Fertiliteitsdiagnostiek anno 2011
Willem Ombelet
Genk
Gent, 12-05-2011
10-15 % van de koppels met kinderwens hebben
fertiliteitsproblemen

Oorzaken
 30% man
 30% vrouw
 30% man & vrouw
 10% onbekend
Spermatogenesis
Female
Male
Serum: infections, hormonal, thyroid, AMH
FSH HSG
Prl
Hysteroscopy
0 2-3
Serum: infections, hormonal
Semen sample
E2, Prog, LH
US uterus & ovaries
PCT
E2, Prog
14
28
menses
Outpatient
Laparoscopy
CT, MRI, ...
Treatment
repeat semen sample
US + Doppler scrotum
Genetics
Oorzaken: vrouw


Baarmoederhalsfactor zz
Implantatiestoornis



Eileiderfactoren




Sterilisatie
post-infectie
erge endometriose
Eisprongstoornissen



Syndr v Asherman
Poliepen, myomen, infecties
PCO
hyperprolactinemie
Andere afwijkingen

Post-heelkunde
Meest frequente vrouwelijke factor
Anovulatie

Oligomenorree (cyclus > 35 d)

Amenorree


Primair (XO - syndr v Turner)
Secundair



normogonadotroop (hyperprolactinemie)
hypogonadotroop
hypergonadotroop (PCO – syndroom)
Hypogonadotrope amenorree


stress, vermagering, sport

Simple weight loss amenorree

Exercise-associated amenorree

Psychogene hypothalame amenorree
Lage E2, laag FSH en LH, hoog cortisol
Hyperprolactinemie
PCO - Syndroom
Oligo- of anovulatie
Cyclus > 35 dagen
Hyperandrogenisme
Hirsutisme, haaruitval
Acne
 testosterone
PCO-echografisch
12 follikels < 10mm – bilat
Of
Ovarieel volume > 10 ml
( 0.5233 x L x B x H )
Ovariële reserve
100
100
104
75
50
103
25
102
0
10
20
30
40
50
60
Ir r e
gul
ar i
ty
25
M en
opa
use
Irregular
cycles
105
50
rilit
y
Menopause
Ons
et
End of
fertility
Ste
Declining
fertility
lity
Optimal
fertility
106
75
Sub
fert
i
Number of follicles
107
Cumulative %
Proportion of poor quality oocytes
Proportion of poor quality oocytes (%)
Number of follicles
0
21
31
41
46
Age (years)
Female Age (yrs)
Website: www.fvvo.be
Broekmans, FV&V in ObGyn, 2009, 2, 79-89
51
61
Accuracy Non Pregnancy prediction
1
0.9
0.8
Sensitivity
0.7
0.6
0.5
0.4
sROC curve AFC
sROC curve AM H
sROC curve FSH
AFC studies
AM H studies
FSH studies
0.3
0.2
0.1
Accuracy Poor Response prediction
0
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
1
1 - Specificity
0.9
0.8
Broekmans, FV&V in ObGyn, 2009, 2, 79-89
Sensitivity
0.7
0.6
0.5
0.4
sROC curve AFC
0.3
sROC curve AM H
AFC studies
0.2
AM H studies
0.1
0
0
0.1
0.2
0.3
0.4
0.5
0.6
1 - Specificity
0.7
0.8
0.9
1
Cavum- en tubapathologie
Female
Male
Serum: infections, hormonal, thyroid
FSH HSG
Prl
Hysteroscopy
0 2-3
Serum: infections, hormonal
Semen sample
E2, Prog, LH
US uterus & ovaries
PCT
E2, Prog
14
28
menses
Outpatient
Laparoscopy
CT, MRI, ...
Treatment
repeat semen sample
US + Doppler scrotum
Genetics
HSG: unicornuate uterus, patent tube
MRI: unicornuate uterus
MRI: ectopic ovary anterior to the
external iliac vessels
Ombelet et al., N Engl J Med, 348, 667, 2003
Diagnostische Hysteroscopie
Laparoscopie
Female
Male
Serum: infections, hormonal, thyroid
FSH HSG
Prl
Hysteroscopy
0 2-3
Serum: infections, hormonal
Semen sample
E2, Prog, LH
US uterus & ovaries
PCT
E2, Prog
14
28
menses
Outpatient
Laparoscopy
CT, MRI, ...
Treatment
repeat semen sample
US + Doppler scrotum
Genetics
WHO 1987: 3555 men with male factor
WHO 1999 : “authority-based” // not “evidence-based”
Normaal :
≥20 mill / ml
Oligozoospermie :
< 20 mill / ml
Asthenozoospermie : < 25 % grade a
< 50 % grade a + b
Teratozoospermie :
< 30 %
< 14 % (strict criteria)
Case-control study
143 fertile
Men from pregnant women < 20 weeks
144 subfertile
Prospective
study
Exclusion: tubal factor & anovulation
Statistics: ROC analysis
W Ombelet et al, Hum Reprod, 12, 987-993, 1997
Results
Area (ROC) Cut-off ROC
P10 (F)
Count
69.4
34
14.3
Motility (a+b)
60.9
45
28
Morphology
77.7
10
5
WHO 2010
4500 men / TTP< 12 months/ P5
Volume
< 1.5 ml
Sperm concentration
< 15 million spermatozoa/ml
Total Sperm number
< 39 million spermatozoa
Motility (grade A+B)
< 32 % progressive motile
Morphology
< 4 % normal
Vitality
< 58 %
Cooper et al., HRU, 16, 231-245, 2010
TUNEL assay. TUNEL-positive nuclei (with double-strand nuclear DNA fragmentation)
of spermatozoa as represented by the intense (A) and dull (B) Texas red fluorescence in the
nuclear region. The healthy nuclei (without DNA fragmentation) are stained blue with
DAPI (C) used as counterstain.
Angelopoulou et al., Reprod Biol Endocrinol, 5, 36, 2007
Sperm Chromatin Structure Assay – SCSA
Green Fluorescence
100
200 cells /minute
5000 cells analysed/sample
Evenson et al., 1980
0
100
Denatured ss DNA: red fluorescence
Algorithm for male subfertility treatment
Tubal Factor
No Tubal Factor
Initial Semen
Sample
Washing
procedure
IMC
IMC
< 1 million
< 1 million
Morphology < 4% Morphology >= 4%
Washing
procedure
IMC
>= 1 million
IMC
IMC
< 1 million
< 1 million
Morphology < 4% Morphology >= 4%
IMC
>= 1 million
IUI 4 x
IVF
< 30% or no fertilisation
ICSI
IVF
< 30% or no fertilisation
ICSI
ICSI
Semen profile in a general population
Aim: to investigate sperm quality in a general population
Website: www.fvvo.be
Ombelet et al., FV&V in ObGyn, 2009, 1, 18-26
Azoospermia: etiology
Non-obstructive
 Maturation

