Reproductive Andrology Workshop III 17-21 January 2016 - Kuwait City - KUWAIT Organized by: Al Jahra Reproductive Medicine Unit - Ministry of Health Lecture 5: Role of IVF Laboratory in Nonobstructive Azoospermia

1.
REPRODUCTIVE ANDROLOGY SURGERY WORKSHOP III
17-21 January 2016 – Reproductive Medicine Unit – Jahra Hospital
KUWAIT
CLINICAL MANAGEMENT OF MEN WITH
NONOBSTRUCTIVE AZOOSPERMIA
Lesson 5: Role of IVF Laboratory
Dr Sandro ESTEVES
Medical and Scientific Director
ANDROFERT - Andrology & Human Reproduction Clinic
Campinas, Brazil

2. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 2
2016
ANDROFERT

3. • Minimal tissue excision
• Mechanical mincing
• Enzymatic tissue digestion
• Tubule measurement
• Laboratory environment
• Sperm vitrification
Esteves & Varghese.
J Hum Reprod Sci 2012; 5:233-43
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 3
2016
ANDROFERT

4. Tissue removed (mg)
Conventional TESE
Micro-TESE
P-value
65 ± 25
8.9 ± 2.5
<0.01
Conven'onal
TESE
Micro-­‐TESE
Verza Jr & Esteves Fertil Steril 2011; Esteves & Varghese J Reprod Sci 2013
Micro-TESE more efficient than
conventional TESE
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 4
2016
ANDROFERT

5. Verza Jr & Esteves Fertil Steril 2011;
Esteves & Varghese J Reprod Sci 2013

6. Seminiferous
tubule
diameter
associated
with
presence
of
sperm
Verza
Jr
S,
Esteves
SC.
Fer$l
Steril
2012;
98:
S242;
Esteves
&
Varghese
J
Reprod
Sci
2012;
5(3):233-­‐43
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
N=54; Tubule Diameter: KW-H (1;54) = 25.2; P<0.001
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 6
2016
ANDROFERT

7. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 7
2016
ANDROFERT

8. AIR-­‐HANDLING
VENTILATION
SYSTEM
(with
carbon
+
KMnO4
filtra[on)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 8
2016
ANDROFERT

9. ISO
5
Cleanroom
IVF
lab
+
VOC
filtra[on
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 9
2016
ANDROFERT

10. 0
50
100
before
a7er
%
TQE
0
20
40
before
a7er
%
miscarriage
0
50
before
a7er
%
LBR
2.3
3.2
Average
No.
Top
Quality
Embryos
ET
Conven[onal
lab
Cleanroom
lab
P=0.01
N=2,315
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 10
2016
ANDROFERT

11. “Vitrifica[on”
of
few
sperm
in
Cell
Sleepers
2
μL
microdroplet
sperm
freezing
media
+
sperm
washing
media
(1:1
ra'o)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 11
2016
ANDROFERT

12. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 12
2016
ANDROFERT
1.
Sperm
pick-­‐up
2.
Sperm
load

13. 3.
Placing
inner
tray
into
outer
vial
5.
Storage
4.
Vapor
freezing
4-­‐5cm
above
LN2
surface
for
2
minutes
(pre-­‐calibrated
minus
115-­‐130oC,
using
a
thermocouple,
Cole-­‐Parmer
Instrument
Company,
USA)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 13
2016
ANDROFERT

14. 3,412
cycles;
Androfert
Individualized
COS
strategies
to
retrieve
10
to
15
oocytes
per
treatment
cycle
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
S ESTEVES, 14
2016
ANDROFERT

15. 47
43.3
64
61
2PN Fertilization (%)
Top Quality Embryos (%)
Non-obstructive (N=365)
Obstructive (N=146)
P<0.01
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 15
2015
ANDROFERT

16. COS
in
cycles
involving
NOA
• Main
goal:
effec[veness
• Clinical
quality
indicator:
number
oocytes
• Protocol
of
choice:
Antagonist
+
tailored
recFSH
dose
according
to
pa[ent
subgroup
cetrorelix
(flexible);
150-­‐300
IU/d
pen
injector
>35yr
and
DOR:
Antagonist
+
recFSH/recLH
cetrorelix
(flexible);
follitropin
alfa
+
lutropin
alfa
2:1
ra'o
(1-­‐2
vials/d);
from
s'mula'on
D1
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 16
2016
ANDROFERT

17. COS
in
poor
responders
involving
NOA
• Goal:
minimum
of
8
MII
oocytes
• Strategy:
Oocyte
banking
+
fresh
cycle
and
micro-­‐TESE
(day
prior
OPU)
-­‐
Antagonist
+
recFSH/recLH
(2:1
ra[o;
2
vials/d
from
Sd1)
-­‐
Minimal
IVF
s[mula[on
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 17
2016
ANDROFERT

18. What about the health of resulting
offspring
Esteves et al Asian J Androl 2014; 16: 602-6
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 18
2016
ANDROFERT

19. Region
N
Outcome
analyzed
Main findings
Palermo et al.
1999
USA
22
Congenital
abnormalities
No difference with obstructive
azoospermia 4.5% vs 1.3%
Vernaeve et al.
2005
Belgium
61
Perinatal data;
Congenital
abnormalities
Lower gestational age (singletons);
Increased frequency of premature twins;
No difference with OA (4% vs 3%)
Fedder et al
2007
Denmark
76
Congenital
abnormalities
No difference with other infertility
categories (0% vs 4.0%)
Belva et al.;
2011
Belgium
193
Perinatal data;
Congenital
abnormalities
Similar perinatal outcomes; no
difference 4.2% SF vs 5.2% OA (ns)
Esteves & Agarwal. Clinics 2013; 68 (Suppl.1): 141-50
Neonatal
Outcome
of
Babies
Born
Health of offspring reassuring
but a call for continuous monitoring needed due
to limited data and lack of long-term follow-up
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 19
2016
ANDROFERT

20. Final
Remarks
1. Nonobstruc[ve
azoospermia
worst
prognos[c
condi[on
in
male
infer[lity
2. Best
management
of
NOA
seeking
fer[lity
includes
proper
diagnosis,
interven[ons
to
op[mize
sperm
produc[on,
microsurgical
SR,
state-­‐of-­‐
art
laboratory
care
&
individualized
COS
3. Mul[disciplinary
team
work
is
key
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 20
2016
ANDROFERT

21. Empirical
treatments
Reproduc[ve
Andrology
Empowering clinical decisions & treatment efficiency
Conventional
semen analysis
Conventional
surgeries
Microsurgery
Genetic
diagnosis
YCMD
molecular
diagnosis
ANDROFERT
Targeted
therapy

22. Thank
you
This
presenta[on
is
available
at
hnp://www.slideshare.net/
sandroesteves
‫ا‬‫شكر‬