role of microsurgery in male infertility

Role of microsurgery in male infer1lity Sandro C. Esteves, MD., PhD. Medical Director, ANDROFERT

Campinas, BRAZIL

Andrology & Male Infer1lity Workshop ISAR 2015 – Chennai

Lecture Outline Overview Varicocelectomy

Sperm retrieval techniques

Vasovasostomy

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2015

ANDROFERT

Vasoepididymostomy

Varicocelectomy

Miyaoka & Esteves. Adv Urol 2012

Technique Recurrence Postop hydrocele

Retroperitoneal (Palomo) 7-‐35% 6-‐10%

Laparoscopy 2-‐7% 0-‐9% Emboliza1on 2-‐24% NR

Inguinal (Ivanissevich)

0-‐37%

7%

Microsurgical Subinguinal 0-‐1% 0-‐1.6%


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Intraopera1ve 20 MHz microvascular doppler


ANDROFERT

VTI Vascular Technology, USA

Microsurgical Varicocele Repair


ANDROFERT

• Microsurgical varicocele repair prior to ICSI (N=80)

•  ICSI with untreated varicocele (N=162)


ANDROFERT

Esteves & Glina

Weedin et al. Meta-‐analysis

No. 17 233

Mean age (yrs) 34.2 30.1

Mo1le sperm postop ejaculate; N (%) 6/17 (35.3) 91/233 (39.0)

Sperm count postop (mean; x106/mL) 0.8 (0.1-‐1.8) 1.6 ± 1.2 Interval between surgery to sperm (mo.) 5 (3-‐9) NR

Spontaneous pregnancy; N (%) 1 (5.8) 14 (6.0)

Mean follow-‐up (months) 18.9 13.3 Adapted from: Esteves SC: Varicocele. In: S.J. Parekagl and A. Agarwal (eds.), Male Infer1lity, 2012

Microsurgical varicocele repair in azoospermia


ANDROFERT

Matura1on arrest and hypospermatogenesis favorable prognosis

Weedin et al J Urol 2010;183:2309-‐15

Among men with NOA and treated varicocele, tes1s histopathology influences presence of sperm in postop. ejaculate


ANDROFERT

Epididymis

Vas deferens

Microsurgery in obstruc1ve azoospermia


ANDROFERT

Esteves et al. Surgical treatment of male infer1lity in the era of intracytoplasmic sperm injec1on – new insights. Clinics 2011; 66:1462-‐77

Vas deferens obstruc1on


ANDROFERT

Author N Technique Patency (%)

Pregnancy (%)

Belker et al. 1991

1247

Single-‐layer 89 57

Two-‐layer 86 51

Boorjian & Lipkin 2004 159 Two-‐layer 95 83

Chan & Goldstein 2004 1048 Two-‐layer 99 54

Kolegs et al. 2006 34 Single and

two-‐layer 76 35

Esteves et al. Surgical treatment of male infer1lity. Clinics 2011; 66:1462-‐77

Microsurgical vasovasostomy


ANDROFERT

Preop: Obstruc1on interval Presence of granuloma Hydrocele

Intra-‐op: Surgeon exper1se Fluid aspect (macro) Fluid assessment for sperm (micro)

Prognos1c factors in microsurgical vaso-‐vaso & vasoepididymostomy


ANDROFERT

Microsurgical vasovasostomy


ANDROFERT

Thomas AJ, Surgery for Male Infer1lity, 2006


ANDROFERT

Microsurgical reconstruc1on in cases of epididymis obstruc1on

Esteves et al. Surgical treatment of male infer1lity in the era of intracytoplasmic sperm injec1on – new insights. Clinics 2011; 66:1462-‐77


ANDROFERT

Microsurgical vasoepididymostomy


ANDROFERT

Epididymis

Ejaculatory duct

Vas deferens

Surgery in Obstructive Azoospermia


ANDROFERT

Clinical features: Obstructive azoospermia Hypospermia (<1.5 mL) Acidic semen pH: <7.2

Congenital Prostatic cyst

(Muller) Ejaculatory duct

cyst (Wolf)

Acquired Iatrogenic

Post-infection

AP diameter (TRUS): 1.5 cm

Ejaculatory Duct Obstruction


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TURED


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Transurethral Resection of Ejaculatory Duct (TURED)

Netto Jr, Neves, Esteves. J Urol. 1998;159: 2048-53

Case series

Etiology Semen quality Improvement (%)

Pregnancy (%)

Acquired 37.5 (3/8) 12.5 (1/8) Congenital 83.0 (5/6) 66.0 (4/6)


ANDROFERT

Obstruc1ve azoospermia

Technique Acronym Percutaneous Epididymal Sperm Aspira1on PESA

Microsurgical Epididymal Sperm Aspira1on MESA

Tes1cular Sperm Aspira1on TESA

Esteves & Agarwal. Sperm Retrieval Techniques. Cambridge University Press, 2011


ANDROFERT

Microsurgical Epididymal Sperm Aspira1on (MESA)


ANDROFERT


ANDROFERT

Percutaneous Epididymal Sperm Aspira1on (PESA)

http://androfert.com.br/videos


ANDROFERT

Tes1cular Sperm Aspira1on (TESA)

100% 96.6% 96.3%

CBAVD Vasectomy Post-‐infection

OBSTRUCTIVE AZOOSPERMIA

78.1 %

97.3%

Successful Retrievals

PESA + rescue TESA PESA alone

Esteves et al. J Urol. 2013; 189(1): 232-‐7

146 patients

Sperm retrieval in CBAVD


ANDROFERT


ANDROFERT


Nonobstruc1ve azoospermia Technique Acronym Success

TesBcular Sperm AspiraBon

TESA 15-‐50%

TesBcular Sperm ExtracBon

TESE 20-‐60%

Microsurgical TesBcular Sperm ExtracBon

Micro-‐TESE 40-‐67%

Esteves & Agarwal. Sperm Retrieval Techniques. Cambridge University Press, 2011

TESE


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http://androfert.com.br/videos Esteves SC, Int Braz J Urol 2013


ANDROFERT

Microdissec1on Tes1cular Sperm Extrac1on (Micro-‐TESE)

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

420

Max

. Tub

ule

Diam

eter

Verza Jr S, Esteves SC. Fertil Steril 2012;98(3):S242

Cutpoint: 260µm

N=54; Tubule Diameter: KW-H(1;54) = 25.2; P<0.001


ANDROFERT

Morphometric evalua1on of sperm-‐containing seminiferous tubules

Micro-‐TESE Prac1cal Points

240 μm ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 32 2015

ANDROFERT

100%

47.0% 19.5%

Hypospermatogenesis (n=84)

Matura1on arrest (n=67) Sertoli cell-‐only (n=205)

Esteves & Agarwal. Asian J Androl 2014;16(4):642

Sperm retrieval rate by micro-‐TESE in NOA (%)

N=356; P<0.001


ANDROFERT

Lecture Outline


ANDROFERT

Role of microsurgery in male infer1lity Varicocelectomy

Sperm retrieval techniques

Vasovasostomy

Vasoepididymostomy

This presentation is available at http://www.slideshare.net/

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role of microsurgery in male infertility

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