Male infertility workshop

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"Serono Meeting for Assisted Reproductive Technology (SMART VI)", Cape Town, South Africa, April 2010

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  • 242 infertile men were included, divided in 2 groups: In group 1, Eighty men had a prior successful microsurgical subinguinal varicocelectomy (all of them performed by the same urologist); and in Group 2, 162 men had any grade of clinical varicocele at the time of ICSI. For group 1, semen analysis results were compared before and after surgery. Clinical pregnancy rates were compared between groups, and a logistic regression analysis was performed to verify if surgical correction of the varicoceles increased the odds of obtaining a clinical pregnancy or decreased the odds of miscarriage occurence.
  • Clinical pregnancy rates after ICSI were significantly higher (60%) in the treated group. Moreover, the chance of obtaining a clinical pregnancy was increased by 69% if the varicocele had been treated before ICSI, as shown by the logistic regression.
  • Male infertility workshop

    1. 1. SMART VI Workshop Cape Town, South Africa 2010 Novel Concepts in Male Infertility
    2. 2. Case #1 <ul><li>Male patient 35 yrs., spouse of 29, infertility for 15 months </li></ul><ul><li>GYN evaluation normal </li></ul><ul><li>Sperm count: 7 M/mL </li></ul><ul><li>Sperm Motility: 40% progressive </li></ul><ul><li>Kruger´s sperm morphology: 5% </li></ul><ul><li>Physical exam: </li></ul>Esteves,
    3. 3. Case #1 - Interactive What do you recommend in this case ? <ul><li>Surgery </li></ul><ul><li>Assisted reproduction </li></ul><ul><li>Medication </li></ul>
    4. 4. Varicocele: surgery Esteves, Technique Testicular Artery preserved Hydrocele (%) Failure (%) Potential morbidity Retroperitoneal No 7 15-45 No Inguinal conventional No 3-39 5-25 No Laparoscopic Yes 10 5-15 Yes Embolization Yes 0 15-25 Yes Microsurgical Yes 0 0.5-3 No
    5. 5. Take home messages: Varicocele (1) Esteves,
    6. 6. O-254: ICSI IN INFERTILE MEN WITH TREATED AND UNTREATED VARICOCELE Esteves, Oliveira & Bertolla – Brazil; ASRM 2009 Group 1 N = 80 Varicocelectomy + ICSI cycle N = 162 ICSI cycle only <ul><li>Semen parameters before and after subinguinal microsurgical varicocelectomy. </li></ul><ul><ul><li>- Paired Student’s T test </li></ul></ul>Materials and Methods Group 2 <ul><li>Groups 1 vs 2: ICSI outcomes </li></ul><ul><ul><li>- Pearson’s Chi-square </li></ul></ul><ul><ul><li>- Logistic regression </li></ul></ul>
    7. 7. O-254: ICSI IN INFERTILE MEN WITH TREATED AND UNTREATED VARICOCELE Esteves, Oliveira & Bertolla – Brazil; ASRM 2009 Results: Clinical Pregnancy Frequency of Clinical Pregnancy *Pearson’s Chi-square test Logistic Regression of Group 1 on Group 2 with Clinical Pregnancy as Dependent Variable Group 1 (N=80; Treated) Group 2 (N=162; Untreated) P-value * Clinical Pregnancy N (%) 48 (60.0) 73 (45.0) 0.03 Group 1 P-value Odds-ratio 95% CI for OR Lower Upper Clinical Pregnancy 0.04 1.69 1.00 2.84
    8. 8. Case #1 - Interactive How long to order a semen analysis after varicocele repair ? <ul><li>1 month </li></ul><ul><li>2 months </li></ul><ul><li>3 months </li></ul>
    9. 9. Spermatogenic cycle length J Urol 2006; 175:242-246 Esteves,
