Male Factor Infertility - Urology Rounds · SEMEN CRYOPRESERVATION Oxidative Stress. 6 Associations...

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Male Factor InfertilityMale Factor Infertility

Jeff McCrackenJeff McCracken

March 2007March 2007

Physeter macrocephalus

OutlineOutline

Oxidative Stress and InfertilityOxidative Stress and Infertility

Infertility GeneticsInfertility Genetics

Workup OverviewWorkup Overview

Assisted Reproductive TechnologiesAssisted Reproductive Technologies

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DefinitionDefinition

1 year unprotected sex without 1 year unprotected sex without

pregnancypregnancy

15% of couples15% of couples

50% male factor50% male factor

50%

20%

30%

Female

Male

Combined

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ImpactImpact

8 million couples in the United States8 million couples in the United States

1% to 10% of male factor infertility 1% to 10% of male factor infertility

–– ? Underlying disease? Underlying disease

AUA and American Society for AUA and American Society for

Reproductive Medicine (ASRM) Reproductive Medicine (ASRM)

–– Evaluation of male and female partners Evaluation of male and female partners

occurs in paralleloccurs in parallel

Surgery

History

Physical

Semen Analysis

Other Tests

Hormones

Medical

Therapy

ART

Basic Male Evaluation

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Surgery

History

Physical

Ovulatory Fn

Anatomy

Ovarian Reserve

Medical

Therapy

ART

Basic Female Evaluation

Etiology of Male InfertilityEtiology of Male Infertility

VaricoceleVaricocele (35(35--40%)40%)

Idiopathic (25%)Idiopathic (25%)

Infection (~10%)Infection (~10%)

Genetic (15%)Genetic (15%)

Endocrine (<5%)Endocrine (<5%)

Immunologic (<5%)Immunologic (<5%)

Obstruction (<5%)Obstruction (<5%)

CryptorchidismCryptorchidism (<5%)(<5%) Greenberg et al, J UrGreenberg et al, J Urology 1978 ology 1978

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Topics in Male InfertilityTopics in Male Infertility

PRIMARY SPERMATOGENIC FAILURE

TESTICULAR BIOPSY TECHNIQUES

TESE TECHNIQUES

TESE AND ICSI IN KLINEFELTER’S SYNDROME

COMBINATIONS WITH ICSI

INTRATESTICULAR OBSTRUCTION

VARICOCELE

HYPOGONADISM

CRYPTORCHIDISM

IDIOPATHIC MALE INFERTILITY

MALE CONTRACEPTION

MALE ACCESSORY GLAND INFECTIONS

GERM CELL MALIGNANCIES AND TESTICULAR MICROCALCIFICATIONS

ENDOCRINE DISRUPTION

DISORDERS OF EJACULATION

SEMEN CRYOPRESERVATION

Oxidative StressOxidative Stress

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AssociationsAssociations

Infection

Varicocele

Cryptorchidism

Behavioural

Environmental

Reactive Oxygen SpeciesReactive Oxygen Species

Altered Altered acrosomeacrosome reactionreaction

Poor motilityPoor motility

DNA damageDNA damage

ApoptosisApoptosis

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ManagementManagement

Lifestyle modification

– Smoking

– Exposure

Antioxidants

– Diet

– Vitamin EImproved acrosome reaction (ZBT)

In VitroIn Vitro

FutureFuture

Sperm Chromatin Structure Assay Sperm Chromatin Structure Assay

(SCSA) (SCSA)

PCR for DNA fragmentation

– Miscarriage high if SCSA >30%

– 16X success w/ IUI SCSA <27%

?Potential to become a useful tool in

infertility evaluation

– Does not r/o normal pregnancy

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GeneticsGenetics

Mandatory in certain cases of male infertility to:Mandatory in certain cases of male infertility to:

Risk of disease transmission to childRisk of disease transmission to child

Prognostic factors for treatment successPrognostic factors for treatment success

Risk to future healthRisk to future health

DiagnosisDiagnosis

OverviewOverview

ICSI has revolutionized Rx for severe male ICSI has revolutionized Rx for severe male

factor infertilityfactor infertility

? Consequences of transmission of ? Consequences of transmission of

abnormal genes to offspringabnormal genes to offspring

Loss of natural selectionLoss of natural selection

= Devolution= Devolution

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Canada

50%

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ConnConn SmytheSmythe WinnersWinners

