Reproductive Andrology Workshop III 17-21 January 2016 - Kuwait City - KUWAIT Organized by: Al Jahra Reproductive Medicine Unit - Ministry of Health Lecture 4: Sperm Retrieval Methods in Nonobstructive Azoospermia

1.
REPRODUCTIVE ANDROLOGY SURGERY WORKSHOP III
17-21 January 2016 – Reproductive Medicine Unit – Jahra Hospital
KUWAIT
CLINICAL MANAGEMENT OF MEN WITH
NONOBSTRUCTIVE AZOOSPERMIA
Lesson 4: Sperm Retrieval Methods
Dr Sandro ESTEVES
Medical and Scientific Director
ANDROFERT - Andrology & Human Reproduction Clinic
Campinas, Brazil

2. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 2
2016
ANDROFERT

3. Esteves et al. Sperm Retrieval Techniques. Int Braz J Urol 2011; 37: 570-83
About 40-50% of men with SF have residual
spermatogenesis within the testis
§ Not enough for sperm to
appear in ejaculate
§ 600-800 seminiferous tubules
§ Goal is identify site of
production and retrieve
sperm for ICSI
§ Geographic location
unpredictable
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 3
2016
ANDROFERT

4. Op#ons
for
sperm
retrieval
in
spermatogenic
failure
Technique
Acronym
Success
Tes#cular
sperm
aspira#on
TESA
15-­‐50%
Tes#cular
sperm
extrac#on
TESE
17-­‐45%
Microdissec#on
tes#cular
sperm
extrac#on
Micro-­‐
TESE
43-­‐63%
Esteves
et
al
Int
Braz
J
Urol
2013;37:570-­‐83;
Deruyver
et
al
Andrology
2014;2:20-­‐4
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 4
2016
ANDROFERT

5. A
threshold
of
3
mature
sperma#ds
per
seminiferous
tubule’s
cross-­‐
sec#on
must
be
exceeded
in
order
for
spermatozoa
to
spill
over
into
the
ejaculate.
Men
with
NOA
have
a
mean
of
0–3
mature
sperma#ds
per
seminiferous
tubule,
thus
explaining
why
rare
sperm
are
occasionally
found
in
ejaculates
Semen
Analysis
at
Day
of
Sperm
Retrieval
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 5
2016
ANDROFERT
Silber
SJ.
Hum
Reprod
2000;
15:
2278–84;
Jaffe
TM
et
al.
J
Urol
1998;
159:
1548–50.

6. http://androfert.com.br/videos
Micro-TESE. Esteves SC Int Braz J Urol 2013; 39(3):440
h;ps://www.youtube.com/watch?v=ynvM6B1GIFA

7. Vascular
pa;ern
of
tesQs
• Extensive
pa;ern
of
vessels
surrounding
tesQs
• Parallel
arteries
inside
tesQs
surrounding
seminiferous
tubules
• Allows
opportunity
to
maintain
blood
supply
but
dissect
between
tubules
throughout
tesQs

8. Photomicrograph courtesy JP Jarow, M.D.

9. IntratesQcular
anatomy

10. Micro-TESE more effective than
conventional TESE
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)
Histology categories
pairwise comparisons:
p<0.0001
Method
P=0.0005
Verza Jr & Esteves. Fertil Steril 2011; 96 (Suppl.): S53
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 10
2016
ANDROFERT

11. ANDROFERT
Micro-­‐TESE
was
1.5
#mes
more
likely
(95%
CI:
1.4–1.6)
to
result
in
successful
SR
than
conven#onal
TESE.
Micro-­‐TESE
vs
cTESE
Fertil Steril Nov;104(5):1099-1103

12. 100%
40.3
% 19.5
%
Esteves & Agarwal. Asian J Androl 2014; 16: 642
Hypospermatogenesis
Maturation arrest
Sertoli cell-only
P<0.01
SR by Micro-TESE according to
histopathology results (N=357)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 12
2016
ANDROFERT

13. Ultrasonographic follow-up
• After microdissection TESE:
No patients
with lesions seen after 6 mo.
• After standard TESE 70% (19/27) patients
had persistent ultrasound-detected
changes within the testes “chronic
changes”
• Schlegel & Ciechanover, 2001
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 13
2016
ANDROFERT

14. A^er
micro-­‐TESE
a
transient
decrease
in
serum
T
is
followed
by
return
to
baseline
levels
in
about
95%
of
the
cases
within
18
months.
However,
effects
tend
to
be
permanent
in
men
with
very
small
testes
and
severely
compromised
androgen
ac#vity
(eg.
Klinefelter
syndrome).
Postoperative Testosterone
Levels
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 14
2016
ANDROFERT
Schiff
JD
et
al.
J
Clin
Endocrinol
Metab
2005;
90:
6263–7.
Ramasamy
R
et
al.
Urology
2005;
65:
1190–4.

15. microTESE (ANDROFERT Experience)
Non-obstructive azoospermia
Source:
Androfert;
Feb
2015
-­‐
Average
female
age:
36.4
±
4.0
years
Retrieval attempts 609
Sperm retrieval 52.9% (322/609)
ICSI cycles 476
Fertilization rate(fresh) 65% (2392/3680)
Fertilization rate (frozen) 54% (563/1210)
Transfers 412
Clin Preg/transfer 43% (177/412)
LBR/transfer 36.4% (150/412)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 15
2016
ANDROFERT

16. Microdissection TESE – Postop.
• 100 men with NOA
• Controlled trial of TESE v. Microdissection
• Serial ultrasound follow-up at 1, 3, 6 mo.
Std TESE Microdissection
Sperm retrieval 30% 47%
Acute changes 48% 15%
Chronic changes 58% 3%
Amer et al., Hum Reprod 15:653, 2000
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 16
2016
ANDROFERT

17. Okada et al.: Microdissection TESE
Std TESE Microdissection
Retrieval rate:
SCO
6.3% 34%
Retrieval rate:
All NOA pts
16.7% 45%
Ultrasound
changes
51% 12%
Complications* 7.5% 2.5%
Okada et al., J Urology 168:1063, 2002
*Decreased
tesQcular
volume
seen
a[er
25%
of
TESE
procedures

18. Repeat
micro-­‐TESE
a^er
an
ini#ally
successful
procedure
can
be
carried
out,
but
should
be
delayed
for
at
least
6
months
due
to
inflammatory
changes.
SR
success
is
markedly
lower
(25%
vs
80%)
if
repeat
micro-­‐
TESE
is
performed
within
6
months
of
the
first
opera#on.
Repeat Micro-TESE
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 18
2016
ANDROFERT
Schlegel
PN,
Su
LM.
Physiological
consequences
of
tes#cular
sperm
extrac#on.
Hum
Reprod
1997;
12:
1688–92.

19. Key Messages – Day 4
Sperm Retrieval Methods
ANDROFERTANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 19
2016
ANDROFERT
Requires use of microscope (15-25x)
Depends on differential size of tubules
Tedious
Learning curve
ü Increased sperm yield
ü Less tissue removal
ü Fewer postoperative changes

20. Thank
you
This
presenta#on
is
available
at
hgp://www.slideshare.net/
sandroesteves
‫ا‬‫شكر‬