testicular sperm retrieval and poor sperm yield: how do we manage?

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

Campinas, Brazil

Testicular Sperm Retrieval and Poor Sperm Yield How do we manage?

2nd SGH SOAR, Singapore 2014

Learning objectives At the completion of this presentation, participants should be able to: •  Differentiate obstructive and non-

obstructive azoospermia •  Identify who are at risk of poor sperm

yield on testicular retrievals •  Learn what can be done to improve

sperm yield at testicular retrievals

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2014 SEPTEMBER

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http://www.androfert.com.br/review

Testicular Sperm Retrieval and Poor

Sperm Yield How do we manage?



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100 lbs

64 cc

>1 billion/mL

Sperm OutputWhere we stand compared to our ‘relatives’

600 lbs

14 cc

5 million/mL

180 lbs

20 cc

64 million/mL

Human Chimpanzee Gorilla



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2.5% 50%

97.5%

4 M/mL 64 M/mL 237 M/mL

Sperm CountGeneral Population of Unscreened Men

Cooper et al. Hum Reprod Update 2009; Esteves et al, Clinics 2011

Azoospermia: Complete lack of sperm in the ejaculate 1-3% male population 10-15% male infertility population



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Diagnosis -‐ Semen Analysis (x2) Centrifuga+on at 3,000g for 15 minutes

The supernatant is discharged and

the pellet is examined

Semen Analysis in Azoospermia



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Differential Diagnosis in Azoospermia Azoospermia

ObstrucIve

Non-‐obstrucIve

Subtypes

Hypo-‐hypo

TesIcular failure

Spermatogenesis

Disrupted

Normal

Clinical Picture

FSH/LH: ! or nl TT: low/nL

Testes: small/nL

NL testes NL FSH, LH, TT

Mechanical block

FSH/LH <1.2 mUI/mL Low TT

Small tesIs Poor virilizaIon



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Frequency of Azoospermia Categories



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Esteves et al. Clinics 2011;66(4):691-700.

•  Deficient virilization; hypotrophic testes •  Azoospermia •  Low FSH and LH (<1.2 mIU/L) •  Low testosterone levels (<300 ng/dL)

Hypogonadotropic Hypogonadism

Congenital: Ø  Kallman syndrome Ø  Prader-Willi

Acquired: Ø  Pituitary tumor; Steroid abuse Ø  Testosterone replacement therapy



ANDROFERT Fraietta et al. Clinics 68; 2013

Classic treatment for male hypogonadism and infertility

Urinary hCG 1,000-2,000 UI IM injections; twice or t.i.w;

minimum 12 weeks

Rec-hCG: SC self-injection w/pre-filled

syringe, qw Fraietta et al., Clinics 2013;68(Suppl.1):81-8.

Adult onset hypo- hypo Specific medical therapy



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Rec-‐hCG for male hypo-‐hypo

Baseline Posttreatment Esteves & Papanikolaou Fertil Steril 2011

Series of men with adult-onset HH; Recombinant hCG (Ovitrelle 250 mcg)



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Obstructive Azoospermia: Etiology

Post-infection (epididymitis, prostatitis, seminal vesiculitis)

Post-surgical (vasectomy, epididymal cysts, hernia, scrotal surgery, bladder neck surgery, prostatectomy)

Iatrogenic (urological endoscopic instrumentation)

Congenital Congenital bilateral absence of vas deferens (CBAVD)

Ejaculatory duct and prostatic cysts

Acquired

Idiopathic (Unknown etiology) Esteves et al. Clinics 2011;66(4):691-700



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Surgical Treatment sperm retrieval and

ICSI

Obstructive Azoospermia (OA) Management



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Sperm Retrieval in OA

Technique Acronym

Percutaneous Epididymal Sperm Aspiration PESA

Microsurgical Epididymal Sperm Aspiration MESA

Testicular Sperm Aspiration TESA

Esteves & Agarwal. Sperm Retrieval Techniques. Cambridge University Press, 2011



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Sperm yield in OA is usually great

100% 96.6% 96.3%

CBAVD Vasectomy Post-‐infection

OBSTRUCTIVE AZOOSPERMIA

Successful Retrievals

PESA + rescue TESA PESA alone

Esteves et al. J Urol. 2013;189(1):232-7

146 patients

Sperm retrieval in CBAVD



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78.1%

~100%



ANDROFERT Esteves et al. J Urol. 2013;189(1):232-7

Non-obstructive Azoospermia: Etiology

Testicular torsion; Trauma Post-inflammatory (eg. Mumps orchitis) Exogenous factors (steroids, cytotoxic drugs, irradiation) Testicular Cancer Systemic diseases (liver cirrhosis, renal failure)

Congenital Testicular dysgenesis/cryptorchidism Genetic abnormalities (Klinefelter syndrome, Yq microdeletions, etc.)

Acquired

Idiopathic (Unknown etiology)

Untreatable condition

Sperm Retrieval and ICSI



ANDROFERT Esteves et al. Clinics 2011;66(4):691-700.