GameshowsGameshows

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MiscellaneousMiscellaneous

BossBoss--Employee RelationsEmployee Relations

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No change hereNo change here

MacNeilysMacNeilys

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Genetic ConsiderationsGenetic Considerations

ClassificationClassification

1.1. Abnormalities of number or structure Abnormalities of number or structure

((KlinefelterKlinefelter’’ss))

2.2. Partial Chromosome Defects (YPartial Chromosome Defects (Y--

microdeletionmicrodeletion))

3.3. Specific Gene Defects (CF Mutation)Specific Gene Defects (CF Mutation)

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Chromosomal abnormalities Infertile 5.8% vs. 0.38%

Sex chromosome abnormalities Infertile 4.2% vs. 0.14%

Autosomal abnormalitiesInfertile 1.5% vs. 0.25%

Abnormalities of numberAbnormalities of number

Polyploidy Polyploidy –– 23n23n

AneuploidyAneuploidy –– gain/loss gain/loss chromsomechromsome

(XXY, (XXY, TrisomyTrisomy 21)21)

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Human Sperm Chromosomal Human Sperm Chromosomal

AneuploidyAneuploidy

Detected by FISHDetected by FISH

DisomyDisomy rate = ~0.1 rate = ~0.1 -- 0.2%0.2%

DiploidyDiploidy = ~0.1%= ~0.1%

= risk of miscarriage, fetal = risk of miscarriage, fetal aneuploidyaneuploidy

23,X 23,Y 24, XY

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KlinefelterKlinefelter’’ss [46,XY; 47,XXY;

47,XXY mosaicism]

Most frequent sex chromosome

abnormality

1/1000 phenotypic males

Small firm testicles devoid of germ cells

Spectrum of normally virilized to:

– female hair distribution

– scanty body hair

– long arms and legs

KlinefelterKlinefelter’’ss

Germ cell presence and sperm production

are variable

Pre-implant FISH

Mosaic

– 24,XY sperm 0.9% - 2.1%

47,XXY

– 25% achieve meiosis

– ?haploid sperm in clone of normal cell

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KlinefelterKlinefelter’’ss

Abnormal sperm/ Abnormal sperm/

embryos should not embryos should not

be implantedbe implanted

Patients require Patients require

lifelong endocrine lifelong endocrine f/uf/u

–– Risk of androgen Risk of androgen

deficiencydeficiency


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X-linked genetic disorders

KallmannKallmann’’ss syndromesyndrome

–– Most common Most common X-linked recessive

– KALIG-1 gene on Xp 22.3

– Autosomal dominant variants

– Wide spectrum

Some only hypo hypo

– Treated with gonadotropins

Other XOther X--linkedlinked

Androgen InsensitivityAndrogen Insensitivity

–– Rare without genital abnormalityRare without genital abnormality

XpXp deletions (rare)deletions (rare)

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YqYq--microdeletionmicrodeletion

1976 1976 –– TiepoloTiepolo & & ZuffardiZuffardi –– Long arm of Y Long arm of Y

chromosome may contain area for chromosome may contain area for

spermatogenesisspermatogenesis

““AzoospermicAzoospermic FactorFactor”” –– AZF AZF


1995 1995 –– ReijoReijo et alet al

““Deleted in Deleted in AzoospermiaAzoospermia RegionRegion”” DAZDAZ

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Testicular failure 1-37%

Severe Oligospermia

1-17.3%

Sertoli Cell only 55%


GenotypeGenotype--Phenotype Phenotype

CorrelationCorrelation

AZFa SCOS

AZFb Maturation arrest

AZFc hypospermatogenesis

AZFd Disordered

spermatogenesis

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YY--microdeletionsmicrodeletions