Idiopathic, cryptorchidism,
mumps, drugs …
 Sertoli

arrest
cell only
Idiopathic, irridiation,
drugs …
Obstructive
 Epididymal

Post-infective, post-surgery,
…
 Vas

deferens obstruction
CBAVD, post-vasectomy ..
 Ejaculatory
 Seminiferous
tubular
sclerosis

Genetic, Klinefelter,
testicular torsion, …
obstruction
duct
obstruction

Prostatic cysts, post-surgical,
post-infective
Azoospermia: diagnosis
Non-obstructive
Genetic
 FSH,

testing
inhibine B
testicular volume
Obstructive
Genetic
 FSH,
testing
inhibine B: nl
 testicular
volume: nl
Karyotype
Count < 5 mill
Yq deletions
13% if nonobstructive azoospermia
3 - 7% with severe oligozoospermia
“Transmitted to male offspring”
AZFa, AZFb,
AZFb +c, Yq deletions
AZFc deletions
All azoospermic
None with sperm on
diagnostic biopsy or TESE
27/42 severely oligospermic
9/20 (45%) with sperm on biopsy
9/12 (75%) had sperm at TESE
Hopps et al, HR, 18, 1660, 2003
EVALUATION OF AZOOSPERMIA
Azoospermia
Vasectomy
Endocrine
evaluation
CBAVD
< 15 years
> 15 years
CF testing
Hypogonadotropic
hypogonadism
Semen volume
< 1 cc
Vas reversal
Sperm retrieval/
ICSI
Sperm retrieval/
ICSI
Gonadotropins
TRUS
CF - 1/2500 births: carriers 1/25
95% - “Wolffian duct abnormalities”
Semen volume
> 1 cc
FSH
< 2x normal
Dilated SV’s
Genetic
evaluation
Testis biopsy/
sperm retrieval
Testis biopsy/
sperm retrieval
Normal
spermatogenesis
Vasogram/
SV gram
Ejaculatory
duct
obstruction
ICSI
No sperm
Decreased sperm
production
TID
adoption
TESE/ICSI
FSH
> 2x normal
Normal
spermatogenesis
Vasogram
Sperm
retrieval/
ICSI
Epididymal
exploration/VE
+/- sperm
retrieval
TURED
balloon dilation
Kolettis PN. J Androl 23:293-305, 2002.
EVALUATION OF AZOOSPERMIA
Azoospermia
Vasectomy
Endocrine
evaluation
CBAVD
< 15 years
> 15 years
CF testing
Hypogonadotropic
hypogonadism
Semen volume
< 1 cc
Vas reversal
Sperm retrieval/
ICSI
Sperm retrieval/
ICSI
Gonadotropins
TRUS
Semen volume
> 1 cc
FSH
< 2x normal
Dilated SV’s
Genetic
evaluation
Testis biopsy/
sperm retrieval
Testis biopsy/
sperm retrieval
Normal
spermatogenesis
Vasogram/
SV gram
Ejaculatory
duct
obstruction
ICSI
No sperm
Decreased sperm
production
TID
adoption
TESE/ICSI
FSH
> 2x normal
Normal
spermatogenesis
Vasogram
Sperm
retrieval/
ICSI
Epididymal
exploration/VE
+/- sperm
retrieval
TURED
balloon dilation
Kolettis PN. J Androl 23:293-305, 2002.
Testicular microlithiasis
tumors
Grade I:
varicocele
Grade II:
Grade III:
Environmental factors
Physical
Chemical
light
medication
heavy metals
(Pb, Cd,...)
pesticides
Biological
Male
Fertility
infections
viral
bacterial
....
temperature
radiation
electromagnetic fields
Socio-economic
nutrition
starvation
occupation
Behavioral
life style
psychologic stress
drug addiction: coffee, smoking, alcohol
extreme weight loss
physical stress: competitive sports
Occupational heat exposure and male
fertility
Cumulative conception rate according
to the male partners exposure to heat.
Exposed = exposed to heat or seated in
a vehicle for more than 3 hours per
day.
Thonneau et al, Lancet, 1996, 347, 204-5 and Bujan et al, 2000, Hum Reprod, 15, 1355 - 7.
Cell phones & oxidative stress
Agarwal, RBMOnline, 15, 266, 2007
Conclusie

Accurate diagnose blijft belangrijk



Anamnese
Klinisch onderzoek
Speciale onderzoeken

Minimale onderzoeken // Maximaal rendement

Infertiliteit ≠ IVF & ICSI
Genk IVF team