Conventional techniques to predict
presence of sperm from reproductive
tract for ICSI
Barış Altay, MD
Associate Professor of Urology
Ege University School of Medicine
Izmir, Turkey
Upgrading Fertility Status
Natural conception
IUI
Increased
Desirability
IVF/ICSI
Ejaculated sperm
Surgical sperm retrieval
for IVF/ICSI
Donor sperm insemination
Adoption
Decreasing
Risk and Cost
Etiology of Male Factor Infertility
%
100
90
80
70
60
50
40
30
20
10
0
Varicocele Obstruction
Testis
failure
Idiopathic Hormonal
Others
Infertility - Azoospermia: 5-20%
%
100
90
80
70
60
50
40
30
20
10
0
Obstruction
Endocrine
Genetic
Testicular failure
Evaluation of Azoospermic Men
10
History
Physical examination
Semen analysis (2x)
Hormonal evaluation
Genetic tests
Radiologic imaging
20
Biopsy/Cytology
TREATMENT
Clinical characteristics of
Obstructive Azoospermic Men
Absolute diagnosis: Testicular biopsy/cytology
→ Normal spermatogenesis
Relative findings:
 Normal serum FSH
 Ejaculate volume ↓
 Testicular volume  16 ml.



Normal consistency
Dilated caput epididymis
Absence of vas deferens
Obstructive Infertility-Localization

Proximal
 Intratesticular (15%)
Congenital
Acquired (Post-inflammatory, post-traumatic)
 Epididymal (60-75%)
Congenital (CBAVD, Young’s syndrome)
Acquired (infection, epididymitis)
 Vasal
Congenital (Agenesis of vas deferens)
Acquired (Vasectomy, hernia repair, orchiopexy)

Distal (5-10%)
 Ejaculatory duct obstruction
Obstructive Azoospermia-Treatment

Proximal Obstruction:

Microsurgical reconstruction



Assisted Reproductive Technology


Vaso-vasostomy
Vasoepididymostomy
Use of sperm for IVF/ICSI
Distal obstruction:


Endoscopic treatment (TUR-ED)
TRUS/Aspiration of Seminal fluid-sperm
retrieval for ART
Pellet (-) Azoospermia
Vas deferens (+)
Vas deferens (-)
Testis volume
Absence of vas deferens (CBAVD)
Normal
Low
CFTR test
FSH
FSH
Epididymal sperm-IVF/ICSI
Adoption
Low
Hypogonad.
hypogonadism
LH, prolactin
Cranial imaging
Gonadotropins
Surgery
Normal
High
Testis Bx
Abnormal
High
Primary failure
Primary failure
Normal
Test. spermIVF/ICSI
Adoption
Test.spermIVF/ICSI
Surgery
Adoption
Waiting for
advanced technology
Indications for Epididymal sperm
aspiration
• Congenital bilateral absence of vas deferens
• Failed vasectomy reversal surgery
• Presence of uncorrectable epididymal
obstruction
• Impossible/failed vasal sperm aspiration
MESA (Microsurgical Epididiymal
Sperm Aspiration)
Advantageous:
• Multiple sampling
• More motile sperm
• Cryopreservation
Disadvantageous:
• Invasive procedure
• Needed anesthesia
• More cost
(Microscopic surgery)
• More experience
• Ideal method in Obstructive azoospermia
• Success rate: >90%
• Sperm density: ~40.9x106/ml
• Motility: 13-29%
Chen 1995
Collins 1996
Silber 1997
Belker 1994
Devroey 1995
Oates 1996
Holden 1997
Schroder-Printzen 2000
Outcomes of MESA
• Fertilization: 60-90%/cycle
• Pregnancy: 14-66%/cycle
• Delivery: 25-36%
Belker 1994
Silber 1995
Ubaldi 1995
Zumbe 1996
Bispink 1997
Schroder-Printzen 1997
Sperm quality in Obstructive
Azoospermia
• Increase in epididymal
sperm quality
Normal
Caput
Cauda
good
Obstruction
good
Sperm Motility and ICSI
Fertilization
Motile sperm
Immotile sperm
Pregnancy
54%
26.4%
29.8%
21.4%
P=0.005
Best Practice & Research Clinical Obstetrics & Gynaecology, 2003
Clinical characteristics of Nonobstructive Azoospermia
Absolute diagnosis: Testicular biopsy/Cytology
Relative findings:
 Normal ejaculate volume
 Testicular volume < 15 ml.





Soft in consistency
Normal epididymis
Serum FSH 
Testosterone/Estradiol  (<10, N: 14-16)
Serum inhibin B 
Non-obstructive Azoospermia
Pathology (-)
Correctable pathology (+)
Genetic tests and counseling
Treatment of varicocele
Treatment of hormonal failure
Clear of gonadal toxins
3-12 months
Semen analysis/ pellet test
Sperm (+)
Pregnancy
Spontaneous
IUI
IVF
IVF/ICSI
Sperm (-)
Testicular biopsy
Mature sperm
TESA-TESE
(IVF/ICSI)
Pregnancy (+)
Spermatid
ROSNI?
Pregnancy (-)
TESA-TESE
Use of freezed sperm or
(6 months later)
embriyos
Sperm (-)
Adoption
Waiting-advanced
technology
Donor sperm
insemination?
Predictive factors for testicular sperm
retrieval in Non-obstructive azoospermia

Conventional
 Testicular sperm retrieval techniques
 Histopathological examination
 Serum hormone levels (FSH, inhibin B)
 Age
 Testicular volume

