Opera&ve techniques for male infer&lity. Ateş Kadıoğlu, MD,FECSM Professor of Urology University of Istanbul

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1 Opera&ve techniques for male infer&lity Ateş Kadıoğlu, MD,FECSM Professor of Urology University of Istanbul

2 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

3 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.

4 Presenta&on Outline Varicocelectomy TUR- ED Micro- TESE MESA

5 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.

6 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

7 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

8 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.

9 Surgical techniques 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

10 Complica&ons Compared 3 methods Follow- up period: 90 day N Artery preserve(%) Recurrence (%) Microsurgery Open palomo Hydrocele (%) Laparoscopic Pajovic B- European Review for Medical and Pharmacological Sciences- 2015; 19:

11 EAU Guideline Male infer&lity 2016 Complica&ons

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13 m 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, I 2 = 67%) 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

14 n 4 studies 870 ICSI cycles N:438 varicocelectomy(+) N:432 varicocelectomy(- ) Asian Journal of Andrology (2016) 18, 1 5

15 Clinical pregnancy 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: , I 2 = 25%) ve (OR = 2.17, 95% CI: , I 2 = 0%) Live birth Asian Journal of Andrology (2016) 18, 1 5

16 Varicocelectomy follow- up 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, Fukuda T- UROLOGY 86: 48e51, 2015.

17 Conclusion 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. No significant change was noted in sperm concentra&ons or mo&li&es between 3 and 12 months arer surgery.

18 Presenta&on Outline Varicocelectomy TUR- ED Micro- TESE MESA

19 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

20 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

21 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 Modgil V- NATURE REVIEWS UROLOGY VOLUME 13 JANUARY 2016 Kadioglu A,Fer&l Steril (1):

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23 Surgical Techniques TUR- ED ResecTon 1- Monopolar 94% 2- Bipolar 90.5% DilataTon 6-8 F Vesikuloskopi 95% Holmium laser incision 91%

24 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

25 Presenta&on Outline Varicocelectomy TUR- ED Micro- TESE MESA

26 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 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

27 Sperm in NOA are like apples on a tree Some branches have them, and some don t

28 SRR; mtese: %52 ctese: %35 Micro- TESE was 1.5 &mes more likely (95% confidence interval ) to result in successful SR as compared with ctese. Fer&lity and Sterility- Vol. -, No. -,

29 A comparison of current and experimental surgical techniques and modalites in the management of nonobstructve azoospermia Ramasamy R et al Indian J Urol 2016

30 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

31 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

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33 Predic&ve value of histopathology? Schlegel 1999 Amer et al Okada et al Tsujimura et al 2002 Ramasamy et al Colpi et al 2009 Ghalayini et al 2011 Sertoli cell only syndrome m- TESE TESE 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% Overall sperm retrieval rate TESE (16.7 to 45%), m- TESE (42.9 to 63%) Deruyver Y et al Andrology 2014

34 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

35 Tes&cular Atrophy - SRRs 1127 pa&ents, NOA Tes&cular volume; SRRs < 2 cc (n:106) 54.7%, 2-10 cc (n:573) 56.2% >10 cc (n:448) 55.1% Successful SRR 56% (n:631) Low tes&cular volume does not affect the sperm retrieval rate CF. Bryson, Ramasamy R- THE JOURNAL OF UROLOGY- Vol. 191, 1-4, January 2014

36 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 /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:

37 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) Ali A Dabaja and Peter N Schlegel- Asian Journal of Andrology (2013) 15, 35 39

38 Presenta&on Outline Varicocelectomy TUR- ED Micro- TESE MESA

39 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

40 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

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42 The advantage of MESA over PESA Prevents hematocele forma&on More sperm is harvested up to 120 x 10 6 /cc and for cryopreserva&on

43 Conclusion Surgical management of male factor infer&lity has expanded in the last 15 years. With advances in both diagnos&c and surgical modali&es, progress of microsurgical and reproduc&ve technology, this field has been revolu&onized.