Esteves SC & Agarwal A. Sperm Retrieval Techniques; In: Gardner D et al (Eds.), Human Assisted Reproductive Technology. Cambridge University Press, pp. 41-53, 2011

Non-obstructive Azoospermia (NOA)



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Overall, 40%-50% men with NOA have minimal production within the testis, but not enough for sperm to appear in ejaculate

—  Goal is to identify site of production and retrieve sperm for ICSI

—  Geographic location unpredictable

Sperm retrieval in NOA Technique Acronym Success

Testicular Sperm Aspiration TESA 15-50%

Testicular Sperm Extraction TESE 20-60%

Microdissection Testicular Sperm Extraction

Micro-TESE 40-67%

Esteves et al. Sperm Retrieval Techniques. Int Braz J Urol 2013;37(5):570-83



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1. Azoospermia is descriptive term of ejaculates lacking sperm without implying specific underlying causes

2. Differential diagnosis include hypo-hypo, obstructive azoospermia (OA) and non-obstructive azoospermia (NOA)

3. Specific medical and surgical treatments exist for hypo-hypo and OA, with overall good results



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4. Obstructive azoospermia is not associated with poor sperm yield; success is high regardless of retrieval method and cause of obstruction



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5. SR only option for men with NOA associated with spermatogenic failure; testis is the target organ for sperm retrieval attempt

6. In general, men with NOA are at risk of poor sperm yield at testicular retrievals

Diagnosis Identify who are at

risk for poor

sperm yield

Select who could benefit

from interventions

prior to testicular SR

Select the best

testicular SR

method

Proper lab handling of surgically-extracted testicular gametes

How to Manage Testicular Retrievals To Avoid Poor Sperm Yield



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FSH levels Testosterone levels

Testicular Volume

Esteves, Miyaoka & Agarwal. Clinics 2011; Verza Jr. & Esteves. Fertil Steril 2011; Carpi et al. Fertil Steril 2009.

No Markers reflect global spermatogenic function but not the presence of a site of sperm production in a dysfunctional testis

SelecIng candidates for SR Can biomarkers predict SR success?

Sperm yield in testicular retrievals

Do biomarkers play a role?



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Sperm yield in testicular retrieval Does histopathology play a role?

93%

64%

20%

Hypospermatogenesis Maturation Arrest Sertoli-cell Only

Sperm Retrieval Success Rates Micro-TESE (N=60)

Verza Jr & Esteves. Fertil Steril 2011

Testicular Histopathology



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Esteves et al., Fertil Steril 94; 2010; Raman and Schlegel. J Urol.170; 2003; Hopps et al. Hum Reprod. 180, 2003; Damani et al. JCO. 15; 2002

Etiology category SR success Cryptorchidism 52-74% Post-infection 67% Torsion >50% Post-chemotherapy/RT 25-75% Genetic (Klinefelter, AZFc Yq microdeletions) 25-70%

Genetic (AZFa and AZFb Yq microdeletions) 0% Idiopathic 50-60%



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Sperm yield in testicular retrieval Does etiology play a role?

✕✕✕

0% 0% 50-70% SRR= Hamada et al. 2013; Krausz et al. 2014; Esteves et al. 2013



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Sperm yield in testicular retrieval

Yq microdeletion screening

Yq microdeletions AZFa, AZFb and AZFb+c associated with virtually no chance of sperm acquisition

Yq microdeletion screening mandatory to “deselect” men from testicular retrieval attempts

Who is at risk of poor sperm yield at testicular retrievals

Key Messages



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Sertoli cell-only hystopathology and non-mosaic Klinefelter syndrome

NOA and hypogonadism (TT<300ng/dL)

NOA and clinical

varicocele

Who can benefit from intervenIons prior to sperm retrieval?

Who benefit from interventions prior to testicular retrieval?



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Ramasamy et al., J Urol. 2009

Ø  68 men with non-mosaic KS Ø NOA and hypogonadism Ø Medication to boost

testosterone production: Aromatase inhibitor, hCG, anti-estrogens (2-3 months)

Ø Micro-TESE as SR method Ø Positive response: increase in

TT >100 ng/dL from baseline levels

72 55

Sperm Retrieval Rate (%)

Positive response

P = 0.03

Medical therapy prior to testicular retrieval Klinefelter Syndrome



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Medical therapy prior to testicular retrievals Favorable testicular histology

64% men had sperm in the ejaculates post-Tx (mean: 3.8 M/mL) Spermatozoa obtained by SR in all who remained azoospermic

43 patients with NOA and hypospermatogenesis on testicular histopathology Anti-estrogen (CC 50mg) every other day; no controls

Hussein et al, J Androl 2005



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Medical therapy before SR General population of men with NOA and

hypogonadism



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51 51

Sperm retrieval rate (%)

Positive response (n=252) No response (n=55)

Ø Case series (n=307) Ø Hypogonadism (TT<300) Ø Micro-TESE Ø Aromatase inhibitor, hCG,

anti-estrogens (min. 2-3 months)

Ø Positive response post-Tx TT >250 ng/dL

Ramasamy et al., J Urol. 2011

hCG in non-obstructive azoospermia prior to testicular sperm retrieval

Shinjo E et al Andrology 2013;1(6):929-35; Shiraishi et al Hum Reprod 2012;27(2):331-9.

