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Sandro Esteves, M.D., Ph.D. Director, ANDROFERT Center for Male Reproduction and Infertility Campinas, BRAZIL Meet the Expert Evening Meeting, Nov 2012 (Jordan, Lebanon, Qatar, Bahrain, Kuwait)

Current Scenarios of Male Infertility for IVF Specialists

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Page 1: Current Scenarios of Male Infertility for IVF Specialists

Sandro Esteves, M.D., Ph.D. Director, ANDROFERT

Center for Male Reproduction and Infertility Campinas, BRAZIL

Meet the Expert Evening Meeting, Nov 2012 (Jordan, Lebanon, Qatar, Bahrain, Kuwait)

Page 2: Current Scenarios of Male Infertility for IVF Specialists

Learning Objectives

New diagnostic tests go far beyond routine semen analysis. Learn which tests are

available and how to use them.

WHO has updated reference limits for semen analysis results. Understand how to adopt and

interpret the new standards.

Esteves

2

Antioxidant supplementation is a hot issue in male infertility. Understand the rationale of its

use and how it can benefit your patients.

Learn what is available for azoospermic men seeking fertility. Biological fatherhood is

possible even in the worst scenarios.

Page 3: Current Scenarios of Male Infertility for IVF Specialists

Review this lecture at: http://www.androfert.com.br/review

Esteves SC, 2012

Page 4: Current Scenarios of Male Infertility for IVF Specialists

45 Kg

64 cc

>1 billion/mL

Spermatogenesis Where do we stand compared to our relatives?

270 Kg

14 cc

5 million/mL

Chimpanzee Gorilla

80 Kg

20 cc

?

Human

Esteves

4

Presenter
Presentation Notes
Spermatogenesis in humans and apes: Chimpanzees, which weight about 100 lbs, have enormous testis with sperm count of about 1 billion/mL. Gorillas, which weight as much as 600 lbs, have tiny testes and sperm output 200 lower than chimpanzees. Humans, the closest living relatives of both chimps and gorillas, how do we stand?
Page 5: Current Scenarios of Male Infertility for IVF Specialists

Centiles 5% 50%* 95% Volume (mL) 1.5 3.7 6.8 Sperm count per mL (x106) 15.0 73.0 213.0 Sperm count per ejaculate (x106) 39.0 255.0 802.0 % Motility (total) 40 61 78 % Motility (progressive) 32 55 72 % Normal Morphology (strict criteria) 4 15 44 % Alive (eosin-nigrosin staining) 58 79 91

Cooper et al: World Health Organization reference values for human semen characteristics. Hum Reprod Update 16: 231-245, 2010

Semen Characteristics Values of 1,953 Recent Fathers

(whose partners had a TTP* ≤ 12 months)

*TTP: time to pregnancy

Esteves

5

Presenter
Presentation Notes
To answer this question, a group of scientists evaluated the semen parameters of recent fathers, whose partners conceived spontaneously after 12 months or less. Semen analyses results were presented as percentiles, and the fifth centile was chosen as the one to represent the lower reference limits for normality.
Page 6: Current Scenarios of Male Infertility for IVF Specialists

WHO 20101

1.5 15 39

32 (a+b) 58 4

<1.0

Semen analysis: New WHO Standards

Semen Parameter Volume (mL) Count (x106/mL) Total sperm number per ejaculate Motility (%) Vitality (%) Morphology (%)2

Leukocytes (x106/mL) 1Lower Limit (5% percentile), Recent fathers; 2Strict criteria

Grade a = rapid progressive motility; Grade b = slow/sluggish progressive motility

Esteves

6

WHO 1999 ≥ 2.0 ≥ 20 ≥ 40

≥ 50 (a + b) ≥ 75 (14) < 1.0

Presenter
Presentation Notes
These cuttoff limits were adopted by the WHO in its newly released (fifth edition) laboratory manual. As you know, most laboratories adopt the guidelines provided by the WHO. The previous one dated from 1999, and here you can compare how the current proposed values stand as compared to the old ones. As you can see, the current reference values to consider a semen specimen normal are markedly changed, and lower than the limits of the 1999 manual. Who in the room has already updated to WHO 2010? So, if you receive a semen analysis report stating this new values as the reference limits, you should understand how they were obtained and what they mean…
Page 7: Current Scenarios of Male Infertility for IVF Specialists

