Sandro Esteves, MD, PhD

Director, ANDROFERTCenter for Male Reproduction and InfertilityCampinas, BRAZIL

Microdissection Testicular Sperm Extraction

(micro-TESE)

Esteves, 1

Esteves, 2

Learning Objectives

Understand the difference between obstructive (OA) and non-obstructive azoospermia (NOA)

Overview of sperm retrieval techniques for NOA (micro-TESE) and how to handle testicular

sperm for ICSI

Learn the success rates and prognostic factors of sperm retrieval in NOA using micro-TESE

Reproductive potential of azoospermic men undergoing assisted conception

Azoospermia• It is not a synonymous of sterility

• Normal sperm production

• Mechanical blockage • Vasectomy, Post-

infectious, Congenital

Obstructive• Sperm production

deficient or absent

• Cryptorchidism, Orchitis, Radiation, Chemotherapy, Trauma, Genetic, Gonadotoxins, Idiopathic

Non-obstructive

Obstructive Azoospermia

• Epididymis• Testis• Simple and

effective

Sperm retrieval for ART

Watch the video at http://androfert.com.br/videos

PERCUTANEOUS RETRIEVAL

CBAVD (N=30) Vasectomy (N=64)

Post-infectious (N=48)

Total (N=142)

100%95.3%

100% 97.9%

SUCCESS RATES IN OBSTRUCTIVE AZOOSPERMIA

Esteves SC, Verza S, Prudencio C, Seol B. Success of percutaneous sperm retrieval and intracytoplasmic sperm injection (ICSI) in obstructive azoospermic (OA) men according to the cause of obstruction. Fertil Steril. 2010;94 (Suppl):S233.

ICSI Ejaculated Sperm n=220

Testicular/Epididymal Sperm

OA; n=93

2PN Fertilization (%) 70.0 73.6

TQE on Day 3 (%) 48.5 46.3

Clinical Pregnancy (%) 43.2 51.3

Miscarriage (%) 12.1 20.0

Sperm defect severity rather than sperm source is associated with lower fertilization rates after

intracytoplasmic sperm injectionVerza Jr S & Esteves SC; Int Braz J Urol 2008; 34

Esteves, Androfert

Not statistically different

Non-obstructive AzoospermiaNon-obstructive Azoospermia

20% of infertile men attending ART Clinics 60-70% of azoospermic men Causes are:

• Pre-testicular: HH • Testicular causes

• Genetic Y chromosome microdeletion Klinefelter syndrome

Varicocele Cryptorchidism Chemotherapy/Radiation Infection Idiopathic

72.8

19.57.7

Male Infertility Di-agnosis

OtherNon-obstructive azoospermiaObstructive azoospermia

Source: ANDROFERT, Brazil

Non-obstructive Azoospermia

• Sperm production reduced or absent

• Geographic location unpredictable

Sperm Retrieval for ART

Untreatable condition

Small testes/elevated FSH/”sterile” Overall production poor

— Inadequate production for sperm in ejaculate

Heterogeneity of sperm production:— 600-800 seminiferous tubules/testis— Single focus of production adequate to

retrieve spermatozoa for ICSI

Goal: To identify and retrieve sperm for ICSI

TESA

TESE

Sperm Retrieval Techniques in Non-obstructive Azoospermia

Controlled studies for NOA men

Needle Aspiration

Open Biopsy

Friedler et al., Human Reprod 12:1488, 1997

4/37 (11%) 16/37 (43%)

Ezeh et al. Human Reprod 13:3075, 1998

5/35 (14%) 22/35 (63%)

Non-obstructive Azoospermia

TESA vs. TESE

Non-obstructive AzoospermiaTesticular microdissection (micro-TESE)

• Method to identify site(s) of production– Based on the diameter of

seminiferous tubules

• Microsurgical approach– Identify site of production– Preserve testis vasculature – Small quantity of tissue excised

Schlegel, Hum Reprod 1999; 14

Microsurgical identification of sperm-producing tubules by

appearance

Vascular pattern of testis

• Extensive pattern of vessels surrounding the testis

Photomicrograph courtesy JP Jarow, M.D.

