the journey male infertility too often ignored & forgotten€¦ · imsi ha sperm selection ......

17-Aug-16

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Male infertility – too often

ignored & forgotten

A review of the guidelines

Joo Teoh

FRANZCOG MRCP(Ire) MRCOG MBBCh MSc(Lon)

MD(Glasgow) SubspecialtyRepromed(UK)

Consultant Obstetrician & Gynaecologist

The journey

1. The optimal evaluation of the men

The optimal evaluation

We got sperms, full stop.


Sperm + Egg = Embryo



The Numbers Game



Surely it is enough?

_,000,000

“I only need 1”

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Tests:

KISS

“Keep it sophisticated and

subspecialised”


DNA integrity

Chromatin assays for DNA

fragmentation evaluation

Sperm chromatin structure assay (SCSA)

TdT-mediated-dUTP nick end labeling (TUNEL)

Sperm chromatin dispersion (SCD)

Acridine orange straining technique (AOT)



Chohan et al; J Androl;

27:53-59


DNA integrity

Copyright© 2010 American Urological Association Education and Research, Inc.®

16

pregnancy loss 25

. However there is insufficient evidence to warrant routine testing in these

couples until further evidence accumulates. A variety of treatments have been suggested for

patients with poor sperm DNA integrity, however there is no evidence demonstrating that

treatment results in improved sperm DNA integrity and improved pregnancy/delivery rates.

Recommendation: Currently there is insuff icient evidence in the literature to

support the routine use of DNA integrity testing in the evaluation and management

of the male partner of an infertile couple. Presently, there are no proven therapies

to correct an abnormal DNA integrity test result.

Reactive oxygen species (ROS)

Reactive oxygen species are generated by both seminal leukocytes and sperm cells, and can

interfere with sperm function by peroxidation of sperm lipid membranes and creation of toxic

fatty acid peroxides. ROS also have a normal physiological role in the regulation of capacitation

and the acrosome reaction. Elevated ROS have been implicated as a cause of male infertility.

Controversy exists regarding the best method of testing for ROS; role of excess ROS in both

natural conception and assisted reproductive technology; and whether therapies are effective at

reducing seminal ROS and improving fecundity. Direct ROS testing is limited by the short

duration of activity of the molecules. Seminal ROS is currently assessed by indirect testing

methods that measure the products of ROS. Studies correlating seminal ROS levels to

pregnancy outcomes are extremely limited or contradictory.26-34

Most studies are limited by lack

of controls and the lack of standardized testing methods for ROS makes comparison between

studies difficult. The literature regarding ROS therapies is flawed by the paucity of randomized

controlled trials and the lack of standardized type and duration of treatment. Review of the

current literature reveals an inconsistent effect of therapies aimed at reducing seminal ROS upon

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Tests:

- To know you I have to kill you

- Difficulty in finding threshold

value



Tests:

- To know you I have to kill you

- Difficulty in finding threshold

value

Sperm selection techniques

HA sperm selection

MACS

IMSI

HA sperm selection

Hyaluronic acid

Bind to HA in vitro

Completed plasma membrane remodelling, cytoplasmic

extrusion and nuclear maturation

Low chromosomal aneuploidies & DNA fragmentation,

good nuclear morphology

Only mature spermatozoa which have extruded their

specific receptors to bind to & digest HA can reach the

oocyte & fertilize it

HA sperm selection

Parmegiani et al. J Assist Reprod Genet (2010) 27:13-16

HA-ICSI sigificantly improves embryo quality & implantation

Awaiting multi-center randomized studies (UK)

IMSI

Morphologically selected sperm injection

What is the best criteria for selection?

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IMSI

Conflicting results:

No difference in fertilisation rate, early embryo cleavage

rate or cleavage rate. Similar proportion of top quality

embryos. (Mauri et al. Eur J Obstet Gynecol Reprod Biol.

2010 May; 150(1):42-6)

Based on motile sperm organellar morphology exam

(MSOME), individuals with best morphologically normal

nucleus has significantly higher pregnancy & delivery rates.

