management of male fertility and gonodotropin role

Management of male infer.lity and role of

gonadotropin Sandro C. Esteves, MD., PhD. Medical Director, ANDROFERT

Andrology & Human Reproduc=on Clinic Campinas, BRAZIL

UAE Reproductive Symposium 2015 - Dubai

Learning Objec.ves 1.  Understand the WHO reference values

for semen analysis and the role of sperm DNA fragmenta.on tes.ng

2.  Appraise which interven.ons may benefit infer.le men candidates to ART

3.  Learn how to manage infer.le males with azoospermia and the role of gonadotropin

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2015

ANDROFERT

Semen analysis is s.ll the most widely used biomarker to predict

male fer.lity


ANDROFERT

1980 1987 1992 1999 Volume (mL) ND ≥2 ≥2 ≥2 Count (106/mL) 20-‐200 ≥20 ≥20 ≥20 Total count (106) ND ≥40 ≥40 ≥40 Mo.lity (%) ≥ 60 ≥50 ≥50 ≥50 Progressive (%) ≥ 2 ≥25% ≥25% (a) ≥25% (a) Vitality (%) ND ≥50 ≥75 ≥75

Morphology (%) 80.5 ≥50 ≥30 (14)* Leukocytes (106/mL) <4.7 <1.0 <1.0 <1.0

*Strict criteria (Tygerberg); Esteves et al. Urology 2012

WHO reference values have changed

2010 ≥1.5 ≥15 ≥39 ≥40 ≥32% ≥58 ≥4* 1.0


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~2,000 specimens; recent fathers

Percen.le 5% 50% 95%

Volume (mL) 1.5 3.7 6.8 Count (x106/mL) 15.0 73.0 213.0 Total count (x106) 39.0 255.0 802.0 % Mo.le 40 61 78 % Progressive mo.lity 32 55 72 % Normal (Kruger) 4 15 44 % Alive 58 79 91


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Urology 2012; 79(1):16-22


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Proposal for a new report template

Esteves, Int Braz J Urol 2014; 40:443-‐53


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History taking, physical examina.on, endocrine profile and laboratory sperm func.on tes.ng are minimum standards

Esteves Int Braz J Urol 2014

Male infer.lity evalua.on must go beyond a simple semen analysis


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Conven.onal semen analysis is not enough

single-strand break

mis-match

damaged base double-strand

break

inter-strand crosslink

intra-strand crosslink


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DNA Damage

Environmental factors Phtalate exposure, radiation, temperature Diseases Varicocele, GTI, fever Life-‐style Obesity, smoking, medication Aging

Factors associated with sperm DNA fragmenta.on

Rubes et al 2007; Esteves & Agarwal 2011


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Frequency of elevated SDF in men with unexplained infer.lity

Elevated SDF (27%)

Androfert; N=987

Elevated SDF (27%)


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19%

1.5%

Normal Elevated

Live birth rates with IUI

N=387; OR = 0.07 [95% CI: 0.01-‐0.48]

Bungum et al. Hum Reprod 2007

IUI outcome is nega.vely affected by elevated SDF


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26% 42%

IVF ICSI

Pregnancy in cases of elevated sperm DNA fragmentation

IVF outcome is nega.vely affected by elevated SDF

Robinson et al. Hum Reprod 2012

Meta-‐analysis of 16 studies; 2,969

couples:

Increased miscarriage in IVF/ICSI associated to high SDF; RR = 2.16 95% CI: 1.54-‐3.03; p<0.00001

Bungum et al. Hum Reprod 2007


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Fer.lity and Sterility 2014; 101(1):58-‐63


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Andrologia 2014; 46(6): 602–9

Pa.ents with varicocele have higher propor.on of sperm with massive DNA damage


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SDF is part of rou.ne work-‐up of male infer.lity at Androfert

Does the patient have high SDF?

Semen analysis

including SDF testing (SCD

assay)

High SDF if results >30%

What does the doctor need

to know?

Determine test and internal

validation

Lab SOP with post-analytical info for clinical

decision


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Role of interven.ons to infer.le men candidates

to ART


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Outcome Effect size (OR; 95% CI)

Live birth 4.85 [1.92, 12.24]

DNA fragmenta.on -‐13.80 [-‐17.50, -‐10.10]

Oral an.oxidants decrease SDF and improve ART outcomes

Showell et al. Cochrane Database Syst Rev 2011


ANDROFERT

Oral an.oxidants to infer.le males Prescrip.on:

Vitamin C 500mg; Vitamin E 400 mg Folic acid 2 mg, Zinc 25 mg Selenium 26 mcg

Dura.on: minimum 2 months

Old concept ~90 days New concept ~60 days

Misell et al. J Urol 2006; Esteves & Agarwal Int Braz J Urol 2011


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Sperm DNA damage in tes.cular and ejaculated samples using the SCD test*

40.7%

8.3%

Ejaculate Tes.s

P<0.001

Sánchez-‐Marqn, Esteves & Gosálvez, in prepara@on

*Dual fluorescent cocktail probe


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Wang YJ et al. Reprod Biomed Online 2012;25:307-‐14