Genetic markers

Radiologic methods
Testicular sperm retrieval techniques


Testicular sperm aspiration (TESA)
Testicular sperm extraction (TESE)
 Macroscopic
 Microscopic (Micro-TESE)
Sperm Retrieval Ratios in NOA
Schlegel et al. (1)
Schlegel et al. (2)
Tsujimura et al.
Raman et al.
Okada et al.
Amer et al.
AVERAGE
TESE
(%)
32
45
35
58
17
30
36
microTESE
(%)
58
63
43
61
45
47
53
(1) Schlegel PN 2005
(2) Schlegel PN 1999
Tsujimura A et al. Human Reprod 2002
Raman J et al. J Urol 2003
Okada H et al., J Urol 2002
Amer M et al,. Human Reprod 2000
Sperm Retrieval Rates and Histopathology
TESE
Hypospermatogenesis
Maturation Arrest
SCO
50%
20%
29%
microTESE
81%
44%
41%
P value
0.35
0.29
0.03
Schlegel et al, Urology 2005
Microscopic TESE
• Tubules containing spermatogenesis
– Dilated
– Opaque/white
No identification of these tubules with
lower magnification
Schlegel PN, Human Reprod 1999
MicroTESE-Update
•
•
•
•
N=684
Sperm retrieval rate: 61%
Fertilization: 55% (per oocyte)
Clinical pregnancy: 47%
Schlegel P, AUA 2007
MicroTESE after unsuccessful
conventional TESE
•
•
•
•
•
NOA
N=50 primary
N=7 unsuccessful conventional TESE
N=18 unsuccessful microTESE
Salvage microTESE
Sperm retrieval (%)
Unsuccessful conventional
TESE
Unsuccessful microTESE
Primary NOA
57
6
56
Okada H, AUA 2007
Histopathologic findings of the Testis
Obstructive Azoospermia

Normal spermatogenesis (>15 spermatid-sperm/
tubule)
Non-obstructive Azoospermia


Complete sclerozis
Complete germ cell aplazia


Focal spermatogenesis/germ cell aplazia




Adult type SCO
Maturation arrest


Sertoli cell-only syndrome
Spermatogonium, spermatocyte
Spermatid arrest
Partial maturation arrest
Hypospermatogenesis
Testis volume
• Testicular volume is inversely correlated with the
probability of the presence of sperm in the testis.
• However, spermatozoa can be successfully
retrieved from a testis with a volume <5ml.
•
•
•
•
•
Testicular volume
Serum FSH level
Age
Testosterone level
Serum Inhibin B level
No
Predictive
Value
Okada H, J Urol 2002
Friedler S ve ark. Human Reprod 2002
Ostad M ve ark. Urology 1998
Su LM ve ark J Urol 1999
Tournaye H, Hum Reprod 1996
Verneave V, Gynecol Obstet Fertil 2004
Kochinski I, Hum Reprod 2005
Ramasamy R, J Urol 2007
• Only testicular histopathology is a predictor for sperm
retrieval in NOA.
Su LM et al J Urol 1999
Testis Histopathology
• In contrast to the predominant spermatogenetic
pattern, the most advanced pattern appears to
affect the TESE results.
•
Ramasamy-Schlegel, J Urol April 2007.
New Classification for testicular
biopsies
1.
2.
3.
4.
5.
6.
7.
Normal testicular biopsy
Hypospermatogenesis
Germ cell arrest
SCO appearence (syndrome)
Seminiferous hyalinization
Carcinoma in situ (CIS)
Immature testis (prepubertal)
Mc Lachlan Hum Reprod 2007
Sperm Retrieval Rates and Histopathology
Su
Seo
Amer
Sousa
Tsujim
ura
Okada
Schlegel
Koscinski
Ramasamy
Mean
Hypospermatogenesis
79
89
85.7
97.7
100
100
74
100
100
91.7
Maturation Arrest
47
62
53.3
75
75
40
45.5
83
60.1
Spermatid arrest
80
80
Primary spermatocyte
arrest
33.3
33.3
SCO
24
16
33.3
29.8
22.5
33.9
40
23.5
51
30.4
Su LM et alJ Urol 1999
Seo TJ et al, Int J Androl 2001
Amer M. Et al,. Hum Reprod 2000
Sousa M., Hum Reprod 2002
Tsujimura A et al, Human Reprod 2002,
Okada H et al, J Urol 2002
Schlegel et al. Urology 2005
Koscinski I, Hum Reprod 2005
Ramasamy R, J Urol 2007
Testis Biopsy
• Diagnostic biopsies were preferred to
determine whether sperm + for ICSI.
• Unfortunately, diagnostic biopsy has
limited prognostic value to predict
microdissection TESE (extensive multiple
biopsies may be needed)
Predictive factors of sperm recovery


178 males with non-obstructive azoospermia

Undergoing TESE procedure for IVF/ICSI

Spermatozoa recovery: 94/178 (52.8%)
Determination of predictive factors


Testicular volume, Histology, FSH
Spermatozoa recovery has no correlation with
testicular volume or serum FSH level
Only testicular histopathology can be used as a predictor of successful sperm
recovery
Seo and Ko, Int J Androl, 2001
Predictive factors of sperm recovery


30 patients with non-obstructive azoospermia

Undergoing TESE procedure for IVF/ICSI

Spermatozoa recovery: 21/30 (70%)
Determination of predictive factors


Age, Histology, FSH
Neither patient age nor FSH was predictive
Only testicular histopathology can be used as a predictor of successful
sperm recovery

Mulhall JP et al, Urology, 1997
Summary

Testicular volume, age and serum hormone levels have no
predictive value.

Only testicular histopathology is a valid predictor for the
successful testicular sperm recovery by testicular biopsies.

Based on conventional techniques, there are no standard
preoperative criteria to predict prospectively presence or
absence of sperm on TESE for an individual man.

Therefore, a new additional techniques and markers are
needed to improve sperm harvesting success from the
reproductive tract.