1. The document discusses testicular failure, also known as non-obstructive azoospermia, which represents the most severe form of male infertility due to absent or minimal sperm production within the testicles. 2. It reviews treatment options for testicular failure including different sperm retrieval techniques like TESA, TESE, and micro-TESE which have success rates ranging from 15-67% depending on the technique. 3. The document also discusses that while factors like hormone levels and testicular volume cannot predict sperm retrieval success, the presence of AZFa or AZFb microdeletions on the Y chromosome indicates no chance of finding sperm, while AZFc deletions still allow for a 70

1. EOFF 2012, Dubai - UAE
Sandro Esteves, MD, PhD
Director, ANDROFERT
Center for Male Reproduction and Infertility
Campinas, BRAZIL

2. Learning Objectives
Understand the concept of
testicular failure
Learn the treatment options and results
for men with testicular failure in the
current ART era
Update on new treatment options and
what the future holds for men with
testicular failure seeking fertility
Esteves, 2

3. Review this lecture at:
http://www.androfert.com.br/review
Pdf slides
Movie

4. Sperm Count in Humans
General Population of Unscreened Men
Centiles
2.5% 50% 97.5%
Sperm count
per mL (x106) 4 64 237
Azoospermia
• Complete absence of sperm in the ejaculate
• 1-3% male population
• ~10-15%% male infertility population
Esteves, 4 Cooper et al. Hum Reprod Update 2009; Esteves et al, CLINICS 2011

5. Semen Analysis and
Azoospermia
Centrifugation
at 3,000g for
15 minutes
The supernatant is
discharged and the
pellet is examined
Esteves, 5

6. Types of Azoospermia
Non-
Obstructive obstructive
• Normal sperm production
• Absent or minimal sperm
• Mechanical blockage anywhere
production within the
along the reproductive tract
testicles
• Epididymis
• Vas Deferens • Testicular failure
• Ejaculatory Duct
Esteves, 6

7. Esteves, 7 UN Census Estimates, 2008

8. Testicular Failure: Etiology
Congenital
Testicular dysgenesis/cryptorchidism
Genetic abnormalities (Klinefelter’s syndrome, Yq microdeletions)
Germ cell aplasia (SCO syndrome)
Spermatogenic (maturation) arrest
Acquired
Testicular torsion; Trauma
Post-inflammatory (eg. mump’s orchitis)
Exogenous factors (steroid medications, cytotoxic drugs, irradiation, heat)
Testicular Cancer; Systemic diseases (liver cirrhosis, renal failure)
Varicocele
Idiopathic (Unknown etiology)
Esteves, 8

9. Understand the concept of
testicular failure
1. Azoospermia is a descriptive
term of ejaculates that lack
spermatozoa without
implying a specific underlying
cause.
2. Testicular failure is synonymous of non-
obstructive azoospermia (most severe form of
male infertility). It represents a spectrum of
testicular disorders that cannot be treated.
Esteves, 9

10. Testicular Failure: The PAST
NOA
Untreatable
condition
Small testes
Elevated FSH AID
Adoption
“Sterile”
Esteves et al. An update on the initial assessment of the infertile male.
Esteves, 10 CLINICS 2011;66:1-10.

11. Testicular Failure:
The FACT
 600-800 seminiferous tubules/testis
 30-50% cases: minimal production
for sperm to appear in the ejaculate
• Heterogeneity of sperm
production
• Foci of sperm production may exist
in dysfunctional testes
Esteves SC & Agarwal A. Sperm Retrieval Techniques; In: Gardner D et al (Eds.), Human
Assisted Reproductive Technology. Cambridge University Press, pp. 41-53, 2011
Esteves, 11

12. Testicular Failure: The PRESENT
 Single focus of
production adequate to
retrieve sperm for ICSI
 Goal: To identify and
retrieve sperm for
ICSI
Esteves SC & Agarwal A. Sperm Retrieval Techniques; In: Gardner D et al (Eds.), Human
Esteves, 12 Assisted Reproductive Technology. Cambridge University Press, pp. 41-53, 2011.