New WHO standards Caution to Adopt and Interpret Results

Esteves

7

Presenter
Presentation Notes
Early this year a group of scientists from different countries joined me to critically evaluate the likely impact of these new reference values on the clinical management of male infertility.
Page 8: Current Scenarios of Male Infertility for IVF Specialists

Critical Appraisal of the WHO New Reference Values for Human Semen and Impact on Diagnosis and Treatment of Subfertile Men

Esteves, Zini, Aziz et al, Urology, in press

Do they represent global semen characteristics of fertile men?

Columbia, MinneapolisUSA

Melbourne Australia

Turku Finland

Oslo Norway

Edimburgh UK

Paris France

Copenhagen Denmark

Esteves

8

Presenter
Presentation Notes
First, we noted that the semen reference limits for the fertile population were drawn from patients coming from Northern Europe, Australia and USA. Other areas were not represented. Millions of fertile men living in China, India, Africa, Middle East and South America are not included into this data analysis. The first conclusion that we draw from these data was that it seems unsound to assume, as proposed by the WHO, that the reference values represented global semen characteristics of fertile men. According to the authors of the original study that referenced WHO manual, laboratories and data were identified through the known literature and personal communication with investigators and the editorial group of the fifth edition of the WHO manual.
Page 9: Current Scenarios of Male Infertility for IVF Specialists

New WHO standards Reasons for Lower Cut-off Values

• Method for semen analysis (QC standards) • Adoption of strict criterion for morphology • Single specimen of each individual

Different way of generating data

• Recent fathers with known TTP • Selection bias

Population Studied

Esteves

9 Esteves et al. Critical Appraisal of the WHO New Reference Values for Human Semen and Impact on Diagnosis and Treatment of Subfertile Men. Urology 2012; 79(1):16-22.

Presenter
Presentation Notes
Second, the lower reference limits should not be misinterpreted as a sign that sperm quality is declining worldwide. The difference from previous limit values is better explained by the adherence of participating laboratories to higher quality control standards, and by incorporating strict sperm morphology evaluation. Moreover, previous WHO reference values were obtained mainly based on the clinical experience of investigators who have studied populations of healthy fertile men of unknown TPP rather than controlled populations of fertile men as in the current edition. Ideally, a systematic review of the literature on semen quality in various populations should provide recommendation for lower reference values. However, this is not feasible because of the variability in the methodology used by several laboratories in assessing sperm characteristics. Further well conducted studies with standardized methodology and a recognized quality control procedure will be required to confirm the validity of global reference ranges as proposed by the 5th edition WHO manual. Finally, a single semen sample was taken to represent each man in the reference studies. The assumption that one ejaculate is representative of a given man semen profile argues against the current knowledge of the high biological variability of semen variables from same individuals.
Page 10: Current Scenarios of Male Infertility for IVF Specialists

New WHO Standards: Implications • Do we need to recall previous semen

analysis reports ?

Abnormal

results WHO 1999

Reclassified as “Normal” WHO 2010

(38.7%)

Couples (N=987) with infertility duration > 12 months

Source: ANDROFERT, Brazil

Morphology by strict criterion accounted for 53% of reclassification

Esteves

10

Presenter
Presentation Notes
This is important because the prevalence of male infertility has not changed because of the publication of the new WHO reference values. However, by blindly adopting such values about 40% of men previously classified as infertile according to the 1999 manual would become considered “fertile” or having unexplained or female-factor infertility. It is unclear at this time, whether this re-classification will result in a more cost-effective evaluation of the infertile couple or in a delay in the male factor evaluation with subsequent delay in the definitive diagnosis and management of the infertile couple.
Page 11: Current Scenarios of Male Infertility for IVF Specialists

Laboratories seeking to adopt the new standard should determine the strategy that would aid the clear communication of the clinical significance of the results.

Esteves

11

New WHO Standards: Interpretation Focus on the 5th percentile

Esteves & Agarwal Impact of the new WHO guidelines on diagnosis and practice of male infertility. Open Reprod Sci J 2011; 3: 7-15.

