Download - Sperm retrieval techniques
Sandro Esteves, MD, PhD
Director, ANDROFERTCenter for Male Reproduction and InfertilityCampinas, BRAZIL
Sperm Retrieval Techniques
Esteves, 1
“Understanding Infertility” – New Delhi, India – August 2011
Esteves, 2
Learning Objectives
Understand the difference between obstructive and non-obstructive azoospermia
Overview of the most common sperm retrieval techniques and laboratory processing of
retrieved sperm for ICSI
Learn the success rates of sperm retrieval in obstructive and non-obstructive azoospermia
Reproductive potential of azoospermic men undergoing assisted conception
Azoospermia• It is not a synonymous of sterility
• Normal sperm production
• Mechanical blockage • Vasectomy, Post-
infectious, Congenital
Obstructive• Sperm production
deficient or absent
• Cryptorchidism, Orchitis, Radiation, Chemotherapy, Trauma, Genetic, Gonadotoxins, Unexplained
Non-obstructive
Obstructive Azoospermia
• Epididymis• Testis• Simple and
effective
Sperm retrieval for ART
Please visit http://androfert.com.br/videos to see the video
PERCUTANEOUS RETRIEVAL
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.
Non-obstructive Azoospermia
• Sperm production reduced or absent
• Geographic location unpredictable
Sperm Retrieval for ART
Untreatable condition
TESA
TESE
Controlled studies for NOA men
Fine Needle Aspiration
Open Biopsy
Friedler et al., Human Reprod 12:1488, 1997
4/37 (11%) 16/37 (43%)
Ezeh et al. Human Reprod 13:3075, 1998
5/35 (14%) 22/35 (63%)
Non-obstructive AzoospermiaTesticular Sperm Aspiration - TESA
Non-obstructive AzoospermiaTesticular microdissection - micro-TESE
• Method to identify site(s) of production– Based on the diameter of
seminiferous tubules
• Microsurgical approach– Identify site of production– Preserve vasculature of
testis– Small quantity of tissue
excised
Schlegel, Hum Reprod 1999; 14
Please visit http://androfert.com.br/videos to see the video
• 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
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
Hypospermatogenesis (HYPO)
Maturation Arrest (MA)
Sertoli Cell Only Syndrome (SCO)
Esteves, Androfert
Sperm Retrieval and Etiology of NOA
Chi-square; NSEsteves 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.
Etiology
Histology Sperm +TESA
Sperm + 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%)
Results (2): Micro-TESE X TESA
Sperm Retrieval in NOA is related to Testicular Histopathology
Esteves SC et al Fertil Steril 2010; 94:S132
Esteves, Androfert
*TESA vs micro-TESE (MA + SCO): P=.03
MICRO-TESE
Success Rate
22%
40.00%
NOA
TESA/TESE
N=131; *hypospermatogenesis excluded
Esteves et al.; Fertil Steril 2010; 94:S132
Micro-TESE39%
P=.03
Chance of finding sperm is dependent on the most advanced site of spermatogenesis within the testis
— FSH— Inhibin B— Testicular volume— Etiology— Testosterone levels— Testis histology
Reflect global spermatogenic function but not the most advanced site of sperm production in a dysfunctional testis
Esteves, Androfert
Predictive Factors for Sperm Retrieval in NOA
Predictive Factors for Sperm Retrieval in NOA
Y Chromosome Microdeletion
AZFa deleted
Germ cell Aplasia
No retrievable sperm
AZFb deleted
Maturation Arrest
No retrievable sperm
AZFc deleted
Hypospermatogenesis
70% chance of retrieving testicular sperm for ICSI
PESA/MESATESA/TESE
Laboratory Sperm Processing for ICSI
Esteves, Androfert
PESA/MESA
TESA
TESE
Reproductive Potential of
Azoospermic Men in ART
Esteves, Androfert
Sperm Defect Severity Rather Than Sperm Source Is Associated With Lower Fertilization Rates After
Intracytoplasmic Sperm InjectionVerza Jr S & Esteves SC; Int Braz J Urol 2008; 34
Obstructive Azoospermia Epididymal Testicular
Female Age (years) 31.5 ± 7.7 36.3 ± 5.1
Mature oocytes (n) 9.4 ± 5.8 9.4 ± 4.9
Embryo Transfer (n) 3.3 ± 1.3 3.7 ± 1.5
2PN Fertilization (%) 74.7 ± 21.2 69.1 ± 19.6
TQE on Day 3 (%) 44.6 ± 30.5 52.7 ± 29.6
Clinical Pregnancy (%) 51.6 50.0
Miscarriage (%) 18.8 25.0
Not statistically different
ICSI Ejaculated Sperm n=220
Testicular/Epididymal Sperm
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
Sperm Defect Severity Rather Than Sperm Source Is Associated With Lower Fertilization Rates After
Intracytoplasmic Sperm InjectionVerza Jr S & Esteves SC; Int Braz J Urol 2008; 34
Esteves, Androfert
Not statistically different
ICSI Ejaculated Sperm (n=220)Sperm Defect
Testicular/Epididymal Sperm
(n=93)
Normal Single Double Triple OA NOA
2PN Fertilization (%) 71.3 73.2 72.1 63.4* 73.6 52.2*
TQE on Day 3 (%) 48.4 50.5 46.9 48.3 46.3 35.7*
Clinical Pregnancy (%) 40.9 36.6 44.4 51.0 51.3 25.9*
Miscarriage (%) 14.9 9.1 12.5 12.0 20.0 14.3
* P<0.05
Sperm Defect Severity Rather Than Sperm Source Is Associated With Lower Fertilization Rates After
Intracytoplasmic Sperm InjectionVerza Jr S & Esteves SC; Int Braz J Urol 2008; 34
Esteves, Androfert
Sperm Retrieval Live Birth
97.9%
38.2%55.2%
25.0%
Obstructive (N=142) Non-obstructive (N=172)
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.
Sperm Retrieval Rates and Reproductive Potential of Azoospermic Men in ICSI
• Sperm retrieval and lab processing simple
• Sperm obtained in virtually all cases
• Chance of Retrieval and ICSI Outcomes: • Independent on obstruction etiology• Independent on retrieval technique• Independent on sperm source• Results similar or better than ejaculated sperm
Obstructive Azoospermia
Sperm Retrieval Techniques Practical Points
• 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
Non-obstructive Azoospermia
Sperm Retrieval Techniques Practical Points