13. Testicular Failure: The PRESENT
Technique Acronym
Testicular Sperm Aspiration TESA; TEFNA NOA
Testicular Sperm Extraction TESE
(single or multiple biopsies)
Untreatable
condition
Microsurgical Testicular Sperm Micro-TESE
Extraction
Sperm
Retrieval
and ICSI
Esteves et al. Sperm Retrieval Techniques for Assisted Reproduction.
Esteves, 13 Int Braz J Urol 2011; 37(5):570-83

14. Testicular Failure: The PRESENT
Critical Issues
Which is the
best technique
to retrieve
sperm?
What are the Is it possible
success to predict
rates and success in
risks of sperm
ICSI? retrieval?
Esteves, 14

15. Sperm Retrieval in Testicular Failure:
which is the best technique?
TESE
Conventional
• 15%- • 20%- • 40%-
TESA
Micro-TESE
50% 63% 67%
SRR SRR SRR
Friedler et al. 1997; Ezeh et al. 1998; Schlegel 1999; Amer et al. 2000; Okada et al.
2002; Okubu et al. 2002; Tsujimura et al. 2002; Ramon et al. 2003;
Esteves, 15 Verza Jr. & Esteves 2011.

16. Sperm Retrieval in Testicular Failure:
which is the best technique?
Schlegel 1999
Amer et al. 2000
Micro-
Controlled Series
Okada et al. 2002
TESE
43%-53%
Okubu et al. 2002
Tsujimura et al. 2002 TESE
25%-41%
Ramon et al. 2003
Esteves et al. 2011
Esteves, 16

17. Goals of Sperm Retrieval in
Testicular Failure
Immediate
Obtain use for
sperm ICSI
for ICSI
Cryopreservation
Future
retrievals
Minimize
damage Testicular
function
Esteves, 17

18. Available at http://androfert.com.br/videos

19. In
Testicular
Failure,
higher chances
of sperm
harvesting by
micro-TESE
Esteves, 19

20. Is it possible to predict success of
sperm retrieval?
FSH levels Testosterone Testicular Testicular
levels Volume Histopathology
No
Markers reflect global spermatogenic function but
not the presence of an advanced site of sperm
production in a dysfunctional testis.
Esteves, Miyaoka & Agarwal. Surgical Treatment of Male Infertility in the ICSI Era.
Clinics 2011; 66:1463-77; Verza Jr. & Esteves. Fertil Steril 2011; 96: S53;
Esteves, 20 Carpi et al. Fertil Steril 2009.

21. Is it possible to predict success of
sperm retrieval?
Etiology Retrieval Rate
Cryptorchidism 52-74%
Varicocele 63-68%
Post-infection 67%
Torsion >50%
Post-chemotherapy/RT 25-75%
Genetic (Klinefelter, AZFc Yq microdeletions) 25-70%
Idiopathic 50-60%
No
Presence of an advanced site of sperm
production is not related to the etiology of
testicular failure.
Esteves et al., Fertil Steril 94; 2010; Raman and Schlegel. J Urol.170; 2003;
Esteves, 21 Hopps et al. Hum Reprod. 180, 2003; Damani et al. JCO. 15; 2002

22. Is it possible to predict success of
sperm retrieval?
Y Chromosome Microdeletion Screening
Prevalence of Yq microdeletions:
1:2.000-3.000 newborns
Men with testicular failure: 5-12%
Esteves, 22
Esteves & Agarwal. Novel concepts in male infertility. Int Braz J Urol 2011.

23. Is it possible to predict success of
sperm retrieval?
Y Chromosome Microdeletion Screening
AZFa AZFb AZFc
deletion deletion deletion
No chance to No chance to Sperm retrieved in
find sperm find sperm ~70% of cases
Yes
The only unfavorable indicator for SR is the
presence of microdeletions in the AZFa and/or
AZFb regions of the Y chromosome long arm
Esteves SC & Agarwal A. Novel concepts in male infertility.
Int Braz J Urol 2011; 37:5-15.
Esteves, 23

24. What are the success rates of ART in
testicular failure ?
Testicular Failure (n=228) Ejaculated sperm (n=621)
Obstructive azoospermia (n=243)
64.5 62.9
*P<0.01
43.7 * *
45.3
47.8
52.5
37.5
*
32.3
19.2 19.6 21.0 21.4
%2PN Fertilization %Top quality % Miscarriage % Live birth
embryos
Esteves & Agarwal. Reproductive outcomes including neonatal data of sperm
injection in men with obstructive and nonobstructive azoospermia: case series
Esteves, 24 and systematic review. CLINICS, in press

