17-Aug-16
The journey
Male infertility – too often
ignored & forgotten
1. The optimal evaluation of the men
A review of the guidelines
Joo Teoh
FRANZCOG MRCP(Ire) MRCOG MBBCh MSc(Lon)
MD(Glasgow) SubspecialtyRepromed(UK)
Consultant Obstetrician & Gynaecologist
The optimal evaluation
We got sperms, full stop.
The optimal evaluation
The optimal evaluation
Sperm + Egg = Embryo
The optimal evaluation
Sperm + Egg = Embryo
Sperm + Egg = Embryo
The Numbers Game
Surely it is enough?
_,000,000
“I only need 1”
1
17-Aug-16
The optimal evaluation
The optimal evaluation
DNA integrity
Tests:
KISS
“Keep it sophisticated and
subspecialised”
Chromatin assays for DNA
fragmentation evaluation
 Sperm chromatin structure assay (SCSA)
 TdT-mediated-dUTP nick end labeling (TUNEL)
 Sperm chromatin dispersion (SCD)
 Acridine orange straining technique (AOT)
Chromatin assays for DNA
fragmentation evaluation
pregnancy loss 25. However there is insufficient evidence to warrant routine testing in these
The optimal evaluation
couples until further evidence accumulates. A variety of treatments have been suggested for
patients with poor sperm DNA integrity, however there is no evidence demonstrating that
integrity
treatmentDNA
results
in improved sperm DNA integrity and improved pregnancy/delivery rates.
Chohan et al; J Androl;
27:53-59
Recommendation: Currently there is insuff icient evidence in the literature to
support the routine use of DNA integrity testing in the evaluation and management
of the male partner of an infertile couple. Presently, there are no proven therapies
to correct an abnormal DNA integrity test result.
Reactive oxygen species (ROS)
Reactive oxygen species are generated by both seminal leukocytes and sperm cells, and can
interfere with sperm function by peroxidation of sperm lipid membranes and creation of toxic
fatty acid peroxides. ROS also have a normal physiological role in the regulation of capacitation
and the acrosome reaction. Elevated ROS have been implicated as a cause of male infertility.
Controversy exists regarding the best method of testing for ROS; role of excess ROS in both
natural conception and assisted reproductive technology; and whether therapies are effective at
reducing seminal ROS and improving fecundity. Direct ROS testing is limited by the short
duration of activity of the molecules. Seminal ROS is currently assessed by indirect testing
methods that measure the products of ROS. Studies correlating seminal ROS levels to
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17-Aug-16
Chromatin assays for DNA
fragmentation evaluation
Chromatin assays for DNA
fragmentation evaluation
Tests:
Tests:
- To know you I have to kill you
- To know you I have to kill you
- Difficulty in finding threshold
value
- Difficulty in finding threshold
value
Sperm selection techniques
HA sperm selection
 HA sperm selection
 Hyaluronic acid
 MACS
 Bind to HA in vitro
 IMSI
 Completed plasma membrane remodelling, cytoplasmic
extrusion and nuclear maturation
 Low chromosomal aneuploidies & DNA fragmentation,
good nuclear morphology
 Only mature spermatozoa which have extruded their
specific receptors to bind to & digest HA can reach the
oocyte & fertilize it
HA sperm selection
IMSI
 Parmegiani et al. J Assist Reprod Genet (2010) 27:13-16
 Morphologically selected sperm injection
 HA-ICSI sigificantly improves embryo quality & implantation
 What is the best criteria for selection?
 Awaiting multi-center randomized studies (UK)
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17-Aug-16
IMSI
IMSI
 Conflicting results:
 Conflicting results:
 No difference in fertilisation rate, early embryo cleavage
rate or cleavage rate. Similar proportion of top quality
embryos. (Mauri et al. Eur J Obstet Gynecol Reprod Biol.
2010 May; 150(1):42-6)
 Based on motile sperm organellar morphology exam
(MSOME), individuals with best morphologically normal
nucleus has significantly higher pregnancy & delivery rates.
Also significantly lower miscarriage rates. (Bertovitz et al.
