Opera&ve techniques for male infer&lity
Ateş Kadıoğlu, MD,FECSM Professor of Urology
University of Istanbul
Infer&lity
• Infer&lity is the inability of a sexually ac&ve, non-‐
contracep&ng couple to achieve spontaneous pregnancy in one year (WHO).
• About 15% of couples do not achieve pregnancy within one year and seek medical treatment for infer&lity.
• In those couples, the reason of infer&lity is
– 50% due to female factor,
– 20% due to the male factor and the remaining 30%
involving a combina&on of both.
EAU Guidelines Of Male Infer&lity – 2016
Surgery
• Surgery is divided into two categories:
– Surgery for curable pathologies (varicocele, proximal ejaculatory duct obstruc&on, distal ejaculatory duct obstruc&on)
– Varicocelectomy,
– Vasovasostomy(VV),
– Vasoepididymostomy(VE),
– Transurethral resec&on of ejaculatory ducts (TUR-‐ED).
– Incurable pathologies (non-‐obstruc&ve azoospermia).
Micro-‐TESE and MESA are the suggested techniques for
sperm retrieval in azoospermic cases.
• Varicocelectomy
• TUR-‐ED
• Micro-‐TESE
• MESA
Presenta&on Outline
Varicocelectomy
• Varicocele is found in approximately
– 15% of the general popula&on,
– 35% of men with primary infer&lity,
– 75% to 81% of men with secondary infer&lity.
Varicocelectomy Indica&ons
• Infer&lity > 2 years and otherwise unexplained infer&lity in the couple.
• Oligospermia,
• Clinical varicocele (palpable)
EAU Guidelines Of Male Infer&lity – 2016
Surgical techniques
• Open via retroperitoneal, inguinal, or subinguinal approaches;
• Microsurgically through an inguinal or subinguinal incision;
• Laparoscopically or robo&cally
• Antegrade or retrograde sclerotherapy, retrograde emboliza&on
EAU Guidelines Of Male Infer&lity – 2016
Microsurgical Inguinal and Subinguinal Opera&ons:
• Varicocelectomy involves
liga&on of the aberrantly
dilated veins within the
sperma&c cord while
preserving arterial and
lympha&c supply and the
deferen&al veins.
Current evidence indicates that microsurgical varicocelectomy is the most effec&ve method among the different varicocelectomy
techniques in terms of recurrence, post surgical hydrocele and tes&cular atrophy
Surgical techniques
Complica&ons
N Artery
preserve(%)
Recurrence (%)
Hydrocele (%)
Microsurgery
35 100 2.85 0
Open palomo
35 91.4 17.14 5.2
Laparoscopic
35 97.1 14.2 8.5
Pajovic B-‐European Review for Medical and Pharmacological Sciences-‐2015; 19: 532-‐538
• Compared 3 methods
• Follow-‐up period: 90 day
EAU Guideline Male infer&lity 2016
Complica&ons
m
There is evidence sugges&ng that treatment of a varicocele in men from couples with otherwise unexplained subfer&lity may improve a couple’s chance of pregnancy.
Fer&lity and Sterility® Vol. 102, No. 6, December 2012
The OR comparing treatment (interven&on) with no treatment (or counselling/
clomiphene citrate) for pregnancy rate was 1.47 (95% CI 1.05 to 2.05, P = 0.03, 894 men, 181 pregnancies, I2 = 67%)
n
• 4 studies
• 870 ICSI cycles
• N:438 varicocelectomy(+)
• N:432 varicocelectomy(-‐)
Asian Journal of Andrology (2016) 18, 1–5
Clinical pregnancy
Live birth
There was a significant increase in the clinical pregnancy rates and live birth rates in the varicocelectomy group compared to the group subjected to ICSI without previous varicocelectomy. . (OR = 1.59, 95% CI: 1.19–2.12, I 2 = 25%) ve (OR = 2.17, 95% CI:1.55–3.06, I 2 = 0%)
Asian Journal of Andrology (2016) 18, 1–5
Fukuda T-‐UROLOGY 86: 48e51, 2015.
• N=71, micro-‐Vx
• Sperm concentra&ons and mo&li&es were significantly increased by 3 and 12 months arer surgery compared with those before surgery
• No significant change was noted in sperm concentra&ons or mo&li&es between 3 and 12 months arer surgery.
