Sandro Esteves, MD, PhD

Director, ANDROFERT Center for Male Reproduction

Campinas, BRAZIL

Esteves, 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

• Complete absence of spermatozoa in the ejaculate after centrifugation Azoospermia

• 1-3% male population • 10% infertile males Prevalence

• Obstructive • Nonobstructive Types

Esteves, Miyaoka & Agarwal. An update on the initial assessment of the infertile male. CLINICS 2011; 66:1-10.

Azoospermia: Definitions

Esteves, 5

Obstructive Azoospermia

Features Normal Sperm

Production Mechanical Blockage

Main Causes: ● Vasectomy, Post-infectious ● Congenital (CBAVD) ● Iatrogenic, Trauma

Sperm Retrieval

Simple and Effective

Sites: ● Epididymis ● Testis ● Vas deferens

Obstructive Azoospermia

http://androfert.com.br/videos

100% 95.3%

100% 97.9%

CBAVD (N=30) Vasectomy(N=64)

Post-infectious(N=48)

Total (N=142)

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.

70

48 43

12

73

46 51

20

Fertilization rate(%)

%TQE Pregnancy (%) Miscarriage (%)

Ejaculate Epididymis/Testicle

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.

P >0.05

Intracytoplasmic Sperm Injection Outcomes Using Ejaculated vs. Surgically-retrieved Sperm from em

with Obstructive Azoospermia

Non-obstructive Azoospermia

Esteves, 9

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

Non-obstructive Azoospermia Untreatable

condition

Esteves, 10

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

Predictive Value of Noninvasive Tests for Sperm Retrieval in NOA

Verza Jr. & Esteves. Fertil Steril 2011; 96: S53

FSH Testosterone

Testicular Volume

Esteves, 12

Predictive Value of Invasive Tests for Sperm Retrieval in NOA

Esteves, 13

Testicular Histopathology

Predictive Value of Histopathology Results in Sperm Retrieval for men

with NOA

Sensitivity (95% CI)

Specificity (95% CI)

Accuracy (%)

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

Predictive Value of Testing for Successful Sperm Retrieval in NOA

Conventional Sperm Retrieval Techniques in NOA

Esteves, 16

Controlled studies for NOA men

Needle Aspiration

Open Biopsy

Friedler et al., Human Reprod 12:1488, 1997

4/37 (11%) 16/37 (43%)

Ezeh et al. Human Reprod 13:3075, 1998

5/35 (14%) 22/35 (63%)

Conventional TESE (open biopsy) in NOA

0

5

10

15

20

25

1 2 3 4 7 8 9 10 14

Num

ber o

f pat

ient

s

Number of testicular fragments excised

Ostad et al., Urology 52:692, 1998. Esteves, 17

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.

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

Vascular pattern of testis

• Extensive pattern of vessels surrounding the testis

Photomicrograph courtesy JP Jarow, M.D.

Intratesticular Anatomy

• Parallel arteries and veins surrounding seminiferous tubules

• Allows dissection between tubules

Microsurgical Identification of Sperm-producing tubules by Appearance

Esteves, 22

OR = 1.63 (95% CI: 1.32 – 2.01)

41% 53%

TESE Micro-TESE

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

Micro-TESE vs TESE Success Rates in Controlled Series

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, 24

TESE Micro-TESE

Microsurgical vs Single-Biopsy TESE in Nonobstructive Azoospermia

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 of 60 patients

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

Histology categories pairwise

comparisons P<0.0001

Method P=0.0005

Esteves, 25

Sperm retrieval method and histopathology category

Odds Ratio [95% Confidence

Interval]

Relative Risk [95%

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 vs Single-Biopsy TESE in Nonobstructive Azoospermia

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

Conventional TESE vs Micro-TESE Tissue Removal

Esteves, 27

Tissue Removal Approach Open Large

Single-Biopsy TESE

Micro-TESE

P-value

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

Microsurgical vs Single-Biopsy TESE in Nonobstructive Azoospermia

Esteves, 28

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

Micro-TESE Results Androfert Experience (2002-2010)

No. of Patients 255 % Retrieval Rate 51.1 No. ICSI cycles 328 Mean ± SD Patient Age

Male Female

37.0 ± 7.6 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

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)

Micro-TESE Results Androfert Experience (2002-2010)

Esteves, 31

Esteves, 32

Subjective (by appearance) identification of sperm-producing tubules

Objective (by size) identification of sperm-producing tubules

Micro-TESE: Current Research

Micro-TESE Objective Identification of Sperm-producing Tubules

Esteves, 33

Maturation Arrest

Normal

Verza Jr & Esteves, Atlas of Human Reproduction, SBRH 2012

Sertoli cell-only

Hypospermatogenesis

Verza Jr & Esteves, Atlas of Human Reproduction, SBRH 2012

Median 25%-75% 5%-95% Raw Data

yes No

Presence of Sperm

160

180

200

220

240

260

280

300

320

340

360

380

400

420M

ax. T

ubul

e Di

amet

er

N = 54; Tubule Diameter: KW-H(1;54) = 25,213; p < 0,0001

Tubule Diameter grouped by Presence of Sperm

Esteves, 37

Esteves, 38

Intraoperative Objective Identification

of Sperm-producing Tubules

Computer-assisted Sperm Retrieval

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

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