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Sandro Esteves, MD, PhD
Director, ANDROFERTCenter for Male Reproduction and InfertilityCampinas, BRAZIL
Microdissection Testicular Sperm Extraction
(micro-TESE)
Esteves, 1
Esteves, 2
Learning Objectives
Understand the difference between obstructive (OA) and non-obstructive azoospermia (NOA)
Overview of sperm retrieval techniques for NOA (micro-TESE) and how to handle testicular
sperm for ICSI
Learn the success rates and prognostic factors of sperm retrieval in NOA using micro-TESE
Reproductive potential of azoospermic men undergoing assisted conception
Azoospermia• It is not a synonymous of sterility
• Normal sperm production
• Mechanical blockage • Vasectomy, Post-
infectious, Congenital
Obstructive• Sperm production
deficient or absent
• Cryptorchidism, Orchitis, Radiation, Chemotherapy, Trauma, Genetic, Gonadotoxins, Idiopathic
Non-obstructive
Obstructive Azoospermia
• Epididymis• Testis• Simple and
effective
Sperm retrieval for ART
Watch the video at http://androfert.com.br/videos
PERCUTANEOUS RETRIEVAL
CBAVD (N=30) Vasectomy (N=64)
Post-infectious (N=48)
Total (N=142)
100%95.3%
100% 97.9%
SUCCESS RATES IN OBSTRUCTIVE AZOOSPERMIA
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.
ICSI Ejaculated Sperm n=220
Testicular/Epididymal Sperm
OA; n=93
2PN Fertilization (%) 70.0 73.6
TQE on Day 3 (%) 48.5 46.3
Clinical Pregnancy (%) 43.2 51.3
Miscarriage (%) 12.1 20.0
Sperm defect severity rather than sperm source is associated with lower fertilization rates after
intracytoplasmic sperm injectionVerza Jr S & Esteves SC; Int Braz J Urol 2008; 34
Esteves, Androfert
Not statistically different
Non-obstructive AzoospermiaNon-obstructive Azoospermia
20% of infertile men attending ART Clinics 60-70% of azoospermic men Causes are:
• Pre-testicular: HH • Testicular causes
• Genetic Y chromosome microdeletion Klinefelter syndrome
Varicocele Cryptorchidism Chemotherapy/Radiation Infection Idiopathic
72.8
19.57.7
Male Infertility Di-agnosis
OtherNon-obstructive azoospermiaObstructive azoospermia
Source: ANDROFERT, Brazil
Non-obstructive Azoospermia
• Sperm production reduced or absent
• Geographic location unpredictable
Sperm Retrieval for ART
Untreatable condition
Small testes/elevated FSH/”sterile” Overall production poor
— Inadequate 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
TESA
TESE
Sperm Retrieval Techniques in Non-obstructive Azoospermia
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%)
Non-obstructive Azoospermia
TESA vs. TESE
Non-obstructive AzoospermiaTesticular microdissection (micro-TESE)
• Method to identify site(s) of production– Based on the diameter of
seminiferous tubules
• Microsurgical approach– Identify site of production– Preserve testis vasculature – Small quantity of tissue excised
Schlegel, Hum Reprod 1999; 14
Microsurgical identification of sperm-producing tubules by
appearance
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
Watch the video at http://androfert.com.br/videos
TESE & micro-TESE
Laboratory Sperm Processing for ICSI
Esteves, Androfert
TESE
Micro-TESE
RESULTS
Microdissection vs. Standard multi-biopsy TESE
Controlled series of 27 patients Standard TESE: 41% (11/27) retrieval Microdissection: 63% (17/27) retrieval
Schlegel, Human Reproduction 14:131, 1999
Microdissection provides sperm retrieval for one-third of men who fail standard multibiopsy TESE
Microdissection TESE
Amer et al 2000 100 45% 30%
Okada et al 2002 98 45% 17%
Okubu et al 2002 17 48% 24%
Tsujimura et al 2002 93 43% 35%
Ramon et al 2003 321 62% 58%
#Pts %MicroTESE %TESEStudy Success Success
49% 33%
The Microdissection TESE
Concept: 100 men with “identical” bilateral histology.
One side TESE, the other microdissection
Approach Success (%) Tissue
TESE biopsy 30/100 (30%) 54 mg
Microdissection 45/100 (45%) 4.6mg
Amer M, et al. Hum Reprod 15: 653, 2000
Amer et al.: Microdissection TESE
100 men with non-obstructive azoospermia Controlled trial of TESE v. Microdissection Serial ultrasound follow-up at 1, 3, 6 mos.
Std TESE Microdissection
Sperm retrieval 30% 47%
Acute changes 48% 15%
Chronic changes 58% 3%
Amer et al., Hum Reprod 15:653, 2000
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 testicular volume seen after 25% of TESE procedures
Why is Sperm Prediction Important?
