Sandro Esteves, MD, PhD Director, ANDROFERT Center for Male Reproduction and Infertility Campinas, BRAZILEsteves, 1
Learning Objectives Understand the difference between obstructive (OA) and non-obstructive azoospermia (NOA) Overview of sperm retrieval techniques for NOA (micro-TESE) and how to handle testicular sperm for ICSI Learn the success rates and prognostic factors of sperm retrieval in NOA using micro-TESE 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-infectious, diation, Chemotherapy, Trau Congenital ma, Genetic, Gonadotoxins, Idiopathic
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SUCCESS RATES IN OBSTRUCTIVE AZOOSPERMIA 100% 100% 97.9% 95.3% CBAVD (N=30) Vasectomy Post-infectious Total (N=142) (N=64) (N=48)Esteves SC, Verza S, Prudencio C, Seol B. Success of percutaneous sperm retrieval andintracytoplasmic sperm injection (ICSI) in obstructive azoospermic (OA) men according tothe cause of obstruction. Fertil Steril. 2010;94 (Suppl):S233.
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 Testicular/ ICSI Ejaculated Sperm Epididymal Sperm n=220 OA; n=93 2PN Fertilization (%) 70.0 73.6 TQE on Day 3 (%) 48.5 46.3 Clinical Pregnancy (%) 43.2 51.3 Miscarriage (%) 12.1 20.0 Not statistically different Esteves, Androfert
Non-obstructive Azoospermia 20% of infertile men attending ART Clinics 60-70% of azoospermic men Causes are: Male Infertility Diagnosis • Pre-testicular: HH • 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 unpredictable Small testes/elevated FSH/”sterile” Overall production poor — Inadequate production for sperm in ejaculate Heterogeneity of sperm production: — 600-800 seminiferous tubules/testis — Single focus of production adequate to retrieve spermatozoa for ICSI Goal: To identify and retrieve sperm for ICSI
Sperm Retrieval Techniques in Non-obstructive AzoospermiaTESATESE
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
Non-obstructive AzoospermiaTesticular microdissection (micro-TESE)• Method to identify site(s) of production – Based on the diameter of seminiferous tubules• Microsurgical approach – Identify site of production – Preserve testis vasculature – Small quantity of tissue excised Schlegel, Hum Reprod 1999; 14
Microsurgical identification of sperm- producing tubules by appearance
Vascular pattern of testis • Extensive pattern of vessels surrounding the testisPhotomicrograph courtesy JP Jarow, M.D.
Intratesticular anatomy • Parallel arteries and veins surrounding seminiferous tubules • Allows dissection between tubules
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TESE & micro-TESELaboratory SpermProcessing for ICSI Esteves, Androfert
Microdissection vs. Standard multi-biopsy TESE Controlled series of 27 patients Standard TESE: 41% (11/27) retrieval Microdissection: 63% (17/27) retrieval Schlegel, Human Reproduction 14:131, 1999 Microdissection provides sperm retrieval for one-third of men who fail standard multibiopsy TESE
Microdissection TESE #Pts %MicroTESE %TESEStudy Success SuccessAmer 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% 49% 33%
The Microdissection TESE Concept: 100 men with “identical” bilateral histology. One side TESE, the other microdissection Approach Success (%) Tissue TESE biopsy 30/100 (30%) 54 mg Microdissection 45/100 (45%) 4.6mg Amer M, et al. Hum Reprod 15: 653, 2000
Amer et al.: Microdissection TESE 100 men with non-obstructive azoospermia Controlled trial of TESE v. Microdissection Serial ultrasound follow-up at 1, 3, 6 mos. Std TESE MicrodissectionSperm retrieval 30% 47%Acute changes 48% 15%Chronic changes 58% 3% Amer et al., Hum Reprod 15:653, 2000
Okada et al.: Microdissection TESE Std TESE Microdissection Retrieval rate: 6.3% 34% SCO Retrieval rate: 16.7% 45% All NOA pts Ultrasound 51% 12% changes Complications* 7.5% 2.5%*Decreased testicular volume seen after 25% of TESE proceduresOkada et al., J Urology 168:1063, 2002
Why is Sperm Prediction Important?1. Can minimize emotional and financial cost of IVF cycles.2. Can minimize trauma/ damage to testis during sperm harvesting.
