Sandro Esteves, MD, PhD Director, ANDROFERT

Center for Male Reproduction and Infertility Campinas, BRAZIL

EOFF 2012, Dubai - UAE

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Learning Objectives

Understand the concept of testicular failure

Learn the treatment options and results for men with testicular failure in the

current ART era

Update on new treatment options and what the future holds for men with testicular failure seeking fertility

Review this lecture at:

http://www.androfert.com.br/review Pdf slides

Movie

Centiles

2.5% 50% 97.5%

Sperm count per mL (x106) 4 64 237

Sperm Count in Humans General Population of Unscreened Men

Cooper et al. Hum Reprod Update 2009; Esteves et al, CLINICS 2011

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

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Semen Analysis and Azoospermia

Centrifugation at 3,000g for 15 minutes

The supernatant is discharged and the pellet is examined

Types of Azoospermia

• Normal sperm production • Mechanical blockage anywhere

along the reproductive tract • Epididymis

• Vas Deferens

• Ejaculatory Duct

Obstructive

• Absent or minimal sperm production within the testicles

• Testicular failure

Non-obstructive

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UN Census Estimates, 2008 Esteves, 7

Testicular Failure: Etiology

Testicular torsion; Trauma

Post-inflammatory (eg. mump’s orchitis)

Exogenous factors (steroid medications, cytotoxic drugs, irradiation, heat)

Testicular Cancer; Systemic diseases (liver cirrhosis, renal failure)

Varicocele

Congenital

Testicular dysgenesis/cryptorchidism

Genetic abnormalities (Klinefelter’s syndrome, Yq microdeletions)

Germ cell aplasia (SCO syndrome)

Spermatogenic (maturation) arrest

Acquired

Idiopathic (Unknown etiology)

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1. Azoospermia is a descriptive term of ejaculates that lack spermatozoa without implying a specific underlying cause.

2. Testicular failure is synonymous of non-obstructive azoospermia (most severe form of male infertility). It represents a spectrum of testicular disorders that cannot be treated.

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Understand the concept of testicular failure

NOA

Untreatable condition

AID Adoption

Testicular Failure: The PAST

Esteves et al. An update on the initial assessment of the infertile male. CLINICS 2011;66:1-10.

Small testes Elevated FSH “Sterile”

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600-800 seminiferous tubules/testis 30-50% cases: minimal production

for sperm to appear in the ejaculate • Heterogeneity of sperm production

• Foci of sperm production may exist in dysfunctional testes

Testicular Failure: The FACT

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Esteves SC & Agarwal A. Sperm Retrieval Techniques; In: Gardner D et al (Eds.), Human Assisted Reproductive Technology. Cambridge University Press, pp. 41-53, 2011

Single focus of production adequate to retrieve sperm for ICSI

Goal: To identify and retrieve sperm for ICSI

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Esteves SC & Agarwal A. Sperm Retrieval Techniques; In: Gardner D et al (Eds.), Human Assisted Reproductive Technology. Cambridge University Press, pp. 41-53, 2011.

Testicular Failure: The PRESENT

NOA

Untreatable condition

Sperm Retrieval and ICSI

Testicular Failure: The PRESENT

Technique Acronym

Testicular Sperm Aspiration TESA; TEFNA

Testicular Sperm Extraction (single or multiple biopsies)

TESE

Microsurgical Testicular Sperm Extraction

Micro-TESE

Esteves et al. Sperm Retrieval Techniques for Assisted Reproduction. Int Braz J Urol 2011; 37(5):570-83 Esteves, 13

Which is the best technique

to retrieve sperm?

Is it possible to predict

success in sperm

retrieval?

What are the success rates and risks of ICSI?

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Testicular Failure: The PRESENT Critical Issues

Sperm Retrieval in Testicular Failure: which is the best technique?

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.

TESA

• 15%-50% SRR

Con

vent

iona

l TE

SE

• 20%-63% SRR

Mic

ro-T

ESE

• 40%-67% SRR

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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

43%-53%

TESE 25%-41%

Sperm Retrieval in Testicular Failure: which is the best technique?

Con

trol

led

Serie

s

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Goals of Sperm Retrieval in Testicular Failure

Immediate use for ICSI

Cryopreservation

Future retrievals

Testicular function

Minimize damage

Obtain sperm for ICSI

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

In Testicular Failure,

higher chances

of sperm

harvesting by

micro-TESE

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Is it possible to predict success of sperm retrieval?

FSH levels Testosterone levels

Testicular Volume

Testicular Histopathology

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Esteves, Miyaoka & Agarwal. Surgical Treatment of Male Infertility in the ICSI Era. Clinics 2011; 66:1463-77; Verza Jr. & Esteves. Fertil Steril 2011; 96: S53;

Carpi et al. Fertil Steril 2009.

No Markers reflect global spermatogenic function but not the presence of an advanced site of sperm production in a dysfunctional testis.

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

Etiology Retrieval Rate Cryptorchidism 52-74% Varicocele 63-68% Post-infection 67% Torsion >50% Post-chemotherapy/RT 25-75% Genetic (Klinefelter, AZFc Yq microdeletions) 25-70% Idiopathic 50-60%

Is it possible to predict success of sperm retrieval?