Meta-‐analysis of 7 studies including 336 pts. indicated that SDF is significantly decreased auer varicocele repair (MD=3.4%; 95% CI -‐4.1 to -‐2.6; p<0.0001)

Effect of varicocele surgery on SDF


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• Varicocele treated prior to ICSI (N=80)

•  ICSI with untreated varicocele (N=162)


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Microsurgical subinguinal varicocele repair with aid of intraopera.ve doppler


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Management of azoospermia and the role of gonadotropin

therapy


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Azoospermia: the complete lack of sperm in ejaculate auer centrifuga.on

10-15% infertile males

1-3% male population

Cooper et al. Hum Reprod Update 2009; Esteves & Agarwal, Clinics 2013


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Obstruc.ve

Non-‐obstruc.ve

Hypo-‐hypo

Spermatogenic failure

Clinical picture

FSH/LH: ñ or nl TT: low or nL

Testes: small or nl

Normal testes & endocrine profile;

Mechanical blockage

FSH/LH <1.2 mUI/mL,

Low TT, small tes.s, poor viriliza.on

Disrupted

Normal

Spermatogenesis

Esteves et al, Clinics 2011


ANDROFERT

Prognosis and management differen.ally affected by type of azoospermia

•  Low FSH and LH (<1.2 mIU/L) •  Low total testosterone (<300 ng/dL) •  Hypotrophic testes

Hypogonadotropic hypogonadism

Congenital: Kallman syndrome Prader-Willi

Acquired: Pituitary tumor Steroid abuse Testosterone replacement therapy Fraieva et al. Clinics 68; 2013


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Classic treatment for male hypogonadism and infer.lity

u-‐hCG 1,000-‐2,000 IU; IM injec.ons; twice or t.i.w; minimum 12 weeks

Rec-‐hCG: SC self-‐injec.on qw Pre-‐filled syringe

Pen device Fraieva et al. Clinics 2013; 68(Suppl.1):81-‐8

Specific therapy in adult onset hypo-‐ hypo


ANDROFERT

Rec-‐hCG for male hypo-‐hypo

Esteves & Papanikolaou Fer@l Steril 2011;96:S230

Series of men with adult-‐onset HH; Recombinant hCG (250 mcg qw for 12 weeks)

Baseline Pos`reatment


ANDROFERT

Tes.cular torsion; trauma Post-‐inflammatory (eg. Mumps orchi=s) Exogenous factors (eg. Cytotoxic drugs, irradia=on) Tes.cular cancer Systemic diseases (eg. Liver cirrhosis, renal failure)

Congenital Tes.cular dysgenesis/cryptorchidism Gene.c abnormali.es (Klinefelter syndrome, Yq microdele=ons, etc.)

Acquired

Idiopathic (unknown e.ology) Esteves et al. Clinics 2011; 66:691-‐700

NOA due to spermatogenic failure: an irreversible condi.on


ANDROFERT

Esteves et al. Int Braz J Urol 2011;37:570-‐83

40-‐50% of men with SF have residual spermatogenesis within the tes.s

§ Not enough for sperm to appear in ejaculate

§ 600-‐800 seminiferous tubules

§ Goals are: i.  Op=mize sperm produc=on (if possible) ii.  Iden=fy site of sperm produc=on (if

present) and retrieve sperm for ICSI


ANDROFERT

Challenges faced by health professionals providing care for men with SF

§  Counseling about the chances of finding tes.cular sperm

§  Usefulness of any medical interven.on before sperm retrieval

§ Which sperm retrieval method to apply §  Reproduc.ve poten.al of retrieved gametes in ICSI treatment

§  Health of offspring


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Complete AZFa, AZFb or AZFa+b microdele.ons unfavorable prognosis

YCMD SR success

AZFa nil AZFb nil AZFc 50-‐70%

Krausz et al. 2014; Esteves et al. 2013; Esteves 2015


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Interven.ons to infer.le males men with SF prior to a sperm retrieval avempt

Matura.on arrest and hypospermatogenesis favorable prognosis

Weedin et al J Urol 2010;183:2309-‐15

Among 233 men with SF and treated varicocele, 1/3 had mo.le sperm in postop.

ejaculate


ANDROFERT

Inci et al J Urol 2009;182:1500-‐5; Haydardedeoglu et al Urology 2010;75:83-‐6

§  Inci 2009 OR: 2.63

(95% CI: 1.05-‐6.60; p=0.03)

Although 2/3 remain azoospermic auer varicocele repair, SRR increased

§ Haydardedeoglu 2010

53 30

Treated (N=66) Untreated (N=30)

SR success (%)

61 38

Treated (N=31) Untreated (N=65)

p<0.01


ANDROFERT

Medica.on Hypogonadism (TT<300 ng/dl) in up to 50% men with SF High ITT levels essen=al for regula=ng spermatogenesis in combina=on with Sertoli cell s=mula=on by FSH