Also significantly lower miscarriage rates. (Bertovitz et al.

Reprod Biomed Online. 2006 May; 12(5):634-8

IMSI

Conflicting results:

IMSI group significantly lower number of cycles with no

embryo transfer. Trend of higher no. of blastocysts, higher

pregnancy rates, less miscarriage rates. Score of

spermatozoa = (2 x head) + (3 x vacuole) + (base). Knez at

al. Reproductive Biology & Endocrinology 2011. 9:123

MACS

Magnetic-activated cell sorting

Colloidal superparamagnetic microbeads conjugated

with annexin V

MACS (meta- analysis)

Gil et al. J Assist Reprod Genet (2013) 30:479-485

MACS (meta- analysis)

Gil et al. J Assist Reprod Genet (2013) 30:479-485

Sperm selection techniques

HA sperm selection

MACS

IMSI

TOO EARLY FOR INTERNATIONAL GUIDELINES

17-Aug-16

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Tests:

KISS

“Keep it sophisticated and

subspecialised”


Tests:

KISS

“Keep it simple & sweet”



Have you got the latest WHO

manual?



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On Weight and Fertility »

New World Health Semen Analysis Parameters

by Julian Escobar, MD | July 18th, 2013

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In 2010 the World Health Organization (WHO) updated its reference values for the Semen Analysis.[1]This update was long overdue as the last version was published in 1999.

There is a significant difference on how the old and new reference ranges were derived. In the past, semendata from random populations of men were analyzed and the results were plotted on a statisticaldistribution curve. The 5th percentile was considered to be the lower limit of normal (or reference), inanother word, 95% of men tested would have sperm parameters higher than the reference ranges.

In WHO 2010, the new normal values are based on data from men with proven fertility, men who wereknown to help their partners conceive in the previous 12 months. Following a large analysis of semenparameters from over 4000 men in 14 countries, a new set of 5th percentile parameters wasrecommended. Below are the comparisons of the old and new reference values:

Parameter WHO 1999 WHO 2010

Volume 2 ml 1.5 ml

Concentration 20 million/ml 15 million/ml

Progressive motility 50% 32%

Normal forms 14% 4%

Based on our experience, concentration and progressive motility are the most important sperm parametersin predicting the likelihood of pregnancy via coitus or intrauterine insemination. For example, whensperm concentration is < 10 million/ml and/or progressive motility < 20%, the chance of pregnancy usingthe conventional methods is very low. In vitro fertilization would provide the best chance of pregnancy.

Somewhat more difficult to interpret is sperm morphology, or the proportion of sperm that appear perfectunder light microscopy. Morphology is the most subjective parameter in a semen analysis with differentcenters using different criteria to evaluate morphology. Moreover, technicians within the same laboratorycan give different values using the same grading scheme.

As can be seen above, there is a large difference between the WHO morphology references for 2010 and1999, reflecting the subjective nature of this parameter. At IVFMD we usually do not use morphologywhen recommending initial treatment. In our experience, as long as sperm Concentration and motility arewithin normal ranges, poor morphology scores do not necessarily preclude pregnancy. Over the years wehave seen many men with isolated low morphology scores (0-3%) who became biological fathers withoutthe need for IVF or ICSI.

The new WHO criteria are unique because for the first time, a semen sample under evaluation can becompared to those of fertile men. We have found the new standards to be quite helpful in assessing themale fertility potential. If you have any questions about the new parameters, do feel free to contact

Reference: Cooper, TG et al. WHO reference values for human semen characteristics. Hum. Reprod. Update. 2010. 16(5):559

| Category: IVFMD |

About Julian Escobar, MD

Dr Escobar graduated with High Honors in Genetics from the University of Georgia and was subsequentlyawarded prestigious research fellowships at the National Institutes of Health and Harvard Medical School.He then obtained his medical degree from the University of Pittsburgh School of Medicine and completedhis OBGYN residency at Northwestern University. He later relocated to Dallas to pursue fellowshiptraining in Reproductive Endocrinology and Infertility at UT Southwestern Medical Center. Dr. Escobar isboard certified in ï»¿Obstetrics & Gynecology. He is an active member of the American College ofObstetrics & Gynecology, the American Society of Reproductive Medicine, the American Association ofGynecological Laparoscopists, the Endocrine Society and the Texas Medical Association. He has lived inseveral Latin American countries and is completely fluent in Spanish.http://www.ivfmd.net

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Why the difference?








