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Sandro Esteves, MD., PhD.
Director, ANDROFERT
Andrology & Human Reproduction Clinic
Campinas, BRAZIL
Abnormal Semen
Parameters
What doctors should know
Reproductive Andrology Surgery Workshop 2014 
Al Jahra Hospital, KUWAIT
ISO 9001:2008
Available at:

h"p://www.androfert.com.br/review	
  
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 2
2014 APRIL
ANDROFERT
Abnormal semen parameters:
what doctors should know
Lecture	
  Outline	
  
Learning objectives 
Epidemiological trends and sperm
development
Routine semen analysis: where we
are today
Importance of sperm chromatin
integrity and its clinical implications
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 3
2014 APRIL
ANDROFERT
Epidemiological Trends
•  10-15% of couples are infertile and 1 in 8 men seeks
medical assistance for male infertility.
•  Male factor infertility is responsible for up to 50% of cases
of infertility: 20% as the sole reason and 30% as
contributory.
•  Increased incidence of male infertility may be attributed to
environmental factors and modern life habits such as
obesity, ageing, exposure to gonadotoxins and certain
endocrine disruptors.
•  Noticeable epidemiological increase in the incidence of
testicular cancer and urogenital anomalies
Irvin S, et al 1996, Auger J et al, 1995, Irvine DS 1994, Jørgensen N et al 2001, Jørgensen N et al 2002,
Swan SH 2003, Feki NC et al, 2009
ANDROFERT
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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 4
2014 APRIL
ANDROFERT
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 5
2014 APRIL
ANDROFERT
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 6
2014 APRIL
ANDROFERT
Abnormal Semen
Multiple causes, not exclusive
–  Hormonal problems 
–  Genetic causes
–  Varicocele
–  Genital infection
–  Chemotherapy, radiotherapy
–  Cryptorchidism
–  Idiopathic 
–  Gonadotoxin exposure
–  Life-style factors
–  Endocrine disruptors
–  Etc.
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 7
2014 APRIL
ANDROFERT
Routine Semen Analysis
Functional
Status of
Reproductive
Tract
Seminal Fluid
and Sperm


Central
Laboratory
Investigation
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 8
2014 APRIL
ANDROFERT
•  Standardization 
•  Quality control
•  Quality assurance
•  Certification
Semen Analysis: Andrology Lab
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 9
2014 APRIL
ANDROFERT
Standards 
ANDROFERT
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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 10
2014 APRIL
ANDROFERT
New WHO Reference Values
WHO 20101
1.5
15
39
32 (a+b)
58
4
<1.0
Semen Parameter
 WHO 1999
Volume (mL)
 ≥ 2.0
Count (x106/mL)
 ≥ 20
Total sperm number/ejaculate
 ≥ 40
Motility (%)
 ≥ 50 (a + b)
Vitality (%)
 ≥ 75
Morphology (%)2
 (14)
Leukocytes (x106/mL)
 < 1.0
1Lower Limit (5% percentile), Recent fathers; 2Strict criteria
Grade a = rapid progressive motility; Grade b = slow/sluggish progressive motility
ANDROFERT
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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 11
2014 APRIL
ANDROFERT
New WHO Reference Values
Caution to Interpret Results
ANDROFERT
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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 12
2014 APRIL
ANDROFERT
New WHO standards

Reasons for Lower Cut-off Values
•  Method for semen analysis (QC standards)
•  Adoption of strict criterion for morphology
•  Single specimen of each individual
Different way of generating data
•  Recent fathers with known TTP (≤ 12months)
•  Selection bias
Population studied
Esteves et al. Urology 2012 
ANDROFERT
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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 13
2014 APRIL
ANDROFERT
Critical Appraisal of the WHO New Reference Values for Human Semen and Impact on
Diagnosis and Treatment of Subfertile Men
Esteves, Zini, Aziz et al, Urology, in press
Columbia
USA
Melbourne
Australia
Turku
Finland
Oslo
Norway
Edinburgh
UK
Paris
France
Copenhagen
Denmark
2010 WHO Reference: 1,953 men
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 14
2014 APRIL
ANDROFERT
 
	
  
Volume (mL)
 1.5
Sperm count (x106/mL)
 15.0
Total count (x106)
 39.0
% Motile (total)
 40
% Motile (progressive)
 32
% Normal (strict criteria)
 4
%Alive
 58
Cooper et al. Hum Reprod Update 2010
	
  WHO	
  2010:	
  Recent	
  fathers	
  TTP≤12	
  
mo.	
   Percentiles
5% 50%*
 95%
3.7
 6.8
73.0
 213.0
255.0
 802.0
61
 78
55
 72
15
 44
79
 91
New WHO Standards

Reasons for Lower Cut-off Values
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 15
2014 APRIL
ANDROFERT
New WHO Standards: Implications
Do we need to recall previous semen analysis
reports?
	
