Optimizing Sperm Retrieval
Paul J. Turek M.D. Director, The Turek Clinic,
Beverly Hills and San Francisco, CA
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Optimizing Sperm Retrieval
Learning Objectives
• Describe the role of medical therapy before sperm retrieval • Delineate two strategies currently used to find and retrieve
testicular sperm in nonobstructive azoospermia • Explain how sperm search can be optimized in the andrology
laboratory
Test Answers
These can be tough cases!
Optimizing Sperm Retrieval
Patient Procedure Laboratory
Medical therapy Cryptozoospermia
TESA/TESE Microdissection FNA Mapping
Search time Sperm banking
Optimizing Sperm Retrieval
Patient Procedure Laboratory
Medical therapy Cryptozoospermia
• N=42 azoospermic men treated with clomid: 64% ejaculated sperm! Hussein et al J. Androl. 26: 787, 2005
Medical Therapy May Help
Shiraishi et al, Hum Reprod. 2012, 27:331-‐9
N=48 failed mTESE
No Rx + Rx
Raman and Schlegel. J Urol. 2002 167:124
Medical Therapy May Help
Motile ejaculated sperm after varicocelectomy
N=233 Overall success=39%
Weedin et al. J Urol. 2010, 183; 2309
Optimizing Sperm Retrieval
Patient Procedure Laboratory
Medical therapy Cryptozoospermia
Strategies-Cryptozoospermia
The Centrifuged Pellet
Jaffe et al. J Urol. 1998; 159: 1548-50
TYPE # Pts % Sperm Variability
Obstructive 70 18.6% 41%
Non obstructive 70 22.8% 12%
(NS, n=17/group)
(600-1000 x g for 15 minutes)
Cryptozoospermia
Reliable ejaculated sperm?
No
IVF-ICSI
Bank Ejaculated Sperm
Yes
FNA Map (1-3 mos)
MicroTESE (<1 mos)
Treat/Improve(3-6
mos)
Testis Testis/Ejaculate Ejaculate Ejaculate
The Turek Clinic Approach
2010-2012 N=40 men with cryptozoospermia Mean age=38 years
No sperm Nonmotile
Motile
Motile and nonmotile
10% 25%
60%
5%
Hagerty et al, 2012
• 85% of men able to bank sperm
• 40% sample-to- sample variability
“Epidemiology” of Cryptozoospermia
• 2010-2012 • N=40 men with cryptozoospermia
• To date, 13/40 couples to IVF-ICSI • Sperm source:
Fresh Ejaculate
77%
Thawed Ejaculate
8%
mTESE 15%
• Mean partner age 32 (27, 41)yr • 60% 2PN rate • 46% (6/13) ongoing preg. rate
Hagerty et al, 2012
“Epidemiology” of Cryptozoospermia
Sperm Source and ICSI Fertilization
NOA-Testis sperm NOA-Cryptozoospermia
X
X
What kind of performance differences do we expect between cryptozoospermic and testicular sperm?
Optimizing Sperm Retrieval
Patient Procedure Laboratory
Medical therapy Cryptozoospermia
TESA/TESE Microdissection FNA Mapping
Vasal (MVSA; PVSA)
Epididymal (MESA, PESA)
Testicular (TESA, TESE, Microdissection TESE)
Sperm Retrieval Sources
Ejaculate
Principle: Primum no nocere Least invasive, least damaging, best yield.
Turek et al. Ass Reprod Rev. 1999, 9: 60-64
Guiding Principle
Epididymal Sperm: Evidence-Based Guidelines
Nicopoullos et al. Fert Steril. 2004, 82: 691-701 Donoso, Tournaye, Devroey. Hum Reprod Upd. 2007, 13: 539-549 Van Peperstraten et al. Cochrane Database Syst Rev. 2006, 3:CD 002807
• For epididymal vs. testicular sperm in obstructive azoospermia: Insufficient evidence to detect a difference in outcome.
• For fresh vs. frozen thawed epididymal sperm:
There is no difference in clinical outcome (FR, OPR)
Testicular Sperm: Evidence-Based Guidelines
Donoso, Tournaye, Devroey. Hum Reprod Upd. 2007, 13: 539-549
Obstructive vs. Nonobstructive Azoospermia Meta-analysis of 1103 cycles, non-randomized studies
Obstructive vs Nonobstructive RR (CI)
2PN fertilization 1.18 (1.13-1.23) Clinical pregnancy rate 1.36 (1.1-1.69) Ongoing preg. rate 1.19 (0.87-1.61) Implantation rate 1.01 (.87-1.61) Miscarriage rate 0.84 (.48-1.48)
Fixed model
Nicopoullos et al. Fert Steril. 2004, 82: 691-701
Testis Sperm: Evidence-Based Guidelines
Donoso, Tournaye, Devroey. Hum Reprod Upd. 2007, 13: 539-549 Van Peperstraten et al. Cochrane Database Syst Rev. 2006, 3:CD 002807 Nicopoullos et al. Fert Steril. 2004, 82: 691-701
• For obstructive vs. nonobstructive azoospermia: Insufficient evidence to recommend one sperm retrieval technique over another.
• Sperm retrieval in cases of nonobstructive azoospermia Can be very difficult due to “patchy” or “focal” nature of production.
