1. Smart Shortcuts Only Experts
Know About Male Infertility
Sandro Esteves, M.D., Ph.D.
Director, ANDROFERT
Andrology & Human Reproduction Clinic
Campinas, BRAZIL
Evening Symposium , June 2013
Kingdom of Saudi Arabia

2. Esteves, 2
Sperm Chromatin Integrity is a new
diagnostic test that go far beyond routine
semen analysis. Learn how to use it.
Obesity is a risk factor for male infertility:
learn how to use aromatase inhibitors to
increase sperm production.
Azoospermia is not a synonymous of
sterility. Biological fatherhood is possible
even in the worst scenarios.

3. Esteves, 3
Smart Shortcuts
Only Experts
Know About
Male Infertility
Sandro Esteves, 2013
Review this Lecture at:
http://www.androfert.com.br/review

4. Esteves, 4
• Normal sperm chromatin essential for
paternal genetic transmission
Background
• Unexplained infertility
• Recurrent pregnancy loss
• Poor outcomes in IUI and IVF
Sperm DNA
Fragmentation
• Quantification of sperm DNA strand
breaks
Principle
• Semen, spermatozoaSpecimen
• Nuclear dyes (Acridine orange, SCSA)
• Direct assessment (TUNEL, COMET)
• Nuclear matrix assays (SCD)
Techniques
Esteves SC & Agarwal A. Novel concepts in male infertility.
Int Braz J Urol 2011; 37:5-15.

5. Esteves, 5
Sperm with intact DNA have “halos”:
Represent dispersed chromatin
without breaks
Sperm with fragmented DNA have no
“halos”:
Represent DNA strand breaks
Sperm Chromatin
Dispersion (SCD) Test
Esteves et al. Arch Gynecol Obstet. 2012; 286: 217-29.
Halosperm®
Semen/Spermatozoa
Quantitative Test:
Normal: <20% cells with fragmented DNA

6. Cochrane Review 2011
Outcome N
studies
N
participants
Effect size
(OR; 95% CI)
Live birth 3 214 4.85 [1.92, 12.24]
Pregnancy rate 15 964 4.18 [2.65, 6.59]
DNA fragmentation 1 64 -13.80 [-17.50, -10.10]
Miscarriage, sperm
count, sperm motility
6-16 242-700 No effect
Improve the outcomes of live birth and pregnancy rate for
subfertile couples undergoing ART cycles
Showell MG et al. Antioxidants for male subfertility.
Cochrane Database Syst Rev 2011 Jan 19;(1):CD007411.Esteves, 6

7. 19%
1.5%
Normal Elevated
Live Birth Rates with
Intrauterine Insemination
OR = 0.07
[95% CI: 0.01-0.48]
Bungum et al. Hum
Reprod 2007; 22: 74–9
Esteves, 7
26%
42%
IVF ICSI
Pregnancy by Method in Cases
of Elevated Sperm DNA
Fragmentation

8. Robinson L et al. Hum Reprod. 2012; 27(10): 2908-17
Population: Meta-analysis of 16 cohort studies
(2,969 couples), 14 prospective.
Techniques for DNA Assessment:
Acridine orange-based assays, TUNEL and COMET.
Findings:
Significant increase in miscarriage rates in patients
undergoing IVF/ICSI with high sperm DNA damage
compared with those with low DNA damage.
Risk ratio (RR) = 2.16 (1.54, 3.03), P < 0.00001).
Esteves, 8

9. Esteves, 9
• Hyaruronic Acid Binding
• Polarization Microscopy
• MSOME
• Electroforetic Sperm Isolation
• Magnetic-activated Cell Sorting
• Microarray Technology
• Proteomics
SpermSelection
Techniques
Normalcy of Sperm
Chromatin Content
Current non-
invasive
techniques
cannot directly
assess sperm
DNA integrity
Dyes are used to reach the
nucleus, using fixed
specimens

10. Sperm % TUNEL + % CPR %IR
Ejaculated (N=18) 23.6 ± 5.1 6 2
Testicular (N=18) 4.8 ± 3.6 44 21
P value < 0.001 <0.05 <0.01
Greco E et al. Hum Reprod 2005;20:226–30
*Absolute differences between two specimens ranging from -3.3% to -56.3%.
Moskovtsev et al. Fertil Steril 2010; 93(4): 1142–6.
Testicular Spermatozoa have three-fold lower
DNA damage (13.3%) when compared with
Ejaculated Spermatozoa (39.7%)*

11. Sperm Chromatin Integrity is a
key biomarker of sperm
function.
SCD is a new and easy-to-use
diagnostic test to assess
sperm chromatin integrity.
Test results have prognostic
value in for assisted
conception and aid in
clinical management.
Sperm Chromatin Integrity is a new
diagnostic test that go far beyond routine
semen analysis. Learn how to use it.