Reprod Biomed Online. 2006 May; 12(5):634-8
MACS
 IMSI group significantly lower number of cycles with no
embryo transfer. Trend of higher no. of blastocysts, higher
pregnancy rates, less miscarriage rates. Score of
spermatozoa = (2 x head) + (3 x vacuole) + (base). Knez at
al. Reproductive Biology & Endocrinology 2011. 9:123
MACS (meta- analysis)
 Magnetic-activated cell sorting
 Colloidal superparamagnetic microbeads conjugated
with annexin V
Gil et al. J Assist Reprod Genet (2013) 30:479-485
MACS (meta- analysis)
Sperm selection techniques
 HA sperm selection
 MACS
 IMSI
TOO EARLY FOR INTERNATIONAL GUIDELINES
Gil et al. J Assist Reprod Genet (2013) 30:479-485
4
17-Aug-16
IVF Success Rates
Donor Egg Program
Donor Egg IVF
Cost of Donor Egg IVF
Become an Egg Donor
Resources
Contact
Injection Techniques
In Town Patient Appointments
Out of Town Patient Appointments
Fertility Sites
IVFMD Forms
IVFMD Videos
Physician Referral Forms
Blog
The optimal evaluation
The optimal evaluation
Tests:
Tests:
KISS
KISS
On Weight and Fertility »
“Keep it sophisticated and
subspecialised”
“Keep it simple & sweet”
New World Health Semen Analysis Parameters
by Julian Escobar, MD | July 18th, 2013
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1
IVF Success Rates
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Donor Egg IVF
Cost of Donor Egg IVF
Become an Egg Donor
Resources
Contact
Injection Techniques
In Town Patient Appointments
Out of Town Patient Appointments
Fertility Sites
IVFMD Forms
IVFMD Videos
Physician Referral Forms
Blog
Tweet
In 2010 the World Health Organization (WHO) updated its reference values for the Semen Analysis.[1]
This update was long overdue as the last version was published in 1999.
The optimal evaluation
The optimal evaluation
Sperm + Egg = Embryo
On Weight and Fertility »
Have you got the latest WHO
New World Health Semen Analysis Parameters
manual?
IVF Success There
Rates is a significant difference on how the old and new reference ranges were derived. In the past, semen
Donor Egg Program
data from random populations of men were analyzed and the results were plotted on a statistical
Donor Egg IVF
distribution curve. The 5th percentile was considered to be the lower limit of normal (or reference), in
Cost of Donor
Egg IVF
another
word, 95% of men tested would have sperm parameters higher than the reference ranges.
Become an Egg Donor
Resources
In WHO 2010, the new normal values are based on data from men with proven fertility, men who were
Contact
known to help their partners conceive in the previous 12 months. Following a large analysis of semen
Injection Techniques
parameters from over 4000 men in 14 countries, a new set of 5th percentile parameters was
recommended.
Below are the comparisons of the old and new reference values:
In Town Patient
Appointments
Out of Town Patient Appointments
WHO 1999
WHO 2010
Fertility SitesParameter
IVFMD Forms
IVFMD Videos
Volume
2 ml
1.5 ml
Physician Referral
Forms
Concentration
20 million/ml
15 million/ml
Blog
Progressive motility 50%
32%
14%
4%
On Weight and Fertility » Normal forms
Sperm + Egg = Embryo
Based on our experience, concentration and progressive motility are the most important sperm parameters
predicting the Semen
likelihood of pregnancy
via coitus orParameters
intrauterine insemination. For example, when
New World insperm
Health
Analysis
concentration is < 10 million/ml and/or progressive motility < 20%, the chance of pregnancy using
the conventional methods is very low. In vitro fertilization would provide the best chance of pregnancy.
Somewhat more difficult to interpret is sperm morphology, or the proportion of sperm that appear perfect
under light microscopy. Morphology is the most subjective parameter in a semen analysis with different
centers using different criteria to evaluate morphology. Moreover, technicians within the same laboratory
can give different values using the same grading scheme.
by Julian Escobar, MD | July 18th, 2013
Like 20 people like this. Be the first of your friends.
1
3
As can be seen above, there is a large difference between the WHO morphology references for 2010 and
1999, reflecting the subjective nature of this parameter. At IVFMD we usually do not use morphology
when recommending initial treatment. In our experience, as long as sperm Concentration and motility are
within normal ranges, poor morphology scores do not necessarily preclude pregnancy. Over the years we
by Julian Escobar, MD | July
2013 men with isolated low morphology scores (0-3%) who became biological fathers without
have18th,
seen many
the need for IVF or ICSI.
Like 20 people like this. Be the first of your friends.
Tweet
In 2010 the World Health Organization (WHO) updated its reference values for the Semen Analysis.[1]
This update was long overdue as the last version was published in 1999.
