Clinical management of men with nonobstructive azoospermia - Azoospermia Differential Diagnosis
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Reproductive Andrology Workshop III 17-21 January 2016 - Kuwait City - KUWAIT Organized by: Al Jahra Reproductive Medicine Unit - Ministry of Health Lecture 1: Azoospermia Differential Diagnosis
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Clinical management of men with nonobstructive azoospermia - Azoospermia Differential Diagnosis
- 1. REPRODUCTIVE ANDROLOGY SURGERY WORKSHOP III 17-21 January 2016 – Reproductive Medicine Unit – Jahra Hospital KUWAIT CLINICAL MANAGEMENT OF MEN WITH NONOBSTRUCTIVE AZOOSPERMIA Lesson 1: Azoospermia Differential Diagnosis Dr Sandro ESTEVES Medical and Scientific Director ANDROFERT - Andrology & Human Reproduction Clinic Campinas, Brazil
- 2. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2016 ANDROFERT
- 3. Azoospermia: the complete lack of sperm in ejaculate a6er centrifuga8on 10-15% infertile males 1-3% male population Cooper et al. Hum Reprod Update 2009; Esteves & Agarwal, Clinics 2013 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 3 2016 ANDROFERT
- 4. Esteves et al Int Braz J Urol 2014; 40: 443-53 Goals of semen analysis are to reduce analytical error and enhance precision Examination of pelleted semen Differentiation between ‘true’ azoospermia and cryptozoospermia Minimum 2 analyses Transient azoospermia due to medical conditions and biological variability Supernatant is discharged Pellet is meticulously examined Centrifugation at 3,000g for 15 minutes ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 4 2016 ANDROFERT
- 5. Prognosis and management differen8ally affected by type of azoospermia Obstruc8ve Non-‐ obstruc8ve Clinical picture Normal testes & endocrine profile; Mechanical blockage Normal Spermatogenesis Esteves et al, Clinics 2011 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 5 2016 ANDROFERT
- 6. Sperm retrieval highly successful regardless of cause of obstruction and method of retrieval Obstructive azoospermia is a favorable prognostic condition in male infertility 100% 96.6% 96.3% CBAVD Vasectomy Post-‐infection OBSTRUCTIVE AZOOSPERMIA Management options include reconstructive surgery and ART OA (N=146) Esteves et al. J Urol. 2013;189: 232-7 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 6 2016 ANDROFERT
- 7. ICSI outcome in obstructive azoospermia comparable with fertile donors 64 61 47 34 61 66 50 38 2PN Fertilization (%) High quality embryos (%) Clinical pregnancy (%) Live birth (%) Obstructive azoospermia (N=146) Donor sperm (N=40) p=NS Esteves et al. Asian J Androl 2014; 16: 602-6 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 7 2016 ANDROFERT
- 8. Prognosis and management differen8ally affected by type of azoospermia Obstruc8ve Non-‐ obstruc8ve Hypo-‐hypo Spermatogenic failure Clinical picture Normal testes & endocrine profile; Mechanical blockage Disrupted Normal Spermatogenesis Esteves et al, Clinics 2011 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 8 2016 ANDROFERT
- 9. • Low FSH and LH levels (<1.2 mIU/L) • Low total testosterone levels (<300 ng/dL) • Hypotrophic testes NOA due to hypogonadotropic hypogonadism Congenital: Kallman syndrome Prader-Willi Acquired: Pituitary tumor Steroid abuse Testosterone replacement therapy FraieTa et al. Clinics 68; 2013 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 9 2016 ANDROFERT
- 10. Rec-‐hCG for male hypo-‐hypo Esteves & Papanikolaou Fer5l Steril 2011;96:S230 Series of men with adult-‐onset HH; Recombinant hCG (Ovitrelle 250 mcg qw for 12 weeks) Baseline Pos<reatment ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 10 2016 ANDROFERT
- 11. Frequency of azoospermia among 2,383 patients attending an Infertility Clinic Esteves et al. Clinics 2011; 66: 691-700. Azoospermia 35% 61% 36% 3% Hypo-hypo OA SF ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 11 2016 ANDROFERT
- 12. Prognosis and management differen8ally affected by type of azoospermia Obstruc8ve Non-‐ obstruc8ve Hypo-‐hypo Spermatogenic failure Clinical picture Testes: small or nl FSH/LH: ñ or nl TT: low or nL Normal testes & endocrine profile; Mechanical blockage Small tes8s, poor viriliza8on FSH/LH <1.2 mUI/ mL, Low TT, Disrupted Normal Spermatogenesis Esteves et al, Clinics 2011 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 12 2016 ANDROFERT
- 13. Tes8cular torsion; trauma Post-‐inflammatory (eg. Mumps orchiBs) Exogenous factors (eg. Cytotoxic drugs, irradiaBon) Tes8cular cancer Systemic diseases (eg. Liver cirrhosis, renal failure) Congenital Tes8cular dysgenesis/cryptorchidism Gene8c abnormali8es (Klinefelter syndrome, Yq microdeleBons, etc.) Acquired Idiopathic (unknown e8ology) Esteves et al. Clinics 2011; 66:691-‐700 NOA due to spermatogenic failure: an irreversible condi8on ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 13 2016 ANDROFERT
- 14. Cryptorchidism, testicular trauma, torsion, infection, radio-/ chemotherapy, congenital abnormalities, systemic diseases Small testes (<15 cc; long axis <4.6 cm) Flat epididymis, palpable vas Elevated FSH levels (>7.6 mIU/ml in 90% men) Low testosterone levels (<300 ng/dl in up to 50%) Diagnostic parameters provide >90% prediction of whether azoospermia is due to spermatogenic failure Medical history Physical examination Endocrine profile Esteves et al Clinics 2011 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 14 2016 ANDROFERT
- 15. Verza Jr & Esteves, Atlas of Human Reproduction SBRH 2013 Isolated diagnostic biopsy rarely indicated provide no definitive proof of whether sperm will be found; may jeopardize future retrieval attempts Differential diagnosis NOA due to complete maturation arrest and obstructive azoospermia Wet examination and cryopreservation if sperm found Hypospermatogenesis Maturation arrest Sertoli cell-only ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 15 2016 ANDROFERT
- 16. Key Messages – Day 1 Azoospermia Differential Diagnosis § Nonobstructive Azoospermia (Spermatogenic Failure) is the worst prognostic condition in male infertility § Should be differentiated from obstructive azoospermia and NOA due to hypo-hypo § Irreversible condition; often termed as “sterile” § History may indicate primary testis pathology § Usual clinical presentation: Azoospermia + small testis + high FSH + low T ANDROFERTANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 16 2016 ANDROFERT
- 17. Thank you This presenta8on is available at hTp://www.slideshare.net/ sandroesteves اشكر