Presenter
Presentation Notes
At present, the matter is still unresolved and certainly more debate is needed. Reference values are important for comparison with values obtained from the patient being assessed. The observed values may be used to aid in the clinical decision-making process by comparing them with reference distributions and reference intervals. Therefore, it is important not only to compare the patient results with the lower reference limit but also with the 50th percentile, which represents the value beneath which 50% of the reference population of ‘fertile’ men falls. This strategy may be more realistic and can help in understanding a patient’s seminal profile in relation to the reference group. It is possible that global reference values are not achievable because of geographical and racial variations. It would be ideal to have well-funded prospective studies designed to evaluate several racial and geographical populations of fertile men. From the discussion above different laboratories seeking to adopt the new standard should determine the strategy that would aid the clear communication of the clinical significance of the results.
Page 12: Current Scenarios of Male Infertility for IVF Specialists

New WHO Standards Not accurate to discriminate fertile and

infertile men

Male infertility workup goes far beyond a simple

semen analysis. History taking, physical examination

and laboratory and sperm function testing are

minimum standards.

Esteves, Miyaoka & Agarwal. An update on the initial assessment of the infertile male.

CLINICS 2011; 66:1-10. Esteves

12

Presenter
Presentation Notes
Caution must be exercised when interpreting these new reference values since it is obvious that the prevalence of couples facing difficulties to conceive has not changed despite publication of new reference values. Every couple attempting to conceive for more than 1 year of unprotected intercourse, or less in the cases of advanced female age or in men with a recognized fertility problem, deserve medical evaluation that must include both partners irrespective of the semen analysis results. It is known that about 30% of men misdiagnosed as having unexplained male infertility, according to the normal semen parameters on routine analyses, present sperm deficiencies that can be solely identified by sperm functional tests, such as the assessment of DNA integrity, oxidative stress and antisperm antibodies. Semen analyses results, as routinely performed, are limited in their validity as surrogates for the assessment of male fertility potential. For this reason, it has been suggested that sperm function tests should be included in the semen analysis of individuals seeking fertility evaluation. The couples’ chance to conceive is influenced by multiple factors and our task, as treating physicians, is multifaceted. It is our responsibility to diagnose existing conditions that may compromise, now or in the future, the fertility potential of our patients. The goal is to identify potential life-threatening diseases and to treat reversible conditions, including poor lifestyle habits, subclinical infections, hormone disorders and clinical varicocele to cite a few. It is important to acknowledge the limitations of semen analysis results in predicting the health and functional capacity of the male reproductive organs and cells. The male evaluation regarding fertility must go far beyond counting spermatozoa and assessing motility and morphology. It has to be complemented with a proper clinical examination, a comprehensive history taking, and relevant endocrine, genetic, and/or other investigations.
Page 13: Current Scenarios of Male Infertility for IVF Specialists

Sperm DNA Integrity

Reactive Oxygen Species

Y Chromosome Microdeletion Screening

Esteves et al. What the gynecologist should know about male infertility: an update. Arch Gynecol Obstet 2012; 286(1): 217-29 Esteves

13

New Diagnostic Tests • Beyond routine semen analysis

Presenter
Presentation Notes
3 new tests are available ; 2 of them are used to assess sperm function and one to determine the diagnosis and treatment strategy in cases of severe male factor infertility;
Page 14: Current Scenarios of Male Infertility for IVF Specialists

Sperm DNA Integrity Testing

• Normal sperm chromatin essential for paternal genetic transmission Background

• Unexplained infertility • Recurrent pregnancy loss • Poor outcomes in IUI and IVF

Sperm DNA Fragmentation

• Quantification of sperm DNA strand breaks Principle

• Semen, spermatozoa Specimen

• Nuclear dyes (Acridine orange, SCSA) • Direct assessment (TUNEL, COMET) • Nuclear matrix assays (SCD)

Techniques

Esteves SC & Agarwal A. Novel concepts in male infertility. Int Braz J Urol 2011; 37:5-15. Esteves

