clinical management of men with nonobstructive azoospermia - sperm retrieval methods

REPRODUCTIVE ANDROLOGY SURGERY WORKSHOP III 17-21 January 2016 – Reproductive Medicine Unit – Jahra Hospital

KUWAIT

CLINICAL MANAGEMENT OF MEN WITH NONOBSTRUCTIVE AZOOSPERMIA Lesson 4: Sperm Retrieval Methods

Dr Sandro ESTEVES Medical and Scientific Director ANDROFERT - Andrology & Human Reproduction Clinic Campinas, Brazil

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

ANDROFERT

Esteves et al. Sperm Retrieval Techniques. Int Braz J Urol 2011; 37: 570-83

About 40-50% of men with SF have residual spermatogenesis within the testis

§  Not enough for sperm to appear in ejaculate

§  600-800 seminiferous tubules §  Goal is identify site of

production and retrieve sperm for ICSI

§  Geographic location unpredictable


ANDROFERT

Op#ons for sperm retrieval in spermatogenic failure

Technique Acronym Success Tes#cular sperm aspira#on TESA 15-‐50%

Tes#cular sperm extrac#on TESE 17-‐45%

Microdissec#on tes#cular sperm extrac#on

Micro-‐TESE 43-‐63%

Esteves et al Int Braz J Urol 2013;37:570-‐83; Deruyver et al Andrology 2014;2:20-‐4


ANDROFERT

A threshold of 3 mature sperma#ds per seminiferous tubule’s cross-‐ sec#on must be exceeded in order for spermatozoa to spill over into the ejaculate. Men with NOA have a mean of 0–3 mature sperma#ds per seminiferous tubule, thus explaining why rare sperm are occasionally found in ejaculates

Semen Analysis at Day of Sperm Retrieval


ANDROFERT

Silber SJ. Hum Reprod 2000; 15: 2278–84; Jaffe TM et al. J Urol 1998; 159: 1548–50.

http://androfert.com.br/videos

Micro-TESE. Esteves SC Int Braz J Urol 2013; 39(3):440

h;ps://www.youtube.com/watch?v=ynvM6B1GIFA

Vascular pa;ern of tesQs •  Extensive pa;ern of vessels surrounding tesQs

•  Parallel arteries inside tesQs surrounding seminiferous tubules

•  Allows opportunity to maintain blood supply but dissect between tubules throughout tesQs

Photomicrograph courtesy JP Jarow, M.D.

IntratesQcular anatomy

Micro-TESE more effective than conventional TESE

45%

93%

64%

20% 25%

64%

9% 6%

Overall Hypospermatogenesis Maturation Arrest Sertoli-cell Only

Sperm Retrieval Success Rates

Micro-TESE single-biopsy TESE

Controlled series (N=60)

Histology categories pairwise comparisons:

p<0.0001

Method P=0.0005

Verza Jr & Esteves. Fertil Steril 2011; 96 (Suppl.): S53


ANDROFERT

ANDROFERT

Micro-‐TESE was 1.5 #mes more likely (95% CI: 1.4–1.6) to result in successful SR than

conven#onal TESE.

Micro-‐TESE vs cTESE

Fertil Steril Nov;104(5):1099-1103

100%

40.3% 19.5

%

Esteves & Agarwal. Asian J Androl 2014; 16: 642

Hypospermatogenesis

Maturation arrest

Sertoli cell-only

P<0.01

SR by Micro-TESE according to histopathology results (N=357)


ANDROFERT

Ultrasonographic follow-up •  After microdissection TESE: No patients

with lesions seen after 6 mo. •  After standard TESE 70% (19/27) patients

had persistent ultrasound-detected changes within the testes “chronic changes”

•  Schlegel & Ciechanover, 2001


ANDROFERT

A^er micro-‐TESE a transient decrease in serum T is followed by return to baseline levels in about 95% of the cases within 18 months.

However, effects tend to be permanent in men with very small testes and severely compromised androgen ac#vity (eg. Klinefelter syndrome).

Postoperative Testosterone Levels


ANDROFERT

Schiff JD et al. J Clin Endocrinol Metab 2005; 90: 6263–7. Ramasamy R et al. Urology 2005; 65: 1190–4.

microTESE (ANDROFERT Experience) Non-obstructive azoospermia

Source: Androfert; Feb 2015 -‐ Average female age: 36.4 ± 4.0 years

Retrieval attempts 609 Sperm retrieval 52.9% (322/609) ICSI cycles 476 Fertilization rate(fresh) 65% (2392/3680) Fertilization rate (frozen) 54% (563/1210) Transfers 412 Clin Preg/transfer 43% (177/412) LBR/transfer 36.4% (150/412)


ANDROFERT

Microdissection TESE – Postop. •  100 men with NOA •  Controlled trial of TESE v. Microdissection •  Serial ultrasound follow-up at 1, 3, 6 mo.

Std TESE Microdissection

Sperm retrieval 30% 47%

Acute changes 48% 15%

Chronic changes 58% 3%

Amer et al., Hum Reprod 15:653, 2000


ANDROFERT

Okada et al.: Microdissection TESE Std TESE Microdissection

Retrieval rate: SCO 6.3% 34%

Retrieval rate: All NOA pts 16.7% 45%

Ultrasound changes 51% 12%

Complications* 7.5% 2.5%

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

*Decreased tesQcular volume seen a[er 25% of TESE procedures

Repeat micro-‐TESE a^er an ini#ally successful procedure can be carried out, but should be delayed for at least 6 months due to inflammatory changes. SR success is markedly lower (25% vs 80%) if repeat micro-‐ TESE is performed within 6 months of the first opera#on.

Repeat Micro-TESE


ANDROFERT

Schlegel PN, Su LM. Physiological consequences of tes#cular sperm extrac#on. Hum Reprod 1997; 12: 1688–92.

Key Messages – Day 4 Sperm Retrieval Methods

ANDROFERTANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 19 2016

ANDROFERT

Requires use of microscope (15-25x) Depends on differential size of tubules Tedious Learning curve

ü Increased sperm yield ü Less tissue removal ü Fewer postoperative changes

Thank you

This presenta#on is available at hgp://www.slideshare.net/

sandroesteves

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clinical management of men with nonobstructive azoospermia - sperm retrieval methods

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