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