• In cases of nonobstructive azoospermia: There is no relationship between the sperm
technique chosen and ICSI outcomes.
What About “Delayed Fresh” Sperm Retrieval?
Morris et al. J Urol. 2007, 178:2087-91
0%
5%
10%
15%
20%
25%
Initial 24 hours 48 hours
OA (n=51)
NOA (n=44)
Time After Sperm Retrieval
% Motility
Testis sperm motility
Study of Motility and Viability of Aspirated Sperm
Bachtell et al. Hum Reprod. 1999, 14:101
Motility *Viability Fresh Thawed Fresh Thawed
Testis, NOA 5% 0.2% 86% 46%
Epididymis, OA 22% 7% 57% 24%
Vas deferens, fertile 71% 38% 91% 51% *Vital Stains: carboxyfluorescein, 0.08mg/mL; propidium iodide, 20mg/mL
Testicular Sperm: Evidence-Based Guidelines
Donoso, Tournaye, Devroey. Hum Reprod Upd. 2007, 13: 539-549 Van Peperstraten et al. Cochrane Database Syst Rev. 2006, 3:CD 002807 Nicopoullos et al. Fert Steril. 2004, 82: 691-701
• For fresh vs. frozen testicular sperm:
RR (CI) Fertilization rate ND Implantation rate 1.75 (1.1-2.8) Clinical pregnancy rate ND Ongoing pregnancy rate ND
Sperm in NOA are Like Apples on a Tree
Some branches have them, and some don’t
Cryptorchidism 52-74% Varicocele 63% Epididymitis 67% Mumps 67% Torsion >50% Post-chemotherapy 55-75% Genetic AZF a, b 0-low% Genetic AZF c 70% Idiopathic 50-60%
Chance of Finding Sperm by NOA Diagnosis
Shefi and Turek, RBM Online, 2009 Raman and Schlegel. J Urol.170:1287, 2003 Hopps et al. Hum Reprod. 180:1660, 2003 Damani et al. JCO. 15: 930, 2002
FNA Sites/Testicle
Sperm Detection
Rate
Beliveau and Turek. Asian J Androl 13; 225, 2011
Where Are We With Sperm Detection?
Microdissection FNA Mapping
NOA Strategies
Courtesy: Netter Images
How is FNA Mapping Different from Microdissection?
Office FNA Map
Sperm Found?
Yes No
IVF/ICSI "Directed" TESE
Donor Sperm Adoption
FNA Mapping Microdissection
TESE in OR
Sperm Found?
IVF/ICSI
Yes No
Donor Sperm Adoption
+/- Pregn
Microdissection
1 2 3
654
987 11
1012 13 14
171615
2019
18 22
21
R L
1 2 3
654
987 11
1012 13 14
171615
2019
18 22
21
R L
1 2 3
654
987 11
1012 13 14
171615
2019
18 22
21
R L
Turek et al. ASRM 2004
FNA Map
Sperm Present (n=83)
TESE (n=29)
MicroTESE (n=16)
IVF-ICSI (n=83 procedures)
<2 sites sperm/map
Success 81%
Success 90%
TESA (n=38)
Most FNA sites/map
Success 98%
Map “Directed”
TESE
>2 sites sperm/map
Testis sperm aspiration (TESA)
Testis sperm extraction (TESE)
Testis microdissection (MicroTESE)
Least Invasive Most invasive
Not all sperm retrieval procedures are the same
IVF-ICSI
Bank Ejaculated Sperm
FNA Map (1-3 mos)
MicroTESE (<1 mos)
Treat/Improve(3-6
mos)
Sperm Retrieval Ejaculate
The Turek Clinic Approach
Nonobstructive Azoospermia
0
20
40
60
80
100
120 100%
53%
92%
% Successful Retrieval
mTESE MAP + mTESE
MAP + TESA/E
How FNA Mapping Helps Sperm Retrieval
(N=96 cases; 12 months, 2013-2014)
49% TESA/E
51% mTESE
19% 14%
% Bilateral Procedures
FNA Mapping & Sperm Retrieval: Bilateral Cases
(N=96 cases; 12 months)
0 10 20 30 40 50 60 70 80 90
mTESE MAP + mTESE
MAP + TESA/E
84%
Optimizing Sperm Retrieval
Patient Procedure Laboratory
Medical therapy Cryptozoospermia
TESA/TESE Microdissection FNA Mapping
Search time Sperm banking
Laboratory Effort in Sperm Retrieval Cases
Turek PJ. Sperm Retrieval Techniques. In: The Practice of Reproductive Endocrinology and Infertility: The Practical Clinic and Laboratory. Ed. D. Carrell. 2010.
Procedure MESA TESA TESE MicroTESE Man-hrs 1hr 1-2hrs 2-4 hrs 4-6 hrs needed
Single sperm cryopreservation on cryoloops: an alternative to hamster zona for cryopreservation of individual spermatozoa Nina Desai, Heather Blackmon, James Goldfarb. Fertil Steril, Vol 80, Suppl. 3, 2003, pp, 55-56
Optimizing Sperm Retrieval Summary
• Patients really only want one sperm retrieval. • They like their testosterone levels where they are. • You have one good shot at them. • So, optimize medical therapy, surgical technique
and laboratory variables for each case.