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SURGICAL SPERM RETRIEVAL

PROCEDURES AND VARICOCELE


REPAIR IN OFFICE UROLOGY
Ponco Birowo, MD, PhD
Department of Urology
Faculty of Medicine Universitas Indonesia - Dr. Cipto Mangunkusumo Hospital
Jakarta
INFERTILITY

Infertility is the inability of a sexually active,


non contracepting couple to achieve
Definition spontaneous pregnancy in one year (WHO,
2000).

• Infertility affects 15-20% of all couples.


• Male factor infertility with abnormal semen
Epidemiology parameters is partially or fully responsible for
approximately 30-55% of infertility cases.

Winters BR and Walsh TJ, Urol Clin N Am 2014


Hamada AJ et al., Clinics 2012
COMMON CAUSES OF MALE INFERTILITY
Testicular
failure
Genital tract Genetic
9%
infections disorders
8-35% 15-30%

Endocrine Antisperm
disorders antibody
>20% 8-19%

Varicocele Male Idiopathic


37-40%
Infertility 30-40%

Tahmasbpour E et al., J Assist Reprod Genet 2014


INITIAL DIAGNOSTIC TESTING:
SEMEN ANALYSIS

Lower reference limit


Parameter
(range)
Semen volume (mL) 1.5 (1.4-1.7)
Total sperm number (106/ejaculate) 39 (33-46)
Sperm concentration (106/mL) 15 (12-16)
Total motility (PR + NP) 40 (38-42)
Progressive motility (PR, %) 32 (31-34)
Vitality (live spermatozoa, %) 58 (55-63)
Sperm morphology (normal forms, %) 4 (3.0-4.0)
PR = progressive; NP = non-progressive
Who Laboratory Manual for the Examination and Processing of Human Semen (5 th
ed), 2010
HORMONES LEVEL AND SCROTAL
ULTRASOUND
• Serum Testosterone, follicle-stimulating hormone (FSH), and luteinizing
hormone (LH).
• Scrotal ultrasound is useful if there is any indication of abnormality, e.g.
testicular atrophy, varicocele, testicular mass.

Anawalt BD, J Clin Endocrinol Metab 2013


TREATMENT OPTIONS
Lifestyle • Weight management for men with overweight or obesity.
• Cessation of smoking.

Changes
• Refraining from excessive alcohol intake.
• Avoidance of activity/clothing which may elevate scrotal temperature.

Medical •Gonadotrophins for hypogonadotrophic hypogonadism.


•Clomiphene citrate and tamoxifen for idiopathic male infertility.

Treatment •Oral antioxidants.

Surgical •Varicocele repair


•Vasectomy reversal

Treatment •Surgical sperm recovery (PESA, MESA, TESA, TESE, mTESE)

Ramalingam M et al., Obstet Gynaecol Reprod Med 2014


Anawalt BD, J Clin Endocrinol Metab 2013
SURGICAL APPROACHES FOR MALE
INFERTILITY
OBSTRUCTIVE AZOOSPERMIA
• Comprises 15-40% of all azoospermia
cases.
• Azoospermia, normal size testicles, and
the levels of FSH, LH, and testosterone
within normal limits.
• Vasectomy, iatrogenic vassal
obstruction (most often after inguinal
hernia repair), congenital
unilateral/bilateral absence of the vas
deferens (CUAVD/CBAVD).

Ramalingam M et al., Obstet Gynaecol Reprod Med 2014


Jarow JP et al., J Urol 1989
Wosnitzer MS and Goldstein M, Urol Clin N Am 2014
NON-OBSTRUCTIVE AZOOSPERMIA

• NOA includes primary testicular failure (hypergonadotrophic


hypogonadism), secondary testicular failure (hypogonadotrophic
hypogonadism), and incomplete or ambiguous testicular failure.

• May result from prior toxic exposures (i.e. chemotherapy, radiation), genetic
abnormality, cryptorchidism, or varicoceles.

