Management of Male fertility and gonodotropin role

1.
Management
of
male
infer.lity
and
role
of
gonadotropin
Sandro
C.
Esteves,
MD.,
PhD.
Medical
Director,
ANDROFERT
Andrology
&
Human
Reproduc=on
Clinic
Campinas,
BRAZIL
UAE Reproductive Symposium 2015 - Dubai

2. Learning
Objec.ves
1. Understand
the
WHO
reference
values
for
semen
analysis
and
the
role
of
sperm
DNA
fragmenta.on
tes.ng
2. Appraise
which
interven.ons
may
benefit
infer.le
men
candidates
to
ART
3. Learn
how
to
manage
infer.le
males
with
azoospermia
and
the
role
of
gonadotropin
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 2
2015
ANDROFERT

3. Semen
analysis
is
s.ll
the
most
widely
used
biomarker
to
predict
male
fer.lity
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 3
2015
ANDROFERT

4.
1980
1987
1992
1999
Volume
(mL)
ND
≥2
≥2
≥2
Count
(106/mL)
20-­‐200
≥20
≥20
≥20
Total
count
(106)
ND
≥40
≥40
≥40
Mo.lity
(%)
≥
60
≥50
≥50
≥50
Progressive
(%)
≥
2
≥25%
≥25%
(a)
≥25%
(a)
Vitality
(%)
ND
≥50
≥75
≥75
Morphology
(%)
80.5
≥50
≥30
(14)*
Leukocytes
(106/mL)
<4.7
<1.0
<1.0
<1.0
*Strict
criteria
(Tygerberg);
Esteves
et
al.
Urology
2012
WHO
reference
values
have
changed
2010
≥1.5
≥15
≥39
≥40
≥32%
≥58
≥4*
1.0
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 4
2015
ANDROFERT

5. ~2,000
specimens;
recent
fathers
Percen.le
5% 50% 95%
Volume
(mL) 1.5 3.7 6.8
Count
(x106/mL) 15.0 73.0 213.0
Total
count
(x106) 39.0 255.0 802.0
%
Mo.le
40 61 78
%
Progressive
mo.lity 32 55 72
%
Normal
(Kruger) 4 15 44
%
Alive 58 79 91
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 5
2015
ANDROFERT

6. Urology 2012; 79(1):16-22
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 6
2015
ANDROFERT

7. Proposal
for
a
new
report
template
Esteves,
Int
Braz
J
Urol
2014;
40:443-­‐53
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 7
2015
ANDROFERT

8. History
taking,
physical
examina.on,
endocrine
profile
and
laboratory
sperm
func.on
tes.ng
are
minimum
standards
Esteves
Int
Braz
J
Urol
2014
Male
infer.lity
evalua.on
must
go
beyond
a
simple
semen
analysis
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 8
2015
ANDROFERT

9. Conven.onal
semen
analysis
is
not
enough
single-strand
break mis-match
damaged base
double-strand
break inter-strand
crosslink
intra-strand
crosslink
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 9
2015
ANDROFERT

10. DNA
Damage
Environmental
factors
Phtalate exposure,
radiation, temperature
Diseases
Varicocele, GTI, fever
Life-­‐style
Obesity, smoking, medication
Aging
Factors
associated
with
sperm
DNA
fragmenta.on
Rubes
et
al
2007;
Esteves
&
Agarwal
2011
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 10
2015
ANDROFERT

11. Frequency
of
elevated
SDF
in
men
with
unexplained
infer.lity
Elevated
SDF
(27%)
Androfert; N=987
Elevated
SDF
(27%)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 11
2015
ANDROFERT

12. 19%
1.5%
Normal Elevated
Live birth rates with IUI
N=387;
OR
=
0.07
[95%
CI:
0.01-­‐0.48]
Bungum
et
al.
Hum
Reprod
2007
IUI
outcome
is
nega.vely
affected
by
elevated
SDF
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 12
2015
ANDROFERT

