Novel Treatments for Male InfertilityNovel Treatments for Male Infertility

Paul J. Turek MD, FACS, FRSM Paul J. Turek MD, FACS, FRSM Director, The Turek Clinic Director, The Turek Clinic

San Francisco, CA San Francisco, CA

The Infertility ProblemThe Infertility Problem

MaleMale

30%

BothBoth

FemaleFemale

20%

50%

Affects 6Affects 6--8 million couples in US (NSFG 2002, NICHD)8 million couples in US (NSFG 2002, NICHD)

History History Physical Physical

ExamExam

Semen Analysis x 2Semen Analysis x 2

Eliminate GonadotoxinsEliminate GonadotoxinsFurther Female EvaluationFurther Female Evaluation

AbnormalAbnormalNormalNormal

AbnormalAbnormal NormalNormal

Treat Treat Female Female Factor Factor

Urology Urology Referral Referral

Not Not ImprovedImproved

ImprovedImproved

Hormone Hormone Evaluation Evaluation

Treat Treat Female Female Factor Factor

Turek PJ.Turek PJ.Nat Clin Nat Clin

Pract Urol. Pract Urol. 2:1, 20052:1, 2005

Diagnostic Evaluation

Correctable Problem? Healthy Patient?

Genetic EvaluationMaternal Reproductive Maternal Reproductive Potential >1yr?Potential >1yr?

NoYes

Yes NoCorrect Male Factor Correct Male Factor

(Varicocele, blockage)(Varicocele, blockage) IUI IVF

IVF-ICSI

Treatment of Treatment of Male InfertilityMale Infertility

Turek. Nat Clin Pract Urol. 2:1, 2005Turek. Nat Clin Pract Urol. 2:1, 2005

Surgical Treatments are Very CompetitiveSurgical Treatments are Very Competitive

VasovasostomyVasovasostomyEpididymovasostomyEpididymovasostomy

IVF-ICSI

VSVS

Yang et al. J. Urol. 2007Yang et al. J. Urol. 2007

Patency Rates by Procedure Type

ICSI

Pregnancy

No pregnancy

Second cycle

Stop

Reconstruction

Patent

Not patent

IC

Pregnancy

No pregnancy

Stop

ICSI

Stop

ICSI

Pregnancy

No pregnancyObstructive Azoospermia

Pregnancy

No pregnancy

Pregnancy

No pregnancy

Decision Analysis:

Vasectomy Reversal

Meng et al. J Urol. 174: 1926, 2005

$20,000

$30,000

$40,000

$50,000

$60,000C

ost p

er P

regn

ancy

(US

$)

0% 25% 50% 75% 100%

Vasectomy Reversal Patency

Decision Modeling: Sensitivity Analysis

ICSI

Reconstruction

78%

Meng et al. Meng et al. J Urol. 174: J Urol. 174: 1926, 20051926, 2005

AnteriorPituitary

Sertoli Cells

Leydig Cells

+ LH

GRH -

-

T

T+FSHFSH

+T

PRLHow Good are How Good are Medical TreatmentsMedical Treatmentsforfor Male Infertility?Male Infertility?

.

It is more than likely that the brain itselfIt is more than likely that the brain itselfis only a sort of great clot of genital fluidis only a sort of great clot of genital fluidheld in suspense or reservedheld in suspense or reserved.

Ezra PoundEzra Pound18851885--19721972

The things that we knowThe things that we know……..

HormonesHormones--When to Order?When to Order?

1. Sperm density <10 x 106 sperm/mL1. Sperm density <10 x 106sperm/mL

2.2. Evidence of impaired sexual functionEvidence of impaired sexual function(low libido, impotence)(low libido, impotence)

3.3. Findings of an endocrinopathy (thyroid)Findings of an endocrinopathy (thyroid)

Sigman M, Jarow JP. Urology, 50: 659, 1997

Jarow JP et al. J. Urol. 167: 2138, 2002Jarow JP et al. J. Urol. 167: 2138, 2002

Diagnosis Findings % Patients Normal Normal 90.4% Germ cell failure Elev. FSH 7.8% Pan testis failure Elev. FSH, LH 0.9% Hyperprolactinemia Elev. PRL 0.5% Leydig tumor Elev. T, Low LH 0.2% IHH Low LH, T 0.2% Androgen resistance Elev. LH, T 0.1%