14

Presenter
Presentation Notes
Normal sperm chromatin structure is essential to transmit the paternal genetic information to the offspring. The principle of sperm DNA testing is to quantify DNA strand breaks in the neat semen. There are several assays available for clinical use; the best one is yet to be defined; however, TUNEL and Sperm cromatin structural assay (SCSA) are the 2 most commonly used to measure DNA damage and have been validated for both fertile and infertile men.
Page 15: Current Scenarios of Male Infertility for IVF Specialists

Sperm DNA Fragmentation and Assisted Conception

19%

1.5%

Normal Elevated

Live Birth Rates by Intrauterine Insemination

OR = 0.07 [95% CI: 0.01-0.48]

Adapted from Bungum et al., Hum Reprod 2007

26%

42%

IVF ICSI

Pregnancy by Method in Cases of Elevated Sperm DNA

Fragmentation

P <0.05

Esteves

15

Presenter
Presentation Notes
Elevated levels of sperm DNA damage is associated with infertility, pregnancy loss and poor outcomes both in IUI and IVF.
Page 16: Current Scenarios of Male Infertility for IVF Specialists

Sperm DNA Fragmentation and Miscarriage

Robinson L et al. Hum Reprod. 2012; 27(10): 2908-17

• Population: Meta-analysis of 16 cohort studies (2,969 couples), 14 prospective.

• Techniques for DNA integrity: Acridine orange-based assays, TUNEL and COMET. • Findings:

Significant increase in miscarriage rates in patients undergoing IVF/ICSI with high sperm DNA damage compared with those

with low DNA damage.

Risk ratio (RR) = 2.16 (1.54, 3.03), P < 0.00001).

Miscarriage rates are positively correlated with sperm DNA damage levels

Esteves

16

Presenter
Presentation Notes
A systematic review and meta-analysis of studies which examined the effect of sperm DNA damage on miscarriage rates was performed. Searches were conducted on MEDLINE, EMBASE and the Cochrane Library without any language restrictions from database inception to January 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: We used the terms 'DNA damage' or 'DNA fragmentation' combined with 'miscarriage', 'abortion' or 'pregnancy' to generate a set of relevant citations. Data extraction was performed by two reviewers. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analysis of relative risks of miscarriage was performed with a random effects model. Subgroup analyses were performed by the type of DNA damage test, whether the sperm examined were prepared or from raw semen and for pregnancies resulting from IVF or ICSI treatment. MAIN RESULTS AND THE ROLE OF CHANCE: We identified 16 cohort studies (2969 couples), 14 of which were prospective. Eight studies used acridine orange-based assays, six the TUNEL assay and two the COMET assay. Meta-analysis showed a significant increase in miscarriage in patients with high DNA damage compared with those with low DNA damage [risk ratio (RR) = 2.16 (1.54, 3.03), P < 0.00001)]. A subgroup analysis showed that the miscarriage association is strongest for the TUNEL assay (RR = 3.94 (2.45, 6.32), P < 0.00001). LIMITATIONS, REASONS FOR CAUTION: There is some variation in study characteristics, including the use of different assays and different thresholds for DNA damage and the definition of pregnancy loss. WIDER IMPLICATIONS OF THE FINDINGS: The use of methods which select sperm without DNA damage for use in assisted conception treatment may reduce the risk of miscarriage. This finding indicates that assays detecting DNA damage could be considered in those suffering from recurrent pregnancy loss. Further research is necessary to study the mechanisms of DNA damage and the potential therapeutic effects of antioxidant therapy.
Page 17: Current Scenarios of Male Infertility for IVF Specialists

Sperm with intact DNA show “halos”: Represent dispersed chromatin without

breaks

Sperm with fragmented DNA do not show “halos” :

Represent DNA strand breaks

Semen/Spermatozoa

Quantitative: Normal: <30% cells with fragmented DNA

Sperm Chromatin Dispersion (SCD)

Quick and Easy Test for Sperm DNA Fragmentation Assessment

Esteves

17 Esteves et al. What the gynecologist should know about male infertility: an update. Arch Gynecol Obstet 2012; 286(1): 217-29

Page 18: Current Scenarios of Male Infertility for IVF Specialists

Y Chromosome Microdeletion Screening

• Deletions linked to spermatogenic failure Background

• Severe oligozoospermia and NOA Who?

