgical sperm recovery and IVF.”
  47. 47. ICSI
  48. 48. ICSI
  49. 49. Microtese Schlegel P. Hum. Rep. 14, 131, 1999
  50. 50. 0 10 20 30 40 50 60 70 80 90 100 Ejaculate (2160) Epididymal (43) Testicular fresh (122) Testicular frozen (106) Transfers Deliveries per transfer ICSI RESULTS AND ORIGIN OF SPERM A. Van Steirteghem, 2004
  51. 51. In favour of ejaculated sperm Crucial role of epididymis in final steps of spermatogenesis: • Epigenetic gene modification • Changes in spermatozoas’ surface proteins • Sperm maturation • DNA stability/ resistance (“survival of the fittest”) • Acrosomal protein for zona pellucida penetration present in epididymal but not testicular sperm • Higher sperm motility the further distal in epididymis • ?Better results with epididymal vs. testicular sperm • Beneficial in conventional fertilisation
  52. 52. In favour of extracted sperm • Needs thorough examination and prolonged preparation • Repeat centriguagation may increase reactive oxidative species/ further quality reduction • Technical challenges with cryopreservation • Mis-timing of oocyte extraction • Oxidative stress/ DNA damage during transit through male genital tract • Higher DNA fragmentation with lowest sperm count • Better ICSI outcomes with extracted sperm in obstructive azoospermia • ICSI bypasses complex mechanisms of oocyte investment and penetration • ICSI technician select sperm with highest motility and best morphology
  53. 53. Mild male factor infertility: NICE 2013 The term ‘mild’ male factor infertility is used extensively in practice and in the literature. However, there is no formally recognised definition of what this means. Therefore, where the term ‘mild’ male factor infertility is applied in this guideline, it is defined as meaning: two or more semen analyses that have one or more variables which fall below the 5th centile as defined by the World Health Organization (WHO, 2010), and where the effect on the chance of pregnancy occurring naturally through vaginal intercourse within a period of 24 months would then be similar to people with unexplained infertility or mild endometriosis. Assisted reproductive treatments: IVF and ICSI are the preferred approaches with increasing degrees of sperm defects.
  54. 54. 83 Men with hypogonadotrophic hypogonadism should be offered gonadotrophin drugs because these are effective in improving fertility. 84 Men with idiopathic semen abnormalities should not be offered antio-estrogens, gonadotrophins, androgens, bromocriptine or kinin-enhancing drugs because they have not been shown to be effective. 85 Men should be informed that the significance of antisperm antibodies is unclear and the effectiveness of systemic corticosteroids is uncertain. 86 Men with leucocytes in their semen should not be offered antibiotic treatment unless there is an identified infection because there is no evidence that this improves pregnancy rates.
  55. 55. Included Evidence 2 further studies with 340 pat / 277 ICSI cycles 6 cohort studies: 578 male pat, 761 ICSI cycles 1993-2014: 541 ejaculated sperm 153 fresh testicular sperm 67 frozen-thawed testicular sperm (all mTESE, TESE or TESE + TESA) Ovarian hyperstimulation: 4x long protocol of GnHR agonist + HMG or FSH 1x super-long protocol 1x not specified
  56. 56. Primary Outcomes 1. Fertilisation rate: number of normally fertilised ova 2. Embryo quality: Size and symmetry of blastomere, fragmentation rate Grade A embryo: 6-8 regular symmetrical blastomeres, no frag Good-quality embryo rate: n Grade A embryos / n fertilasations 3. Implantation rate: n gestational sacs / n of embryo transfers 4. Pregnancy rate n pregnancies / n ICSI cycles
  57. 57. Kang et al, Nature 2018
  58. 58. Fertilisation rate +8%
  59. 59. Good-Embryo rate +17%
  60. 60. Implantation rate +52%
  61. 61. Pregnancy rate +74%
  62. 62. Strengths Best systematic review with high statistical power Inclusion of 2 further studies with high numbers Exclusion of case reports Correction of error in use of Bendickson data
  63. 63. Limitations and Biases 1. Unable to separate intention-to-treat from per-protocol 2. Insufficient information re: risks from testicular biopsy 3. Heterogeneity of fresh/ frozen/ mixed sperm data No stat significance (but trends) in sub-group analyses (How does cryopreservation affect ICSI outcomes?) 4. Difference in ovarian hyperstimulation protocols 5. Maturity and morphology of oocytes 6. No reflection on complications of TESE RCTs ?unethical (random allocation or “sham” procedures) Did info on complications affect couples’ choice? 7. Maternal age 8. Severity of cryptozoospermia? 9. No data on other types of ‘poor quality sperm’ or idiopathic male/ mixed infertility
  64. 64. Summary • Guidelines and evidence in favour of testicular sperm/ ICSI in severe male-factor infertility • Evidence in favour of testicular sperm/ ICSI in cryptozoospermia • Not (yet) universally supported in reproductive community • Medical and surgical treatment are reasonable and recommended for reversible male infertility (and perseverance with natural conception, or use of ejaculated sperm) • Female factors incl. age important • Couple preferences and ethical considerations important

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