This document summarizes a presentation on the management of male infertility. It discusses diagnosis of male infertility including semen analysis and tests of sperm DNA integrity. It reviews medical treatments including antioxidants and treatments for specific conditions like varicocele and hypogonadism. Surgical treatments for varicocele are discussed. Assisted reproduction techniques are summarized including outcomes of ICSI for treated vs untreated varicocele and sperm retrieval techniques for obstructive and non-obstructive azoospermia. Key findings are that varicocele repair and antioxidant treatment can improve fertility outcomes, while sperm retrieved from the testes have lower DNA damage than ejaculated sperm.

1. XVIII Annual Ob-Gyn Conference, KUWAIT 2013
Management of Male Infertility
What the GYN need to know
Sandro C. Esteves, MD, PhD
Director, ANDROFERT
Campinas, Brazil

2. Contents
DIAGNOSIS
MEDICAL TREATMENT
SURGICAL TREATMENT
ASSISTED REPRODUCTION
Esteves, 2
ANDROFERT, Referral Center for Male Reproduction

3. Management of Male Infertility
Available at:
http://www.androfert.com.br/review
Esteves, 3
ANDROFERT, Referral Center for Male Reproduction

4. Semen Analysis
Central
Laboratory
Investigation
Esteves, 4
Functional
Status of
Reproductive
Tract
Seminal Fluid
and Sperm
ANDROFERT, Referral Center for Male Reproduction

5. WHO 2010: Recent fathers TTP≤12 mo.
Volume (mL)
Sperm count (x106/mL)
Total count (x106)
% Motile (total)
% Motile (progressive)
% Normal (strict criteria)
% Alive
5%
1.5
15.0
39.0
40
32
4
58
Percentiles
50%*
95%
3.7
6.8
73.0
213.0
255.0
802.0
61
78
55
72
15
44
79
91
Cooper et al. Hum Reprod Update 2010
Esteves, 5
ANDROFERT, Referral Center for Male Reproduction

6. Esteves, 6
ANDROFERT, Referral Center for Male Reproduction

7. Sperm DNA Integrity
Background
Normal sperm chromatin essential for
paternal genetic transmission
Increased Sperm
DNA Fragmentation
Unexplained infertility
Recurrent pregnancy loss
Poor outcomes in IUI and IVF
Principle
Quantification of sperm DNA strand breaks
Specimen
Semen, spermatozoa
Techniques
Nuclear dyes (Acridine orange, SCSA)
Direct assessment (TUNEL, COMET)
Nuclear matrix assays (SCD)
Esteves & Agarwal Int Braz J Urol 2011
Esteves, 7
ANDROFERT, Referral Center for Male Reproduction

8. Quick and Easy Test
Sperm Chromatin Integrity Test (SCD)
Intact DNA: Sperm with “Halo”
Represents dispersed chromatin
without breaks
Absent/small “Halo”: Damaged DNA
Represents DNA strand breaks
Semen/Spermatozoa
Quantitative Test:
Normal: <20% sperm with fragmented
DNA
Feijo & Esteves Fertil Steril 2013
Esteves, 8
ANDROFERT, Referral Center for Male Reproduction

9. IUI Outcome in Men with
High Sperm DNA Damage
Live Birth Rates with
Intrauterine Insemination
19%
OR = 0.07
[95% CI: 0.01-0.48]
1.5%
Normal
Esteves, 9
Bungum et al. Hum Reprod 2007
Elevated
ANDROFERT, Referral Center for Male Reproduction

10. IVF Outcome in Men with
High Sperm DNA Damage
Pregnancy by Method in
Cases of Elevated Sperm DNA
Fragmentation
42%
Increased miscarriage in couples
undergoing IVF/ICSI with high
sperm DNA damage
26%
IVF
Meta-analysis of 16 studies and
2,969 couples
ICSI
Risk ratio (RR) = 2.16
95% CI: 1.54-3.03; p<0.00001
Robinson et al. Hum Reprod 2012
Bungum et al. Hum Reprod 2007
Esteves, 10
ANDROFERT, Referral Center for Male Reproduction

11. Sperm DNA Damage is Associated to
Elevated Oxidative Stress
DNA damage
DNA Damage
Evaluation of
Evaluation of
DNA damage
DNA Damage
Esteves & Agarwal Int Braz J Urol 2011
Esteves, 11
ANDROFERT, Referral Center for Male Reproduction

