surgical techniques in male factor infertility

Sandro C. Esteves, MD., PhD. Director, ANDROFERT

Andrology & Human Reproduction Clinic Campinas, BRAZIL

Surgical Techniques in Male Infertility

Reproductive Andrology Surgery Workshop 2014 Al Jahra Hospital, KUWAIT

ISO 9001:2008

Lecture Outline Overview Varicocelectomy

Sperm retrieval techniques for ART

Transurethral resection of ejaculatory duct

Vasovasostomy and vasoepididymostomy

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2014 APRIL

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Miyaoka & Esteves. Adv Urol 2012 Agarwal, Esteves, Hamada. Nature Urol Rev 2013

Varicocele

35% subfertile men Lower sperm count and quality Lower sperm function Elevated oxidative stress Elevated sperm DNA damage



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Varicocele Treatment for Infertility

Indications Infertile couples

Normal female or treatable female infertility

Abnormal semen analysis and/or sperm function test

(all criteria met)

ASRM Practice Committee, Fertil Steril 2008



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Marmar et al., Fertil Steril 2008

Varicocele Surgery and Spontaneous Pregnancy



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Varicocelectomy

Miyaoka & Esteves. Adv Urol 2012

Technique Recurrence Postop Hydrocele

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

Laparoscopy 2-7% 0-9%

Embolization 2-24% NR

Inguinal (Ivanissevich)

0-37%

7%

Microsurgical Subinguinal 0-1% 0-1.6%



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Intraoperative VTI 20 MHz Microvascular Doppler



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Courtesy of Dr. M. Cocuzza

Microsurgical Varicocelectomy & Intraoperative Doppler

Cocuzza et al, Fertil Steril ; Mar, 2009



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Fertility Improvement

ICSI

Outcomes

Sperm Retrieval in Azoospermia

Fertility Restoration

Spontaneous Pregnancy



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Varicocele treated prior to ICSI (N=80)

ICSI with untreated varicocele (N=162)

SC Esteves, FV Oliveira, RP Bertolla ANDROFERT and Division of Urology, São Paulo Federal University, BRAZIL

The Journal of Urology; Vol. 184: 1442-6, 2010

Clinical Outcome of Intracytoplasmic Sperm Injection in Infertile Men With Treated and Untreated Clinical

Varicocele



ANDROFERT

Esteves & Glina Weedin et al.

Meta-Analysis No. 17 233 Mean age (yrs) 34.2 30.1 Motile 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 microsurgery and sperm (mo.) 5 (3-9) NR Results by testicular histopathology; N (%)*

Hypospermatogenesis Maturation arrest

Sertoli-cell only

5/6 (83.3) 3/5 (75.0) 0/6 (0.0)

30/55 (54.5) 24/57 (42.0) 5/44 (11.4)

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. Parekattil and A. Agarwal (eds.), Male Infertility, 2012

Varicocele Repair in Azoospermia



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K Inci, M Hascicek, O Kara et al. Department of Urology, Hacettepe University, Ankara, Turkey

The Journal of Urology Vol. 182,1500-5, 2009

53% 30%

Successful Sperm Retrieval

Treated Varicocele Untreated Varicocele

OR: 2.63 (95% CI: 1.05-6.60; P=0.03)

Microsurgical varicocele repair prior to sperm retrieval ICSI (N=66)

Sperm retrieval in the presence of varicocele (N=30)

Sperm Retrieval and Intracytoplasmic Sperm Injection in Men With Nonobstructive Azoospermia, and Treated and

Untreated Varicocele



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Epididymis

Ejaculatory duct

Vas deferens

Surgery in Obstructive Azoospermia



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

Vas Deferens Obstruction



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VasovasostomyMacroscopic vs microscopic

49

88

32

59

0 10 20 30 40 50 60 70 80 90

100

Macro Micro

patency (%)

pregnancy (%)

Derrick 1973 Lee & McLoughlin 1980 Soonawala, Lal 1984 Middleton 1987 Meinertz 1990 Kabalin 1991

Owen 1977 Silber 1977 Lee & McLoughlin 1980 Cos et al. 1983 Requeda et al. 1983 Owen & Kapila 1984 Soonawala, Lal 1984 Lee 1986 VVSG 1991 Fox 1994



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Author

N

Technique

Patency (%)

Pregnancy (%)

Vasovasostomy Technique

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

Kolettis et al. 2006 34 Single and two-layer 76 35

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



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Preop: Obstruction interval Presence of granuloma Hydrocele

Intra-op: Surgeon expertise Fluid aspect (macro) Fluid assessment for presence of sperm

Vasovasostomy & VasoepididymostomyPrognostic factors



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< 3 3 - 8 9 - 14 15 0

20

40

60

100

80

Patency

Pregnancy

Adapted from Belker et al. J Urol. 145: 505-511, 1991 Obstruction interval (yrs)

86 89

56 74

525 600

253 478

205 261

92 209

32 45

11 37

97%

76% 88%

53%

79%

44%

71%

30% 40%

ART

Pregnancy Results

Microsurgical Vasovasostomy



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Thomas AJ, in Surgery for Male Infertility, 2006