Yq

Yp5A

5E

AZFb

DFFRY

DBY

UTY

TB4Y

5M

6B

AZFa

E1F 1 AY

RBM

PRY

TTY2

6F

6C

AZFc

DAZ

BPY2

PRY

CDY

AZFd

Clinical RelevanceClinical Relevance

1.1. DiagnosticDiagnostic

2.2. PrognosticPrognostic

3.3. Affected OffspringAffected Offspring

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Cystic Fibrosis and Male InfertilityCystic Fibrosis and Male Infertility

1969 1969 –– CF men CF men azospermicazospermic, all CBAVD, all CBAVD

1988 1988 –– CBAVD CBAVD �� IVFIVF


Cystic Fibrosis Cystic Fibrosis transmembranetransmembrane conductance conductance

regulator gene (CFTR) chromosome 7regulator gene (CFTR) chromosome 7

AutosomalAutosomal recessive disorderrecessive disorder

Carrier Status Carrier Status 1 in 25 1 in 25

Cystic fibrosisCystic fibrosis 1 in 25001 in 2500

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Over 550 mutations have been found for Over 550 mutations have been found for

the CFTR genethe CFTR gene

Mild Mild �� SevereSevere

Infertility may be only manifestationInfertility may be only manifestation

–– MildMild

–– CarrierCarrier


Clinical CF = CBAVD (95%)Clinical CF = CBAVD (95%)

Overall CBAVD = 1Overall CBAVD = 1--2% infertile men2% infertile men

1 mutation ~501 mutation ~50--82%82%

2 mutations ~10%2 mutations ~10%

Unilateral AVD = 43% CFTR mutationUnilateral AVD = 43% CFTR mutation

EpididymalEpididymal Obstruction = 47% CFTR Obstruction = 47% CFTR

mutationmutation

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Congenital Bilateral Absence of Congenital Bilateral Absence of

Vas DeferensVas Deferens

Clinical diagnosisClinical diagnosis

Can be isolated Can be isolated

absence of vas absence of vas

deferens or deferens or

Absence of entire Absence of entire

Wolffian structures Wolffian structures

(distal (distal epiepi, seminal , seminal

vesicles, ejaculatory vesicles, ejaculatory

ducts)ducts)

Estimation of risk of having CF in Estimation of risk of having CF in

children of men with infertilitychildren of men with infertility

????1/12501/1250--15001500

Likely not severeLikely not severe

Sperm Sperm

AbnormalitiesAbnormalities

????1/1000 1/1000 -- 1500 1500

Likely not severeLikely not severe

EpididymalEpididymal obstobst

1/51/51/1501/150CBAVDCBAVD

Atypical CFAtypical CFCFCF

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Renal Anomalies in CBAVDRenal Anomalies in CBAVD

Common derivation from Common derivation from mesonephmesoneph. duct. duct

–– vas deferens and vas deferens and uretericureteric budbud

Unilateral absence of VD Unilateral absence of VD

–– More commonMore common

Frequency of CF mutations in men Frequency of CF mutations in men

with infertilitywith infertility

Should all men with infertility be tested for Should all men with infertility be tested for

CF?CF?

–– Risk of clinically significant CF in the manRisk of clinically significant CF in the man

–– Risk of clinically significant CF in the childRisk of clinically significant CF in the child

Partner is main concern for Partner is main concern for testingtesting

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WorkupWorkup

What?What?

Standard Standard

–– History History

(Questionnaire)(Questionnaire)

–– Physical Physical

examinationexamination

–– Standard semen Standard semen

analysisanalysis

Optional Additional Optional Additional

Evaluation:Evaluation:

–– Hormonal evaluationHormonal evaluation

–– Genetic evaluationGenetic evaluation

–– Specialized semen Specialized semen

and sperm function and sperm function

teststests

–– Imaging studiesImaging studies

–– Testis biopsyTestis biopsy

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When?When?

