1. Sandro Esteves, MD, PhD
Director, ANDROFERT
Center for Male Reproduction
Campinas, BRAZIL

2. Learning Objectives
Learn the definitions and difference between
obstructive (OA) and non-obstructive
azoospermia (NOA)
Overview of conventional sperm retrieval
techniques and results for azoospermic men
Understand the rationale of using micro-TESE
for the worst azoospermia scenarios
Micro-TESE: technique and results
Esteves, 2

4. Azoospermia: Definitions
• Complete absence of spermatozoa
Azoospermia in the ejaculate after centrifugation
• 1-3% male population
Prevalence • 10% infertile males
• Obstructive
Types • Nonobstructive
Esteves, Miyaoka & Agarwal.
An update on the initial assessment of the infertile male. CLINICS 2011; 66:1-10.

5. Obstructive Azoospermia
Features Sperm Retrieval
Normal Sperm
Production Simple and Effective
Mechanical Blockage
Main Causes: Sites:
● Epididymis
● Vasectomy, Post-infectious
● Testis
● Congenital (CBAVD)
● Vas deferens
● Iatrogenic, Trauma
Esteves, 5

6. Obstructive Azoospermia
http://androfert.com.br/videos

7. 100% 100% 97.9%
95.3%
CBAVD (N=30) Vasectomy Post-infectious Total (N=142)
(N=64) (N=48)
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.

8. Intracytoplasmic Sperm Injection Outcomes Using
Ejaculated vs. Surgically-retrieved Sperm from em
with Obstructive Azoospermia
Ejaculate Epididymis/Testicle
70 73
P >0.05
48 46 51
43
20
12
Fertilization rate %TQE Pregnancy (%) Miscarriage (%)
(%)
Verza Jr S & Esteves SC. Sperm defect severity rather than sperm source is associated
with lower fertilization rates after intracytoplasmic sperm injection.
Int Braz J Urol 2008; 34:49-56.

9. Non-obstructive Azoospermia
Esteves, 9

10. Non-obstructive
Untreatable Azoospermia
condition
 Small testes/elevated FSH/”sterile”
 Absent or poor production for sperm
in ejaculate
 Heterogeneity of sperm production:
600-800 seminiferous tubules/testis;
Single focus of production adequate to
retrieve spermatozoa for ICSI
 Goal: To identify and retrieve sperm
for ICSI
Geographic location unpredictable
Esteves, 10

11. Can We Predict Sperm Retrieval
Success in NOA?
Important because:
1. Can minimize emotional and financial cost of IVF
cycles.
2. Can minimize trauma/damage to testis during sperm
harvesting.
Esteves, 11

12. Predictive Value of Noninvasive Tests
for Sperm Retrieval in NOA
FSH Testosterone
Testicular Volume
Verza Jr. & Esteves. Fertil Steril 2011; 96: S53
Esteves, 12

13. Predictive Value of Invasive Tests for
Sperm Retrieval in NOA
Testicular Histopathology
Esteves, 13

14. Predictive Value of Histopathology
Results in Sperm Retrieval for men
with NOA
Sensitivity Specificity Accuracy
(95% CI) (95% CI) (%)
HYPO 93 (66-100) 70 (54-82)
81.9
MA 64 (31-89) 59 (44-73)
SCO 20 (08-37) 20 (07-41)
Verza Jr. & Esteves. Fertil Steril 2011; 96: S53
Esteves, 14

15. Predictive Value of Testing for
Successful Sperm Retrieval in NOA

16. Conventional Sperm Retrieval
Techniques in NOA
Controlled studies Needle Open Biopsy
for NOA men Aspiration
Friedler et al., 4/37 (11%) 16/37 (43%)
Human Reprod 12:1488, 1997
Ezeh et al. 5/35 (14%) 22/35 (63%)
Human Reprod 13:3075, 1998
Esteves, 16

17. Conventional TESE (open biopsy) in NOA
Number of patients 25
20
15
10
5
0
1 2 3 4 7 8 9 10 14
Number of testicular fragments excised
Ostad et al., Urology 52:692, 1998.
Esteves, 17

18. Testicular 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 PN. Testicular sperm extraction: microdissection improves sperm yield with
minimal tissue excision. Hum Reprod. 1999;14:131-135.

19. Watch the video at http://androfert.com.br/videos

20. Vascular pattern of testis
• Extensive pattern
of vessels
surrounding the
testis
Photomicrograph courtesy JP Jarow, M.D.

21. Intratesticular Anatomy
• Parallel arteries
and veins
surrounding
seminiferous
tubules
• Allows dissection
between tubules

22. Microsurgical Identification of Sperm-
producing tubules by Appearance
Esteves, 22

23. Micro-TESE vs TESE
Success Rates in Controlled Series
Schlegel 1999
Amer et al. 2000
Okada et al. 2002
Okubu et al. 2002 53%
41%
Tsujimura et al. 2002
Ramon et al. 2003 TESE Micro-TESE
Esteves et al. 2011
OR = 1.63 (95% CI: 1.32 – 2.01)

24. Microsurgical versus conventional single-biopsy testicular sperm
extraction in nonobstructive azoospermia: a prospective
controlled study
Verza Jr S, Esteves SC. Fertil Steril 2011; 96 (3): S53
TESE Micro-TESE
Esteves, 24