Diagnosis Findings % Patients Normal Normal 90.4% Germ cell failure Elev. FSH 7.8% Pan testis failure Elev. FSH, LH 0.9% Hyperprolactinemia Elev. PRL 0.5% Leydig tumor Elev. T, Low LH 0.2% IHH Low LH, T 0.2% Androgen resistance Elev. LH, T 0.1%

Endocrine Evaluation-FindingsEndocrine Evaluation-Findings(n=1035 men)(n=1035 men)

Sigman M, Jarow JP. Urology, 50: 659, 1997Sigman M, Jarow JP. Urology, 50: 659, 1997

Normal SpermatogenesisNormal Spermatogenesis

FSH T

Both Both testosteronetestosterone and and FSHFSH are are required for required for quantitatively normalquantitatively normalspermatogenesis.spermatogenesis.

Physiology Physiology andand TherapyTherapy

50 days

14 days

Thinking therapy? Think 60Thinking therapy? Think 60--70 days70 days

20

40

60

80

100

0 10 20 30 40 50 60 70 80 90 100Days

% n

ew c

ells

Misell et al. J Urol. 175. 242, 2006Misell et al. J Urol. 175. 242, 2006

One must show the greatest respect towards any thing that increases exponentially, no matter how smallOne must show the greatest respect towards any thing that increases exponentially, no matter how small

G. Hardin, 1968G. Hardin, 1968

Spermatogenic WisdomSpermatogenic Wisdom

Hyperprolactinemia Hyperprolactinemia andand Male InfertilityMale Infertility••Elevated prolactin generally presents with Elevated prolactin generally presents with low libidolow libidoand and erectile dysfunctionerectile dysfunction. Isolated spermatogenic failure . Isolated spermatogenic failure is rare.is rare.

••Elevated prolactin is correlated with low testosterone, Elevated prolactin is correlated with low testosterone, but not necessarily lower FSH and LH. Estradiol is but not necessarily lower FSH and LH. Estradiol is generally unchanged. generally unchanged. Micic et al. Arch Androl. 1985;15;123Micic et al. Arch Androl. 1985;15;123

••Prolactin needs to be elevated at least 2x normal to cause Prolactin needs to be elevated at least 2x normal to cause infertility. infertility. Nishimura et al. Arch Androl. 1999; 43: 207Nishimura et al. Arch Androl. 1999; 43: 207

••The treatment of low sperm counts in infertile men with The treatment of low sperm counts in infertile men with normal prolactin is unsuccessful (4 controlled studies)normal prolactin is unsuccessful (4 controlled studies)

Vandekerckhove et al. Cochrane Database Vandekerckhove et al. Cochrane Database Syst Syst Rev. 2000, (2) CD000152Rev. 2000, (2) CD000152

OK!

Replacement Therapy Replacement Therapy andand Male InfertilityMale Infertility••Thyroid DisordersThyroid Disorders.. Fertility returns when thyroid disease Fertility returns when thyroid disease

is stabilized.is stabilized.••Obesity.Obesity. Relationship between BMI and male infertility Relationship between BMI and male infertility

is real. Danish cohort study: 26,303 planned is real. Danish cohort study: 26,303 planned pregnancies. Adjusting for partner BMI, coital pregnancies. Adjusting for partner BMI, coital frequency, ages and smoking habitsfrequency, ages and smoking habits

••OpiatesOpiates cause hypogonadism. Produces hypogonadotrophic cause hypogonadism. Produces hypogonadotrophic hypogonadism) in 75hypogonadism) in 75--100% of chronic opiate users.100% of chronic opiate users.

••Renal DiseaseRenal Disease. The fertility of renal transplant patients is . The fertility of renal transplant patients is normal.normal.

OK!

Daniel HW. J Pain. 2002, 3:377Daniel HW. J Pain. 2002, 3:377

BMI OR of infertility (CI)<25.5 125-30 1.2 1.04-1.3830-35 1.36 1.13-1.63

Hammoud et al Hammoud et al Fert Steril. 90: Fert Steril. 90: 2222, 20082222, 2008

Case studyCase study34 yo male with 4 year history of primary infertility. .

Exam: Tall, light facial hair.10cc (2 x 1.5 cm) testes bilaterally.