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Volume 2 ml 1.5 ml

Concentration 20 million/ml 15 million/ml

Progressive motility 50% 32%

Normal forms 14% 4%

Based on our experience, concentration and progressive motility are the most important sperm parametersin predicting the likelihood of pregnancy via coitus or intrauterine insemination. For example, whensperm concentration is < 10 million/ml and/or progressive motility < 20%, the chance of pregnancy usingthe conventional methods is very low. In vitro fertilization would provide the best chance of pregnancy.

Somewhat more difficult to interpret is sperm morphology, or the proportion of sperm that appear perfectunder light microscopy. Morphology is the most subjective parameter in a semen analysis with differentcenters using different criteria to evaluate morphology. Moreover, technicians within the same laboratorycan give different values using the same grading scheme.

As can be seen above, there is a large difference between the WHO morphology references for 2010 and1999, reflecting the subjective nature of this parameter. At IVFMD we usually do not use morphologywhen recommending initial treatment. In our experience, as long as sperm Concentration and motility arewithin normal ranges, poor morphology scores do not necessarily preclude pregnancy. Over the years wehave seen many men with isolated low morphology scores (0-3%) who became biological fathers withoutthe need for IVF or ICSI.

The new WHO criteria are unique because for the first time, a semen sample under evaluation can becompared to those of fertile men. We have found the new standards to be quite helpful in assessing themale fertility potential. If you have any questions about the new parameters, do feel free to contact

Reference: Cooper, TG et al. WHO reference values for human semen characteristics. Hum. Reprod. Update. 2010. 16(5):559

| Category: IVFMD |

About Julian Escobar, MD

Dr Escobar graduated with High Honors in Genetics from the University of Georgia and was subsequentlyawarded prestigious research fellowships at the National Institutes of Health and Harvard Medical School.He then obtained his medical degree from the University of Pittsburgh School of Medicine and completedhis OBGYN residency at Northwestern University. He later relocated to Dallas to pursue fellowshiptraining in Reproductive Endocrinology and Infertility at UT Southwestern Medical Center. Dr. Escobar isboard certified in ï»¿Obstetrics & Gynecology. He is an active member of the American College ofObstetrics & Gynecology, the American Society of Reproductive Medicine, the American Association ofGynecological Laparoscopists, the Endocrine Society and the Texas Medical Association. He has lived inseveral Latin American countries and is completely fluent in Spanish.http://www.ivfmd.net

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Name (required)









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One step back- history and examination!!





The optimal evaluation The optimal evaluation


17-Aug-16

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The journey


2. Further investigations

Further investigations

What is needed and when to test?



11

Other procedures and tests for assessing male fertility

Endocrine evaluation

Hormonal abnormalities of the hypothalamic-pituitary testicular axis are well-recognized, though

not common causes of male infertility. An endocrine evaluation should be performed if there is:

1) an abnormal semen analysis, especially if the sperm concentration is less than 10 million/ml;

2) impaired sexual function; or 3) other clinical findings suggestive of a specific endocrinopathy.

Some experts believe that all infertile males should have an endocrine evaluation, but there is no

consensus of opinion on this controversy. The minimum initial hormonal evaluation should

consist of measurements of serum follicle-stimulating-hormone (FSH) and serum testosterone

levels. If the testosterone level is low, a repeat measurement of total and free testosterone (or

bioavailable testosterone), as well as determination of serum luteinizing hormone (LH) and

prolactin levels should be obtained. Although serum gonadotropin levels are variable because

they are secreted in a pulsatile manner, a single measurement is usually sufficient to determine a

patient’s clinical endocrine status. The relationship of testosterone, LH, FSH and prolactin helps

to identify the clinical condition (see Table 2). A normal serum FSH level does not guarantee the

presence of intact spermatogenesis, however, an elevated FSH level even in the upper range of

“normal” is indicative of an abnormality in spermatogenesis.