25. Microsurgical vs Single-Biopsy TESE
in Nonobstructive Azoospermia
Controlled series of 60 patients
Sperm Retrieval Success Rates
Micro-TESE single-biopsy TESE
93%
Method Histology categories
P=0.0005 64% 64% pairwise
comparisons
45%
P<0.0001
25%
20%
9% 6%
Overall Hypospermatogenesis Maturation Arrest Sertoli-cell Only
Microsurgical versus conventional single-biopsy testicular sperm extraction in
nonobstructive azoospermia: a prospective controlled study
Esteves, 25 Verza Jr S, Esteves SC. Fertil Steril 2011; 96 (3): S53

26. Microsurgical vs Single-Biopsy TESE
in Nonobstructive Azoospermia
Sperm retrieval method and Odds Ratio Relative Risk
histopathology category [95% Confidence [95%
Interval] Confidence
Interval]
Micro-TESE vs. TESE 3.97 [1.86-8.49] 1.64 [1.18-2.28]
HYPO vs. MA 5.15 [1.16-22.97] 1.61 [0.97-2.68]
HYPO vs. SCO 29.75 [6.96-127.27] 5.25 [2.53-10.91]
MA vs. SCO 5.77 [1.41-23.62] 3.26 [1.38-7.68]
Microsurgical versus conventional single-biopsy testicular sperm extraction in
nonobstructive azoospermia: a prospective controlled study
Verza Jr S, Esteves SC. Fertil Steril 2011; 96 (3): S53
Esteves, 26

27. Conventional TESE vs Micro-TESE
Tissue Removal
Esteves, 27

28. Microsurgical vs Single-Biopsy TESE
in Nonobstructive Azoospermia
Tissue Removal
Approach Open Large Micro- P-
Single-Biopsy TESE value
TESE
Success Rate 15/60 (25%) 27/60 (45%) 0.02
Tissue Removed (mg) 65 ± 25 8.9 ± 2.5 <0.01
HYPO 58 ± 12 4.2 ± 1.9
MA 68 ± 17 10.1 ± 3.8
SCO 51 ± 9 7.5 ± 3.7
Microsurgical versus conventional single-biopsy testicular sperm extraction in
nonobstructive azoospermia: a prospective controlled study
Verza Jr S, Esteves SC. Fertil Steril 2011; 96 (3): S53
Esteves, 28

29. Chance of Sperm Retrieval by
NOA Diagnosis
 Cryptorchidism 52-74%
 Varicocele 63-68%
 Post-infection (mumps, etc.) 67%
 Torsion >50%
 Post-radiation/chemotherapy 55-75%
 Genetic (Klinefelter, Y microdeletion) 0-75%
 Idiopathic 50-60%
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
Esteves, 29

30. Micro-TESE Results
Androfert Experience (2002-2010)
No. of Patients 255
% Retrieval Rate 51.1
No. ICSI cycles 328
Mean ± SD Patient Age
Male 37.0 ± 7.6
Female 32.4 ± 4.7
Mean ± No. Injected Oocytes 9.8 ± 7.2
Mean ± %2PN Fertilization 43.7 ± 27.9
No. Transfer 298
Mean ± No. Embryos Transferred 2.4
No. Clinical Pregnancy (%) 86 (28.9)
No. Live birth (%) 64 (21.5)
Esteves, 30

31. Micro-TESE Results
Androfert Experience
(2002-2010)
No. of Babies Born 102
No. Multiple Deliveries (%) 29 (28.4)
Mean ± SD Gestational Age 35.5 ± 2.7
Mean ± Birth Weight 2532 ± 601
Gender ratio; boy/girl 1.0/1.3
No. Perinatal Deaths 6 (5.9)
No. Birth Defects (%) 3 (2.9)
Esteves, 31

32. Micro-TESE: Current Research
Subjective (by appearance)
identification of sperm-
producing tubules
Objective
(by size)
identification of
sperm-
producing
tubules
Esteves, 32

33. Micro-TESE
Objective Identification of
Sperm-producing Tubules
Esteves, 33

35. Normal
Maturation Arrest
Verza Jr & Esteves, Atlas of Human Reproduction, SBRH 2012

36. Hypospermatogenesis
Sertoli cell-only
Verza Jr & Esteves, Atlas of Human Reproduction, SBRH 2012

37. Tubule Diameter grouped by
Presence of Sperm
420
400
380
Max. Tubule Diameter
360
340
320
300
280
260
240
220
200
180 Median
160 25%-75%
yes No 5%-95%
Raw Data
Presence of Sperm
Esteves, 37
N = 54; Tubule Diameter: KW-H(1;54) = 25,213; p < 0,0001

38. Intraoperative
Objective Identification
of Sperm-producing
Tubules
Computer-assisted Sperm Retrieval
Esteves, 38

39. Objective Identification of
Sperm-producing Tubules
1. Minimize trauma/damage to the testis:
minimal tissue excision.
2. Decrease operative time.
3. Facilitate laboratory tissue processing
and sperm search.
4. Improve success.
Esteves, 39

40. Conclusions
Nonobstructive azoospermia:
Most severe form of male infertility
Not synonymous of sterility
Current testing not predictive of successful SR.
Heterogenic pattern of sperm production in NOA:
Geographic location unpredictable
Microsurgical-guided Testicular Sperm Extraction:
Significantly higher SRR and chance of fatherhod
for men with NOA
Esteves, 40