There is a significant
difference on how the old and new reference ranges were derived. In the past, semen
The optimal
evaluation
data from random populations of men were analyzed and the results were plotted on a statistical
1
Tweet
The new WHO criteria are unique because for the first time, a semen sample under evaluation can be
compared to those of fertile men. We have found the new standards to be quite helpful in assessing the
male fertility potential. If you have any questions about the new parameters, do feel free to contact
3
The optimal evaluation
Reference: Cooper, TG et al. WHO reference values for human semen characteristics. Hum. Reprod. Update. 2010. 16(5):559
| Category: IVFMD |
distribution curve. The 5th percentile was considered to be the lower limit of normal (or reference), in
In 2010 the World HealthAbout
Organization
updated
another word, 95% of men tested would have sperm parameters higher than the reference ranges.
Julian(WHO)
Escobar,
MDits reference values for the Semen Analysis.[1]
This update was long overdue as the last version was published in 1999.
In WHO 2010, the new normal values are based on data from men with proven fertility, men who were
known to help their partners conceive in the previous 12 months. Following a large analysis of semen There is a significant difference on how the old and new reference ranges were derived. In the past, semen
data from random populations of men were analyzed and the results were plotted on a statistical
parameters from over 4000 men in 14 countries, a new set of 5th percentile parameters was
distribution curve. The 5th percentile was considered to be the lower limit of normal (or reference), in
recommended. Below are the comparisons of the old and new reference values:
another word, 95% of men tested would have sperm parameters higher than the reference ranges.
Parameter
WHO 1999
WHO 2010
Dr Escobar graduated with High Honors in Genetics from the University of Georgia and was subsequently
In WHO 2010, the new normal
values are based on data from men with proven fertility, men who were
awarded prestigious research fellowships at the National Institutes of Health and Harvard Medical School.
known to help their partners
conceive
in the
12 months.
a large
analysis of
semen
Volume
2 ml
1.5 ml
He then
obtained
hisprevious
medical degree
from Following
the University
of Pittsburgh
School
of Medicine and completed
parameters from over 4000
men
in 14residency
countries,ataNorthwestern
new set of 5th
percentileHe
parameters
was to Dallas to pursue fellowship
his OBGYN
University.
later relocated
Concentration
20 million/ml
15 million/ml
recommended. Below aretraining
the comparisons
of the Endocrinology
old and new reference
values:
in
Reproductive
and
Infertility
at
UT
Southwestern
Medical
Center. Dr. Escobar is
Progressive motility 50%
32%
board certified in Obstetrics & Gynecology. He is an active member of the American College of
Normal forms
14%
4%
Parameter
WHO
1999 & Gynecology,
WHO 2010
Obstetrics
the American Society of Reproductive Medicine, the American Association of
Gynecological Laparoscopists, the Endocrine Society and the Texas Medical Association. He has lived in
Based on our experience, concentration and progressive motility are the most important sperm parameters
several Latin American countries and is completely fluent in Spanish.
in predicting the likelihood of pregnancy via coitus or intrauterine insemination. For example, when
http://www.ivfmd.net
sperm concentration is < 10 million/ml and/or progressive motility < 20%, the chance of pregnancy using
the conventional methods is very low. In vitro fertilization would provide the best chance of pregnancy.
Leave a Reply
Sperm + Egg = Embryo
Why the difference?
Somewhat more difficult to interpret is sperm morphology, or the proportion of sperm that appear perfect
under light microscopy. Morphology is the most subjective parameter in a semen analysis with different
centers using different criteria to evaluate morphology. Moreover, technicians within the same laboratory
can give different values using the same grading scheme.
Name (required)
As can be seen above, there is a large difference between the WHO morphology references for 2010 and
1999, reflecting the subjective nature of this parameter. At IVFMD we usually do not use morphology
when recommending initial treatment. In our experience, as long as sperm Concentration and motility are
within normal ranges, poor morphology scores do not necessarily preclude pregnancy. Over the years we
have seen many men with isolated low morphology scores (0-3%) who became biological fathers without
the need for IVF or ICSI.
The new WHO criteria are unique because for the first time, a semen sample under evaluation can be
compared to those of fertile men. We have found the new standards to be quite helpful in assessing the
male fertility potential. If you have any questions about the new parameters, do feel free to contact
5
17-Aug-16
The optimal evaluation
The optimal evaluation
One step back- history and examination!!
One step back- history and examination!!
The optimal evaluation
One step back- history and examination!!
The optimal evaluation
The optimal evaluation
One step back- history and examination!!
6
17-Aug-16
The journey
Further investigations
1. The optimal evaluation of the men
What is needed and when to test?