1. Can minimize emotional and financial cost of IVF cycles.
2. Can minimize trauma/ damage to testis during sperm harvesting.
Chance of finding sperm is dependent on the most advanced site of spermatogenesis within the testis
— FSH— Inhibin B— Testicular volume— Etiology— Testosterone levels— Testis histology
Reflect global spermatogenic function but not the most advanced site of sperm production in a dysfunctional testis
Esteves, Androfert
Predictive Factors for Sperm Retrieval in NOA
Predictive Factors for Sperm Retrieval in NOA
Y Chromosome Microdeletion
AZFa deleted
Germ cell Aplasia
No retrievable sperm
AZFb deleted
Maturation Arrest
No retrievable sperm
AZFc deleted
Hypospermatogenesis
70% chance of retrieving testicular sperm for ICSI
Predictive Values of Noninvasive Tests or Techniques for Sperm Retrieval
OverallParameter predictive or exam Sensitivity % Specificity % value %
Testicular volume 7.6–50 6.7–71
FSH 9–71 40–90
Inhibin B 44.6 63.4
FSH, total T, Inhibin B 71 71.4
Testicular volume + hormones 80.8
Doppler ultrasound imaging 47.3 89
Carpi. Controversies in nonobstructive azoospermia. Fertil Steril 2009.
• 176 NOA men (mean age 36.9 years)• Microdissection TESE or TESA• Classified according to the Etiology of NOA• Biopsy for histology concomitant or prior to SR
Sperm Retrieval Rates in NOA are Related to Testicular Histopathology but not to the Etiology of
Azoospermia
Esteves SC, Verza Jr S, Prudencio C, Seol B; Fertil Steril 2010
Hypospermatogenesis (HYPO)
Maturation Arrest (MA)
Sertoli Cell Only Syndrome (SCO)
Esteves, Androfert
Sperm Retrieval and Etiology of NOA
Chi-square; NSEsteves SC, Verza S, Prudencio C, Seol B. Sperm retrieval rates (SRR) in nonobstructive azoospermia (NOA) are related to testicular histopathology results but not to the etiology of azoospermia. Fertil Steril. 2010;94(Suppl.):S132.
Etiology
Histology Sperm +TESA
Sperm + Micro-TESE
HYPO 26/26 (100.0%) 19/19 (100.0%)
MA 2/6 (33.3%) 7/12 (60.0%)*
SCO 6/29 (20.7%) 13/39 (33.3%)*
Total 34/61 (55.7%) 39/70 (55.7%)
Results (2): Micro-TESE X TESA
Sperm Retrieval in NOA is related to Testicular Histopathology
Esteves SC et al Fertil Steril 2010; 94:S132
Esteves, Androfert
*TESA vs micro-TESE (MA + SCO): P=.03
Finding Testicular Sperm in Non Obstructive Azoospermia
Histological Pattern Cases Recovery Rate (%)
Normal 157 100%
Hypospermatogenesis 16 90%
Maturation arrest 94 63%
Sertoli cell-only (pure) 156 13%
Tubular sclerosis 18 39%
Harris et al. Urologic Clinics North America 2008
Avg Rec Rate 52%
MICRO-TESE
Success Rate
22%
40.00%
NOA
TESA/TESE
N=131; *hypospermatogenesis excluded
Esteves et al.; Fertil Steril 2010; 94:S132
Micro-TESE39%
P=.03
Chance of Sperm Retrieval by NOA Diagnosis
Cryptorchidism
52-74% Varicocele
63-68% Epididymitis
67% Mumps
67% Torsion
>50% Post-chemotherapy
55-75% Genetic AZF a, b
0% Genetic AZF c
50-75% Orchitis, Gonadotoxins, Endocrine
100% Idiopathic
50-60%
Esteves, 2011; Shefi and Turek, submitted; Raman and Schlegel. J Urol.170:1287, 2003;Hopps et al. Hum Reprod. 180:1660, 2003; Damani et al. JCO. 15: 930, 2002
Candidates for sperm retrievalNon-obstructive azoospermia
“Testicular failure” Klinefelter’s syndrome Sertoli cell-only Post-chemotherapy (e.g., lymphoma, testis) Cryptorchidism Maturation arrest Previously failed attempt at “biopsy”
retrieval
Reproductive Potential of
Testicular Sperm from NOA men used for ART
Esteves, Androfert
ICSIEjaculated
Sperm
N=220
Testicular/Epididymal Sperm (OA)
N=39
Testicular Sperm NOA N=52
P-value*
%2PN Fertilization 70.0 73.6 52.2* 0.01
%TQE on Day 3 48.5 46.3 35.7* 0.03
%Clinical Pregnancy Rate 43.2 51.3 25.9* 0.04
Miscarriage (%) 12.1 20.0 14.3 NS
Sperm Defect Severity Rather Than Sperm Source Is Associated With Lower Fertilization Rates After
Intracytoplasmic Sperm InjectionVerza Jr S & Esteves SC; Int Braz J Urol 2008; 34
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
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): Suppl. S232-233.
Sperm Retrieval Rates and Reproductive Potential of Azoospermic Men in ICSI
Microdissection TESE
Requires use of microscope (15-20x) Learning curve Depends on differential size of tubules Tedious
Increased sperm yield Less tissue removal Fewer postoperative changes
Schlegel, Hum Reprod 14:131, 1999 Amer et al., Hum Reprod 15:653, 2000 Okada et al., J Urology 168:1063, 2002
• Sperm production deficient or absent
• Overall, retrieval rates ~50%
• Labor-intensive lab sperm processing• Retrieval rates dependent on technique
• Micro-TESE yields better SRR • Predictive factors: testis histology & Y-chromosome
• Reproductive potential by ICSI lower than OA and non-azoospermic men
Non-obstructive Azoospermia
Sperm Retrieval Techniques Practical Points