1 year infertile1 year infertile

OROR

Male risk factorsMale risk factorsEgEg. bilateral . bilateral cryptorchidismcryptorchidism

Female risk factorsFemale risk factorsAge >35 yearsAge >35 years

Anxiety or questioning fertility potentialAnxiety or questioning fertility potential

HistoryHistory

GonadotoxinGonadotoxin exposureexposure

–– PesticidesPesticides

–– MedicationMedication

–– Recreational drugsRecreational drugs

–– Anabolic steroidsAnabolic steroids

–– SmokingSmoking

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History: SmokingHistory: Smoking

Reduced sperm densityReduced sperm density

Decreased sperm functionDecreased sperm function

Increased sperm DNA fragmentation Increased sperm DNA fragmentation

Vine et al, Vine et al, FertilFertil SterilSteril 19941994

Vine et al, Vine et al, FertilFertil SterilSteril 19961996

Sun et al, Sun et al, BiolBiol ReprodReprod 19971997

Lab TestsLab Tests

Semen analysisSemen analysis

–– More than one sampleMore than one sample

–– Different spermatogenic cyclesDifferent spermatogenic cycles

–– Abstinence 2 to 3 daysAbstinence 2 to 3 days

–– Proper collection/ prompt analysisProper collection/ prompt analysis

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SemenalysisSemenalysis

““Minimal Standards of AdequacyMinimal Standards of Adequacy””

–– Ejaculate volumeEjaculate volume 1.5 to 5 ml1.5 to 5 ml

–– Sperm densitySperm density >20 million/ml>20 million/ml

–– Total spermTotal sperm >40 million/ejaculate>40 million/ejaculate

–– MotilityMotility >50%>50%

–– Forward progressionForward progression >2 (0 to 4)>2 (0 to 4)

–– MorphologyMorphology >50% (>14% KSC) normal>50% (>14% KSC) normal

–– No significant agglutinationNo significant agglutination

–– No significant No significant pyospermiapyospermia

–– No No hyperviscosityhyperviscosity

Overview of TestsOverview of Tests

EndocrineEndocrine

Post Ejaculate UrinalysisPost Ejaculate Urinalysis

TRUSTRUS

Semen/sperm testsSemen/sperm tests

–– Leukocyte Leukocyte QuantitationQuantitation

–– AntispermAntisperm antibodiesantibodies

–– Sperm viability testsSperm viability tests

–– SpermSperm--cervical mucus interactioncervical mucus interaction

– Zona free hamster oocyte test

– Computer-aided sperm analysis

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Workup of Low VolumeWorkup of Low Volume

Retrieve sperm

from bladder

Negative

no antegrade ejaculation

Use Sym agent

prior to sex

Positive

antegrade ejaculation

Sympathomimetic

Retrograde ejaculation

Resection of EDO

Ejaculatory duct

obstruction (EDO)

Low semen volume

Normal Volume Normal Volume AzoospermiaAzoospermia

Hypothalamic or

Pituitary deficiency

Low FSH

Obstructive

Azoospermia (OA)

Activespermatogenesis

Testis failure

Non-obstructive

azoospermia (NOA)

Reduced or nospermatogenesis

Testis Biopsy

Normal FSH

Testis failure

Non-obstructive

azoospermia (NOA)

High FSH

Azoospermia

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Hormonal EvaluationHormonal Evaluation

normalnormal/highlowLH

ObstructionTestisHypothal-pit

normallowlowTest

normalhighlowFSH

NonNon--Obstructive Obstructive AzoospermiaAzoospermia

(NOA) (NOA)

HypospermatogenesisHypospermatogenesis (0(0--6 mature 6 mature spermatidsspermatids/tubule)/tubule)

Maturation arrestMaturation arrest(absence of mature (absence of mature spermatidsspermatids))

SertoliSertoli--cell onlycell only

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Genetic screening

Karyotypic chromosomal abnormalities

Y-chromosome microdeletions

Cystic fibrosis gene mutations

Recommended Genetic TestingRecommended Genetic Testing

OligospermiaOligospermia

–– KaryotypeKaryotype

–– YY--MicrodeletionMicrodeletion

–– (CF Screen)(CF Screen)

Non Obstructive Non Obstructive AzospermiaAzospermia

–– KaryotypeKaryotype

–– YY--MicrodeletionMicrodeletion

Obstructive Obstructive AzospermiaAzospermia

–– CF ScreenCF Screen

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Genetic DiagnosesGenetic Diagnoses

