Craig Niederberger MD FACSClarence C. Saelhof Professor and Head, Department of Urology, UIC College of MedicineProfessor, Department of Bioengineering, UIC College of Engineering

Sperm retrieval – preparation, technique, fresh or frozen, and when should attempting retrieval be deemed futile?

July 19, 2016

29th Annual IN VITRO FERTILIZATION AND EMBRYO TRANSFER A Comprehensive Update

Disclosures

No relationship presents a conflict of interest with the material in this presentation.

ASRM Journal Editor Medical Communications

AUA Journal Section Editor Medical Communications

Ferring Investigator Scientific Study

NexHand Co-Founder Medical Device Company

Disclosures

These drugs are off-label:

rFSHhMGClomipheneTamoxifenAnastrozoleTestolactone

Questions?

How do you know if it’s not reconstructable?

Testis or epididymis?Open, percutaneous, or microsurgical?When do you say it’s helpless?Fresh or frozen?

Retrieving sperm

Cryopreserving tissue

Medication

Azoospermia

Schoor RA, Elhanbly S, Niederberger CS, Ross LS. J Urol. 2002 Jan;167(1):197-200.

FSH and Testis Size

0%

20%

40%

60%

80%

100%96%89%

ASD: FSH > 7.6, TLA < 4.6 OA: FSH < 7.6, TLA > 4.6

You don’t need to do a biopsy for diagnosis only!

Diagnose Azoospermia

1Ubaldi F, et al. Andrologia. 1996;28 Suppl 1:71-5. 2Watkins W, et al. Fertil Steril. 1997 Mar;67(3):527-35.

Epididymal Sperm

Early on...

Van Steirteghem1

128 ICSI/MESA vs. 120 ICSI/TESE cycles

Fertilization rate 58% MESA, 60% TESE

Watkins2

72 ICSI/MESA cycles and 40 ICSI/TESE cycles

FR 67% MESA, 50% TESE, but higher implantation rates for TESE, so pregnancy rates similar: 25% TESE, 29% MESA

Required for ICSI?

If you take sperm from the epididymis, make sure the patient can’t or doesn’t want to be

reconstructed

Turek PJ, Cha I, Ljung BM.;67(3):527-35. Urology. 1997 May;49(5):743-8.

Testis Mapping

“In 27.1% of cases the fine needle aspiration map found sperm in men with sperm negative biopsies.”

Schlegel PN. Hum Reprod. 1999 Jan;14(1):131-5.

Microdissection TESE

Schlegel PN. Hum Reprod. 1999 Jan;14(1):131-5.

Microdissection TESE

TESE micro-TESE

Sperm retrieval 45% 63%

Sperm number 64K ± 52K 160K ± 270K*

Mass 720 mg 9.4 mg**

Fertilization 52% 65%*p < 0.01, **p <

0.0001

49 men, biopsy confirmed ASD22 standard TESE, 27 micro-TESE + standard TESE

TESETESE micro-TESEmicro-TESE

Sperm retrievalSperm retrieval 45%45% 63%63%

Sperm numberSperm number 64K ± 52K64K ± 52K 160K ± 270K*160K ± 270K*

MassMass 720 mg720 mg 9.4 mg**9.4 mg**

FertilizationFertilization 52%52% 65%65%

Berookhim BM, Palermo GD, Zaninovic N, Rosenwaks Z, Schlegel PN. Fertil Steril. 2014 Nov;102(5):1282-6.

FSH and Outcome

Ramasamy R, Lin K, Gosden LV, Rosenwaks Z, Palermo GD, Schlegel PN. Fertil Steril. 2009 Aug;92(2):590-3.

Sper

m re

triev

al ra

te

0%

20%

40%

60%

80%

100%

FSH (IU/L)<15 16-30 31-45 >45

60%67%

60%51%

Ramasamy R et al. Fertil Steril. 2011 Aug;96(2):299–302.

Ramasamy R et al. Fertil Steril. 2011 Aug;96(2):299–302.

“Of the 501 men for whom sperm were not identified by andrologists in the OR, sperm were found in the laboratory for an additional 35 (7%).”

With all the techniques available, With all the techniques available, what’s the best to do?

If it’s obstructive, you can do If it’s obstructive, you can do anything, but try to leave the anything, but try to leave the epididymis alone.If it’s spermatogenic dysfunction, go If it’s spermatogenic dysfunction, go straight to micro-TESE.Don’t biopsy to make the diagnosis!

Cryopreservation

Ohlander S, Hotaling J, Kirshenbaum E, Niederberger C, Eisenberg ML. Fertil Steril. 2014 Feb;101(2):344-9.

Failure Reanalysis

Ohlander S, Hotaling J, Kirshenbaum E, Niederberger C, Eisenberg ML. Fertil Steril. 2014 Feb;101(2):344-9.

Failure Reanalysis

Ohlander S, Hotaling J, Kirshenbaum E, Niederberger C, Eisenberg ML. Fertil Steril. 2014 Feb;101(2):344-9.

Failure Reanalysis

Moghadam KK, et al. J Androl. 2005 Sep;26(5):619–23.

Motility is Useless

Zhong C1, et al. Cell Stem Cell. 2015 Aug 6;17(2):221-32.

It’s the DNA

Zhong C1, et al. Cell Stem Cell. 2015 Aug 6;17(2):221-32.

It’s the DNA

Tanaka A, et al. Proc Natl Acad Sci U S A. 2015 Nov 24;112(47):14629-34.

It’s the DNA

Medication to improve outcomes

Hussein A, Ozgok Y, Ross L, Rao P, Niederberger C. 2013 Mar;111(3 Pt B):E110-4.

Medical TherapyPrior to TESE

Hussein A, Ozgok Y, Ross L, Rao P, Niederberger C. 2013 Mar;111(3 Pt B):E110-4.

Medical TherapyPrior to TESE

Mehta A, Bolyakov A, Roosma J, Schlegel PN, Paduch DA. Fertil Steril. 2013 Oct;100(4):970-4.

Klinefelter Syndrome

Mehta A, Bolyakov A, Roosma J, Schlegel PN, Paduch DA. Fertil Steril. 2013 Oct;100(4):970-4.

Klinefelter Syndrome

Retrieving sperm

Cryopreserving tissue

Medication

Answers!How do you know if it’s not reconstructable?

Use testis size and FSHTestis or epididymis?

TestisOpen, percutaneous, or microsurgical?

If not reconstructable, microsurgicalWhen do you say it’s helpless?

NeverFresh or frozen?

FrozenStimulate with medication beforehand?

If possible, yes

Thank You