Recommendation: An initial endocrine evaluation should include at least a serum

testosterone and FSH. It should be performed if there is: (1) an abnormally low

sperm concentration, especially if less than 10 million/ml; (2) impaired sexual

function; or (3) other clinical findings suggestive of a specific endocrinopathy.




Genetic studies


24

Karyotype

A karyotype analyzes all chromosomes for the gain or loss of entire chromosomes as well as

structural defects, including chromosome rearrangements (translocations), duplications,

deletions, and inversions. Chromosome abnormalities account for about 6% of all male

infertility, and the prevalence increases with increased spermatogenic impairment (severe

oligospermia and nonobstructive azoospermia). Paternal transmission of chromosome defects

can result in pregnancy loss, birth defects, male infertility, and other genomic syndromes.

Recommendation: Karyotyping and genetic counseling should be offered to all

patients with nonobstructive azoospermia and severe oligospermia (<5 million

sperm/ml).

Y-chromosome microdeletions

Approximately 13 % of men with nonobstructive azoospermia or severe oligospermia have an

underlying Y-chromosome microdeletion.57

Y chromosome microdeletions responsible for

infertility — regions AZF a, b, or c — are detected using sequence tagged sites (STS) and

polymerase chain reaction (PCR) analysis. There is no consensus on the number of STS required

for optimal detection of AZF deletions. Detection has both prognostic and ethical significance.

Successful testicular sperm extraction has not been reported in infertile men with either an AZFa

or AZFb deletion but the total number of reports is limited.58

In contrast, up to 80% of men with

AZFc deletions have retrievable sperm for ICSI. Furthermore, the couple must be counseled on

the inheritance of this compromised fertility potential in all male offspring.59-60

Recommendation: There are insufficient data to recommend a minimal number of

sequence tagged sites to test for in patients undergoing Y chromosome

microdeletion analysis. Although the prognosis for sperm retrieval is poor in

Further investigationsGenetic studies


22

of only 11%. However, for those patients who have CBAVD and CFTR mutations the

prevalence of renal anomalies is extremely rare.47

Therefore, imaging of the kidneys with either

ultrasound or CT scan is more likely to detect abnormalities in men with unilateral vasal agenesis

or men with CBAVD who do not have mutations in CFTR.

Recommendations: Men with congenital bilateral absence of the vasa deferentia

should be offered genetic counseling and testing for cystic fibrosis transmembrane

conductance regulator mutations. The female partner should also be offered cystic

fibrosis transmembrane conductance regulator mutations testing before proceeding

with treatments that utilize the sperm of a man with congenital bilateral absence of

the vasa deferentia. Imaging for renal abnormalities should be offered to men with

unilateral vasal agenesis or congenital bilateral absence of the vasa deferentia and

no evidence of cystic fibrosis transmembrane conductance regulator abnormalities.

Cystic fibrosis transmembrane conductance regulator testing

Routine screening for mutations of CFTR is currently performed by testing for a panel of

specific mutations that are known to be prevalent rather than sequencing the entire gene. The

CFTR gene is extremely large and the number of mutations potentially infinite. Clinical

laboratories typically test for the 30–50 most common mutations found in patients with clinical

cystic fibrosis. However, the mutations associated with CBAVD may be different. There are

more extended panels available that test up to 100 mutations. Because over 1,300 different

mutations have been identified in this gene, this type of limited analysis is only informative if a

mutation is found. A negative test result only indicates that the CBAVD patient does not have

the most common mutations causing cystic fibrosis. Direct sequence analysis of the entire gene

is commercially available but very costly. In addition to point mutations, variations of intron 8

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Further investigationsGenetic studies

Y-microdeletion testing

Is there anything I can do to

improve my sperms? The journey



3. Strategy to improve sperm parameters

Strategy to improve sperms

Medical Surgical


Medical Surgical

The insult can be permanent

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Medical


Medical


Medical


Medical

NO MENTION OF MALE SUPPLEMENT!