Intratesticular anatomy

• Parallel arteries and veins surrounding seminiferous tubules

• Allows dissection between tubules

Watch the video at http://androfert.com.br/videos

TESE & micro-TESE

Laboratory Sperm Processing for ICSI

Esteves, Androfert

TESE

Micro-TESE

RESULTS

Microdissection vs. Standard multi-biopsy TESE

Controlled series of 27 patients Standard TESE: 41% (11/27) retrieval Microdissection: 63% (17/27) retrieval

Schlegel, Human Reproduction 14:131, 1999

Microdissection provides sperm retrieval for one-third of men who fail standard multibiopsy TESE

Microdissection TESE

Amer et al 2000 100 45% 30%

Okada et al 2002 98 45% 17%

Okubu et al 2002 17 48% 24%

Tsujimura et al 2002 93 43% 35%

Ramon et al 2003 321 62% 58%

#Pts %MicroTESE %TESEStudy Success Success

49% 33%

The Microdissection TESE

Concept: 100 men with “identical” bilateral histology.

One side TESE, the other microdissection

Approach Success (%) Tissue

TESE biopsy 30/100 (30%) 54 mg

Microdissection 45/100 (45%) 4.6mg

Amer M, et al. Hum Reprod 15: 653, 2000

Amer et al.: Microdissection TESE

100 men with non-obstructive azoospermia Controlled trial of TESE v. Microdissection Serial ultrasound follow-up at 1, 3, 6 mos.

Std TESE Microdissection

Sperm retrieval 30% 47%

Acute changes 48% 15%

Chronic changes 58% 3%

Amer et al., Hum Reprod 15:653, 2000

Okada et al.: Microdissection TESE

Std TESE Microdissection

Retrieval rate: SCO

6.3% 34%

Retrieval rate: All NOA pts

16.7% 45%

Ultrasound changes

51% 12%

Complications* 7.5% 2.5%

Okada et al., J Urology 168:1063, 2002

*Decreased testicular volume seen after 25% of TESE procedures

Why is Sperm Prediction Important?

1. Can minimize emotional and financial cost of IVF cycles.

2. Can minimize trauma/ damage to testis during sperm harvesting.

Chance of finding sperm is dependent on the most advanced site of spermatogenesis within the testis

— FSH— Inhibin B— Testicular volume— Etiology— Testosterone levels— Testis histology

Reflect global spermatogenic function but not the most advanced site of sperm production in a dysfunctional testis

Esteves, Androfert

Predictive Factors for Sperm Retrieval in NOA

Predictive Factors for Sperm Retrieval in NOA

Y Chromosome Microdeletion

AZFa deleted

Germ cell Aplasia

No retrievable sperm

AZFb deleted

Maturation Arrest

No retrievable sperm

AZFc deleted

Hypospermatogenesis

70% chance of retrieving testicular sperm for ICSI

Predictive Values of Noninvasive Tests or Techniques for Sperm Retrieval

OverallParameter predictive or exam Sensitivity % Specificity % value %

Testicular volume 7.6–50 6.7–71

FSH 9–71 40–90

Inhibin B 44.6 63.4

FSH, total T, Inhibin B 71 71.4

Testicular volume + hormones 80.8

Doppler ultrasound imaging 47.3 89

Carpi. Controversies in nonobstructive azoospermia. Fertil Steril 2009.

• 176 NOA men (mean age 36.9 years)• Microdissection TESE or TESA• Classified according to the Etiology of NOA• Biopsy for histology concomitant or prior to SR

Sperm Retrieval Rates in NOA are Related to Testicular Histopathology but not to the Etiology of

Azoospermia

Esteves SC, Verza Jr S, Prudencio C, Seol B; Fertil Steril 2010

Hypospermatogenesis (HYPO)

Maturation Arrest (MA)

Sertoli Cell Only Syndrome (SCO)

Esteves, Androfert

Sperm Retrieval and Etiology of NOA

Chi-square; NSEsteves SC, Verza S, Prudencio C, Seol B. Sperm retrieval rates (SRR) in nonobstructive azoospermia (NOA) are related to testicular histopathology results but not to the etiology of azoospermia. Fertil Steril. 2010;94(Suppl.):S132.