    10. 10. Case #2 <ul><li>Male patient of 30yo.; bilateral orchidopexy at age 9. </li></ul><ul><li>Sperm analysis (2X): azoospermia post-centrifugation, 3 mL volume; pH=7.5 </li></ul><ul><li>Bilateral reduced testes (L:12; R:15 cm3) </li></ul><ul><li>FSH level: 25 mIU/mL; normal testosterone </li></ul>Esteves,
    11. 11. Case #2 - Interactive <ul><li>Sperm analysis (2X: azospermia post-centrifugation, normal volume and pH </li></ul><ul><li>Bilateral reduced testes </li></ul><ul><li>FSH: 25 mIU/mL; orchidopexy at age 9 </li></ul><ul><li>Which type of azoospermia ? </li></ul><ul><ul><li>Obstructive </li></ul></ul><ul><ul><li>Non-obstructive </li></ul></ul><ul><ul><li>More information is needed </li></ul></ul>
    12. 12. Case #2 - Azoospermia <ul><li>Diagnostic testis biopsy: </li></ul><ul><ul><li>Sertoli cell-only (SCO) </li></ul></ul><ul><ul><li>Non-obstructive Azoospermia </li></ul></ul><ul><li>Genetics: </li></ul><ul><ul><li>Karyotype: 46,XY </li></ul></ul><ul><ul><li>Y chromosome microdeletion: absent </li></ul></ul>Esteves,
    13. 13. Case #2 - Interactive <ul><li>Treatment options.... </li></ul><ul><ul><li>PESA-ICSI </li></ul></ul><ul><ul><li>TESA-ICSI </li></ul></ul><ul><ul><li>MicroTESE-ICSI </li></ul></ul><ul><ul><li>Sperm donor </li></ul></ul>
    14. 14. I. Successful sperm retrieval by TESE Microdissection TESE Schlegel 1999 27 63 41 .01 Amer 2000 100 47 30 <.05 Okada 2002 50 45 17 <.05 Esteves 2003 13 61 38 <.05 Year N Microsurgery Conventional P II. Testicular tissue removed (mg) Schlegel 1999 27 9.4 722 .01 Amer 2000 100 4.6 54 <.05 Year N Microsurgery Conventional P
    15. 15. Case #3 <ul><li>39yo pt, infertility for 2 years </li></ul><ul><li>Female partner normal work-up - Heavy smoking, mild sexual life - Taking anti-depressive for 7 mo. </li></ul><ul><ul><ul><li>Normal FSH/LH levels </li></ul></ul></ul><ul><ul><ul><li>Testosterone (T)=270ng/dL; E2=45pmol/L - Normal testicles (~18cm3) - Absence of varicocele - Palpable vas - Normal virilized; BMI=29 kg/m2 </li></ul></ul></ul>Esteves,
    16. 16. <ul><li>Your recommendation… </li></ul><ul><ul><li>Antioxidants </li></ul></ul><ul><ul><li>Aromatase inhibitor </li></ul></ul><ul><ul><li>Assisted reproduction </li></ul></ul><ul><ul><li>Quit smoking/Reduce weight/re-evaluate medication </li></ul></ul><ul><ul><li>A+ </li></ul></ul>Case #3 - Interactive Semen analysis results S-A #1 S-A #2 Volume (mL) 2.5 2.2 Sperm count (million/mL) 18.0 22.8 Motility (%) 35 45 Kruger morphology (%) 05 07 WBC (endtz test) (million/mL) 0.2 0.5
    17. 17. Case #3 <ul><li>Your antioxidant prescription… </li></ul><ul><ul><li>Vitamins (1,0g C + 400 mg E) </li></ul></ul><ul><ul><li>Vitamins (500mg C + 400mgE) </li></ul></ul><ul><ul><li>Folic acid + option B </li></ul></ul><ul><ul><li>Zinc + Vitamin B + option C </li></ul></ul>
    18. 18. Esteves,
    19. 19. Chances for successful sperm retrieval in nonobstructed azoospermic man with AZF microdeletions are…. <ul><ul><li>About 50% </li></ul></ul><ul><ul><li>Zero </li></ul></ul><ul><ul><li>Depends on microdeleted region </li></ul></ul><ul><ul><li>Depends on testis size and FSH levels </li></ul></ul>
    20. 20. Techniques for Sperm DNA Integrity Assessment include…. <ul><ul><li>Karyotype and Acridine orange </li></ul></ul><ul><ul><li>TUNEL and Comet assay </li></ul></ul><ul><ul><li>SCSA and Lipid Peroxidation assay </li></ul></ul>

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