25. What are the success rates and risks
of ART in testicular failure ?
Testicular Failure (n=63)
Ejaculated Sperm (n=247)
Obstructive Azoospermia (n=117)
273.3
244.6 257.7
P = NS
35.7 36.9 37.0
6.3 2.0 2.5 3.2 1.2 1.7
Gestational age Birth weight % Perinatal death % Birth defects
(wks) (gramsx10)
Esteves & Agarwal. Reproductive outcomes including neonatal data of sperm
injection in men with obstructive and nonobstructive azoospermia: case series
and systematic review. CLINICS, in press
Esteves, 25

26. What are the success rates and risks
of ART in testicular failure ?
N children
Region Testicular Outcomes Main findings
failure vs OA
Palermo et USA 22 vs 158 Congenital 4.5% TF vs 1.3% OA (ns)
al. 1999 abnormalities
Vernaeve et Belgium 61 vs 196 Perinatal data Lower gestational age
al. 2005 (singletons); Increased
frequency of premature twins
Congenital 4% TF vs 3% OA (ns)
abnormalities
Fedder et al Denmark 76 vs 282 Congenital 0% TF vs 4.0% OA (ns)
2007 abnormalities
Belva et al.; Belgium 193 vs 474 Perinatal data; Similar perinatal outcomes;
2011
Congenital
4.2% TF vs 5.2% OA (ns)
abnormalities
Esteves et al. Reproductive outcomes including neonatal data of sperm injection in men
with obstructive and nonobstructive azoospermia: case series and systematic review.
Esteves, 26
CLINICS, accepted

27. Learn the treatment options and results
for men with testicular failure in the
current ART era
1. Men with testicular failure
are not sterile.
2. Sperm retrieval and ICSI
using testicular sperm
viable option to achieve
biological fatherhood.
3. So far, post-natal follow-up of
babies born from such fathers are
reassuring.
Esteves, 27

28. Testicular Failure
New Insights & Future Perspectives
Medication Surgery; Artificial
Sperm Male
Retrieval Gamete
Techniques
Esteves, 28

29. Testicular Failure: New Insights (1)
Medication prior to Sperm Retrieval
 Case series: 68 men with
testicular failure (non-mosaic Positive response
Klinefelter Syndrome; micro-
72
TESE
 Medication to boost
55
testosterone production: P = 0.03
Aromatase inhibitor, hCG, anti-
estrogens (min. 2-3 months)
 Positive response: increase in
TT >100 ng/dL from baseline Sperm Retrieval Rate (%)
levels
Esteves, 29
Ramasamy et al., J Urol. 2009; 182: 1108-13.

30. Testicular Failure: New Insights (2)
Anti-estrogens Microsurgical
43 pts. with favorable testicular Varicocele Repair
histopathology, no controls; Meta-analysis of case series;
CC 50mg every other day; 39% men had motile sperm in
64% men had sperm in the ejaculates postop. (mean: 1.6 M/mL)
ejaculates (mean: 3.8 M/mL); Weedin JW et al, J Urol. 2010
All who remained azoospermic Increased the chances of Sperm
had success in Sperm Retrieval. Retrieval by 2.6-fold in men who
remained azoospermic.
Hussein et al, J Androl 2005 Inci et al, J Urol. 2009
Esteves, 30

31. Testicular Failure: The Future (1)
Novel Sperm
Retrieval
Methods for
Identification of Confocal fluorescence
microscopy
Spermatogenic (in vivo; murine model)
Sites
Multi-photon microscopy
(ex vivo; human model)
Full-field optical coherence
tomography
(ex vivo; rat model)
Najari et al, J Urol 2012; Smith et al J Urol 2012; Ramasamy et al., J Pathol Inform 2012

32. Testicular Failure: The Future (2)
NOA
Treatable
condition
Biotechnology
Methods to
Create Artificial
Gametes
Aponte PM, Schlatt S, Franca LR.
Biotechnological possibilities for the treatment of
aspermatogenic men. Clinics 2012
Esteves, 32

33. Be informed on the new treatment options and
what the future holds for men with testicular failure
seeking fertility
1. Aromatase inhibitors, anti-
estrogens and varicocele
repair may improve outcomes
in selected cases.
2. Novel methodologies of sperm
harvesting are under research.
3. Novel biotechnological methodologies are under
research to rescue fertility while maintaining
biological fatherhood.
Esteves, 33

34. Thank you.