• PCR of the long arm of Y-chromosome Principle

• Peripheral blood Specimen

• Diagnosis and predictive value for sperm retrieval

Clinical Significance

80%

5% 10% 5%

Genetic Causes of Male Infertility

Klinefelter Syndrome (47,XXY)Y-chromosome microdeletionCongenital Vas Absence

Esteves SC & Agarwal A. Novel concepts in male infertility. Int Braz J Urol 2011; 37:5-15.

Esteves

18

Presenter
Presentation Notes
Another diagnostic tool is the Y chromosome microdeletion test. This test is particularly useful for the group of men with azoospermia, because genetic abnormalities are the cause of azoospermia in about 20% of the cases. Sperm can be found within the testis of azoospermic men in certain cases, and intracytoplasmic sperm injection using testicular sperm can be used to assist these patients to conceive. However, it is virtually impossible to predict which patients with testicular failure have sperm production without using invasive measures such as a testis biopsy. The only exception is the case of the azoospermic male with Y-chromosome microdeletions, in whom a simple molecular biology test can predict if sperm production exist.
Page 19: Current Scenarios of Male Infertility for IVF Specialists

Esteves SC & Agarwal A. Novel concepts in male infertility. Int Braz J Urol 2011; 37:5-15.

AZFa deletion

No retrievable sperm

AZFc deletion

Sperm retrieved in 70% of cases

AZFb deletion

No retrievable sperm

Predictive Value of Yq Microdeletion Screening for

Sperm Retrieval in NOA

Esteves

19

Presenter
Presentation Notes
Imagine the Y-chromosome as a book. This book has 3 chapters named AZFa, AZFb and AZFc that encode the “recipe” of normal spermatogenesis. The most important chapters are AZFa and b. If chapter AZFa is absent, no germ cell can be found within the testis. If chapter AZFb is absent, germ cells exist but spermatogenesis is arrested at the spermatocyte stage and again, no sperm can be found. Conversely, if chapter AZFc is absent, but chapters a and b are present, there is a 70% chance of finding testicular sperm that can be used in association with ICSI. Therefore, azoospermic patients with Y-chromosome microdeletions in the AZFa or b regions are NOT candidates for Sperm retrieval, because no sperm can be found. This simple test can identify these individuals and an invasive procedure for sperm retrieval can be avoided.
Page 20: Current Scenarios of Male Infertility for IVF Specialists

Outcome N studies

N participants

Effect size (OR; 95% CI)

Live birth 3 214 4.85 [1.92, 12.24]

Pregnancy rate 15 964 4.18 [2.65, 6.59]

DNA fragmentation 1 64 -13.80 [-17.50, -10.10]

Miscarriage, sperm count, sperm motility

6-16 242-700 No effect

Adverse effects 6 426 No effect

Esteves

20

Oral Antioxidant Therapy for Male Infertility

Improve the outcomes of live birth and pregnancy rate for subfertile couples undergoing ART cycles

Showell MG et al. Antioxidants for male subfertility. Cochrane Database Syst Rev 2011 Jan 19;(1):CD007411.

Presenter
Presentation Notes
Cochrane review analyzed 34 randomized controlled trials ( RCT) involving 2876 couples. The study evaluated the effect of oral antioxidant supplementation for male partners of couples undergoing assisted reproduction techniques (ART). A recent Cochrane meta-analysis on the use of oral antioxidants in male infertility found that these agents significantly improved pregnancy rates and live births and decreased sperm DNA damage [101]. An associated statistically significant increase in live birth rate [pooled odds ratio (OR) = 4.85; 95% CI 1.92–12.24; P = 0.0008; I (2) = 0%] has been obtained when men taking antioxidants were compared to controls. No studies reported harmful side effects from the antioxidant therapy used. Nevertheless, improvements in semen parameters were not well evident. The evidence suggests that antioxidant supplementation in subfertile males may improve the outcomes of live birth and pregnancy rate for subfertile couples undergoing fertility treatment. However, clinical trials are still necessary to identify the superiority of one antioxidant over the other in different subpopulations of infertile males, as well as other important aspects such as dose and duration of therapy. The beneficial effects of antioxidants are not seen in the parameters normally assessed in the routine semen analysis. Increasing evidence suggest that these substances positively impact on the sperm DNA integrity by decreasing oxidative stress. The substances that have been extensively studied are: Selenium, folic acid, vitamin E, Vitamin C, carotenoids, zinc . These substances are known to be effective scavenger of oxidative species molecules and help control endogenous seminal radicals. Carotenoids are found in red and orange pigmented vegetables (tomatoes, carrots). Zinc is an important component of superoxide dismutase, a potent antioxidant enzyme. Menevit: Ascorbic acid (vitamin C) 100mg; Zinc (as zinc sulphate monohydrate) 25mg; d-alpha-tocopherol (vitamin E) 400iu; Folic Acid 500mcg; Lycopene 6mg; Garlic oil (equiv. allium sativum bulb fresh 1g) 333mcg; Selenium (as selenomethionine) 26mcg��
Page 21: Current Scenarios of Male Infertility for IVF Specialists