  
Abnormal
results 
WHO 1999
Reclassified
as “Normal” 
WHO 2010
(38.7%)
Couples (N=987) with infertility
duration >12 months
Source: ANDROFERT, Brazil
Morphology by strict 
criterion accounted for 
53% of reclassification
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 16
2014 APRIL
ANDROFERT
Referral Deferment
Semen Parameters
Case
study
Volume (mL)
 2.3
Count (106/mL)
 16.5 
Progressive motility (%)
 40
Vitality (%)
 65
Morphology (%)
 9
Reference
1999
 2010
≥ 2
 ≥ 1.5 
≥ 20 
 ≥ 15 
≥ 50 
 ≥ 32 
≥ 75 
 ≥ 58
(14)
 ≥ 4
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 17
2014 APRIL
ANDROFERT
Laboratories adopting the new standards should
determine the strategy to communicate clinical
significance of the reported results 
WHO Standards Interpretation
Esteves SC. Int Braz J Urol 2014
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 18
2014 APRIL
ANDROFERT
Semen Analysis Results 
Not accurate to discriminate fertile from
infertile men 
Male infertility workup
goes far beyond a simple
semen analysis. History,
physical examination,
laboratory and sperm
function tests are minimum
standards
Esteves, et al 2011; 2012; 2014 
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 19
2014 APRIL
ANDROFERT
Practical Points
•  Routine semen analysis still central in
laboratory evaluation of male infertility
•  WHO new reference limits are lowered
compared with previous references
•  Caution to interpret new references
–  Comparison with 90% percentile distribution is
advisable
–  Results not accurate to discriminate infertile
from fertile males unless if at extreme levels 
–  Complete male infertility evaluation should be
undertaken
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 20
2014 APRIL
ANDROFERT
Lecture	
  Outline	
  
Learning objectives 
Epidemiological trends and sperm
development
Routine semen analysis: where we
are today
Importance of sperm chromatin
integrity and its clinical implications
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 21
2014 APRIL
ANDROFERT
Why semen analysis is not
enough
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 22
2014 APRIL
ANDROFERT
Defects in Sperm DNA Structure
single-strand
break mis-match
damaged base
double-strand
break inter-strand
crosslink
intra-strand
crosslink
Single-strand DNA break (ss-DB)
Double-strand DNA break (ds-DB)
Base deletion or modification
Inter or intra-strand cross linkage


Esteves et al 2013; Alvarez and Gosálbez 2011; Ward 2011 
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 23
2014 APRIL
ANDROFERT
Biological mechanisms of SDF
Protamination Failure
Replacement of histone to protamines during
spermiogenesis
Oxidative Stress
Epididymis transit
Post-ejaculation: leukocytes, immature sperm,
abnormal levels seminal plasma antioxidants
Apoptosis
During sperm maturation (testis & epididymis)


 Fernández et al. 2009; Alvarez and Sakkas 2010; Agarwal et al. 2013
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 24
2014 APRIL
ANDROFERT
DNA	
  Damage	
  
Environmental factors
Phtalate exposure, radiation,
temperature
Diseases
Varicocele, GTI, fever
Life-style
Obesity, smoking
Aging


