AZOOSPERMIA: RISULTATI
DEI TRATTAMENTI
DR. ETTORE CAROPPO
UO FISIOPATOLOGIA DELLA RIPRODUZIONE UMANA E P.M.A.
AZOOSPERMIA
1% DELLA POPOLAZIONE
MASCHILE
10-15% DELLA POPOLAZIONE
MASCHILE INFERTILE
Evidences for OA >NOA
6
Key issues
• Most published studies that addressed pregnancy and neonatal outcome of children born after the use of nonejaculated sperm suffer from methodological shortcomings. The population included is small, and in general, no discrimination is made between OA and NOA
• To date, few studies have directly compared pregnancy outcomes between OA and NOA, and the data are limited. Most of the studies were not designed to detect differences in pregnancy and live birth rates and
had low power to detect differences in less-frequent outcomes, such as multiple births and complications
• In general, clinical pregnancy and live birth rates reported in the literature range from 26-57% for NOA and 18-55% for OA, and the results are similar to those reported with ICSI using ejaculated sperm. Published studies have shown either a decrease or no difference in pregnancy outcomes with ICSI in cases of NOA and OA. No major difference was noted in short-term neonatal outcomes and congenital malformation rates between children from fathers with NOA and OA. However, these results are based on a very limited
population, and tendencies towards lower gestational age and birth weight of babies born from azoospermic fathers call for continued monitoring.
• No follow-up study has yet compared the long-term physical, neurological and developmental outcomes of children born with ICSI using sperm from azoospermic men with OA and NOA
• Due to the relative lack of data on fetal, neonatal and long-term outcomes of children born from
azoospermic fathers, future studies should include the use of multicenter trials with adequate sample size and development of standard datasets to differentiate between the groups of men with OA and NOA. Efforts should also be made to reach a consensus on significant clinical differences regarding sample size estimates, especially for less common outcomes, thus facilitating meta-analyses.
• Currently, the limited evidence regarding pregnancy and postnatal outcomes of ICSI using surgically-derived sperm from azoospermic men is reassuring, but a call for continuous monitoring is of utmost importance to support the recommendation of sperm retrieval and ICSI in such male infertility categories.
Tecniche di
prelievo di
spermatozoi
testicolari: quale
adoperare?
“Sperm retrieval rates for men with
OA using ICSI are excellent (96%–100%)
•Tecnica di prelievo e sede di ostruzione nessun
impatto su SRR
• MESA: maggior numero di spz ma più invasiva
• Spz epididimo = spz testicolo
Conclusions: TESE with multiple samples > FNA SCO: MicroTESE > TESE Safety: MicroTESE >FNA >TESE
•There is insufficient data from randomized trials to recommend any particular surgical sperm-retrieval techniques for either OA or NOA.
• The least invasive and simplest technique method for surgical retrieval of sperm is to be used
• The more invasive methods should be reserved for situations where sperm cannot be retrieved by a less invasive techinique or for evaluation in the context of a randomized trial
Conclusions
MicroTESE > TESE in SCO No clinical predictors of SRR
MANCATO RECUPERO DI
SPERMATOZOI: UTILE RIPETERE
TESE/MICROTESE?
Vernaeve V et al, Hum Reprod 2006; 21: 1551-4
Talas H et al, Asian J Androl 2007; 9: 668-73
Ramasamy R et al, J Urol 2011; 185: 1027-31
SRR e
TESE/microTESE:
fattori predittivi?
•
792 men with NOA enrolled
from 1997 to 2006
SR - SR + FSH level (mIU/ml) 20.0 (17.5-20.3) 18.8 (18.7-21.3)SR + SR -Testicular volume (mean + SD) 9.1 + 4.85 ml 9.1 + 5.6 ml
SRR e microTESE:
effetto della
Hormonal treatment
Authors No patients Treatment Outcome
Shinjo et al, Andrology 2013; 1:929-35
20 with failed microTESE
hCG SR 3/20 (15% )in pz with pre-treatment low ITT
Shiraishi et al, Hum Reprod 2012; 27:331-9 48 with failed microTESE hCG/hCG +FSH (28 pz) No treatment (20 pz) SR 6/28 (21,4%) of treated SR 0/20 untreated Hussein et al, BJU
int 2013 ;111:E110-4; 612 pz CC treated 116 untreated 372 pz CC(FSH, LH, T rise) 62 pz CC+ hCG (FSH rise, LH e T unmodif) 46 pz HMG+hCG (FSH, LH, T unmodif) 16 pz HMG+hCG (T decrease) Sperm in ejaculate: 41/372 (10.9%) 7/62 (11.3%) 4/46 (8.7%) 2/16 (12.6%) microTESE SR: 252/442 (57%) treated 39/116 (33.6%) control Reifsneider et al, J Urol
2012; 188: 552-7 736 pz 388 normal T (untreated) 348 low T 307 (88%) treated (hCG, CC, AI) 41 (12%) untreated SR 56% SR 52%. SR 51% SR 61%
S. di Klinefelter e
azoospermie
Sperm retrieval rate 42.9%
Fertilization rate 57.1%
Pregnancy rate 50%
Sperm retrieval rate 42%
Pregnancy rate 27%
Live birth rate 19%
2° TESE with prior hCG treatment in 6 pz SR in 2/6 pz (33%)
Klinefelter syndrome: an argument for early aggressive hormonal and
fertility management. Fert Steril 2012; 98: 274-83
Klinefelter vs NOA
Klinefelter NOA Klinefelter NOA Klinefelter NOA
SRR (%) 56 44 47 50 28.4 22.2 Fert Rate (%) - - 57 65* 28 21* Clin PR (%) 39 33 53 55 - -Impl R (%) 23 23 25 27 - -Live BR (%) - - 13 3*
Bakircioglu, Fert Ster 2011 Sabbaghian Urology 2014 Yarali, Reprod Biomed
74 non mosaic KS undergoing microTESE 42/76 (56.7%) sperm recovery (SR)
Age cut-off = 30.5 years (78% sensitivity, 48% specificity) Age and SR inverse correlation (OR 0.854 – CI 0.76-0.95)
•Multiple site-bilateral TESE, sperm cryopreservation # Ejaculate