Medical


Medical

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Medical Surgical

• Urology


Surgical

Urology

Obstruction


Surgical

Urology

Varicocoele

Varicocoele repair


Surgical

Urology

Varicocoele


Surgical

Urology

Varicocoele

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Surgical

Urology

Varicocoele

The insult can be permanent

The journey




4. Surgical sperm retrieval

Surgical sperm retrieval

Esteves et al, International Braz J Urol, 2011

578

Sperm Retrieval for Assisted Reproduction

of sperm collection. TESA retrieval rates range

from 10-30% (22,23,39-41), except in the favora-

ble cases of previous successful TESA or testicu-

lar histopathology showing hypospermatogenesis.

In such cases, TESA SRR range from 70-100%

(6,10). In a recent systematic review the mean re-

ported SRR for TESE was 49.5% (23). TESE with

multiple biopsies resulted in higher SRR than fine -

-needle aspiration (TEFNA), a variation of TESA,

especially in cases of Sertoli-cell-only (SCO) and

maturation arrest (23). Retrieval rates ranging from

35% to 77% have been reported for micro-TESE

Table 2 - Advantages and Disadvantages of Sperm Retrieval Techniques for Assisted Reproduction.

Advantages Disadvantages

PESA Fast and low cost

Minimal morbidity, repeatable

No microsurgical expertise required

Few instruments and materials

No surgical exploration

Few sperm retrieved

Cryopreservation limited

Fibrosis and obstruction at

aspiration site

Risk of hematoma/spermatocele

MESA Large number of sperm retrieved

Excellent chance of sperm cryopreservation

Reduced risk of hematoma

Reconstruction possible 1

Surgical exploration required

Increased cost and time-

demanding

Microsurgical instruments and

expertise required

Postoperative discomfort

TESA Fast and low cost

Repeatable

No microsurgical expertise required

Few instruments and materials

No surgical exploration

Minimal/mild postoperative discomfort

Relatively low success rate in

NOA

Few sperm retrieved in NOA

Cryopreservation limited

Risk of hematoma/testicular

atrophy

TESE No microsurgical expertise required

Fast and repeatable

Relatively low success rate in

NOA

Relatively few sperm retrieved in

NOA

Risk of testicular atrophy (with

multiple biopsies)


Micro-TESE Higher success rates in NOA 2

Larger number of sperm retrieved 2

Relatively higher chance of sperm cryopreservation 2

Low risk of complications

Surgical exploration required

Increased cost and time-

demanding

Microsurgical instruments and

expertise required


PESA: percutaneous epididymal sperm aspiration; MESA: microsurgical epididymal sperm Aspiration; TESA: per-

cutaneous testicular sperm aspiration; TESE: conventional testicular sperm extraction; micro-TESE: microsurgical

testicular sperm extraction.

1 - In cases of vasectomy; 2 - Compared to TESA and TESE in NOA

Surgical sperm retrieval

The journey




4. Surgical sperm retrieval

5. Counselling

Summary

Semen analysis

History & examination

Referral for further evaluation & treatment

If <10 million/ml

FSH, LH, prolactin, testosterone, TFT

Karyotyping

Y- chromosome deletion

Cystic fibrosis if absent vas deferens

Surgical sperm retrieval for azoospermia, or severe oligospermia when appropriate

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Quiz

How about eggs…

How many is enough in a fresh cycle?

Quiz

How about eggs

How many is enough in a fresh cycle?

Egg number and live birth rate

Sunkara et al., Hum Reprod. 2011

Thank you

the journey male infertility too often ignored & forgotten€¦ · imsi ha sperm selection ......

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