273

1348

Before After

ITT (ng/dl)

Increase in ITT levels Increase in

spermatogonial DNA synthesis

PCNA expression



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Shiraishi et al Hum Reprod 2012;27(2):331-9

hCG in non-obstructive azoospermia prior to sperm retrieval



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•  Successful SR in ~15% of patients with previous failed SR attempts after hCG alone or hCG+FSH

Estradiol Levels

Total Testosterone

levels

<300 ng/dL

(10.4 nmol/L)

T/E ratio <10

Hypogonadism category

T/E ratio >10 (nl)

Aromatase hyperactivity

Pure

Medication prior SR in NOA Androfert algorithm

Treatment

Aromatase inhibitors

(anastrozole 1mg qid, 12

weeks

Rec-hCG 250 mcg 1x/week; CC 25mg qid;

12 week



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Klinefelter syndrome; Obesity SCO; Hypospermatogenesis

Inci et al, J Urol. 2009

Weedin JW et al, J Urol. 2010

Meta-analysis of 11 series (N=233) 39% men had motile sperm in postop. ejaculates (mean: 1.6 M/mL)

Retrospective study with 96 pts. with treated and untreated varicocele SR success: 53% vs 30% (increased by 2.6-fold in treated pts.)



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Varicocele repair prior testicular retrieval in NOA

AI, CC, hCG may increase sperm yield in some patients, particularly those with hypogonadism

Microsurgical varicocelectomy may be useful in selected patients with clinical varicocele

Interventions in men with NOA prior to testicular retrieval

Key Messages



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Schlegel 1999

Amer et al. 2000

Okada et al. 2002

Okubu et al. 2002

Tsujimura et al. 2002

Ramon et al. 2003

Esteves et al. 2011

43%-63%

17%-45% Con

trol

led

Serie

s Testicular sperm retrieval in NOA

which is the best technique?

TESE

Esteves et al. Int Braz J Urol 2011; Deruyver et al. Andrology 2014



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http://androfert.com.br/videos

Esteves SC, Int Braz J Urol 2013; 39(3):440

Microsurgical vs Single-Biopsy TESE in NOA according to testicular histology

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)

Verza Jr & Esteves. Fertil Steril 2011

Histology categories pairwise

Comparisons: p<0.0001

Method P=0.0005



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Selecting the best retrieval method is key to increase sperm yield at

testicular retrievals



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Higher retrieval rates with micro-TESE in patients at risk of poor sperm yield, such as those with NOA

Deruyver et al. Microdissection TESE compared with conventional TESE in non-obstructive azoospermia: a systematic review.

Andrology 2014; 2(1):20-4

Laboratory handling of surgically-retrieved spermatozoa

Optimize sperm retrieval Mechanical mincing

Enzymatic tissue digestion Avoid iatrogenic damage

Sperm yield in testicular retrieval Does the lab play a role?



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Tissue removed (mg) Open Large

Single-Biopsy TESE

Micro-TESE

P-value

65 ± 25 8.9 ± 2.5 <0.01

Quantity of tissue extracted does

matter

Conven+onal TESE Micro-‐TESE

Fragment weight Fragment weight

Verza Jr & Esteves Fertil Steril 2011; Esteves & Varghese J Reprod Sci 2013



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Esteves et al. Asian J Androl. 2014;16(4):602-6

Sperm Retrieval and ICSI Outcome

41.4 47 43.3 20

100 64 61

34.2

Sperm retrieval (%)

2PN Fertilization (%)

Top Quality Embryos (%)

Live Birth (%)

Non-obstructive Obstructive

OR=0.033 95% CI: 0.007-0.164; p<0.001

OR=0.38 95% CI: 0.23-0.61; p<0.001

P<0.01



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Region N children NOA vs OA Outcomes Main findings

Palermo et al. 1999

USA 22 vs 158 Congenital abnormalities

4.5% TF vs 1.3% OA (ns)

Vernaeve et al. 2005

Belgium 61 vs 196 Perinatal data Congenital abnormalities

Lower gestational age (singletons); Increased frequency of premature twins

4% TF vs 3% OA (ns)

Fedder et al 2007

Denmark 76 vs 282 Congenital abnormalities

0% TF vs 4.0% OA (ns)

Belva et al.; 2011

Belgium 193 vs 474 Perinatal data; Congenital abnormalities

Similar perinatal outcomes; 4.2% TF vs 5.2% OA (ns)

352 children No major

difference

Esteves & Agarwal. Clinics 2013;68(Suppl.1):141-50

Neonatal Outcome of Babies Born Health of offspring



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testicular sperm retrieval and poor sperm yield: how do we manage?

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