• The level of improvement in semen parameters at 3 months arer varicocelectomy may be stable at 12 months arer surgery,
Varicocelectomy follow-‐up
Conclusion
No significant change was noted in sperm
concentra&ons or mo&li&es between 3 and 12 months arer surgery.
Current evidence indicates that microsurgical varicocelectomy is the most effec&ve method The findings of a systema&c review and
meta‑analysis indicate that performing
varicocelectomy in pa&ents with clinical varicocele
prior to ICSI is associated with improved pregnancy
outcomes.
• Varicocelectomy
• TUR-‐ED
• Micro-‐TESE
• MESA
Presenta&on Outline
Transurethral resec&on of the ejaculatory ducts (TURED)
• Ejaculatory duct obstruc&on(EDO) is found in 1-‐3% of cases of OA.
• Low semen volume(<1.5 cc), Acid pH (<7.2)
• Normal tes&s and hormonal profile
• Imaging findings suggest dilated seminal vesicles (SVs), prosta&c cysts or calcifica&ons, or dilated ejaculatory ducts on transrectal ultrasound (TRUS)
EAU Guidelines Of Male Infer&lity – 2016
TUR-‐ED
• The resectoscope, with the 24-‐Fr cutng loop, is engaged with a finger placed in the rectum
providing anterior displacement of the posterior lobe of the
prostate.
• Resec&on of the veru will oren reveal the dilated ejaculatory duct orifice or cyst cavity.
• Resec&on should be carried out in this region with great care in order to preserve the bladder neck proximally, the striated sphincter distally and the rectal mucosa posteriorly.
TUR-‐ED
• Gold standard treatment, TUR-‐ED
• Alterna&ve treatment, Endoscopic laser-‐assisted resec&on
Antegrade seminal-‐vesicle lavage Dilata&on of the ejaculatory ducts using 9F seminal vesicoscopy or
balloon
Kadioglu A,Fer&l Steril 2001 76(1):138–142
Modgil V-‐NATURE REVIEWS | UROLOGY VOLUME 13 | JANUARY 2016 |
Surgical Techniques
TUR-‐ED
ResecTon 1-‐Monopolar 94%
2-‐Bipolar 90.5%
DilataTon 6-‐8 F Vesikuloskopi
95%
Holmium laser incision 91%
Predic&ve factors
u Complete EDO:(59% of pa&ents demonstrated improvement) u Par&al EDO:(94% of pa&ents demonstrated improvement) u Congenital EDO
• Improvement in semen parameters : 100% (mo&lity and volume)
• Improvement in semen count:83%
• Pregnancy (+):66%
u Acquired EDO
• Improvement in semen parameters : 37.5%
• Pregnancy: %12.5
Modgil VNATURE REVIEWS | UROLOGY VOLUME 13 | JANUARY 2016 |
• Varicocelectomy
• TUR-‐ED
• Micro-‐TESE
• MESA
Presenta&on Outline
Micro TESE
• NOA, which is diagnosed in about 2/3 of azoospermic men.
• Micro-‐TESE, currently one of the most popular sperm retrieval procedures for men with NOA, was first
described in 1999.
• Micro-‐TESE provides the advantage of allowing the
surgeon to selec&vely iden&fy seminiferous tubules most likely to contain spermatozoa based on the larger and
more opaque appearance of those tubules.
• Sperm retrieval rates significantly higher when the
procedure is performed with a microsurgical approach
Ali A Dabaja and Peter N Schlegel-‐Asian Journal of Andrology (2013) 15, 35–39
S perm in NOA are like apples on a tree
Some branches have them, and some don’t
• SRR;
• mTESE: %52
• cTESE: %35
Micro-‐TESE was 1.5 &mes more likely (95% confidence interval 1.4–1.6) to result in successful SR as compared with cTESE.
Fer&lity and Sterility-‐ Vol. -‐, No. -‐, -‐ 2015
A comparison of current and experimental surgical techniques and modaliTes in the management of nonobstrucTve azoospermia
Ramasamy R et al Indian J Urol 2016
Surgical Technique
• Due to the heterogeneity of sperm produc&on in the
tes&cle, microdissec&on permits examina&on of all seminiferous tubules.