Predictive Factors for Sperm Retrieval in NOAChance of finding sperm is dependent on the most advanced site of spermatogenesis within the testis — FSH — Inhibin B Reflect global spermatogenic — Testicular volume function but not the — Etiology most advanced site — Testosterone levels of sperm production — Testis histology in a dysfunctional testis Esteves, Androfert
Predictive Factors for Sperm Retrieval in NOAY Chromosome Microdeletion AZFa deleted AZFb deleted AZFc deleted Germ cell Aplasia Maturation Arrest HypospermatogenesisNo retrievable sperm No retrievable sperm 70% chance of retrieving testicular sperm for ICSI
Predictive Values of Noninvasive Tests or Techniques for Sperm Retrieval OverallParameter predictiveor exam Sensitivity % Specificity % value %Testicular volume 7.6–50 6.7–71FSH 9–71 40–90Inhibin B 44.6 63.4FSH, total T, Inhibin B 71 71.4Testicular volume + hormones 80.8Doppler ultrasound imaging 47.3 89 Carpi. Controversies in nonobstructive azoospermia. Fertil Steril 2009.
Sperm Retrieval Rates in NOA are Related toTesticular Histopathology but not to the Etiology of Azoospermia Esteves SC, Verza Jr S, Prudencio C, Seol B; Fertil Steril 2010 • 176 NOA men (mean age 36.9 years) • Microdissection TESE or TESA • Classified according to the Etiology of NOA • Biopsy for histology concomitant or prior to SR Hypospermatogenesis (HYPO) Maturation Arrest (MA) Sertoli Cell Only Syndrome (SCO) Esteves, Androfert
Sperm Retrieval and Etiology of NOA Etiology Chi-square; NSEsteves SC, Verza S, Prudencio C, Seol B. Sperm retrieval rates (SRR) in nonobstructive azoospermia(NOA) are related to testicular histopathology results but not to the etiology of azoospermia. FertilSteril. 2010;94(Suppl.):S132.
Sperm Retrieval in NOA is related to Testicular Histopathology Esteves SC et al Fertil Steril 2010; 94:S132 Results (2): Micro-TESE X TESA Sperm + Sperm + Histology TESA Micro-TESEHYPO 26/26 (100.0%) 19/19 (100.0%)MA 2/6 (33.3%) 7/12 (60.0%)*SCO 6/29 (20.7%) 13/39 (33.3%)*Total 34/61 (55.7%) 39/70 (55.7%) *TESA vs micro-TESE (MA + SCO): P=.03 Esteves, Androfert
Finding Testicular Sperm in Non Obstructive AzoospermiaHistological Pattern Cases Recovery Rate (%)Normal 157 100%Hypospermatogenesis 16 90%Maturation arrest 94 63% Avg Rec Rate 52%Sertoli cell-only (pure) 156 13%Tubular sclerosis 18 39% Harris et al. Urologic Clinics North America 2008
Reproductive Potential ofTesticular Sperm from NOA men used for ART Esteves, Androfert
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 Ejaculated Testicular/ Testicular ICSI Sperm Epididymal Sperm P-value* Sperm (OA) NOA N=220 N=39 N=52%2PN Fertilization 70.0 73.6 52.2* 0.01%TQE on Day 3 48.5 46.3 35.7* 0.03%Clinical 43.2 51.3 25.9* 0.04Pregnancy RateMiscarriage (%) 12.1 20.0 14.3 NS
Sperm Retrieval Rates and Reproductive Potential of Azoospermic Men in ICSI 97.9% Obstructive (N=142) Non-obstructive (N=172) 55.2% 38.2% 25.0% Sperm Retrieval Live BirthOdds ratio 43.0 1.8695% CI 10.3 – 179.5 1.03 – 2.89P-value <0.01 0.03Prudencio C, Seoul B, Esteves SC. Reproductive potential of azoospermic men undergoingintracytoplasmic sperm injection is dependent on the type of azoospermia. Fertil Steril 2010; 94 (4): Suppl. S232-233.
Microdissection TESE Requires use of microscope (15-20x) Learning curve Depends on differential size of tubules Tedious Increased sperm yield Less tissue removal Fewer postoperative changes Schlegel, Hum Reprod 14:131, 1999 Amer et al., Hum Reprod 15:653, 2000 Okada et al., J Urology 168:1063, 2002
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