Paradoxically weak s.mula.on of Leydig and Sertoli cells by endogenous gonadotropins Due to high baseline FSH and LH levels the rela=ve amplitudes are low

Shiraishi et al Hum Reprod 2012;27:331-‐9; Sussman et al Urol Clin N Am 2008;35:147-‐55


ANDROFERT

Study Study design Study group Medication Findings

Pavlovich et al. 2001 Case series 43 men with

T/E ratio <10 Testolactone No effect

Hussein et al. 2005

Prospective cohort

42 men with favorable hystology

Clomiphene Sperm found in SA in 64.3%; All men

who remained azoospermic had success at SR

Selman et al. 2006

Prospective cohort

49 men with maturation

arrest rec-hFSH and hCG No return of sperm in ejaculate;

posttreatment SRR were 21.4%

Ramasamy et al. 2009 Case series

56 men with nonmosaic Klinefelter

Testolactone or anastrozole, alone or combined with hCG SRR increased by 1.4-fold

Reifsnyder et al. 2012

Retrospective cohort

307 men with hypogonadis

m

Aromatase inhibitors, hCG or Clomiphene, alone or

combined No effect

Shiraishi et al. 2012

Prospective cohort

28 men with idiopathic SF

hCG alone or combined with rec-hFSH

SR success in 21% of the treated men vs. none in untreated men

Hussein et al. 2013

Prospective cohort

612 unselected

men

Clomiphene alone or combined with hCG or hMG

Sperm found in SA in 10.9% of treated males; SRR higher in men who

remained azoospermic and treated (57.0 vs. 33.6%, p<0.001)

!

Aromatase inhibitors and gonadotropins have been used with variable results

Esteves Asian J Androl 2015;17:1-‐12


ANDROFERT

ITT levels increase auer hCG; s.mulatory effect on residual spermatogenic areas

Shinjo E et al Andrology 2013;1:929-‐35; Shiraishi et al Hum Reprod 2012;27:331-‐9

273

1348

Before After

ITT (ng/dl)

ITT levels increased auer hCG-‐based therapy

Spermatogonial DNA synthesis increased

PCNA expression


ANDROFERT

1Shiraishi et al Hum Reprod 2012;27:331-‐9; Esteves Int Braz J Urol 2013;39:440

hCG-‐based therapy may increase SR success in men with SF

Microdissec.on TESE Rescue ~15% of pa.ents with previous failed SR avempts1


ANDROFERT

Testosterone and estradiol levels

<300 ng/dL

(10.4 nmol/L)

Hypogonadism category

Pure

Medica.on algorithm at Androfert Tx aimed at boos.ng T

Aromatase inhibitor (anastrozole 1mg orally

qid)

Rec-‐hCG (250 mcg SC qw); rec-‐FSH added (75 IU SC biw) if FSH levels <1.5 mIU/ml

T/E ra.o <10

Aromatase hyperac.vity

T/E ra.o >10 (nl)


ANDROFERT

Esteves Asian J Androl 2015;17:1-‐12


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Sperm retrieval methods in NOA due to spermatogenic failure

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

Tes.cular sperm extrac.on TESE 20-‐60%

Microdissec.on tes.cular sperm extrac.on

Micro-‐TESE 40-‐67%

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


ANDROFERT

http://androfert.com.br/videos Esteves SC Int Braz J Urol 2013; 39(3):440

41.4 47 43.3 20

100 64 61 34.2

Sperm retrieval (%)

2PN Fertilization

(%)

Top Quality Embryos (%)

Live Birth (%)

Non-obstructive (N=365) Obstructive (N=146)

P<0.01


ANDROFERT

Morphometric evalua.on of seminiferous tubules increases SR efficiency

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

. Tub

ule

Dia

met

er

Verza Jr S, Esteves SC. Fer@l Steril 2012; 98: S242; Esteves & Varghese J Reprod Sci 2012; 5(3):233-‐43

N=54; Tubule Diameter: KW-H (1;54) = 25.2; P<0.001


ANDROFERT


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On average, one top-‐quality addi.onal embryo for transfer or cryopreserva.on

Clean Room Technology & ICSI Results 2,315 pa.ents; 14,660 embryos

Esteves & Bento. Reprod Biomed Online 2013;26:9-‐21


ANDROFERT

3,412 cycles

Tailored COS strategy to increase LBR in ICSI cycles involving severe male factor

0%

10%

20%

30%

40%

50%

60%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 20 25 Number of oocytes retrieved

Clinical pregnancy Live birth


ANDROFERT

Conclusions 1.  Conven.onal semen analysis limited as

surrogate for assessing fer.lity; SDF tes.ng valuable laboratory tool for clinical decision

2.  An.oxidant therapy, microsurgical varicocele repair and TESA-‐ICSI may improve ART outcome in selected individuals

3.  Best management of azoospermia includes proper diagnosis, interven.ons to op.mize sperm produc.on, microsurgical SR, state-‐of-‐art laboratory care and tailored COS to ART candidates


ANDROFERT

Thank you Obrigado شكرا

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

sandroesteves

management of male fertility and gonodotropin role

Health & Medicine