2. Further investigations
Other procedures and tests for assessing male fertility
Endocrine evaluation
Hormonal abnormalities of the hypothalamic-pituitary testicular axis are well-recognized, though
not common causes of male infertility. An endocrine evaluation should be performed if there is:
1) an abnormal semen analysis, especially if the sperm concentration is less than 10 million/ml;
2) impaired sexual function; or 3) other clinical findings suggestive of a specific endocrinopathy.
Some experts believe that all infertile males should have an endocrine evaluation, but there is no
consensus of opinion on this controversy. The minimum initial hormonal evaluation should
consist of measurements of serum follicle-stimulating-hormone (FSH) and serum testosterone
levels. If the testosterone level is low, a repeat measurement of total and free testosterone (or
bioavailable testosterone), as well as determination of serum luteinizing hormone (LH) and
prolactin levels should be obtained. Although serum gonadotropin levels are variable because
they are secreted in a pulsatile manner, a single measurement is usually sufficient to determine a
patient’s clinical endocrine status. The relationship of testosterone, LH, FSH and prolactin helps
to identify the clinical condition (see Table 2). A normal serum FSH level does not guarantee the
Further investigations
presence of intact spermatogenesis, however, an elevated FSH level even in the upper range of
Endocrine evaluation
“normal”Endocrine
is indicative
of an abnormality in spermatogenesis.
evaluation
Recommendation: An initial endocrine evaluation should include at least a serum
testosterone and FSH. It should be performed if there is: (1) an abnormally low
sperm concentration, especially if less than 10 million/ml; (2) impaired sexual
function; or (3) other clinical findings suggestive of a specific endocrinopathy.
Copyright© 2010 American Urological Association Education and Research, Inc.®
11
Karyotype
A karyotype analyzes all chromosomes for the gain or loss of entire chromosomes as well as
structural defects, including chromosome rearrangements (translocations), duplications,
of only 11%. However, for those patients who have CBAVD and CFTR mutations the
deletions, and inversions. Chromosome abnormalities account for about 6% of all male
prevalence of renal anomalies is extremely rare.47 Therefore, imaging of the kidneys with either
Further investigations
infertility, and the prevalence increases with increased spermatogenic impairment (severe
oligospermia and nonobstructive azoospermia). Paternal transmission of chromosome defects
Genetic studies
Further investigations
ultrasound or CT scan is more likely to detect abnormalities in men with unilateral vasal agenesis
or men with CBAVD who do not have mutations in CFTR.
Genetic studies
Recommendations: Men with congenital bilateral absence of the vasa deferentia
can result in pregnancy loss, birth defects, male infertility, and other genomic syndromes.
Recommendation: Karyotyping and genetic counseling should be offered to all
should be offered genetic counseling and testing for cystic fibrosis transmembrane
conductance regulator mutations. The female partner should also be offered cystic
patients with nonobstructive azoospermia and severe oligospermia (<5 million
fibrosis transmembrane conductance regulator mutations testing before proceeding
sperm/ml).
with treatments that utilize the sperm of a man with congenital bilateral absence of
the vasa deferentia. Imaging for renal abnormalities should be offered to men with
Y-chromosome microdeletions
Approximately 13 % of men with nonobstructive azoospermia or severe oligospermia have an
57
underlying Y-chromosome microdeletion.
Y chromosome microdeletions responsible for
infertility — regions AZF a, b, or c — are detected using sequence tagged sites (STS) and
unilateral vasal agenesis or congenital bilateral absence of the vasa deferentia and
no evidence of cystic fibrosis transmembrane conductance regulator abnormalities.
Cystic fibrosis transmembrane conductance regulator testing
Routine screening for mutations of CFTR is currently performed by testing for a panel of
polymerase chain reaction (PCR) analysis. There is no consensus on the number of STS required
specific mutations that are known to be prevalent rather than sequencing the entire gene. The
for optimal detection of AZF deletions. Detection has both prognostic and ethical significance.
CFTR gene is extremely large and the number of mutations potentially infinite. Clinical
Successful testicular sperm extraction has not been reported in infertile men with either an AZFa
laboratories typically test for the 30–50 most common mutations found in patients with clinical
or AZFb deletion but the total number of reports is limited.
58
In contrast, up to 80% of men with
AZFc deletions have retrievable sperm for ICSI. Furthermore, the couple must be counseled on
the inheritance of this compromised fertility potential in all male offspring.59-60
cystic fibrosis. However, the mutations associated with CBAVD may be different. There are
more extended panels available that test up to 100 mutations. Because over 1,300 different
mutations have been identified in this gene, this type of limited analysis is only informative if a
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17-Aug-16
Further investigations
Y-microdeletion testing
Genetic studies
Is there anything I can do to
improve my sperms?