Wosnitzer MS et al., Spermatogenesis 2014


SURGICAL SPERM-RETRIEVAL
PROCEDURES IN AZOOSPERMIA
• Percutaneous epididymal sperm aspiration (PESA)
• Microsurgical epididymal sperm aspiration (MESA)
• Testicular sperm extraction (TESE)
• Microdissection testicular sperm extraction (mTESE)
SURGICAL SPERM RETRIEVAL
TECHNIQUES IN OA
• Surgical sperm retrieval combined with intracytoplasmic sperm injection
(ICSI) give favorable result in OA.
• MESA is regarded as the gold standard procedure to obtain epididymal
sperm.
• PESA has been introduced as a less invasive alternative for epididymal sperm
retrieval in patients with OA.

Yafi FA and Zini A, J Urol 2013


MESA

• MESA is considered to be the gold


standard procedure for sperm Illustration of MESA
retrieval in OA. performed by
aspiration of
• During MESA, sperm-containing epididymal fluid into
epididymal fluid is aspirated from a micropipette
optimal areas of the epididymis using high-power
sampled using high-power optical optical
magnification provided by an magnification
operating microscope.

Bernie AM et al., Asian J Androl 2013


OPTIMAL AREA OF THE EPIDIDYMIS FOR SPERM
RETRIEVAL

In obstructive azoospermia (OA), distal epididymal sperm shows senescent


changes, increased DNA fragmentation, and are non-motile compared to
sperm retrieved from the proximal part of the epididymis

Wely MV et al., Hum Rep 2015


MESA VS TESE: RESULT OF A RETROSPECTIVE
COHORT OF 374 MEN WITH OA
• Subjects with OA due to CBAVD or vasectomy underwent MESA or TESE.
• 280 subjects underwent MESA, 94 subjects underwent TESE.

Wely MV et al., Hum Rep 2015


PESA
• Relatively simple procedure, minimal postoperative morbidity: pain,
infection, hematoma.
• Unlike MESA, does not require operating microscope.
• Associated with less postoperative fibrosis, thus making repeat PESA possible
with reasonable chances of retrieving motile sperm on subsequent
aspiration.

Yafi FA and Zini A, J Urol 2013


EUROPEAN ASSOCIATION OF UROLOGY
(EAU) RECOMMENDATIONS ON OA

Jungwirth A et al., Eur Urol 2015


PESA VS MESA

“The rates of fertilization and pregnancy were 56% and 39% in the 66 PESA-ICSI
cycles, respectively, and 47% and 45% in the 40 MESA-ICSI cycles. No significant
differences were found in fertilization rates or pregnancy rates among the various
sperm retrieval methods and obstruction etiologies.”

Lin YM et al., J Formos Med Assoc 2000


CASE 1
• A couple (42 y.o. male and 36 y.o. female) with 15 years of primary infertility.
• Female partner’s gynecological diagnosis: normal.
• Semen analysis of the male partner: azoospermia.
• Hormonal examination:
o FSH 9.05 mIU/mL
o LH 4.5 mIU/mL
o Testosterone 356.0 ng/dL
• Patient underwent bilateral varicoceles repair with microsurgical subinguinal
technique 9 months prior.
CASE 1 (CONT’D)
• Following washing and centrifugation of the aspirated sperms:
o Left testicle  motile spermatozoa: 300 x 103, immotile spermatozoa: 28 x 106.
o Right testicle  motile spermatozoa: 800 x 103, immotile spermatozoa: 700 x 103.
TESE
• Until recently, conventional TESE was considered as the gold standard for
retrieving spermatozoa in men with NOA.
• In TESE, the seminiferous tubules are extracted directly and blindly from the
testicles, through a small incision .
• Complications are low but include loss of significant amount of testicular
tissue, hematoma, inflammatory changes, and permanent
devascularization.

Deruyver Y et al., Andrology 2013


mTESE
• In mTESE, the tunica albuginea is widely opened and examination of the
testicular tissue is carried out at 20-25x magnification under an operating
microscope allowing visualization of dilated seminiferous tubules.
• The concept of this technique is that these tubules are more likely to contain
active spermatogenesis.
• Better identification of sub-tunical vessels  reducing risk of
devascularization.

Deruyver Y et al., Andrology 2013


Result of a Systematic Review on the Outcome
of mTESE Compared with Conventional TESE
• 7 studies with a total of 1,062 NOA patients.