Rationale for Antioxidants in Male Infertility: Oxidative Stress

Esteves

21

00,5

11,5

22,5

Fertile Infertile

Seminal Reactive Oxygen Species (ROS)

(Log ROS + 1; cpm)

Pasqualotto et al., Fertil Steril 2000

30%-80% of infertile men have elevated markers of OS

Agarwal et al., Urology 2006

Presenter
Presentation Notes
An emerging explanation for several types of male infertility arises from oxidative stress (OS) which is believed to be present anywhere from 30 to 80% of infertile men. Basically, oxidative stress emerges from the unbalanced presence of Superoxide (O2-), Hydroxyl radicals (OH) or Nitric derivates (NO) and may be externally or internally dangerous for all types of cells. Most of the infertile patients that we see in our clinical practice are at risk of excessive Oxidative Stress. Reactive oxygen species are products of aerobic metabolism. At certain levels they are not detrimental, but several conditions induce an overproduction of ROS, causing oxidative stress. Oxidative stress, that can be measured either in the seminal plasma or directly in the sperm by different methods, are higher in infertile men than fertile ones. Regardless of its cause, the end product of OS is the oxidation of sperm structures that become dysfunctional. The impairment of sperm function caused by OS may be either the only factor causing infertility or a contributor to a recognized disease that cause infertility. Options to minimize OS include: i) the treatment of the underlying pathology, if possible, ii) the removal of risk factors, which is not always feasible, or iii) by the administration of antioxidant supplementation. OS is defined as the imbalance between prooxidative and antioxidative molecules in a biological system which arises as a consequence of excessive production of free radicals and impaired antioxidant defense mechanisms. ROS: Chemical species with unpaired electron capable to oxidize lipids, proteins and nucleic acids: Superoxide anion (•O-2) Hydroxyl radical (•OH) Hydrogen peroxide (H2O2) Peroxyl radical (ROO•) Hypochlorite ion (OCl-) Generated from aerobic metabolism in mitochondria. Sources: Leukocytes (extrinsic) Spermatozoa (intrinsic) Sperm and Seminal Plasma Antioxidants: Enzymatic (SOD, catalase, GPX): inactivate ROS (conversion into other substances) Non-enzymatic (ascorbic acid, alpha-tocopherol, carnitine, etc.): neutralize ROS
Page 22: Current Scenarios of Male Infertility for IVF Specialists

Principle: reduction of nitroblue

tetrazolium into formazan (coloured intermediate)