Patient educationPatient education

May uncover underlying pathologyMay uncover underlying pathology

Genetic CounselingGenetic Counseling

KaryotypeKaryotype

Peripheral leukocytes

Abnormality in 7% of infertile men

– Inversely Related to Sperm Count

10-15 % in azoospermic

5% in oligospermic

<1% in normospermic

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Sex Chromosomal Aneuploidy

KlinefelterKlinefelter’’ss = 66% of abnormal= 66% of abnormal

Gross Gross karyotypickaryotypic abnormality = higher risk abnormality = higher risk

of congenital and chromosomal defects in of congenital and chromosomal defects in

offspringoffspring

Y-chromosome microdeletions

1010--15% 15% azoospermiaazoospermia/severe /severe oligooligo

PCR w/ tagged sequencesPCR w/ tagged sequences

Most deletions non-overlapping region

– long arm of the Y chromosome (Yq11)

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CF gene mutationsCF gene mutations

CFTR on Chromosome 7CFTR on Chromosome 7

CBAVD in near all clinical CFCBAVD in near all clinical CF

66% of CBAVD has CF gene66% of CBAVD has CF gene

Partner becomes focusPartner becomes focus

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Workup SummaryWorkup Summary

Low vs. normal volume Low vs. normal volume azoospermiaazoospermia

CFTR and CFTR and KaryotypicKaryotypic abnormalities can abnormalities can

have impact on healthhave impact on health

All genetic diagnosis require counseling All genetic diagnosis require counseling

regarding risk to offspringregarding risk to offspring

Partners must be screened if CBAVDPartners must be screened if CBAVD

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Assisted Reproductive Assisted Reproductive

Technologies (ART)Technologies (ART)

DefinitionDefinition

“Any procedure that requires

manipulation of gametes or embryos in

vitro”

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IncludesIncludes

Intra uterine insemination (IUI)Intra uterine insemination (IUI)

IVFIVF

MicromanipulationsMicromanipulations

--Partial Partial ZonaZona Dissection (PZD)Dissection (PZD)

--Sub Sub zonalzonal injection of sperm (SUZI)injection of sperm (SUZI)

--Intra Intra cytoplasmiccytoplasmic sperm injection sperm injection

(ICSI)(ICSI)

OutcomesOutcomes

Pregnancy per cycle

Live birth per cycle

Live birth per egg retrieval

Live birth per transfer rate (highest)

Singleton live birth per cycle – Important ART outcome

– Singleton births = lower risk adverse outcomeslow birth weight

Disability

Death

Singleton live birth per transfer

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DecisionsDecisions

IUI IndicationsIUI Indications

Cervical Factor – Anatomic or Physiologic

Low sperm quality

Antisperm antibodies

Men w/ problems of sperm delivery

– Hypospadias

– Impotence

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IUIIUI

5 to 40 million motile

sperm

> 5 million motile

sperm inseminated

Success = 1% to 12%

–– Lower if MFILower if MFI

–– Higher than baselineHigher than baseline

IUIIUI

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In vitro fertilization (IVF)

1) Controlled ovarian

stimulation

2) Egg retrieval

3) In vitro fertilization

4) Embryo transfer to the

uterus

IVFIVF

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IVFIVF

OocytesOocytes incubated with washed sperm x incubated with washed sperm x

24 hours24 hours

Incubated 1Incubated 1--5 days5 days

Day 3 = 6 to 8-cell stage

Transferred to uterine fundus

Younger = fewer embryos

>40 years = 4-5 embryos

MorphologyMorphology

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Intracytoplasmic sperm injection

(ICSI)

Sperm tail crushed = immotile

Injected through the ZP

– Through perivitelline space

– Into egg cytoplasm

Only need one sperm/egg

– ‘‘Immature’’ sperm

PR 30-40%

56% of IVF include ICSI

ICSIICSI

May use sperm from May use sperm from

Vas, Vas, EpididymisEpididymis, ,

TestisTestis

No evidence to No evidence to

demonstrate one area demonstrate one area

better (metabetter (meta--analysis)analysis)