External factors leading to SDF
Kort et al. 2006; Rubes et al 2007; Viloria et al 2007; Esteves & Agarwal 2011
SDF and Male Infertility Etiologies
Gosálbez et al. 2013
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 26
2014 APRIL
ANDROFERT
SDF and Infertility: Why bother?
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 27
2014 APRIL
ANDROFERT
19%
1.5%
Normal Elevated
Live Birth Rates with
Intrauterine Insemination
OR = 0.07
[95% CI: 0.01-0.48]
Bungum et al. Hum Reprod 2007
IUI Outcome and SDF
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 28
2014 APRIL
ANDROFERT
26%
42%
IVF
 ICSI
Pregnancy by Method in
Cases of Elevated Sperm
DNA Fragmentation
IVF Outcome and SDF
Robinson et al. Hum Reprod 2012
Meta-analysis of 16 studies
and 2,969 couples 
Increased miscarriage in
couples undergoing IVF/ICSI
with high sperm DNA damage
Risk ratio (RR) = 2.16 
95% CI: 1.54-3.03; p<0.00001
Bungum et al. Hum Reprod 2007
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 29
2014 APRIL
ANDROFERT
Frequency of elevated SDF in men
with normal semen analysis
Normal semen analysis
results (WHO)
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 30
2014 APRIL
ANDROFERT
Androfert; N=987
Practical Implications
•  Successful pregnancies in IVF/ICSI cycles can be
obtained using semen samples with a high
proportion of DNA damage
•  Sperm DNA damage is promutagenic and can give
rise to mutations after fertilization, as the oocyte
attempts to repair DNA damage before the initiation
of the first cleavage.
•  Mutations occurring at this point will be fixed in the
germline and may be responsible for the induction of
infertility, childhood cancer in the offspring and for a
higher risk of imprinting diseases
PANG M. G. et al Hum Reprod, 20: 1688–1694, 2005.
Burrello et al Cytogenet Genome Res, 111:363–365, 2005.
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 31
2014 APRIL
ANDROFERT
Fertility and Sterility 2014; 101(1):58-63
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 32
2014 APRIL
ANDROFERT
Correlation between SCD and
TUNEL
SCD more sensitive than
TUNEL. 
Important to distinguish
between the methods as
they differently evaluate
SDF.
20.6
11.5
% SDF
SCD
 TUNEL
 Feijo & Esteves
Fertil Steril 2014; 101(1):58-63
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 33
2014 APRIL
ANDROFERT
Management
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 34
2014 APRIL
ANDROFERT
Take-home Messages (1)
•  Male infertility is a important health issue
•  Despite being genetically-determined,
male fertility is modulated by external
factors
•  Life-style modifications should be
considered in males seeking fatherhood
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 35
2014 APRIL
ANDROFERT
Take-home Messages (2)
•  Normal semen analysis is not a
guarantee of fertility, and vice-versa
•  Male infertility evaluation should go far
beyond routine semen analysis
•  Minimal standards include history
taking, physical examination, semen
analysis, sperm functional tests, and
other tests as appropriate 
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 36
2014 APRIL
ANDROFERT
Take-home Messages (3)
•  Sperm chromatin integrity critical for a
viable pregnancy 
•  Sperm DNA fragmentation common in men
with unexplained infertility
•  SDF testing provides information that is
different and of better prognostic value
than semen analysis
•  Grading SDF may help in designing a cost
effective management
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 37
2014 APRIL
ANDROFERT
Thank you Obrigado 

‫شكرا‬
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 38
2014 APRIL
ANDROFERT

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Abnormal Semen Parameters: What doctors should know