Labs: Test. 80 ng/ml (NL 260-1200)FSH 2 IU/ml (NL 2-10)LH 3 IU/ml (NL 3-15)

Semen:Low volume; azoospermia: fructose present

34 yo male with 4 year history of primary infertility.

Exam: Tall, light facial hair.10cc (2 x 1.5 cm) testes bilaterally.

Labs: Test. 80 ng/ml (NL 260-1200)FSH 2 IU/ml (NL 2-10)LH 3 IU/ml (NL 3-15)

Semen:Low volume; azoospermia: fructose present

Hypogonadotropic hypogonadismHypogonadotropic hypogonadism

PRLPRL 8 IU/ml (NL 28 IU/ml (NL 2--8)8)

If acquired, consider If acquired, consider Sickle cell anemia,Sickle cell anemia,HemachromatosisHemachromatosis

Hypogonadotropic Hypogonadism

www.driesen.com/olfactorywww.driesen.com/olfactory

••Olfactory nerve and LHRH Olfactory nerve and LHRH secreting cells cosecreting cells co--migrate migrate during development.during development.

••Migration failure results in Migration failure results in defective LHRH and anosmiadefective LHRH and anosmia--

Kallmann Syndrome Kallmann Syndrome or or

hypogonadotropic hypogonadotropic hypogonadismhypogonadism

Hypogonadotrophic Hypogonadism

Hypothalamus

AnteriorPituitary

GnRH

FSH LH

LHRHReceptor

1Genes associated with Genes associated with migration failure: migration failure:

Kallmann syndrome Kallmann syndrome interval gene interval gene (KALIG)(KALIG)

DescriptorDescriptor InheritanceInheritance GeneGene LocationLocation

KALKAL--11 XX--linkedlinked KALIGKALIG--11 Xp22.3Xp22.3

KALKAL--22 Autos. dom.Autos. dom. FGFRFGFR--11 8p118p11--1212

KALKAL--33 Autos. recess.Autos. recess. NoneNone

Gonadotropin ReplacementGonadotropin Replacement

00 33MonthsMonths

66 99 1212 1515 1818

hCG 2000U 3x wk

hCG 2000U 3x wk

hMG 75IU 2x wk

hMG 75IU 2x wk

.. .. .. .. .... ..

Sperm CountSperm Count 15 x106 sperm/mL15 x106 sperm/mL

O'Dea et al. Fert Steril 70: 3 (28A), 1998O'Dea et al. Fert Steril 70: 3 (28A), 1998Bouloux et al. Fert Steril. 77: 270, 2002Bouloux et al. Fert Steril. 77: 270, 2002

OK!

What About Other Therapies?

Aromatase InhibitorsAromatase Inhibitors(Testolactone, Arimidex)(Testolactone, Arimidex)

Rx Oral testolactone 100Oral testolactone 100--200 mg/daily200 mg/daily

Follow semen analyses q 3 monthsFollow semen analyses q 3 months.

..Side Effects: well tolerated. ? Lipid and bone effects.Side Effects: well tolerated. ? Lipid and bone effects.Efficacy: T/E ratios increased from 5Efficacy: T/E ratios increased from 5--7 range to 127 range to 12--18.18.

Semen volume, concentration improved.Semen volume, concentration improved.

Theory: estrogen-testosterone imbalance is a cause ofdecreased spermatogenesis

Aromatase converts testosterone to estrogens

Theory: estrogen-testosterone imbalance is a cause ofdecreased spermatogenesis. Seek T/E ratio of 15/1.Seek T/E ratio of 15/1.

Aromatase converts testosterone to estrogensAromatase inhibitors block estrogen productionAromatase inhibitors block estrogen production

TT

E2E2

Raman and Schlegel. J Urol. 168.1509, 2002Raman and Schlegel. J Urol. 168.1509, 2002

Oral Anastrozole (Arimidex) 1mg/dailyOral Anastrozole (Arimidex) 1mg/daily

A Pill for Every Ill?A Pill for Every Ill?