• Use of the opera&ng
microscope at 15X to 20X
• Targe&ng the larger and
dilated tubules, improves the yield of sperm retrieval and limits the amount of
tes&cular &ssue that needs to be removed by 70-‐fold
Schlegel PN et al Asian J Androl 2013
Surgeon’s experience
• At least 50 cases are needed to pass the steepest por&on of the learning curve.
• More than 500 m-‐TESE: Further subtle increase in SRRs
• As the number of cases increases, dilated and opaque seminiferous tubules are iden&fied easier and opera&on &me decreases
Schlegel P et al Asian J of Andrology 2013
Predic&ve value of histopathology ?
Schlegel 1999 Amer et al. 2000 Okada et al. 2002 Tsujimura et al 2002 Ramasamy et al. 2005 Colpi et al 2009
Ghalayini et al 2011
m-‐TESE TESE Sertoli cell only
syndrome
22.5 to 41% 6.3 to 29%
Matura&on arrest 36.4 to 75% 0 to 37.5%
Hypospermatogenesis 81 to 100% 50 to 84%
Deruyver Y et al Andrology 2014
Overall sperm retrieval rate TESE (16.7 to 45%), m-‐TESE (42.9
to 63%)
AZF Dele&on
• Good prognosis:
AZFc dele&on
• Bad prognosis:
Complete AZFa and AZFb dele&on
Gene&c tes&ng for Y chromosome microdele&on is
prognos&c factor for m-‐TESE
Tes&cular Atrophy -‐SRRs
• 1127 pa&ents, NOA Tes&cular volume;
• < 2 cc (n:106) 2-‐10 cc (n:573) >10 cc (n:448)
• Successful SRR 56% (n:631)
• Low tes&cular volume does not affect the sperm retrieval rate
SRRs
54.7%, 56.2%
55.1%
CF. Bryson, Ramasamy R-‐THE JOURNAL OF UROLOGY-‐ Vol. 191, 1-‐4, January 2014
Klinefelter’s Syndrome
• Klinefelter’s syndrome is the
most common sex chromosome abnormality
• 11 % , azoospermia
• %80 47,XXY non-‐mosaic,
• %20 46,XY/47,XXY mosaicism
• 48,XXXY-‐ 48,XXYY 50.000/1
EAU Male infer&lity Guidelines.2016
AUA Male infer&lity guidelines 2010 Paduch DA, et al.Semin Reprod Med.2009 Frühmesser/Kotzot et al Sex Dev 2011;5:109–123
Klinefelter’s Syndrome-‐SRRs
• Mean SRR :65%
• Clinical pregnancy:40%
• No predic&ve value of serum FSH, LH and tes&s volume in SRR
• Men with who responded to preopera&ve hormonal therapy SRR é
• Sperm retrieval was higher for micro-‐TESE compared with cTESE(%67& 42)
I. Plo{on et al. / Annales d’Endocrinologie 75 (2014) 118–125
Ali A Dabaja and Peter N Schlegel-‐Asian Journal of Andrology (2013) 15, 35–39
• Varicocelectomy
• TUR-‐ED
• Micro-‐TESE
• MESA
Presenta&on Outline
Microsurgical epididymal sperm aspira&on (MESA)
• MESA was first described in 1985
• This surgical technique requires tes&s delivery through a 2-‐3-‐cm transverse scrotal incision.
• The epididymal tunica is incised, and an enlarged tubule is selected.
• Then, the epididymal tubule is dissected and opened with sharp microsurgical scissors.
• The fluid that flows out of the
tubule is aspirated with the aid of a silicone tube or a needle a{ached to a tuberculin syringe
Esteves SC et al Clinics(Sao Paulo) 2013
MESA
• The fluid that flows out of the
tubule is aspirated with the aid of a silicone tube or a needle
a{ached to a tuberculin syringe
• MESA can be repeated at a different site on the same
epididymis (from the cauda to caput regions) and/or the
contralateral epididymis un&l an adequate number of mo&le
sperm is retrieved
• MESA oren provides enough sperm for cryopreserva&on.
Esteves SC et al Clinics(Sao Paulo) 2013