12. Oral Antioxidants for the Male
Outcome
No. studies
Effect size
(OR; 95% CI)
Live birth
3
4.85 [1.92, 12.24]
Pregnancy rate
15
4.18 [2.65, 6.59]
DNA fragmentation
1
-13.80 [-17.50, -10.10]
Miscarriage, sperm count, sperm
motility
6-16
No effect
Showell MG et al. Cochrane Database Syst Rev 2011
Esteves, 12
ANDROFERT, Referral Center for Male Reproduction

13. Empirical Medical Treatment for
Idiopathic Male Infertility
Androgens
hCG/HMG
FSH
Anti-estrogens
Bromocriptine
Alpha-blockers
Systemic corticosteroids
In general,
NOT
EFFECTIVE
Guidelines on Male Infertility.
European Association of Urology 2012
Esteves, 13
ANDROFERT, Referral Center for Male Reproduction

14. Anti-estrogens for the Male
1400
ng/dL
ITT levels
ral
ent
fall
ative c ck
eg
N
feedba
1200
1000
Upper Limit
800
600
Normal Testosterone
Levels
400
200
0
Esteves, 14
Lower
Sperm
Counts
Lower Limit
Before
Clomiphene
After
90d; 25mg/d
Da Ros CT, Averbeck MA Int Braz J Urol 2012
ANDROFERT, Referral Center for Male Reproduction

15. Injectable Testosterone is Detrimental
GnRH
Azoospermia
FSH/LH
Marked fall in ITT levels
Between the seminiferous tubules,
Leydig cells produce testosterone
Esteves, 15
ANDROFERT, Referral Center for Male Reproduction

16. Male Hypogonadotropic Hypogonadism
Specific Medical Therapy
Deficient virilization
Hypotrophic testes
Azoospermia
Low FSH, LH and testosterone
• Congenital:
Kallman syndrome
Prader-Willi
• Acquired:
Pituitary tumor
Steroid abuse
Testosterone replacement therapy
Esteves, 16
ANDROFERT, Referral Center for Male Reproduction

17. Male Hypogonadotropic Hypogonadism
Specific Medical Therapy
Series of men with adult-onset HH
Recombinant hCG; 250 mcg per week; 12 weeks
SC self-injection
w/pre-filled
syringe, qw
Esteves & Papanikolaou Fertil Steril 2011
Fraietta et al, Clinics 2013
Esteves, 17
ANDROFERT, Referral Center for Male Reproduction

18. Contents
DIAGNOSIS
MEDICAL TREATMENT
SURGICAL TREATMENT
ASSISTED REPRODUCTION
Esteves, 18
ANDROFERT, Referral Center for Male Reproduction

19. Varicocele
35% subfertile men
Lower Sperm Count and Quality
Lower Sperm Function
Elevated Oxidative Stress Levels
Elevated Sperm DNA Damage
Miyaoka & Esteves. Adv Urol 2012
Agarwal, Esteves, Hamada. Nature Urol Rev 2013
Esteves, 19
ANDROFERT, Referral Center for Male Reproduction

20. Varicocele Treatment for Infertility
Indications (all criteria met):
Infertile couples;
Normal female or treatable
female infertility;
Abnormal semen analysis and/or
sperm function test.
ASRM Practice Committee, Fertil Steril 2008
Esteves, 20
ANDROFERT, Referral Center for Male Reproduction

21. Varicocele Surgery and Spontaneous
Pregnancy
Marmar et al., Fertil Steril 2008
Esteves, 21
ANDROFERT, Referral Center for Male Reproduction

22. Varicocele Treatment
Technique
Recurrence
Postop
Hydrocele
Retroperitoneal
(Palomo)
7-35%
6-10%
Laparoscopy
2-7%
0-9%
Embolization
2-24%
NR
Inguinal
(Ivanissevich)
0-37%
7%
Microsurgical
Subinguinal
0-1%
0-1.6%
Miyaoka & Esteves. Adv Urol 2012
Esteves, 22
ANDROFERT, Referral Center for Male Reproduction

23. Fer&lity
Restora&on
Spontaneous
Pregnancy
Fer&lity
Improvement
ICSI
Outcomes
Fer&lity
Improvement
Sperm
Retrieval
in
Azoospermia
Esteves, 23
ANDROFERT, Referral Center for Male Reproduction

24. Male Factor and ART
Varicocele Repair
Sperm Retrieval
Esteves, 24
ANDROFERT, Referral Center for Male Reproduction

25. Clinical Outcome of Intracytoplasmic Sperm Injection in Infertile Men
With Treated and Untreated Clinical Varicocele
SC Esteves, FV Oliveira, RP Bertolla
ANDROFERT and Division of Urology, São Paulo Federal University, BRAZIL
The Journal of Urology; Vol. 184: 1442-6, 2010
Varicocele Treated
prior to ICSI (N=80)
ICSI with Untreated
Varicocele (N=162)
Esteves, 25
ANDROFERT, Referral Center for Male Reproduction