••A problem in the field of male infertility (read A problem in the field of male infertility (read ““medicinemedicine””))••Everyone wants a Everyone wants a ““pill.pill.””••n=500 consecutive male infertility patients surveyed on n=500 consecutive male infertility patients surveyed on

alternative and hormonal therapies.alternative and hormonal therapies.••n=481 (96%) completed survey. 31% used alternative n=481 (96%) completed survey. 31% used alternative

therapies:therapies:63% of those men were using antioxidants63% of those men were using antioxidants12% were using herbal remedies12% were using herbal remedies17% were using testosterone or antiestrogens17% were using testosterone or antiestrogens1/4 of latter did not inform care providers 1/4 of latter did not inform care providers

Zini et al. Urology. 2004, 63: 141Zini et al. Urology. 2004, 63: 141

How About SERMHow About SERM’’s for Oligospermia?s for Oligospermia?

••First generation drug, clomiphene citrate, used to First generation drug, clomiphene citrate, used to induce ovulation in anovulatory women. induce ovulation in anovulatory women. Not FDA approved for men in U.S.Not FDA approved for men in U.S.

••Clomiphene citrate is a racemic mixture of Clomiphene citrate is a racemic mixture of two geometric isomers, enclomifene (Etwo geometric isomers, enclomifene (E--clomifene) and zuclomifene (Zclomifene) and zuclomifene (Z--clomifene).clomifene).

EE--clomifeneclomifene ZZ--clomifeneclomifene

How Does Clomiphene Citrate Work?

Leydig CellsLeydig Cells

GnRHGnRH

LHLH

TTTT

FSHFSH

E2E2Nonsteroidal SERMNonsteroidal SERMActs as antiActs as anti--estrogenestrogenIncreases GnRH outputIncreases GnRH output

Rxx 12.512.5--25 mg/day25 mg/dayCheck FSH, T in 4 weeksCheck FSH, T in 4 weeksMonitor semen q 3 mosMonitor semen q 3 mos

Side Effects: gynecomastia,Side Effects: gynecomastia,weight gain, visuals, skinweight gain, visuals, skin

Does Clomiphene Citrate Really Work?

Author Number Semen Pregnancy OutcomePatients Improvement Rate

Foss, 1973 114 NR 17% both Neg.Paulson, 1979 40 70% vs 40% 35% vs 17% Posit.Ronnberg, 1980 56 78% vs 21% 10% vs 3% Posit.Abel 1980 187 0% vs 0% 17% vs 17 Neg.Wang, 1980 37 NR 36% vs 0% Posit.Micic, 1985 101 32% vs 7% 13% vs 9 ?Sokol, 1988 46 NR 9% vs 32% Neg.Check, 1988 100 NR 58% vs 16% Posit.WHO, 1992 200 NR 8% vs 12% Neg.

Author Number Semen Pregnancy OutcomePatients Improvement Rate

Foss, 1973 114 NR 17% both Neg.Paulson, 1979 40 70% vs 40% 35% vs 17% Posit.Ronnberg, 1980 56 78% vs 21% 10% vs 3% Posit.Abel 1980 187 0% vs 0% 17% vs 17 Neg.Wang, 1980Micic, 1985Sokol, 1988Check, 1988WHO, 1992

37 NR 36% vs 0% Posit.101 32% vs 7% 13% vs 9 ?46 NR 9% vs 32% Neg.100 NR 58% vs 16% Posit.200 NR 8% vs 12% Neg.

"Hung jury"

Efficacy Studies for Idiopathic Male Infertility

Does Clomiphene Citrate Really Work?

•• Cochrane review of antiCochrane review of anti--estrogens for idiopathic estrogens for idiopathic oligospermia.oligospermia.

•• Included randomized trials, > 3months duration.Included randomized trials, > 3months duration.•• n=10 trials with n=738 patients.n=10 trials with n=738 patients.•• Antiestrogens Antiestrogens ““had a positive effect on endocrine had a positive effect on endocrine

outcomes.outcomes.””•• No difference in pregnancy rate: OR 1.26 (.99No difference in pregnancy rate: OR 1.26 (.99--1.56).1.56).•• Overall pregnancy rate no different: 15.4% treated vs. Overall pregnancy rate no different: 15.4% treated vs.

12.5% untreated.12.5% untreated.

Vandekerckhove et al. Cochrane Database Syst Rev. 2000, (2) CD00Vandekerckhove et al. Cochrane Database Syst Rev. 2000, (2) CD0001510151

Is There a Rationale Use for Clomiphene Citrate in Male Infertility?