13. 26%
42%
IVF
ICSI
Pregnancy in cases of elevated
sperm DNA fragmentation
IVF
outcome
is
nega.vely
affected
by
elevated
SDF
Robinson
et
al.
Hum
Reprod
2012
Meta-­‐analysis
of
16
studies;
2,969
couples:
Increased
miscarriage
in
IVF/ICSI
associated
to
high
SDF;
RR
=
2.16
95%
CI:
1.54-­‐3.03;
p<0.00001
Bungum
et
al.
Hum
Reprod
2007
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 13
2015
ANDROFERT

14. Fer.lity
and
Sterility
2014;
101(1):58-­‐63
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 14
2015
ANDROFERT

15. Andrologia
2014;
46(6):
602–9
Pa.ents
with
varicocele
have
higher
propor.on
of
sperm
with
massive
DNA
damage
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 15
2015
ANDROFERT

16. SDF
is
part
of
rou.ne
work-­‐up
of
male
infer.lity
at
Androfert
Does the
patient have
high SDF?
Semen
analysis
including SDF
testing (SCD
assay)
High SDF if
results >30%
What does the
doctor need
to know?
Determine
test and
internal
validation
Lab SOP with
post-analytical
info for clinical
decision
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 16
2015
ANDROFERT

17. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 17
2015
ANDROFERT

18. Role
of
interven.ons
to
infer.le
men
candidates
to
ART
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 18
2015
ANDROFERT

19. Outcome
Effect
size
(OR;
95%
CI)
Live
birth
4.85
[1.92,
12.24]
DNA
fragmenta.on
-­‐13.80
[-­‐17.50,
-­‐10.10]
Oral
an.oxidants
decrease
SDF
and
improve
ART
outcomes
Showell
et
al.
Cochrane
Database
Syst
Rev
2011
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 19
2015
ANDROFERT

20. Oral
an.oxidants
to
infer.le
males
Prescrip.on:
Vitamin
C
500mg;
Vitamin
E
400
mg
Folic
acid
2
mg,
Zinc
25
mg
Selenium
26
mcg
Dura.on:
minimum
2
months
Old
concept
~90
days
New
concept
~60
days
Misell
et
al.
J
Urol
2006;
Esteves
&
Agarwal
Int
Braz
J
Urol
2011
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 20
2015
ANDROFERT

21. Sperm
DNA
damage
in
tes.cular
and
ejaculated
samples
using
the
SCD
test*
40.7%
8.3%
Ejaculate
Tes.s
P<0.001
Sánchez-­‐Marqn,
Esteves
&
Gosálvez,
in
prepara@on
*Dual
fluorescent
cocktail
probe
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 21
2015
ANDROFERT

22. Wang
YJ
et
al.
Reprod
Biomed
Online
2012;25:307-­‐14
Meta-­‐analysis
of
7
studies
including
336
pts.
indicated
that
SDF
is
significantly
decreased
auer
varicocele
repair
(MD=3.4%;
95%
CI
-­‐4.1
to
-­‐2.6;
p<0.0001)
Effect
of
varicocele
surgery
on
SDF
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 22
2015
ANDROFERT

23. • Varicocele
treated
prior
to
ICSI
(N=80)
• ICSI
with
untreated
varicocele
(N=162)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 23
2015
ANDROFERT

24. Microsurgical
subinguinal
varicocele
repair
with
aid
of
intraopera.ve
doppler
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 24
2015
ANDROFERT

25. Management
of
azoospermia
and
the
role
of
gonadotropin
therapy
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 25
2015
ANDROFERT

26. Azoospermia:
the
complete
lack
of
sperm
in
ejaculate
auer
centrifuga.on
10-15% infertile
males
1-3% male
population
Cooper
et
al.
Hum
Reprod
Update
2009;
Esteves
&
Agarwal,
Clinics
2013
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 26
2015
ANDROFERT