Overall sperm retrieval rate (SRR) ranged from 16.7-45% in the conventional TESE vs 42.9-63% in the mTESE.
Deruyver Y et al., Andrology 2013
Result of a Meta-Analysis on the Outcome of
mTESE Compared with Conventional TESE

• 15 studies with a total of 1,890 NOA


patients.
• SRR was higher for mTESE compared
with conventional TESE.
• mTESE was 1.5 times more likely
(95% CI 1.4-1.6) to result in successful
SRR as compared with conventional
TESE.

Bernie AM et al., Fertil Steril 2015


CASE 2
• A couple (37 y.o. male and 31 y.o. female) with 5 years of primary infertility.
• Female partner’s gynecological diagnosis: normal.
• Semen analysis of the male partner: azoospermia.
• Hormonal examination:
o FSH 35.07 mIU/mL
o LH 17.45 mIU/mL
o Testosterone 677.7 ng/dL
• Scrotal USG: bilateral varicoceles (diameter of pampiniform plexus: non-
valsava  0.25-0.34 cm, valsava  0.35-0.41 cm) and bilateral testicular
hypotrophies (left testicular volume: 3.12 cc, right testicular volume: 3.15 cc).
CASE 2 (CONT’D)
• No spermatozoa was found.
• Testicular biopsies were performed on both testes and examined for
testicular histopathology (result pending).
• Considered for varicoceles repair.
VARICOCELE
• Varicocele is the dilation or tortuosity of the
pampiniform plexus.
• Most common cause of male infertility (15-
40%).
• Impaired spermatogenesis, testicular
atrophy, decreased testosterone level,
increased DNA fragmentation index (DFI).

Iafrate M et al, World J Urol 2009


Agarwal A et al, Urology 2007
DIFFERENCES IN SEMEN PARAMETERS BETWEEN FERTILE
MEN W/O VARICOCELE, INFERTILE MEN W/
VARICOCELE, AND INFERTILE MEN W/O VARICOCELE

Infertile men Infertile men


with clinical without clinical
varicocele varicocele

Saleh RA et al, Fertility and Sterility 2003


VARICOCELE REPAIR AND SPERM RETRIEVAL OUTCOME IN
AZOOSPERMIC MEN WITH VARICOCELE

Motile-Sperm Retrieval Relative Risk


Intervention Rate (95% Confidence p-value
n (%) Interval)
Overall
PESA/TESE (N=136) 57 (41.9) ref. 0.008
Varicocele repair + PESA/TESE (N=43) 28 (65.1) 1.554 (1.157-2.087)
FSH ≥ 12mIU/mL
PESA/TESE (N = 56) 7 (12.5) ref.
<0.001
Varicocele repair before PESA/TESE (N = 9 (56.2) 4.500 (1.989-10.183)
16)
FSH < 12mIU/mL
PESA/TESE (N = 80) 50 (62.5) ref.
0.46
Varicocele repair before PESA/TESE (N = 19 (70.4) 1.126 (0.836-1.517)
27)
Age range: 27-60 (p=0.251)
Birowo P et al., in press 2016
TECHNIQUES OF VARICOCELE REPAIR

• Retroperitoneal (high) ligation of the testicular artery and vein above the
internal inguinal ring (Palomo technique).
• High ligation of the vein while sparing the artery (Bernardi technique).
• Ligation of the cremasteric and internal spermatic veins within the inguinal
canal (Ivanissevich technique).
• Inguinal microsurgical technique.
• Subinguinal microsurgical technique.
• Laparoscopic high ligation.
• Ante/retrograde sclerotherapy.

Baazeem A et al., Eur Urol 2011


INCIDENCE OF RECURRENT VARICOCELE IN
DIFFERENT VARICOCELE REPAIR TECHNIQUES

• A meta-analysis consisting of 4 RCTs


with a total of 1,015 patients in total.
• The incidences of recurrent
varicocele and postoperative
hydrocele were significantly lower
after microsurgery than after
laparoscopic or open
varicocelectomy.

Ding H et al., BJUI 2011


TAKE HOME MESSAGE
• PESA is a less invasive, less morbid, and cost-effective alternative to MESA for
surgical sperm retrieval in OA.
• Microdissection TESE has a higher SRR compared to conventional TESE for
surgical sperm retrieval in NOA.
• Varicocele repair must be considered in infertile couple with varicocele and
abnormal semen parameter.
• Microsurgical subinguinal technique for varicocele repair has the lowest
recurrent rate compared to laparoscopic and open techniques.
THANK YOU