Potential application:Potential application:Improving anterior pituitary Improving anterior pituitary function (LH and FSH) in function (LH and FSH) in men with secondary men with secondary hypogonadotrophic hypogonadotrophic hypogonadism (HH) due to: hypogonadism (HH) due to:

Idiopathic causes Idiopathic causes Prolactinoma resection Prolactinoma resection Acromegaly Acromegaly DiabetesDiabetes

Whitten et al. Fertil Steril. 2006, 86: 1664Whitten et al. Fertil Steril. 2006, 86: 1664

Response to Clomiphene Citrate in HH men with Male Infertility

•• n=10 men; 2 centers; 5 years. Testosterone <164 ng/dLn=10 men; 2 centers; 5 years. Testosterone <164 ng/dL•• Treated 3 classes of HH with CC 50mg 3x weeklyTreated 3 classes of HH with CC 50mg 3x weekly

With anosmia (Kallmann) 4 0/4No anosmia (idiopathic, acquired) 4 3/4Panhypopituitary patients 2 1/2

CategoryCategory # Pts# Pts Semen Semen ResponseResponse

•• Stated that CC may work for idiopathic, adult onset, HHStated that CC may work for idiopathic, adult onset, HH

How Semen Quality Changes How Semen Quality Changes inin Hypogonadal Men Hypogonadal Men onon Clomiphene CitrateClomiphene Citrate

Carson Lawall MDCarson Lawall MDUche Ezeh MD Uche Ezeh MD Blake Tyrell MDBlake Tyrell MDPaul Turek MDPaul Turek MD

ASRM 2004ASRM 2004

Study Objective

Assess changes in hormones, symptoms and Assess changes in hormones, symptoms and semen quality in men taking clomiphene citrate semen quality in men taking clomiphene citrate for secondary hypogonadotrophic hypogonadism.for secondary hypogonadotrophic hypogonadism.

Methods

••Prospective analysis of men treated with CC.Prospective analysis of men treated with CC.

••Inclusion criteria: Inclusion criteria:

Total testosterone <250ng/mL. Total testosterone <250ng/mL. Normal or Low LH level. Normal or Low LH level. Clinical symptoms (ED, infertility, libido)Clinical symptoms (ED, infertility, libido)

••Given Clomid at 12.5Given Clomid at 12.5--25mg daily. Hormone 25mg daily. Hormone response assessed 3 weeks later. Titrated response assessed 3 weeks later. Titrated treatment to achieve testosterone levels in the treatment to achieve testosterone levels in the 400400--700ng/mL range700ng/mL range

Results

•22 men enrolled. Mean age 40y.o. (range 21-56)

•Treatment indications: InfertilityInfertility 14 patients 14 patients Infertility/libidoInfertility/libido 2 patients 2 patients ED and libido 2 patients ED and libido 2 patients EDED 1 patient 1 patient Infertility and ED 1 patient Infertility and ED 1 patient Decreased libido 1 patient Decreased libido 1 patient ED and gynecomastia 1 patientED and gynecomastia 1 patient

•Pathologic conditions:Prolactinoma Rxn 4 patients Acromegaly 2 patients Intracranial germinoma 1 patient Idiopathic 15 patients

Results

•Chemical response to clomiphene citrate:Laboratory Laboratory PrePre--clomiphene clomiphene PostPost--clomipheneclomipheneTotal TestosteroneTotal Testosterone 143 ng/mL143 ng/mL 479 ng/mL 479 ng/mL FSHFSH 3.4 mIU/mL3.4 mIU/mL 6.9 mIU/mL 6.9 mIU/mL LHLH 2.0 mIU/mL 5.7 mIU/mL2.0 mIU/mL 5.7 mIU/mL

•A subset of 11 men with infertility had pre- and post-treatment semen analysis available for comparison

86% of patients had >50% increase in testosterone.86% of patients had >50% increase in testosterone.

Results

••Semen quality response (mean values) to clomiphene Semen quality response (mean values) to clomiphene citrate treatment (n=11 men):citrate treatment (n=11 men):

••Responders:Responders: 7/11 men (64%) had a >50% increase in 7/11 men (64%) had a >50% increase in total motile sperm count. Gains mainly in counts total motile sperm count. Gains mainly in counts (5.8x). 2/7 men conceived naturally.(5.8x). 2/7 men conceived naturally.