12. Obesity is a risk factor for male infertility:
how to use aromatase inhibitors to increase
sperm production
Esteves, 12

13. Jensen et al. Fertil Steril 2004; 82: 863; Hammoud et al. Fertil Steril 2008; 90: 2222; Kriegel et
al. RBM Online 2009; 19: 660; Martini et al. Fertil Steril 2010; 94: 1739.Esteves, 13

14. Esteves, 14

15. Aromatase Inhibitors for
Infertile Obese Men
Serum Levels of Total
Testosterone and Estradiol
T/E2 Ratio
Normal > 10
Zumoff et al. Reversal of the hypogonadotropic hypogonadism of obese men by
administration of the aromatase inhibitor testolactone. Metabolism 2003; 52: 1126. Raman
& Schlegel Aromatase inhibitors for male infertility. J Urol 2002; 167: 624.
T/E2 <10
Aromatase Hyperactivity
Anastrozole 1 mg
q1d 60 days
Esteves, 15

16. Raman JD, Schlegel PN. Aromatase inhibitors for male infertility. J Urol. 2002;167:624-9
5.9
2.9
5.5
15.6
3.5
15.6
0
2
4
6
8
10
12
14
16
18
T/E ratio Ejaculate volume
(mL)
Sperm Count
(million/mL)
Anastrazole for oligozoospermic men
(1mg q1d for 3-6 months)
Pre-treatment Post-treatment
Aromatase Inhibitors for
Obesity-related Male Infertility
Esteves, 16

17. hCG Preparations
LH activity
(IU/ampule
or vial)
Ampoule/vi
al filling
method
% Protein
contamination
Source Technology Route of
administration
Urinary hCG 1,000-
10,000
Filled-by-
bioassay
<5% Urine Chemical
extraction
IM
Recombinant
hCG
250µg Filled-by-
mass (FbM)
Negligible Transfected
CHO cells
Recombinant
DNA
SC
Esteves SC, Papanikolaou V; Fertil Steril 2011; Vol 96:S230
SC self-
injection
w/pre-filled
syringe, qw

18. Aromatase Inhibitors for
Obesity-related Male Infertility
1. Peripheral androgen aromatization
is enhanced in men with elevated
BMI. Obese men show increased
plasma estradiol and low
testosterone levels.
2. Lowering estradiol levels, by administration of AI,
increases LH and FSH levels by pituitary modulation,
and increase testosterone levels.
3. Aromatase inhibitors stimulate sperm production;
effects upon fertility are still to be determined.

19. • Normal sperm production
• Mechanical blockage
• Vasectomy, Post-
infectious, Congenital
Obstructive
• Sperm production deficient
or absent
• Cryptorchidism, Radiation,
Chemotherapy, Trauma,
Genetic, Orchitis,
Varicocele, Gonadotoxins,
Unexplained
Non-
obstructive
Complete absence of sperm in the ejaculate
1-3% male population; ~10-15%% male infertility
Azoospermia is not a synonymous of
sterility. Biological fatherhood is possible
even in the worst scenarios.
Esteves, 19

20. • Sperm production
reduced or absent
• Geographic location
unpredictable
Sperm
Retrieval
for ART
Untreatable
condition
TESA
• 15%-
50%
SRR
Conventional
TESE
• 20%-
63%
SRR
Micro-TESE
• 40%-
67%
SRR
Friedler et al. 1997; Ezeh et al. 1998; Schlegel 1999; Amer et al. 2000; Okada et al. 2002; Okubu
et al. 2002; Tsujimura et al. 2002; Ramon et al. 2003; Verza Jr. & Esteves 2011.

21. http://androfert.com.br/videos
Esteves SC, Int Braz J Urol 2013

22. Azoospermia is not a synonymous of
sterility. Biological fatherhood is possible
even in the worst scenarios.
1. Testicular failure (non-
obstructive azoospermia) is the
most severe form of male
infertility and cannot be treated.
2. Sperm retrieval and ICSI only option for achieving
biological fatherhood.
3. Micro-TESE, a microsurgical-guided biopsy,
increases SR success and preserve testicular
function.