Semen or seminal plasma

Qualitative colorimetric

Detection of Superoxide Anion

Quick and Easy Test for Reactive Oxygen Species

Assessment

Esteves

22 Tunc et al. Development of the NBT assay as a marker of sperm oxidative stress. Int J Androl 2010; 33(1): 13-21.

Presenter
Presentation Notes
The test uses a Reactive Gel (RG) that has the capacity to change its original color when it reacts with the superoxide anion that is responsible for generating oxidative stress in human sperm. Depending on the concentration of the superoxide anion, a precipitate with a color that will vary from a light pink to dark purple or almost black will form. The intensity of the color is related to the level of oxidative stress in the sample. It detects the presence of Superoxide in a cell-containing media based on the the reduction of NitroBlueTetrazolium via the production of a coloured intermediate and visible form formazan. 1. Place the tube with the RG, using the float, in a precipitation glass, and heat for 1 minute in a microwave at maximum potency. Alternatively, the RG can be liquefied in a water bath at 90ºC for approximately 5 minutes. 2. Reduce the temperature of the RG to 37°C. 3. Mix the RG with the semen sample in one of the eppendorf. Incubate for 45 minutes at 37°C. 4. After these 45 minutes have transpired, compare the colour of the sample with the colour scheme, and observe the level of oxidative stress in the sample.
Page 23: Current Scenarios of Male Infertility for IVF Specialists

How to use Antioxidants Treatment Strategy

Ascorbic acid (Vit. C) α- tocopherol (Vit. E)

Glutathione N-acetyl-cysteine

Carnitine Coenzyme Q10

Lycopene Picnogenol

Pentoxifylline Selenium

Shao-Fu-Zhu-Yu-Tang Astaxanthin

Lepidium meyenii α -linolenic acid and lignans

Folic acid Zinc

Select antioxidant formulation and dosage

Testing for

Leukocytes in Semen

Differentiate between sperm and leukocyte

source of ROS

Varicocele Genital Infection

Smoking Medication Drug abuse

Systemic diseases Pollution Radiation

Once OS is diagnosed, focus on identifying

and controlling source of increased ROS

Esteves

23

Page 24: Current Scenarios of Male Infertility for IVF Specialists

Oral Antioxidants in Male Infertility Our formula

Vitamin C 500mg Vitamin E 400 mg Folic acid 2 mg Zinc 25 mg Selenium 26 mcg

How long: minimum 2 months

Old concept ~80 days

New concept ~60 days

From initiation of sperm production to ejaculation

Misell LM et al. J Urol. 2006

Esteves & Agarwal. Novel concepts in male infertility. Int Braz J Urol 2011; 37 (1): 5-15 Esteves

24

Presenter
Presentation Notes
Based on several studies, our center has derived an empiric regimen of synthetic vit C and E, folate, zinc and selenium for men demonstrating elevated oxidative stress levels in their semen profile.
Page 25: Current Scenarios of Male Infertility for IVF Specialists

Azoospermia • It is not a synonymous of sterility

• Normal sperm production

• Mechanical blockage • Vasectomy, Post-infectious,

Congenital

Obstructive

• Sperm production deficient or absent

• Cryptorchidism, Radiation, Chemotherapy, Trauma, Genetic, Orchitis, Varicocele, Gonadotoxins, Unexplained

Non-obstructive

• Complete absence of sperm in the ejaculate • 1-3% male population; ~10-15%% male infertility

Esteves

25

Presenter
Presentation Notes
My final topic is Azoospermia, defined as the absence of sperm in the ejaculate. In cases of azoospermia, two totally different clinical situations exist. In obstructive azoospermia, spermatogenesis is normal but a mechanical blockage exists in the genital tract, somewhere between the epididymis and the ejaculatory duct. Common causes of OA include vasectomy, post-infectious diseases, congenital conditions. In nonobstructive azoospermia, sperm production is extremely deficient or absent inside the testicles . Common causes of NOA include cryptorchidism, orquitis, Radio/Chemotherapy, use of gonadotoxic medication and sterioids, and genetic origin.
Page 26: Current Scenarios of Male Infertility for IVF Specialists

Obstructive Azoospermia

• Microsurgical reconstruction

• TURED Potentially treatable

• Epididymis • Testis • Simple and

effective

Sperm retrieval for ART

Esteves, Miyaoka & Agarwal. Surgical Treatment of Male Infertility in the ICSI Era. CLINICS 2011; 66:1463-77.

