This Presentation about Azoospermia by Dr. Khaled Mokhtar - Assistant Professor of Urology Ain-Shams University - Cairo , Egypt

1. History of
Azoospermia in Era of
ART
Khaled Mokhatr
MD Urology
Ain Shams University

2. History of infertility
 Ancient Egyptian papyri (2000 BC)
“Man is the source of life, through his seeds and
woman is a reservoir of these seeds”.

3. History of infertility
 Leonardo Da Vinci (1500 AC):
 Anatomy of genital system
Netherland MRI 2002 DaVinci 1500

4. History of infertility
 Anton Leeuwenhoek (1632-1723),
discovered the sperms
(Animalcules).
I am sending a letter to show my
observation, you may consider it as
scientific discovery or HOAX.

5. History of infertility
 Franzy Leydig, german Zoologist, (1850):
discovered Leydig cell

6. History of infertility
Enrico Sertoli, Italin
Anatomist, (1865):
discovered Sertoli cell

7. Spermist vs Ovist
1600 till 1700
 Spermist  Ovist
 ovum is harboring
small fetous and it just
need to contact the
male fluid to be
released

8. Only in 1779
 Italian, Lazzaro Spallanzani,
 Scientific proof that the sperm fertilizes the
ovum
 To produce pregnancy was first available
(Spallanzani).

9. History of infertility
 Robert Dicknson
(BJM, 1921) IUI
 Stepto& Edward
First Test-Tube Baby - Louise Brown
(Lancet, 1977) IVF

10. History of infertility
 Palermo et al
(Lancet, 1992)
ICSI.
 Devroey et al
(Hum. Reprod.,
1995) TESE/ICSI

11. “Infertile men, wherever
they live, should have a
chance to become genetic
fathers”
Westlander J (Human Reprod. 2000)

13. Azoospermia
 1% of all men
 10% of infertile men
Azoo spermic
Infertile
fertile

14. Introduction
 Azoospermia is an absolute barrier against
spontaneous pregnancy.
 Until recently, men with azoospermia have little
or even no hope to be biologic father.
 Recent advances in microsurgery and
reproductive technology have allowed many
azoospermic men to father children.
 Pregnancy rate is a real reflection of all these
advances

15. Obstructive
Azoospermia

16. Obstructive Azoospermia
 Obstructive azoospermia (OA) are
potentially correctable with the aid of
microsurgery (VE) or endoscopic (TURED).
 Irreparable OA e.g. CBAVD, requires sperm
retrieval (PESA.MESA) combined with
IVF/ICSI.

17. Obstructive Azoospermia:
Sperm Retrieval Options
è Epididymis
 MESA (microsurgical epididymal sperm
aspiration)
 PESA (percutaneous epididymal sperm
aspiration)

20. Obstructive Azoospermia:
Sperm Retrieval Options
Testis
 TESA (testicular sperm aspiration)
 TESE (testicular sperm extraction - therapeutic
testis biopsy)

22. Obstructive Azoospermia:
Results with IVF/ICSI (Experienced
Centres)
Epididymal Testicular
Sperm Retrieval ~100% ~100%
Fertilization rates 50-70% 40-70%
Clin. Pregnancy rates 30-50% 30-50%
Live birth rate 30-40% 20-40%
Palermo et al, Hum Reprod 1999
Devroey et al, Hum Reprod 1996
De Croo et al, Hum Reprod 2008

23. Non Obstructive
Azoospermia..
Testicular failure
It is not an absolute failure

24. NOA
 Non Obstructive Azoospermia (NOA),
recently, have been granted the hope to
father their children after testicular extraction
and ICSI (Devroey et al, Hum Rprod, 1995) .

25. New concept.
+ve sperm identification in
failed testes
 20% to 70% of non obstructed azoospermia still
harbor foci of active spermatogenesis with
mature spermatozoa that could be retrieved and
the only way to use it is ICSI

26. Testicular histology in testicular
failure
56
45
40
35
20 SCO n=44
30
14 Mat. Arrest n=15
25
10 Hypo n=8
20
Mixed n=11
15
10
5
0
NOA

27. Distribution of spermatogenesis in OA Vs
NOA
 There must be at least 4
sperms per tubule as a
minimum quantitative
threshold of
spermatogenesis to reach
the ejaculate.
 Mapping of
spermatogenesis in NOA
testes shows that
Spermatogenesis is
diffuse rather than
regional.
Silber et al, Hum Reprod 2000

28. Non-Obstructive Azoospermia: Sperm
Retrieval Options
 TESE (testicular sperm extraction)
 Singlevs multiple open biopsies
 Microdissection- microTESE
TESA (testicular sperm aspiration)
is not recommended
Silber et al, Hum Reprod 1997
Schlegel et al, Hum Reprod 2004

30. Non-Obstructive Azoospermia:
Sperm Retrieval: Microdissection
 Small areas of spermatogenesis may be distinguished
from areas of Sertoli cell-only by microscopic
examination
 Microdissection enhances sperm yield and reduces
volume of tissue excised
Schlegel et al, Hum Reprod 1999

32. Micro. TESE

33. Doctor patient
Minimally invasive procedure
Minimally invasive for a Doctor is
not Minimally invasive for patients

34. The only way to use retrieved sperms is via ICSI

36. Non-Obstructive Azoospermia (NOA):
Results with IVF/ICSI (Experienced Centres)
NOA OA
Testic. Sperm Retrieval 20-80% ~100% *
Fertilization rates 40-60% 40-70%
Clin. Pregnancy rates 30-40% 30-50%
Live birth rate 20-30% 20-40%
Nagy et al, Fertil Steril 1995
Devroey et al, Hum Reprod 1996
Kahraman et al, Hum Reprod 1996
Palermo et al, Hum Reprod 2002

37. In Egypt..
We are different

38. In Egypt.. We are different, why?
 More prevalent of NOA > OA
 Low incidence of CF mutation gene
 Misdiagnosis of active spermatogenesis by many
pathologists.
 However, we do not have good statistical
reports of true incidence of any of theses

39. CONCLUSION
 OA can be effectively and successfully managed
with microsurgery.
 non-constructible OA, (CBAVD) sperm retrieval
combined with IVF/ICSI can be highly effective in
achieving pregnancy.
 NOA has been recently revolutionized by successful
TESE/ICSI with resultant successful pregnancy.
 The high cost compared to pregnancy outcome is a
considerable limiting factor against the
popularization of TESE/IVF-ICSI.

40. The future
 In vitro maturation of oocyte (IVM)
 In vitro spermatogenesis (Tesarik et al.,Lancet,
1998) Tissue culture system fortified with
RFSH, T. spermatogenesis could be
completed in vitro with an unusual speed,
but the resulting gametes are
morphologically abnormal.

41. Design Final Touch:
Ahmad Al-Sabbagh
March 2012*