The journey
1. The optimal evaluation of the men
2. Further investigations
3. Strategy to improve sperm parameters
Strategy to improve sperms
Medical
Surgical
Strategy to improve sperms
Medical
Surgical
The insult can be permanent
8
17-Aug-16
Strategy to improve sperms
Strategy to improve sperms
 Medical
 Medical
Strategy to improve sperms
Strategy to improve sperms
 Medical
 Medical
NO MENTION OF MALE SUPPLEMENT!
Strategy to improve sperms
Strategy to improve sperms
 Medical
 Medical
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17-Aug-16
Strategy to improve sperms
Strategy to improve sperms
 Surgical
 Urology
 Obstruction
Medical
Surgical
• Urology
Strategy to improve sperms
Varicocoele repair
 Surgical
 Urology
 Varicocoele
Strategy to improve sperms
Strategy to improve sperms
 Surgical
 Surgical
 Urology
 Varicocoele
 Urology
 Varicocoele
10
17-Aug-16
Strategy to improve sperms
The journey
 Surgical
1. The optimal evaluation of the men
 Urology
2. Further investigations
 Varicocoele
3. Strategy to improve sperm parameters
4. Surgical sperm retrieval
The insult can be permanent
Sperm Retrieval for Assisted Reproduction
Table 2 - Advantages and Disadvantages of Sperm Retrieval Techniques for Assisted Reproduction.
Advantages
Disadvantages
Fast and low cost
Minimal morbidity, repeatable
No microsurgical expertise required
Few instruments and materials
No surgical exploration
Few sperm retrieved
Cryopreservation limited
Fibrosis and obstruction at
aspiration site
Risk of hematoma/spermatocele
MESA
Large number of sperm retrieved
Excellent chance of sperm cryopreservation
Reduced risk of hematoma
Reconstruction possible 1
Surgical exploration required
Increased cost and timedemanding
Microsurgical instruments and
expertise required
Postoperative discomfort
TESA
Fast and low cost
Repeatable
No microsurgical expertise required
Few instruments and materials
No surgical exploration
Minimal/mild postoperative discomfort
Relatively low success rate in
NOA
Few sperm retrieved in NOA
Cryopreservation limited
Risk of hematoma/testicular
atrophy
TESE
No microsurgical expertise required
Fast and repeatable
Relatively low success rate in
NOA
Relatively few sperm retrieved in
NOA
Risk of testicular atrophy (with
multiple biopsies)
Postoperative discomfort
Higher success rates in NOA 2
Larger number of sperm retrieved 2
Relatively higher chance of sperm cryopreservation 2
Low risk of complications
Surgical exploration required
Increased cost and timedemanding
Microsurgical instruments and
expertise required
Postoperative discomfort
PESA
Surgical sperm retrieval
Micro-TESE
Surgical sperm retrieval
PESA: percutaneous
epididymal
sperm aspiration; MESA:
Esteves
et al,
International
Brazmicrosurgical
J Urol,epididymal
2011 sperm Aspiration; TESA: percutaneous testicular sperm aspiration; TESE: conventional testicular sperm extraction; micro-TESE: microsurgical
testicular sperm extraction.
1 - In cases of vasectomy; 2 - Compared to TESA and TESE in NOA
of sperm collection. TESA retrieval rates range
from 10-30% (22,23,39-41), except in the favorable cases of previous successful TESA or testicular histopathology showing hypospermatogenesis.
In such cases, TESA SRR range from 70-100%
(6,10). In a recent systematic review the mean re-
ported SRR for TESE was 49.5% (23). TESE with
multiple biopsies resulted in higher SRR than
e fin -needle aspiration (TEFNA), a variation of TESA,
especially in cases of Sertoli-cell-only (SCO) and
maturation arrest (23). Retrieval rates ranging from
35% to 77% have been reported for micro-TESE
578
The journey
Summary
1. The optimal evaluation of the men
 Semen analysis
2. Further investigations
 History & examination
3. Strategy to improve sperm parameters
4. Surgical sperm retrieval
5. Counselling
 Referral for further evaluation & treatment
 If <10 million/ml




FSH, LH, prolactin, testosterone, TFT
Karyotyping
Y- chromosome deletion
Cystic fibrosis if absent vas deferens
 Surgical sperm retrieval for azoospermia, or severe
oligospermia when appropriate
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17-Aug-16
Egg number and live birth rate
Quiz
Quiz
 How about eggs…
 How about eggs
 How many is enough in a fresh cycle?
 How many is enough in a fresh cycle?
Sunkara et al., Hum Reprod. 2011
Thank you
12