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Sperm selection, stabilization and Sperm selection, stabilization and

pick uppick up

Egg membrane penetration & Egg membrane penetration &

sperm injectionsperm injection

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SUZI and ICSISUZI and ICSI

Past and Future ARTPast and Future ART

Gamete intra-fallopian transfer

Embryo culture manipulation

Pre-implantation genetic diagnosis

Gamete and embryo cryopreservation

Ovarian tissue freezing

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Embry transferEmbry transfer

Indications for IVFIndications for IVF--ICSIICSI

AbsoluteAbsolute– Use of surgically retrieved sperm

Rare pregnancies from VD sperm w/ IUI

Relative indications– Immunological infertility

– Failure to conceive w/ IUI

– <5 million/ejaculate

– Poor sperm morphology

– Male genetic infertilityY chromosome microdeletions

Karyotype abnormalities

– Low motile sperm count

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Advanced Maternal AgeAdvanced Maternal Age

ComplicationsComplications--FemaleFemale

Ovarian torsion

Ovarian hyperstimulation syndrome (OHSS)

– Excessive gonadotropin stimulation

– Severe = <1% of IVF cycles

– Can be life threatening

– Dramatic increase in estrogen

Electrolyte imbalances

Hypovolemia

Thrombotic events/DVT/PE

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ComplicationsComplications--FemaleFemale

Procedure related

– <1%

Procedure associated

–Multiple births (35% vs 1%)

lower birth weights

higher complication rates

Increased learning disabilities

– Birth defect

– Imprinting disorders

OffspringOffspring

Major birth defects (3.3%)

– Equivalent with intercourse

Risks of sex chromosome anomalies

– 0.8% vs. 0.2%

– Infertility

Hypospadias (1.6% vs. 0.3%)

Imprinting disorders

– Beckwith-Weideman syndrome

– Anglemann syndrome

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Cost EffectivenessCost Effectiveness

VaricocelectomyVaricocelectomy vs. IVF/ICSIvs. IVF/ICSI

–– ??VaricocelectomyVaricocelectomy effectiveeffective

3030--50% Severe MFI 50% Severe MFI ““rescuedrescued””

–– Not effective Not effective

Y Y microdeletionmicrodeletion

KaryotypeKaryotype abnormalityabnormality

Cost EffectivenessCost Effectiveness

VV/VE vs. ARTVV/VE vs. ART

– Vasectomy reversal likely cheaper

– >10 year vasectomies still cheaper

– Advanced maternal age cheaper

VV/VE requires patency rate of >79%

– Quality standards imperative

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Sperm Retrieval OptionsSperm Retrieval Options

EpididymalEpididymal or or testicular sperm for testicular sperm for OAOA

Testicular sperm Testicular sperm (micro(micro--TESE) for TESE) for NOANOA

ElectroElectro--ejaculation ejaculation or or vibrovibro--stimulation stimulation for for anejaculationanejaculation..

MicroMicro--TeseTese

Larger tubules =SpermLarger tubules =Sperm

Thinner tubules =SCO Thinner tubules =SCO

Operating microscope view

SCO

Sperm

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MicroMicro--TeseTese Success RatesSuccess Rates

Retrieval Attempts N=81Retrieval Attempts N=81

Sperm Retrieval 58% (47/81)Sperm Retrieval 58% (47/81)

Fertilization Rate 61% (268/439)Fertilization Rate 61% (268/439)

Clinical Pregnancy 55% (26/47)Clinical Pregnancy 55% (26/47)

Ongoing/Delivery 40% (19/47)Ongoing/Delivery 40% (19/47)

Overall Pregnancy 32% (26/81)Overall Pregnancy 32% (26/81)

Cornell University Web site

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ART SummaryART Summary

IUI if >5 million spermIUI if >5 million sperm

IVF more successful with ICSIIVF more successful with ICSI

VaricocelectomyVaricocelectomy and VV/VE still more cost and VV/VE still more cost

effective for patienteffective for patient

MicroMicro--TeseTese good success with minimal good success with minimal

damage to testicledamage to testicle

Male Factor Infertility - Urology Rounds · SEMEN CRYOPRESERVATION Oxidative Stress. 6 Associations...

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Transcript of Male Factor Infertility - Urology Rounds · SEMEN CRYOPRESERVATION Oxidative Stress. 6 Associations...