26. Sperm Retrieval and Intracytoplasmic Sperm Injection in Men With
Nonobstructive Azoospermia, and Treated and Untreated Varicocele
K Inci, M Hascicek, O Kara et al.
Department of Urology, Hacettepe University, Ankara, Turkey
The Journal of Urology Vol. 182,1500-5, 2009
Microsurgical
varicocele repair prior
to sperm retrieval ICSI
(N=66)
Sperm Retrieval in the
presence of varicocele
(N=30)
Successful Sperm Retrieval
OR: 2.63 (95% CI: 1.05-6.60; P=0.03)
53%
30%
Treated Varicocele
Untreated Varicocele
Esteves, 26
ANDROFERT, Referral Center for Male Reproduction

27. Sperm Retrieval in Azoospermia
Normal sperm production
Mechanical blockage
Vasectomy, Post-infectious,
Congenital
Esteves, 27
Sperm production deficient or
absent
Cryptorchidism, Radiation,
Chemotherapy, Trauma, Genetic,
Orchitis, Varicocele,
Gonadotoxins, Unexplained
ANDROFERT, Referral Center for Male Reproduction

28. Obstructive Azoospermia
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
Esteves, 28
ANDROFERT, Referral Center for Male Reproduction

29. http://androfert.com.br/videos
Esteves, 29
ANDROFERT, Referral Center for Male Reproduction

30. http://androfert.com.br/videos
Esteves, 30
ANDROFERT, Referral Center for Male Reproduction

31. Obstructive Azoospermia
PESA + rescue TESA
OBSTRUCTIVE
AZOOSPERMIA
PESA alone
97.3
%
100%
96.6%
96.3%
78.1
%
CBAVD
Successful Retrievals
Esteves, 31
Vasectomy
Post-­‐infection
Esteves et al. J Urol 2013
ANDROFERT, Referral Center for Male Reproduction

32. Non-Obstructive Azoospermia
Sperm production minimal or
absent for sperm in ejaculate
Technique
Geographic location unpredictable
TESE
Testicular
Sperm
Aspiration
Testicular
Sperm
Extraction
Microsurgical
Testicular
Sperm
Extraction
Acronym
Success
TESA
15-50%
TESE
20-60%
Micro-TESE
40-67%
Esteves & Agarwal. Sperm Retrieval Techniques.
Cambridge University Press, 2011
Esteves, 32
ANDROFERT, Referral Center for Male Reproduction

33. Esteves SC, Int Braz J Urol 2013
http://androfert.com.br/videos

34. Sperm Retrieval and ICSI in Azoospermia
Non-obstructive
Obstructive
100
41.4
P<0.01
47
64
43.3
61
20
Sperm retrieval (%)
2PN Fertilization (%) Top Quality Embryos
(%)
OR=0.033
95% CI: 0.007-0.164; p<0.001
34.2
Live Birth (%)
OR=0.38
95% CI: 0.23-0.61; p<0.001
Esteves et al. Asian J Androl. In press
Esteves, 34
ANDROFERT, Referral Center for Male Reproduction

35. TESA-ICSI and Sperm DNA Damage
Sperm
% TUNEL +
% CPR
Ejaculated (N=18)
23.6
6
Testicular (N=18)
4.8
44
<0.001
<0.05
P value
Greco et al. Hum Reprod 2005
DNA damage in Testicular Spermatozoa (13.3%) is three-fold
lower compared with Ejaculated Spermatozoa (39.7%)*
*Absolute differences between two specimens ranging from -3.3% to -56.3%.
Moskovtsev et al. Fertil Steril 2010
Esteves, 35
ANDROFERT, Referral Center for Male Reproduction

36. Take-home Messages
Routine semen analysis not a good male fertility discriminator.
Sperm DNA damage provides information of great prognostic
value.
Antioxidants helpful to decrease oxidative stress and DNA
damage. Specific medical therapy only valid for hypogonadism
Microsurgical varicocele repair increases chances of
spontaneous and assisted conception
Sperm retrieval is routinely used in ART.
Reproductive potential of surgically-retrieved sperm depends
on type of azoospermia
Esteves, 36
ANDROFERT, Referral Center for Male Reproduction

37. Thank You