  • 1. Sandro Esteves, MD., PhD. Director, ANDROFERT Andrology & Human Reproduction Clinic Campinas, BRAZIL Abnormal Semen Parameters What doctors should know Reproductive Andrology Surgery Workshop 2014 Al Jahra Hospital, KUWAIT ISO 9001:2008
  • 2. Available at: h"p://www.androfert.com.br/review   ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2014 APRIL ANDROFERT Abnormal semen parameters: what doctors should know
  • 3. Lecture  Outline   Learning objectives Epidemiological trends and sperm development Routine semen analysis: where we are today Importance of sperm chromatin integrity and its clinical implications ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 3 2014 APRIL ANDROFERT
  • 4. Epidemiological Trends •  10-15% of couples are infertile and 1 in 8 men seeks medical assistance for male infertility. •  Male factor infertility is responsible for up to 50% of cases of infertility: 20% as the sole reason and 30% as contributory. •  Increased incidence of male infertility may be attributed to environmental factors and modern life habits such as obesity, ageing, exposure to gonadotoxins and certain endocrine disruptors. •  Noticeable epidemiological increase in the incidence of testicular cancer and urogenital anomalies Irvin S, et al 1996, Auger J et al, 1995, Irvine DS 1994, Jørgensen N et al 2001, Jørgensen N et al 2002, Swan SH 2003, Feki NC et al, 2009 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 4 2014 APRIL ANDROFERT
  • 5. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 5 2014 APRIL ANDROFERT
  • 6. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 6 2014 APRIL ANDROFERT
  • 7. Abnormal Semen Multiple causes, not exclusive –  Hormonal problems –  Genetic causes –  Varicocele –  Genital infection –  Chemotherapy, radiotherapy –  Cryptorchidism –  Idiopathic –  Gonadotoxin exposure –  Life-style factors –  Endocrine disruptors –  Etc. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 7 2014 APRIL ANDROFERT
  • 8. Routine Semen Analysis Functional Status of Reproductive Tract Seminal Fluid and Sperm Central Laboratory Investigation ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 8 2014 APRIL ANDROFERT
  • 9. •  Standardization •  Quality control •  Quality assurance •  Certification Semen Analysis: Andrology Lab ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 9 2014 APRIL ANDROFERT
  • 10. Standards ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 10 2014 APRIL ANDROFERT
  • 11. New WHO Reference Values WHO 20101 1.5 15 39 32 (a+b) 58 4 <1.0 Semen Parameter WHO 1999 Volume (mL) ≥ 2.0 Count (x106/mL) ≥ 20 Total sperm number/ejaculate ≥ 40 Motility (%) ≥ 50 (a + b) Vitality (%) ≥ 75 Morphology (%)2 (14) Leukocytes (x106/mL) < 1.0 1Lower Limit (5% percentile), Recent fathers; 2Strict criteria Grade a = rapid progressive motility; Grade b = slow/sluggish progressive motility ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 11 2014 APRIL ANDROFERT
  • 12. New WHO Reference Values Caution to Interpret Results ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 12 2014 APRIL ANDROFERT
  • 13. New WHO standards
 Reasons for Lower Cut-off Values •  Method for semen analysis (QC standards) •  Adoption of strict criterion for morphology •  Single specimen of each individual Different way of generating data •  Recent fathers with known TTP (≤ 12months) •  Selection bias Population studied Esteves et al. Urology 2012 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 13 2014 APRIL ANDROFERT
  • 14. Critical Appraisal of the WHO New Reference Values for Human Semen and Impact on Diagnosis and Treatment of Subfertile Men Esteves, Zini, Aziz et al, Urology, in press Columbia USA Melbourne Australia Turku Finland Oslo Norway Edinburgh UK Paris France Copenhagen Denmark 2010 WHO Reference: 1,953 men ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 14 2014 APRIL ANDROFERT
  • 15.     Volume (mL) 1.5 Sperm count (x106/mL) 15.0 Total count (x106) 39.0 % Motile (total) 40 % Motile (progressive) 32 % Normal (strict criteria) 4 %Alive 58 Cooper et al. Hum Reprod Update 2010  WHO  2010:  Recent  fathers  TTP≤12   mo.   Percentiles 5% 50%* 95% 3.7 6.8 73.0 213.0 255.0 802.0 61 78 55 72 15 44 79 91 New WHO Standards
 Reasons for Lower Cut-off Values ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 15 2014 APRIL ANDROFERT
  • 16. New WHO Standards: Implications Do we need to recall previous semen analysis reports?   Abnormal results WHO 1999 Reclassified as “Normal” WHO 2010 (38.7%) Couples (N=987) with infertility duration >12 months Source: ANDROFERT, Brazil Morphology by strict criterion accounted for 53% of reclassification ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 16 2014 APRIL ANDROFERT
  • 17. Referral Deferment Semen Parameters Case study Volume (mL) 2.3 Count (106/mL) 16.5 Progressive motility (%) 40 Vitality (%) 65 Morphology (%) 9 Reference 1999 2010 ≥ 2 ≥ 1.5 ≥ 20 ≥ 15 ≥ 50 ≥ 32 ≥ 75 ≥ 58 (14) ≥ 4 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 17 2014 APRIL ANDROFERT
  • 18. Laboratories adopting the new standards should determine the strategy to communicate clinical significance of the reported results WHO Standards Interpretation Esteves SC. Int Braz J Urol 2014 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 18 2014 APRIL ANDROFERT
  • 19. Semen Analysis Results Not accurate to discriminate fertile from infertile men Male infertility workup goes far beyond a simple semen analysis. History, physical examination, laboratory and sperm function tests are minimum standards Esteves, et al 2011; 2012; 2014 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 19 2014 APRIL ANDROFERT