••NonNon--respondersresponders: 2/4 had bilateral varicoceles and 2/4 : 2/4 had bilateral varicoceles and 2/4 had extensive pituitary resection.had extensive pituitary resection.

Parameter Parameter PrePre--clomiphene clomiphene PostPost--clomipheneclomipheneVolume Volume 2.5 mL2.5 mL 2.6 mL 2.6 mL Sperm concentrationSperm concentration 15.7 mill/mL 30.8 mill/mL 15.7 mill/mL 30.8 mill/mL MotilityMotility 15%15% 24% 24%

Total Motile Sperm Total Motile Sperm 11 million 11 million 33 million33 million

Conclusions

••Daily clomiphene citrate may be a rationale Daily clomiphene citrate may be a rationale treatment for men with secondary hypogonadism.treatment for men with secondary hypogonadism.

••TwoTwo--thirds of men with known and unknown thirds of men with known and unknown causes of pituitary dysfunction responded causes of pituitary dysfunction responded chemically. chemically.

••Semen parameters showed dramatic increases Semen parameters showed dramatic increases and natural pregnancies occurred in treated men.and natural pregnancies occurred in treated men.

••Is there a role for clomiphene citrate in male Is there a role for clomiphene citrate in male infertility after all?infertility after all?

OK!

Case studyCase study

••35 yo man presents with low libido, erectile dyfunction and 35 yo man presents with low libido, erectile dyfunction and infertility.infertility.

••Diagnosis of Type II diabetes 2 years earlier. Treated with Diagnosis of Type II diabetes 2 years earlier. Treated with multiple oral agents, including metformin. multiple oral agents, including metformin.

••Diagnosed with hypogonadism (T=172) and started on T gel Diagnosed with hypogonadism (T=172) and started on T gel replacement. Libido and erections improved.replacement. Libido and erections improved.

••I switched to clomiphene citrate 25mg daily. T=472. I switched to clomiphene citrate 25mg daily. T=472. ••Conceived 9 months later. Staying on clomiphene Conceived 9 months later. Staying on clomiphene for near for near

term.term.

Injectable FSH Injectable FSH forfor Very Low Sperm CountsVery Low Sperm Counts•• n=33 men with severely low sperm counts and failed IVFn=33 men with severely low sperm counts and failed IVF--ICSI.ICSI.•• Given 3 months of recombinant FSH at 150 IU/mL (n=23) or no Given 3 months of recombinant FSH at 150 IU/mL (n=23) or no

treatment (n=10) prior to next IVFtreatment (n=10) prior to next IVF--ICSI cycle.ICSI cycle.•• Could FSH improve ICSI fertilization and pregnancy rates? Could FSH improve ICSI fertilization and pregnancy rates? •• Found a trend toward higher fertilization rates (62% vs 47%). Found a trend toward higher fertilization rates (62% vs 47%). ••CouldnCouldn’’t really assess differences in pregnancy rates (low #t really assess differences in pregnancy rates (low #’’s).s).

••HOWEVER, mean ejaculated sperm concentrations increased from HOWEVER, mean ejaculated sperm concentrations increased from 1.3 million/mL, to 3.8 million/mL (normal > 20) in the treated 1.3 million/mL, to 3.8 million/mL (normal > 20) in the treated group.group. Controls showed no change.Controls showed no change.

••SO, can we drive the failing, azoospermic testis to make 100 or SO, can we drive the failing, azoospermic testis to make 100 or even even 1000 sperm in the ejaculate and avoid costly and invasive 1000 sperm in the ejaculate and avoid costly and invasive sperm retrieval procedures? sperm retrieval procedures?

Case study (2)Case study (2)

••38 yo man with infertility, azoospermia and CML.38 yo man with infertility, azoospermia and CML.••FNA mapping show a single site of sperm.FNA mapping show a single site of sperm.••Underwent 3 months of recombinant FSH therapyUnderwent 3 months of recombinant FSH therapy••Retrieved enough sperm for all eggs at IVFRetrieved enough sperm for all eggs at IVF--ICSI by testis ICSI by testis

microdissection.microdissection.••Couple now has healthy twins. Couple now has healthy twins.