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Epididymis Obstruction

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



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%

Belker et al. Vasovasostomy Study Group. J Urol 145, 1991

27% 20% 14% 9%

30

44 53

76

0 5

10 15 20 25 30

<3 3-8 9-14 >/= 15 0 10 20 30 40 50 60 70 80 Epididymal obstruction

Pregnancy (%)

Obstruction interval (yrs)



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Vasectomy interval and epididymis obstruction

Author

N

Technique

Patency (%)

Pregnancy (%)

Vasoepididymostomy

Silber 1978 139 Termino-lateral 78 56

Thomas 1987 137 Termino-lateral 79 50

Berger 1998 12 Triangulation 92 NR

Marmar 2000 9 Modified triangulation 78 22

Chan et al. 2005 68 Triangulation 84 40

Schiff et al. 2005 153

Termino-terminal 73 NR

Termino-lateral 74 Intussusception (3-suture) 84 Intussusception (2-suture) 80

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



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Epididymis

Ejaculatory duct

Vas deferens

Surgery in Obstructive Azoospermia



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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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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)



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Lecture Outline Overview Varicocelectomy

Sperm retrieval techniques for ART

Transurethral resection of ejaculatory duct

Vasovasostomy and vasoepididymostomy



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Sperm Retrieval in Azoospermia

Normal sperm production

Mechanical blockage

Vasectomy, Post-infectious, Congenital

Sperm production deficient or absent

Cryptorchidism, Radiation, Chemotherapy, Trauma, Genetic, Orchitis, Varicocele, Gonadotoxins, Unexplained



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Azoospermia Differential Diagnosis

Azoospermia

Obstructive

Non-obstructive

Subtypes

Hypo-hypo

Testicular failure

Spermatogenesis

Disrupted

Normal

Clinical Picture

High FSH/LH (NL) Low TT (NL)

Small testis (NL)

FSH/LH <1.2 mUI/mL Low TT

Small testis Poor virilization

NL testis NL FSH, LH, TT

Mechanical block



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Obstructive Azoospermia

Technique Acronym

Percutaneous Epididymal Sperm Aspiration PESA

Microsurgical Epididymal Sperm Aspiration MESA

Testicular Sperm Aspiration TESA

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



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http://androfert.com.br/videos



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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

146 patients

Sperm retrieval in CBAVD



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Testicular torsion; Trauma Post-inflammatory (eg. mumps orchitis) Exogenous factors (steroids, cytotoxic drugs, irradiation) Testicular Cancer Systemic diseases (liver cirrhosis, renal failure) Varicocele

Congenital Testicular dysgenesis/cryptorchidism Genetic abnormalities (eg. Klinefelter syndrome, Yq microdeletions)

Acquired

Idiopathic (unknown etiology)

Untreatable condition

Sperm Retrieval and ICSI



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Non-Obstructive Azoospermia

Non-Obstructive Azoospermia Technique Acronym Success

Testicular Sperm Aspiration

TESA 15-50%

Testicular Sperm Extraction

TESE 20-60%

Microsurgical Testicular Sperm Extraction

Micro-TESE 40-67%

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

TESE



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30-50% cases: minimal production within the testis, but not enough for sperm to appear in ejaculate

Goal is to identify site of production and retrieve sperm for ICSI

Geographic location unpredictable

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

Which is the best sperm retrieval technique in NOA ?

Non-Obstructive Azoospermia



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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

43%-53%

25%-41% Con

trol

led

Serie

s Sperm retrieval in NOA

which is the best technique?

TESE

Esteves et al. Sperm retrieval Techniques. Int Braz J Urol 2011

SR Techniques in NOA



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Microsurgical vs Single-Biopsy TESE in NOA according to testicular histology

45%

93%

64%

20% 25%

64%

9% 6%

Overall Hypospermatogenesis Maturation Arrest Sertoli-cell Only

Sperm Retrieval Success Rates

Micro-TESE single-biopsy TESE

Controlled series (N=60)

Verza Jr & Esteves. Fertil Steril 2011

Histology categories pairwise

Comparisons: p<0.0001

Method P=0.0005



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



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Esteves et al. Asian J Androl. 2014; doi: 10.4103/1008-682X.126015

Sperm Retrieval and ICSI Results

41.4 47 43.3 20

100

64 61 34.2

Sperm retrieval (%)

2PN Fertilization (%)

Top Quality Embryos (%)

Live Birth (%)

Non-obstructive Obstructive

OR=0.033 95% CI: 0.007-0.164; p<0.001

OR=0.38 95% CI: 0.23-0.61; p<0.001

P<0.01



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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

NOA (n=63) Ejaculated Sperm (n=247) Obstructive Azoospermia (n=117)

P = NS

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

and systematic review. Clinics 2013

Health of Babies Born in NOA



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Lecture Outline Summary Varicoce repair

Subinguinal microsurgical technique

Sperm retrieval techniques for ART PESA, TESA, MESA, micro-TESE

Transurethral resection of ejaculatory duct TURED

Vasovasostomy and vasoepididymostomy Microsurgical techniques



ANDROFERT

Thank you

surgical techniques in male factor infertility

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