No Presence of an advanced site of sperm production is not related to the etiology of testicular failure.

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Prevalence of Yq microdeletions: 1:2.000-3.000 newborns Men with testicular failure: 5-12%

Esteves, 22 Esteves & Agarwal. Novel concepts in male infertility. Int Braz J Urol 2011.

Is it possible to predict success of sperm retrieval?

Y Chromosome Microdeletion Screening

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

AZFa deletion

No chance to find sperm

AZFc deletion Sperm retrieved in

~70% of cases

AZFb deletion

No chance to find sperm

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Is it possible to predict success of sperm retrieval? Y Chromosome Microdeletion Screening

Yes The only unfavorable indicator for SR is the presence of microdeletions in the AZFa and/or AZFb regions of the Y chromosome long arm

43.7 45.3

19.2 21.4

64.5

47.8

19.6

32.3

62.9

52.5

21.0

37.5

%2PN Fertilization %Top qualityembryos

% Miscarriage % Live birth

Testicular Failure (n=228) Ejaculated sperm (n=621)Obstructive azoospermia (n=243)

*

*P<0.01

Esteves & Agarwal. Reproductive outcomes including neonatal data of sperm injection in men with obstructive and nonobstructive azoospermia: case series

and systematic review. CLINICS, in press

* *

What are the success rates of ART in testicular failure ?

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35.7

244.6

6.3 3.2 36.9

273.3

2.0 1.2 37.0

257.7

2.5 1.7

Gestational age(wks)

Birth weight(gramsx10)

% Perinatal death % Birth defects

Testicular Failure (n=63)Ejaculated Sperm (n=247)Obstructive Azoospermia (n=117)

What are the success rates and risks of ART in testicular failure ?

Esteves & Agarwal. Reproductive outcomes including neonatal data of sperm injection in men with obstructive and nonobstructive azoospermia: case series

and systematic review. CLINICS, in press

P = NS

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Region

N children Testicular

failure vs OA

Outcomes

Main findings

Palermo et al. 1999

USA 22 vs 158 Congenital abnormalities

4.5% TF vs 1.3% OA (ns)

Vernaeve et al. 2005

Belgium 61 vs 196 Perinatal data Congenital abnormalities

Lower gestational age (singletons); Increased frequency of premature twins

4% TF vs 3% OA (ns)

Fedder et al 2007

Denmark 76 vs 282 Congenital abnormalities

0% TF vs 4.0% OA (ns)

Belva et al.; 2011

Belgium 193 vs 474 Perinatal data;

Congenital abnormalities

Similar perinatal outcomes; 4.2% TF vs 5.2% OA (ns)

Esteves et al. Reproductive outcomes including neonatal data of sperm injection in men with obstructive and nonobstructive azoospermia: case series and systematic review.

CLINICS, accepted

What are the success rates and risks of ART in testicular failure ?

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1. Men with testicular failure are not sterile.

Learn the treatment options and results for men with testicular failure in the

current ART era

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2. Sperm retrieval and ICSI using testicular sperm viable option to achieve biological fatherhood.

3. So far, post-natal follow-up of babies born from such fathers are reassuring.

Testicular Failure New Insights & Future Perspectives

Medication Surgery; Sperm

Retrieval Techniques

Artificial Male

Gamete

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Testicular Failure: New Insights (1) Medication prior to Sperm Retrieval

Ramasamy et al., J Urol. 2009; 182: 1108-13.

Case series: 68 men with testicular failure (non-mosaic Klinefelter Syndrome; micro-TESE

Medication to boost testosterone production: Aromatase inhibitor, hCG, anti-estrogens (min. 2-3 months)

Positive response: increase in TT >100 ng/dL from baseline levels

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72 55

Sperm Retrieval Rate (%)

Positive response

P = 0.03

Testicular Failure: New Insights (2)

Anti-estrogens 43 pts. with favorable testicular histopathology, no controls;

CC 50mg every other day;

64% men had sperm in the ejaculates (mean: 3.8 M/mL);

All who remained azoospermic had success in Sperm Retrieval.

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Hussein et al, J Androl 2005

Microsurgical Varicocele Repair

Meta-analysis of case series;

39% men had motile sperm in ejaculates postop. (mean: 1.6 M/mL)

Increased the chances of Sperm Retrieval by 2.6-fold in men who remained azoospermic.

Weedin JW et al, J Urol. 2010

Inci et al, J Urol. 2009

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

Testicular Failure: The Future (1)

Novel Sperm Retrieval

Methods for Identification of Spermatogenic

Sites

NOA

Treatable condition

Biotechnology Methods to

Create Artificial Gametes

Aponte PM, Schlatt S, Franca LR. Biotechnological possibilities for the treatment of

aspermatogenic men. Clinics 2012 Esteves, 32

Testicular Failure: The Future (2)

1. Aromatase inhibitors, anti-estrogens and varicocele repair may improve outcomes in selected cases.

2. Novel methodologies of sperm harvesting are under research.

3. Novel biotechnological methodologies are under

research to rescue fertility while maintaining biological fatherhood.

Be informed on the new treatment options and what the future holds for men with testicular failure

seeking fertility

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Thank you.