“Understanding Infertility”: A CME Course in Reproductive Medicine August 12-14th, 2011 New Delhi, India

1. Sperm Retrieval Techniques “Understanding Infertility” – New Delhi, India – August 2011 SandroEsteves, MD, PhD Director, ANDROFERT Center for Male Reproduction and Infertility Campinas, BRAZIL Esteves, 1

2. Learning Objectives Esteves, 2

4. Testis

6. PERCUTANEOUS RETRIEVAL 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.

8. Geographic location unpredictableTESA TESE

9. Non-obstructive AzoospermiaTesticular Sperm Aspiration - TESA

11. Based on the diameter of seminiferous tubules

12. Microsurgical approach

13. Identify site of production

14. Preserve vasculature of testis

15. Small quantity of tissue excisedSchlegel, Hum Reprod 1999; 14

16. Pleasevisithttp://androfert.com.br/videostoseethevideo

18. Microdissection TESE or TESA

19. Classified according to the Etiology of NOA

20. Biopsy for histology concomitant or prior to SRHypospermatogenesis (HYPO) Maturation Arrest (MA) Sertoli Cell Only Syndrome (SCO)

21. SpermRetrievalandEtiologyof NOA Etiology Chi-square; NS Esteves 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. FertilSteril. 2010;94(Suppl.):S132.

22. Esteves, Androfert SpermRetrieval in NOA isrelatedto Testicular Histopathology Esteves SC et al FertilSteril 2010; 94:S132 Results (2): Micro-TESE X TESA *TESA vs micro-TESE (MA + SCO): P=.03

23. Micro-TESE 39% P=.03 Micro-TESE TESA/TESE N=131; *hypospermatogenesis excluded Esteveset al.; FertilSteril 2010; 94:S132

24. Esteves, Androfert Predictive Factors for Sperm Retrieval in NOA Chance of finding sperm is dependent on the most advanced site of spermatogenesis within the testis FSH InhibinB Testicular volume Etiology Testosterone levels Testis histology Reflect global spermatogenic function but not the most advanced site of sperm production in a dysfunctional testis

25. Predictive Factors for Sperm Retrieval in NOAY 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

26. Esteves, Androfert PESA/MESATESA/TESELaboratory Sperm Processing for ICSI

27. PESA/MESA

28. TESA

29. TESE

30. Esteves, Androfert Reproductive Potential of Azoospermic Men in ART

31. SpermDefectSeverityRatherThanSpermSourceIs Associated WithLowerFertilization Rates AfterIntracytoplasmicSpermInjection Verza Jr S & Esteves SC; IntBraz J Urol 2008; 34 Not statistically different

32. Esteves, Androfert SpermDefectSeverityRatherThanSpermSourceIs Associated WithLowerFertilization Rates AfterIntracytoplasmicSpermInjection Verza Jr S & Esteves SC; IntBraz J Urol 2008; 34 Not statistically different

33. Esteves, Androfert SpermDefectSeverityRatherThanSpermSourceIs Associated WithLowerFertilization Rates AfterIntracytoplasmicSpermInjection Verza Jr S & Esteves SC; IntBraz J Urol 2008; 34 * P<0.05

34. Sperm Retrieval Rates and Reproductive Potential of Azoospermic Men in ICSI Prudencio C, Seoul B, Esteves SC. Reproductive potential of azoospermic men undergoing intracytoplasmic sperm injection is dependent on the type of azoospermia. FertilSteril 2010; 94 (4): Suppl. S232-233.

36. Sperm obtained in virtually all cases

37. Chance of Retrieval and ICSI Outcomes:

38. Independent on obstruction etiology

39. Independent on retrieval technique

40. Independent on sperm source

42. Overall, retrieval rates ~50%

43. Labor-intensive lab sperm processing

44. Retrieval rates dependent on technique

45. Micro-TESE yields better SRR

46. Predictive factors: testis histology & Y-chromosome

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