Injectable FSH Injectable FSH forfor NonObstructive AzoospermiaNonObstructive Azoospermia

Concept:Concept: Give rFSH to infertile men with testis Give rFSH to infertile men with testis failure who demonstrate pockets of sperm on FNA failure who demonstrate pockets of sperm on FNA mapping. mapping.

Objective:Objective: To improve sperm yield from testicular To improve sperm yield from testicular dissection procedures or to eliminate need for such dissection procedures or to eliminate need for such procedures (by finding sperm in ejaculate) with rFSH procedures (by finding sperm in ejaculate) with rFSH therapy.therapy.

Injectable FSH Injectable FSH forfor NonObstructive AzoospermiaNonObstructive Azoospermia

FSH - 30 36 77% 0FSH + 17 37 85% 3 (18%)

Treatment #Pts Mean % Sperm # EjaculatedAge Success Sperm

The Medical Management of Male Infertility: Does it Work?

For For specificspecific treatment of medical conditions treatment of medical conditions with known correctable pathology (Kallmann, with known correctable pathology (Kallmann, hyperprolactinemia, acquired HH): hyperprolactinemia, acquired HH): Absolutely!Absolutely!

For For empiricalempirical treatment of medical conditions treatment of medical conditions with unclear pathology: with unclear pathology: Well, maybe! Well, maybe!

That was most fun IThat was most fun I’’ve ever had without ve ever had without laughinglaughing……

Annie Hall (1977)Annie Hall (1977)

Woody Allen on sex:Woody Allen on sex:

MenMen’’s Reproductive Health: Erectile Dysfunction s Reproductive Health: Erectile Dysfunction

1.1. Erectile dysfunction and heart disease involve Erectile dysfunction and heart disease involve endothelial cell dysfunction.endothelial cell dysfunction.

2.2. PDE5 inhibitors were developed to treat angina. PDE5 inhibitors were developed to treat angina. 3.3. Erectile dysfunction is a marker of silent cardiac and Erectile dysfunction is a marker of silent cardiac and

vascular disease.vascular disease.4.4. Erectile dysfunction predicts occurrence of significant Erectile dysfunction predicts occurrence of significant

cardiovascular events 5cardiovascular events 5--10 years later. 10 years later.

MenMen’’s Reproductive Health: Infertility s Reproductive Health: Infertility

1.1. Male infertility and subsequent testis cancerMale infertility and subsequent testis cancer2.2. Male infertility and subsequent prostate cancerMale infertility and subsequent prostate cancer

Male Infertility Male Infertility andand Germ Cell CancerGerm Cell CancerAn Epidemiologic Study: An Epidemiologic Study:

Do Infertile Men Have Higher Rates of Testis Do Infertile Men Have Higher Rates of Testis Cancer?Cancer?

51,318 infertile males

• 15 California centers

• 1965 to 1998

California Cancer Registry (CCR)

• 10 SEER Regions 1973 to 2003– Testis cancer– Prostate cancer– Colon cancer– Melanoma ??

Walsh et al. Arch Int Med, Feb 2009 Walsh et al. Arch Int Med, Feb 2009

Fertility Status No. of Men SIR (95% CI)

All Men 42,283 1.7 (1.2, 2.2)*Male Factor Infertility 7,494 3.7 (2.1, 6.1)*

No Male Factor Infertility 25,159 1.4 (0.9, 2.1)

*P<0.05

AgeAge--Aggregated Standardized Incidence Ratios (SIR) Aggregated Standardized Incidence Ratios (SIR) and 95% Confidence Intervals for Testicular Cancer in and 95% Confidence Intervals for Testicular Cancer in Men with and without Male Factor InfertilityMen with and without Male Factor Infertility

Walsh et al. Arch Int Med, Feb 2009 Walsh et al. Arch Int Med, Feb 2009

Characteristic No. Men Observed cases Expected cases SIR (95% CI) Colorectal Cancer Entire cohort 42,283 97 120 0.81 (0.65, 0.98)* With male factor 7,494 25 21 1.21 (0.78, 1.79) Without male factor 25,159 41 58 0.71 (0.51, 0.96)* Melanoma Entire cohort 42,283 161 113 1.42 (1.21, 1.66)* With male factor 7,494 32 18 1.74 (1.19, 2.46)* Without male factor 25,159 80 58 1.38 (1.10, 1.72)* Prostate Cancer Entire cohort 42,283 286 146 1.96 (1.74, 2.20)* With male factor 7,494 77 27 2.90 (2.29, 3.63)* Without male factor 25,159 108 63 1.72 (1.41, 2.08)*