27. Obstruc.ve
Non-­‐
obstruc.ve
Hypo-­‐hypo
Spermatogenic
failure
Clinical
picture
FSH/LH:
ñ
or
nl
TT:
low
or
nL
Testes:
small
or
nl
Normal
testes
&
endocrine
profile;
Mechanical
blockage
FSH/LH
<1.2
mUI/
mL,
Low
TT,
small
tes.s,
poor
viriliza.on
Disrupted
Normal
Spermatogenesis
Esteves
et
al,
Clinics
2011
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 27
2015
ANDROFERT
Prognosis
and
management
differen.ally
affected
by
type
of
azoospermia

28. • Low FSH and LH (<1.2 mIU/L)
• Low total testosterone (<300 ng/dL)
• Hypotrophic testes
Hypogonadotropic
hypogonadism
Congenital:
Kallman syndrome
Prader-Willi
Acquired:
Pituitary tumor
Steroid abuse
Testosterone replacement therapy
Fraieva
et
al.
Clinics
68;
2013
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 28
2015
ANDROFERT

29. Classic
treatment
for
male
hypogonadism
and
infer.lity
u-­‐hCG
1,000-­‐2,000
IU;
IM
injec.ons;
twice
or
t.i.w;
minimum
12
weeks
Rec-­‐hCG:
SC
self-­‐
injec.on
qw
Pre-­‐filled
syringe
Pen
device
Fraieva
et
al.
Clinics
2013;
68(Suppl.1):81-­‐8
Specific
therapy
in
adult
onset
hypo-­‐
hypo
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 29
2015
ANDROFERT

30. Rec-­‐hCG
for
male
hypo-­‐hypo
Esteves
&
Papanikolaou
Fer@l
Steril
2011;96:S230
Series
of
men
with
adult-­‐onset
HH;
Recombinant
hCG
(250
mcg
qw
for
12
weeks)
Baseline
Pos`reatment
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 30
2015
ANDROFERT

31. Tes.cular
torsion;
trauma
Post-­‐inflammatory
(eg.
Mumps
orchi=s)
Exogenous
factors
(eg.
Cytotoxic
drugs,
irradia=on)
Tes.cular
cancer
Systemic
diseases
(eg.
Liver
cirrhosis,
renal
failure)
Congenital
Tes.cular
dysgenesis/cryptorchidism
Gene.c
abnormali.es
(Klinefelter
syndrome,
Yq
microdele=ons,
etc.)
Acquired
Idiopathic
(unknown
e.ology)
Esteves
et
al.
Clinics
2011;
66:691-­‐700
NOA
due
to
spermatogenic
failure:
an
irreversible
condi.on
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 31
2015
ANDROFERT

32. Esteves
et
al.
Int
Braz
J
Urol
2011;37:570-­‐83
40-­‐50%
of
men
with
SF
have
residual
spermatogenesis
within
the
tes.s
§ Not
enough
for
sperm
to
appear
in
ejaculate
§ 600-­‐800
seminiferous
tubules
§ Goals
are:
i. Op=mize
sperm
produc=on
(if
possible)
ii. Iden=fy
site
of
sperm
produc=on
(if
present)
and
retrieve
sperm
for
ICSI
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 32
2015
ANDROFERT

33. Challenges
faced
by
health
professionals
providing
care
for
men
with
SF
§ Counseling
about
the
chances
of
finding
tes.cular
sperm
§ Usefulness
of
any
medical
interven.on
before
sperm
retrieval
§ Which
sperm
retrieval
method
to
apply
§ Reproduc.ve
poten.al
of
retrieved
gametes
in
ICSI
treatment
§ Health
of
offspring
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 33
2015
ANDROFERT

34. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 34
2015
ANDROFERT

35. Complete
AZFa,
AZFb
or
AZFa+b
microdele.ons
unfavorable
prognosis
YCMD
SR
success
AZFa
nil
AZFb
nil
AZFc
50-­‐70%
Krausz
et
al.
2014;
Esteves
et
al.
2013;
Esteves
2015
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 35
2015
ANDROFERT

36. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 36
2015
ANDROFERT
Interven.ons
to
infer.le
males
men
with
SF
prior
to
a
sperm
retrieval
avempt

37. Matura.on
arrest
and
hypospermatogenesis
favorable
prognosis
Weedin
et
al
J
Urol
2010;183:2309-­‐15
Among
233
men
with
SF
and
treated
varicocele,
1/3
had
mo.le
sperm
in
postop.
ejaculate
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 37
2015
ANDROFERT

38. Inci
et
al
J
Urol
2009;182:1500-­‐5;
Haydardedeoglu
et
al
Urology
2010;75:83-­‐6
§ Inci
2009
OR:
2.63
(95%
CI:
1.05-­‐6.60;
p=0.03)
Although
2/3
remain
azoospermic
auer
varicocele
repair,
SRR
increased
§ Haydardedeoglu
2010
53
30
Treated (N=66)
Untreated
(N=30)
SR success (%)
61
38
Treated (N=31)
Untreated
(N=65)
p<0.01
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 38
2015
ANDROFERT

39. Medica.on
Hypogonadism
(TT<300
ng/dl)
in
up
to
50%
men
with
SF
High
ITT
levels
essen=al
for
regula=ng
spermatogenesis
in
combina=on
with
Sertoli
cell
s=mula=on
by
FSH
Paradoxically
weak
s.mula.on
of
Leydig
and
Sertoli
cells
by
endogenous
gonadotropins
Due
to
high
baseline
FSH
and
LH
levels
the
rela=ve
amplitudes
are
low
Shiraishi
et
al
Hum
Reprod
2012;27:331-­‐9;
Sussman
et
al
Urol
Clin
N
Am
2008;35:147-­‐55
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 39
2015
ANDROFERT

40. Study Study design Study group Medication Findings
Pavlovich
et al. 2001
Case series
43 men with
T/E ratio <10
Testolactone No effect
Hussein et
al. 2005
Prospective
cohort
42 men with
favorable
hystology
Clomiphene
Sperm found in SA in 64.3%; All men
who remained azoospermic had
success at SR
Selman et
al. 2006
Prospective
cohort
49 men with
maturation
arrest
rec-hFSH and hCG
No return of sperm in ejaculate;
posttreatment SRR were 21.4%
Ramasamy
et al. 2009
Case series
56 men with
nonmosaic
Klinefelter
Testolactone or anastrozole,
alone or combined with hCG
SRR increased by 1.4-fold
Reifsnyder
et al. 2012
Retrospective
cohort
307 men with
hypogonadis
m
Aromatase inhibitors, hCG or
Clomiphene, alone or
combined
No effect
Shiraishi et
al. 2012
Prospective
cohort
28 men with
idiopathic SF
hCG alone or combined with
rec-hFSH
SR success in 21% of the treated men
vs. none in untreated men
Hussein et
al. 2013
Prospective
cohort
612
unselected
men
Clomiphene alone or
combined with hCG or hMG
Sperm found in SA in 10.9% of treated
males; SRR higher in men who
remained azoospermic and treated
(57.0 vs. 33.6%, p<0.001)
!
Aromatase
inhibitors
and
gonadotropins
have
been
used
with
variable
results
Esteves
Asian
J
Androl
2015;17:1-­‐12
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 40
2015
ANDROFERT

41. ITT
levels
increase
auer
hCG;
s.mulatory
effect
on
residual
spermatogenic
areas
Shinjo
E
et
al
Andrology
2013;1:929-­‐35;
Shiraishi
et
al
Hum
Reprod
2012;27:331-­‐9
273
1348
Before
After
ITT (ng/dl)
ITT
levels
increased
auer
hCG-­‐based
therapy
Spermatogonial
DNA
synthesis
increased
PCNA
expression
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 41
2015
ANDROFERT