  • 20. Practical Points •  Routine semen analysis still central in laboratory evaluation of male infertility •  WHO new reference limits are lowered compared with previous references •  Caution to interpret new references –  Comparison with 90% percentile distribution is advisable –  Results not accurate to discriminate infertile from fertile males unless if at extreme levels –  Complete male infertility evaluation should be undertaken ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 20 2014 APRIL ANDROFERT
  • 21. Lecture  Outline   Learning objectives Epidemiological trends and sperm development Routine semen analysis: where we are today Importance of sperm chromatin integrity and its clinical implications ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 21 2014 APRIL ANDROFERT
  • 22. Why semen analysis is not enough ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 22 2014 APRIL ANDROFERT
  • 23. Defects in Sperm DNA Structure single-strand break mis-match damaged base double-strand break inter-strand crosslink intra-strand crosslink Single-strand DNA break (ss-DB) Double-strand DNA break (ds-DB) Base deletion or modification Inter or intra-strand cross linkage Esteves et al 2013; Alvarez and Gosálbez 2011; Ward 2011 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 23 2014 APRIL ANDROFERT
  • 24. Biological mechanisms of SDF Protamination Failure Replacement of histone to protamines during spermiogenesis Oxidative Stress Epididymis transit Post-ejaculation: leukocytes, immature sperm, abnormal levels seminal plasma antioxidants Apoptosis During sperm maturation (testis & epididymis) Fernández et al. 2009; Alvarez and Sakkas 2010; Agarwal et al. 2013 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 24 2014 APRIL ANDROFERT
  • 25. DNA  Damage   Environmental factors Phtalate exposure, radiation, temperature Diseases Varicocele, GTI, fever Life-style Obesity, smoking Aging External factors leading to SDF Kort et al. 2006; Rubes et al 2007; Viloria et al 2007; Esteves & Agarwal 2011
  • 26. SDF and Male Infertility Etiologies Gosálbez et al. 2013 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 26 2014 APRIL ANDROFERT
  • 27. SDF and Infertility: Why bother? ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 27 2014 APRIL ANDROFERT
  • 28. 19% 1.5% Normal Elevated Live Birth Rates with Intrauterine Insemination OR = 0.07 [95% CI: 0.01-0.48] Bungum et al. Hum Reprod 2007 IUI Outcome and SDF ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 28 2014 APRIL ANDROFERT
  • 29. 26% 42% IVF ICSI Pregnancy by Method in Cases of Elevated Sperm DNA Fragmentation IVF Outcome and SDF Robinson et al. Hum Reprod 2012 Meta-analysis of 16 studies and 2,969 couples Increased miscarriage in couples undergoing IVF/ICSI with high sperm DNA damage Risk ratio (RR) = 2.16 95% CI: 1.54-3.03; p<0.00001 Bungum et al. Hum Reprod 2007 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 29 2014 APRIL ANDROFERT
  • 30. Frequency of elevated SDF in men with normal semen analysis Normal semen analysis results (WHO) ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 30 2014 APRIL ANDROFERT Androfert; N=987
  • 31. Practical Implications •  Successful pregnancies in IVF/ICSI cycles can be obtained using semen samples with a high proportion of DNA damage •  Sperm DNA damage is promutagenic and can give rise to mutations after fertilization, as the oocyte attempts to repair DNA damage before the initiation of the first cleavage. •  Mutations occurring at this point will be fixed in the germline and may be responsible for the induction of infertility, childhood cancer in the offspring and for a higher risk of imprinting diseases PANG M. G. et al Hum Reprod, 20: 1688–1694, 2005. Burrello et al Cytogenet Genome Res, 111:363–365, 2005. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 31 2014 APRIL ANDROFERT
  • 32. Fertility and Sterility 2014; 101(1):58-63 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 32 2014 APRIL ANDROFERT
  • 33. Correlation between SCD and TUNEL SCD more sensitive than TUNEL. Important to distinguish between the methods as they differently evaluate SDF. 20.6 11.5 % SDF SCD TUNEL Feijo & Esteves Fertil Steril 2014; 101(1):58-63 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 33 2014 APRIL ANDROFERT
  • 34. Management ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 34 2014 APRIL ANDROFERT
  • 35. Take-home Messages (1) •  Male infertility is a important health issue •  Despite being genetically-determined, male fertility is modulated by external factors •  Life-style modifications should be considered in males seeking fatherhood ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 35 2014 APRIL ANDROFERT
  • 36. Take-home Messages (2) •  Normal semen analysis is not a guarantee of fertility, and vice-versa •  Male infertility evaluation should go far beyond routine semen analysis •  Minimal standards include history taking, physical examination, semen analysis, sperm functional tests, and other tests as appropriate ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 36 2014 APRIL ANDROFERT
  • 37. Take-home Messages (3) •  Sperm chromatin integrity critical for a viable pregnancy •  Sperm DNA fragmentation common in men with unexplained infertility •  SDF testing provides information that is different and of better prognostic value than semen analysis •  Grading SDF may help in designing a cost effective management ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 37 2014 APRIL ANDROFERT
  • 38. Thank you Obrigado ‫شكرا‬ ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 38 2014 APRIL ANDROFERT