Standardized Incidence Ratios for Diagnosing Standardized Incidence Ratios for Diagnosing Colorectal, Melanoma, and Prostate Cancers inColorectal, Melanoma, and Prostate Cancers in

42,283 Men Evaluated for Infertility (1987 42,283 Men Evaluated for Infertility (1987 -- 1998)1998)

P<0.05

Walsh et al. SubmittedWalsh et al. Submitted

Gonsalves et al. Hum Mol Gen. Gonsalves et al. Hum Mol Gen. 13: 2875, 200413: 2875, 2004

Infertile Men have Evidence of Faulty DNA Repair and Infertile Men have Evidence of Faulty DNA Repair and Abnormal RecombinationAbnormal Recombination

Leptotene E. Zygotene L.Zygotene

E.Pachytene L.Pachytene Diplotene

CentromeresCentromeres--blue; SCPblue; SCP--red; MLH1red; MLH1--yellowyellow

BlastocystBlastocyst

Inner Inner cell cell massmass

Embryonic stem cellEmbryonic stem cell

PluripotencyPluripotency

EctodermEctodermMesodermMesodermEndodermEndoderm

ChimerasChimeras

TeratomaTeratoma

Neonatal testisNeonatal testis? cell? celltypetype

Multipotent Multipotent germline stem cellgermline stem cell

Adult testisAdult testis

? cell? celltypetype

Multipotent adultMultipotent adultgermline stem cellgermline stem cell

SpermatogonialSpermatogonialstem cellstem cell

DifferentiationDifferentiation

SpermatogenesisSpermatogenesis

PrimordialPrimordialgerm cell (PGC)germ cell (PGC)

GonocytesGonocytes

DifferentiationDifferentiation

SpermatogenesisSpermatogenesis

The Ultimate Treatment for Male Infertility?The Ultimate Treatment for Male Infertility?Embryonic Stem cells from Adult Testis?Embryonic Stem cells from Adult Testis?

ELSRS

SC

SPG

SPC

The Normal Testicle

Embryonic Embryonic stem cellsstem cells

Primordial Primordial germ cellsgerm cells SpermatogoniaSpermatogonia

Can We Create Male Can We Create Male EmbryonicEmbryonic Stem Cells?Stem Cells?

CancerCancerCISCIS

SpermSperm

KanatsuKanatsu--Shinohara et al. Cell. 119: Shinohara et al. Cell. 119: 1001, 2004 1001, 2004

Guan et al. Nature. 440: 1199, 2006Guan et al. Nature. 440: 1199, 2006

Developing a Human Spermatogonial Stem Cell LineDeveloping a Human Spermatogonial Stem Cell Line

Mechanical Mechanical disintegreation, disintegreation, collagenase collagenase digestion digestion

Wash, plate Wash, plate and incubate and incubate @ 34@ 34°°CC SpermatogoniaSpermatogonia

FibroblastsFibroblasts

Generation of Human Spermatogonial Cell LinesGeneration of Human Spermatogonial Cell Lines

Kossack et al. Stem Cells 27:138, 2009.Kossack et al. Stem Cells 27:138, 2009.

Adult Testis CellsAdult Testis Cells

Colonies @ 2 weeksColonies @ 2 weeks

Transfer to hES mediaTransfer to hES media

Kossack et al.Kossack et al.Stem Cells 27: Stem Cells 27: 138, 2009138, 2009

Creating:Creating:

••Patient specificPatient specific••Genetically unmodifiedGenetically unmodified••NonNon--embryo derivedembryo derived

stem cells for men.stem cells for men.

SummarySummary

••A paradigm shift is occurring regarding the causes of A paradigm shift is occurring regarding the causes of male infertility and its disease associations.male infertility and its disease associations.

••Novel treatments are being pursued and incredibly Novel treatments are being pursued and incredibly novel (stem cell) treatments loom in the future.novel (stem cell) treatments loom in the future.