42. 1Shiraishi
et
al
Hum
Reprod
2012;27:331-­‐9;
Esteves
Int
Braz
J
Urol
2013;39:440
hCG-­‐based
therapy
may
increase
SR
success
in
men
with
SF
Microdissec.on
TESE
Rescue
~15%
of
pa.ents
with
previous
failed
SR
avempts1
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 42
2015
ANDROFERT

43. Testosterone
and
estradiol
levels
<300
ng/dL
(10.4
nmol/L)
Hypogonadism
category
Pure
Medica.on
algorithm
at
Androfert
Tx
aimed
at
boos.ng
T
Aromatase
inhibitor
(anastrozole
1mg
orally
qid)
Rec-­‐hCG
(250
mcg
SC
qw);
rec-­‐FSH
added
(75
IU
SC
biw)
if
FSH
levels
<1.5
mIU/ml
T/E
ra.o
<10
Aromatase
hyperac.vity
T/E
ra.o
>10
(nl)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 43
2015
ANDROFERT

44. Esteves
Asian
J
Androl
2015;17:1-­‐12
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 44
2015
ANDROFERT

45. Sperm
retrieval
methods
in
NOA
due
to
spermatogenic
failure
Technique
Acronym
Success
Tes.cular
sperm
aspira.on
TESA
15-­‐50%
Tes.cular
sperm
extrac.on
TESE
20-­‐60%
Microdissec.on
tes.cular
sperm
extrac.on
Micro-­‐
TESE
40-­‐67%
Esteves
et
al
Int
Braz
J
Urol
2013;37:570-­‐83;
Deruyver
et
al
Andrology
2014;2:20-­‐4
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 45
2015
ANDROFERT

46. http://androfert.com.br/videos
Esteves SC Int Braz J Urol 2013; 39(3):440

47. 41.4
47
43.3
20
100
64
61
34.2
Sperm
retrieval (%)
2PN
Fertilization
(%)
Top Quality
Embryos (%)
Live Birth (%)
Non-obstructive (N=365)
Obstructive (N=146)
P<0.01
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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ANDROFERT

48. Morphometric
evalua.on
of
seminiferous
tubules
increases
SR
efficiency
Median
25%-75%
5%-95%
Raw Data
yes No
Presence of Sperm
160
180
200
220
240
260
280
300
320
340
360
380
400
420
Max.TubuleDiameter
Verza
Jr
S,
Esteves
SC.
Fer@l
Steril
2012;
98:
S242;
Esteves
&
Varghese
J
Reprod
Sci
2012;
5(3):233-­‐43
N=54; Tubule Diameter: KW-H (1;54) = 25.2; P<0.001
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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49. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 49
2015
ANDROFERT

50. On
average,
one
top-­‐quality
addi.onal
embryo
for
transfer
or
cryopreserva.on
Clean
Room
Technology
&
ICSI
Results
2,315
pa.ents;
14,660
embryos
Esteves
&
Bento.
Reprod
Biomed
Online
2013;26:9-­‐21
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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51. 3,412
cycles
Tailored
COS
strategy
to
increase
LBR
in
ICSI
cycles
involving
severe
male
factor
0%
10%
20%
30%
40%
50%
60%
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
20
25
Number
of
oocytes
retrieved
Clinical
pregnancy
Live
birth
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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52. Conclusions
1. Conven.onal
semen
analysis
limited
as
surrogate
for
assessing
fer.lity;
SDF
tes.ng
valuable
laboratory
tool
for
clinical
decision
2. An.oxidant
therapy,
microsurgical
varicocele
repair
and
TESA-­‐ICSI
may
improve
ART
outcome
in
selected
individuals
3. Best
management
of
azoospermia
includes
proper
diagnosis,
interven.ons
to
op.mize
sperm
produc.on,
microsurgical
SR,
state-­‐of-­‐
art
laboratory
care
and
tailored
COS
to
ART
candidates
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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ANDROFERT

53. Thank
you
‫ا‬‫شكر‬ Obrigado
This
presenta.on
is
available
at
hvp://www.slideshare.net/
sandroesteves