This document provides an overview of sperm retrieval techniques for non-obstructive azoospermia (NOA). It discusses that sperm retrieval rates are related to testicular histopathology, not etiology of azoospermia. Microdissection TESE has higher sperm retrieval rates than standard TESE, especially for men with maturation arrest or Sertoli cell only syndrome. The chances of sperm retrieval and live birth through ICSI are dependent on the type of azoospermia, with higher success rates for obstructive versus non-obstructive causes.

1. Sandro Esteves, MD, PhD
Director, ANDROFERT
Center for Male Reproduction and Infertility
Campinas, BRAZIL
Esteves, 1

2. 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 conception
Esteves, 2

3. 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

4. Obstructive Azoospermia
Sperm • Epididymis
• Testis
retrieval • Simple and
for ART effective

5. Watch the video at http://androfert.com.br/videos

6. 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 and
intracytoplasmic sperm injection (ICSI) in obstructive azoospermic (OA) men according to
the cause of obstruction. Fertil Steril. 2010;94 (Suppl):S233.

7. 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

8. 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

9. Non-obstructive Azoospermia
Sperm • Sperm production
Untreatable 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

10. Sperm Retrieval Techniques in
Non-obstructive Azoospermia
TESA
TESE

11. Non-obstructive Azoospermia
TESA vs. TESE
Controlled studies Needle Open Biopsy
for NOA men Aspiration
Friedler et al., 4/37 (11%) 16/37 (43%)
Human Reprod 12:1488, 1997
Ezeh et al. 5/35 (14%) 22/35 (63%)
Human Reprod 13:3075, 1998

12. Non-obstructive Azoospermia
Testicular 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

13. Microsurgical identification of sperm-
producing tubules by appearance

14. Vascular pattern of testis
• Extensive pattern
of vessels
surrounding the
testis
Photomicrograph courtesy JP Jarow, M.D.

15. Intratesticular anatomy
• Parallel arteries
and veins
surrounding
seminiferous
tubules
• Allows dissection
between tubules

16. Watch the video at http://androfert.com.br/videos

17. TESE & micro-TESE
Laboratory Sperm
Processing for ICSI
Esteves, Androfert

18. TESE

19. Micro-TESE
RESULTS

20. 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

21. Microdissection TESE
#Pts %MicroTESE %TESE
Study Success Success
Amer 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%

22. 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

23. 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 Microdissection
Sperm retrieval 30% 47%
Acute changes 48% 15%
Chronic changes 58% 3%
Amer et al., Hum Reprod 15:653, 2000

24. 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 procedures
Okada et al., J Urology 168:1063, 2002

25. 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.

26. Predictive Factors for Sperm
Retrieval in NOA
Chance 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

27. Predictive Factors for Sperm
Retrieval in NOA
Y Chromosome Microdeletion
AZFa deleted AZFb deleted AZFc deleted
Germ cell Aplasia Maturation Arrest Hypospermatogenesis
No retrievable sperm No retrievable sperm 70% chance of retrieving
testicular sperm for ICSI

28. Predictive Values of Noninvasive Tests
or Techniques for Sperm Retrieval
Overall
Parameter predictive
or exam Sensitivity % Specificity % value %
Testicular volume 7.6–50 6.7–71
FSH 9–71 40–90
Inhibin B 44.6 63.4
FSH, total T,
Inhibin B 71 71.4
Testicular volume
+ hormones 80.8
Doppler ultrasound
imaging 47.3 89
Carpi. Controversies in nonobstructive azoospermia. Fertil Steril 2009.

29. Sperm Retrieval Rates in NOA are Related to
Testicular 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

30. Sperm Retrieval and Etiology of NOA
Etiology
Chi-square; NS
Esteves 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. Fertil
Steril. 2010;94(Suppl.):S132.

31. 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-TESE
HYPO 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

32. Finding Testicular Sperm in Non
Obstructive Azoospermia
Histological 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

33. NOA
39%
P=.03 Micro-TESE
TESA/TESE
Success Rate
N=131; *hypospermatogenesis excluded
Esteves et al.; Fertil Steril 2010; 94:S132

34. Chance of Sperm Retrieval by
NOA Diagnosis
 Cryptorchidism 52-74%
 Varicocele 63-68%
 Epididymitis 67%
 Mumps 67%
 Torsion >50%
 Post-chemotherapy 55-75%
 Genetic AZF a, b 0%
 Genetic AZF c 50-75%
 Orchitis, Gonadotoxins, Endocrine 100%
 Idiopathic 50-60%
Esteves, 2011; Shefi and Turek, submitted; Raman and Schlegel. J
Urol.170:1287, 2003;
Hopps et al. Hum Reprod. 180:1660, 2003; Damani et al. JCO. 15: 930, 2002

35. Candidates for sperm retrieval
Non-obstructive azoospermia
 “Testicular failure”
 Klinefelter’s syndrome
 Sertoli cell-only
 Post-chemotherapy (e.g., lymphoma, testis)
 Cryptorchidism
 Maturation arrest
 Previously failed attempt at “biopsy”
retrieval

36. Reproductive
Potential of
Testicular Sperm
from NOA men
used for ART
Esteves, Androfert

37. 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* 0.04
Pregnancy Rate
Miscarriage (%) 12.1 20.0 14.3 NS

38. 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 Birth
Odds ratio 43.0 1.86
95% CI 10.3 – 179.5 1.03 – 2.89
P-value <0.01 0.03
Prudencio C, Seoul B, Esteves SC. Reproductive potential of azoospermic men undergoing
intracytoplasmic sperm injection is dependent on the type of azoospermia.
Fertil Steril 2010; 94 (4): Suppl. S232-233.

39. 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

40. 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