Esteves

26

Presenter
Presentation Notes
Certain cases of OA are potentially reversible by using microsurgical or endoscopic methods. Another option for this group of patients is ART. Sperm can be easily obtained from the epididymis or testicles by percutaneous or microsurgical methods.
Page 27: Current Scenarios of Male Infertility for IVF Specialists

Esteves et al. J Urol 12013; 189: http://dx.doi.org/10.1016/j.juro.2012.08.084

34.4 35.8

265

32.2 37.0

277

36.4 35.5

250

% Live birth Gestational age (wks) Birth weight(gramsx10)

CBAVD Post-vasectomy Post-infection

Sperm Retrieval and ICSI Outcome Obstructive

Azoospermia

Esteves

27

Page 28: Current Scenarios of Male Infertility for IVF Specialists

Non-obstructive Azoospermia • Sperm production

reduced or absent • Geographic location

unpredictable

Sperm Retrieval for ART

Untreatable condition

Esteves

28

TESA

• 15%-50% SRR

Con

vent

iona

l TE

SE

• 20%-63% SRR

Mic

ro-T

ESE

• 40%-67% SRR

Friedler et al. 1997; Ezeh et al. 1998; Schlegel 1999; Amer et al. 2000; Okada et al. 2002; Okubu et al. 2002; Tsujimura et al. 2002; Ramon et al. 2003; Verza Jr. & Esteves 2011.

Presenter
Presentation Notes
NOA is a complete different story. It is an untreatable condition and men with NOA have been the most difficult to treat. The goal in NOA is to find testicular sperm for ICSI, but the problem is that sperm production is focal or absent in such cases, and geographic distribution of sperm production is not predictable. Percutaneous and open testicular biopsy are used to retrieve sperm; however, the open biopsy using microsurgery is the one that yields better retrieval rates. The principle is to open the testicle and look for enlarged seminiferous tubules using the operating microscope. Enlarged tubules are removed because they are likely to contain active spermatogenesis.
Page 29: Current Scenarios of Male Infertility for IVF Specialists

Esteves

29 Available at http://androfert.com.br/videos

Page 30: Current Scenarios of Male Infertility for IVF Specialists

Adapted from: Verza Jr & Esteves. Atlas of Human Reproduction, SBRH 2012 Esteves

30

Page 31: Current Scenarios of Male Infertility for IVF Specialists

Multi-photon microscopy (ex vivo; human model)

Confocal fluorescence microscopy

(in vivo; murine model)

Full-field optical coherence tomography

(ex vivo; rat model)

Najari et al, J Urol 2012; Smith et al J Urol 2012; Ramasamy et al., J Pathol Inform 2012

Novel Sperm Retrieval

Methods for Identification of Spermatogenic

Sites

Sperm Retrieval in Testicular Failure

Page 32: Current Scenarios of Male Infertility for IVF Specialists

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

Sperm Retrieval and Reproductive Potential of Azoospermic Men in ART

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):S232-3. Esteves

32

Presenter
Presentation Notes
The chances of finding sperm, and the chances of achieving a live birth by ICSI is completely different depending on the type of azoospermia. Successful sperm retrieval are 43 times higher in man with OA compared to NOA. Although men with NOA should not be considered sterile, their chances of having their own offspring is significantly lower compared to the counterpart with OA.
Page 33: Current Scenarios of Male Infertility for IVF Specialists

Key Messages (1)

Esteves

WHO references for semen analysis have been lowered.

Exercise caution to interpret results for they have important shortcomings.

New diagnostic tests allow assessment to sperm DNA integrity, seminal ROS and Y-chromosome genetic infertility.

Tests results aid in the clinical management and/or have prognostic

value in ART. 33

Page 34: Current Scenarios of Male Infertility for IVF Specialists

Key Messages (2)

Esteves

34

Oxidative stress is a risk factor for male infertility and miscarriage.

Antioxidant supplementation improve the chances for pregnancy and live

birth for couples undergoing ART.

Azoospermia is not synonymous of sterility.

Treatment options include microsurgery and sperm retrieval coupled with ICSI.

Reproductive potential in ART is dependent on the type of azoospermia.

Presenter
Presentation Notes
Now that you have been updated I call you for action: integrate your patients partners to the process. Do not look at the male as a mere sperm provider anymore. Bring him to the center field as you do with your female patients. Thank you.
Page 35: Current Scenarios of Male Infertility for IVF Specialists
Presenter
Presentation Notes
Now that you have been updated I call you for action: integrate your patients partners to the process. Do not look at the male as a mere sperm provider anymore. Bring him to the center field as you do with your female patients. Thank you.