Role of microsurgery in male infertility
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Microsurgery plays an important role in treating male infertility. The document discusses microsurgical techniques for varicocelectomy, vasovasostomy, vasoepididymostomy, and sperm retrieval. Varicocelectomy by the subinguinal microsurgical approach has the lowest recurrence and postoperative hydrocele rates compared to other techniques. Microsurgical vasovasostomy can achieve patency rates of over 90% and pregnancy rates of over 50%. Prognostic factors for microsurgical reconstruction include the obstruction interval and presence of granuloma. Microsurgical epididymal sperm aspiration and testicular sperm aspiration are effective techniques for sperm retrieval in obstructive azoospermia.
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Role of microsurgery in male infertility
- 1. Role of microsurgery in male infer1lity Sandro C. Esteves, MD., PhD. Medical Director, ANDROFERT Campinas, BRAZIL Andrology & Male Infer1lity Workshop ISAR 2015 – Chennai
- 2. Lecture Outline Overview Varicocelectomy Sperm retrieval techniques Vasovasostomy ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2015 ANDROFERT Vasoepididymostomy
- 3. Varicocelectomy Miyaoka & Esteves. Adv Urol 2012 Technique Recurrence Postop hydrocele Retroperitoneal (Palomo) 7-‐35% 6-‐10% Laparoscopy 2-‐7% 0-‐9% Emboliza1on 2-‐24% NR Inguinal (Ivanissevich) 0-‐37% 7% Microsurgical Subinguinal 0-‐1% 0-‐1.6% ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 3 2015 ANDROFERT
- 4. Intraopera1ve 20 MHz microvascular doppler ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 4 2015 ANDROFERT VTI Vascular Technology, USA
- 5. Microsurgical Varicocele Repair ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 5 2015 ANDROFERT
- 6. • Microsurgical varicocele repair prior to ICSI (N=80) • ICSI with untreated varicocele (N=162) ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 6 2015 ANDROFERT
- 7. Esteves & Glina Weedin et al. Meta-‐analysis No. 17 233 Mean age (yrs) 34.2 30.1 Mo1le sperm postop ejaculate; N (%) 6/17 (35.3) 91/233 (39.0) Sperm count postop (mean; x106/mL) 0.8 (0.1-‐1.8) 1.6 ± 1.2 Interval between surgery to sperm (mo.) 5 (3-‐9) NR Spontaneous pregnancy; N (%) 1 (5.8) 14 (6.0) Mean follow-‐up (months) 18.9 13.3 Adapted from: Esteves SC: Varicocele. In: S.J. Parekagl and A. Agarwal (eds.), Male Infer1lity, 2012 Microsurgical varicocele repair in azoospermia ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 7 2015 ANDROFERT
- 8. Matura1on arrest and hypospermatogenesis favorable prognosis Weedin et al J Urol 2010;183:2309-‐15 Among men with NOA and treated varicocele, tes1s histopathology influences presence of sperm in postop. ejaculate ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 8 2015 ANDROFERT
- 9. Epididymis Vas deferens Microsurgery in obstruc1ve azoospermia ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 9 2015 ANDROFERT
- 10. Esteves et al. Surgical treatment of male infer1lity in the era of intracytoplasmic sperm injec1on – new insights. Clinics 2011; 66:1462-‐77 Vas deferens obstruc1on ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 10 2015 ANDROFERT
- 11. Author N Technique Patency (%) Pregnancy (%) Belker et al. 1991 1247 Single-‐layer 89 57 Two-‐layer 86 51 Boorjian & Lipkin 2004 159 Two-‐layer 95 83 Chan & Goldstein 2004 1048 Two-‐layer 99 54 Kolegs et al. 2006 34 Single and two-‐layer 76 35 Esteves et al. Surgical treatment of male infer1lity. Clinics 2011; 66:1462-‐77 Microsurgical vasovasostomy ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 11 2015 ANDROFERT
- 12. Preop: Obstruc1on interval Presence of granuloma Hydrocele Intra-‐op: Surgeon exper1se Fluid aspect (macro) Fluid assessment for sperm (micro) Prognos1c factors in microsurgical vaso-‐vaso & vasoepididymostomy ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 12 2015 ANDROFERT
- 13. Microsurgical vasovasostomy ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 13 2015 ANDROFERT
- 14. Thomas AJ, Surgery for Male Infer1lity, 2006 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 14 2015 ANDROFERT