Etiology

Histology Sperm +TESA

Sperm + Micro-TESE

HYPO 26/26 (100.0%) 19/19 (100.0%)

MA 2/6 (33.3%) 7/12 (60.0%)*

SCO 6/29 (20.7%) 13/39 (33.3%)*

Total 34/61 (55.7%) 39/70 (55.7%)

Results (2): Micro-TESE X TESA

Sperm Retrieval in NOA is related to Testicular Histopathology

Esteves SC et al Fertil Steril 2010; 94:S132

Esteves, Androfert

*TESA vs micro-TESE (MA + SCO): P=.03

Finding Testicular Sperm in Non Obstructive Azoospermia

Histological Pattern Cases Recovery Rate (%)

Normal 157 100%

Hypospermatogenesis 16 90%

Maturation arrest 94 63%

Sertoli cell-only (pure) 156 13%

Tubular sclerosis 18 39%

Harris et al. Urologic Clinics North America 2008

Avg Rec Rate 52%

MICRO-TESE

Success Rate

22%

40.00%

NOA

TESA/TESE

N=131; *hypospermatogenesis excluded

Esteves et al.; Fertil Steril 2010; 94:S132

Micro-TESE39%

P=.03

Chance of Sperm Retrieval by NOA Diagnosis

Cryptorchidism

52-74% Varicocele

63-68% Epididymitis

67% Mumps

67% Torsion

>50% Post-chemotherapy

55-75% Genetic AZF a, b

0% Genetic AZF c

50-75% Orchitis, Gonadotoxins, Endocrine

100% Idiopathic

50-60%

Esteves, 2011; Shefi and Turek, submitted; Raman and Schlegel. J Urol.170:1287, 2003;Hopps et al. Hum Reprod. 180:1660, 2003; Damani et al. JCO. 15: 930, 2002

Candidates for sperm retrievalNon-obstructive azoospermia

“Testicular failure” Klinefelter’s syndrome Sertoli cell-only Post-chemotherapy (e.g., lymphoma, testis) Cryptorchidism Maturation arrest Previously failed attempt at “biopsy”

retrieval

Reproductive Potential of

Testicular Sperm from NOA men used for ART

Esteves, Androfert

ICSIEjaculated

Sperm

N=220

Testicular/Epididymal Sperm (OA)

N=39

Testicular Sperm NOA N=52

P-value*

%2PN Fertilization 70.0 73.6 52.2* 0.01

%TQE on Day 3 48.5 46.3 35.7* 0.03

%Clinical Pregnancy Rate 43.2 51.3 25.9* 0.04

Miscarriage (%) 12.1 20.0 14.3 NS

Sperm Defect Severity Rather Than Sperm Source Is Associated With Lower Fertilization Rates After

Intracytoplasmic Sperm InjectionVerza Jr S & Esteves SC; Int Braz J Urol 2008; 34

Sperm Retrieval Live Birth

97.9%

38.2%55.2%

25.0%

Obstructive (N=142) Non-obstructive (N=172)

Odds ratio 43.0 1.86

95% CI 10.3 – 179.5 1.03 – 2.89

P-value <0.01 0.03

Prudencio C, Seoul B, Esteves SC. Reproductive potential of azoospermic men undergoing intracytoplasmic sperm injection is dependent on the type of azoospermia. Fertil Steril 2010; 94 (4): Suppl. S232-233.

Sperm Retrieval Rates and Reproductive Potential of Azoospermic Men in ICSI

Microdissection TESE

Requires use of microscope (15-20x) Learning curve Depends on differential size of tubules Tedious

Increased sperm yield Less tissue removal Fewer postoperative changes

Schlegel, Hum Reprod 14:131, 1999 Amer et al., Hum Reprod 15:653, 2000 Okada et al., J Urology 168:1063, 2002

• Sperm production deficient or absent

• Overall, retrieval rates ~50%

• Labor-intensive lab sperm processing• Retrieval rates dependent on technique

• Micro-TESE yields better SRR • Predictive factors: testis histology & Y-chromosome

• Reproductive potential by ICSI lower than OA and non-azoospermic men

Non-obstructive Azoospermia

Sperm Retrieval Techniques Practical Points