- 15. Microsurgical reconstruc1on in cases of epididymis obstruc1on Esteves et al. Surgical treatment of male infer1lity in the era of intracytoplasmic sperm injec1on – new insights. Clinics 2011; 66:1462-‐77 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 15 2015 ANDROFERT
- 16. Microsurgical vasoepididymostomy ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 16 2015 ANDROFERT
- 17. Epididymis Ejaculatory duct Vas deferens Surgery in Obstructive Azoospermia ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 17 2015 ANDROFERT
- 18. Clinical features: Obstructive azoospermia Hypospermia (<1.5 mL) Acidic semen pH: <7.2 Congenital Prostatic cyst (Muller) Ejaculatory duct cyst (Wolf) Acquired Iatrogenic Post-infection AP diameter (TRUS): 1.5 cm Ejaculatory Duct Obstruction ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 18 2015 ANDROFERT
- 19. TURED ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 19 2015 ANDROFERT
- 20. Transurethral Resection of Ejaculatory Duct (TURED) Netto Jr, Neves, Esteves. J Urol. 1998;159: 2048-53 Case series Etiology Semen quality Improvement (%) Pregnancy (%) Acquired 37.5 (3/8) 12.5 (1/8) Congenital 83.0 (5/6) 66.0 (4/6) ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 20 2015 ANDROFERT
- 21. Obstruc1ve azoospermia Technique Acronym Percutaneous Epididymal Sperm Aspira1on PESA Microsurgical Epididymal Sperm Aspira1on MESA Tes1cular Sperm Aspira1on TESA Esteves & Agarwal. Sperm Retrieval Techniques. Cambridge University Press, 2011 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 21 2015 ANDROFERT
- 22. Microsurgical Epididymal Sperm Aspira1on (MESA) ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 22 2015 ANDROFERT
- 23. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 23 2015 ANDROFERT Percutaneous Epididymal Sperm Aspira1on (PESA)
- 24. http://androfert.com.br/videos ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 24 2015 ANDROFERT Tes1cular Sperm Aspira1on (TESA)
- 25. 100% 96.6% 96.3% CBAVD Vasectomy Post-‐infection OBSTRUCTIVE AZOOSPERMIA 78.1 % 97.3 % Successful Retrievals PESA + rescue TESA PESA alone Esteves et al. J Urol. 2013; 189(1): 232-‐7 146 patients Sperm retrieval in CBAVD ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 25 2015 ANDROFERT
- 26. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 26 2015 ANDROFERT Esteves et al. J Urol. 2013; 189(1): 232-‐7
- 27. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 27 2015 ANDROFERT Esteves et al. J Urol. 2013; 189(1): 232-‐7
- 28. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 28 2015 ANDROFERT Esteves et al. J Urol. 2013; 189(1): 232-‐7
- 29. Nonobstruc1ve azoospermia Technique Acronym Success TesBcular Sperm AspiraBon TESA 15-‐50% TesBcular Sperm ExtracBon TESE 20-‐60% Microsurgical TesBcular Sperm ExtracBon Micro-‐ TESE 40-‐67% Esteves & Agarwal. Sperm Retrieval Techniques. Cambridge University Press, 2011 TESE ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 29 2015 ANDROFERT
- 30. http://androfert.com.br/videos Esteves SC, Int Braz J Urol 2013 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 30 2015 ANDROFERT Microdissec1on Tes1cular Sperm Extrac1on (Micro-‐TESE)
- 31. 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. Fertil Steril 2012;98(3):S242 Cutpoint: 260µm 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, 31 2015 ANDROFERT Morphometric evalua1on of sperm-‐ containing seminiferous tubules
- 32. Micro-‐TESE Prac1cal Points 240 μm ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 32 2015 ANDROFERT
- 33. 100% 47.0% 19.5% Hypospermatogenesis (n=84) Matura1on arrest (n=67) Sertoli cell-‐only (n=205) Esteves & Agarwal. Asian J Androl 2014;16(4):642 Sperm retrieval rate by micro-‐TESE in NOA (%) N=356; P<0.001 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 33 2015 ANDROFERT
- 34. Lecture Outline ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 34 2015 ANDROFERT Role of microsurgery in male infer1lity Varicocelectomy Sperm retrieval techniques Vasovasostomy Vasoepididymostomy
- 35. This presentation is available at http://www.slideshare.net/ sandroesteves Thank you धन्यवाद Obrigado