AZOOSPERMIA: RISULTATI DEI TRATTAMENTI

Transcription

1 AZOOSPERMIA: RISULTATI DEI TRATTAMENTI DR. ETTORE CAROPPO UO FISIOPATOLOGIA DELLA RIPRODUZIONE UMANA E P.M.A. ASL BARI, PTA F. JAIA, CONVERSANO (BA)

2 AZOOSPERMIA 1% DELLA POPOLAZIONE MASCHILE 10-15% DELLA POPOLAZIONE MASCHILE INFERTILE Clinics (Sao Paulo) 2013; 68:15-26

3

4 OA: TESA/PESA; NOA TESA/microTESE

5

6 Evidences for OA >NOA 6 Evidences for OA =NOA 6

7

8 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.

9 Tecniche di prelievo di spermatozoi testicolari: quale adoperare?

10 Sperm retrieval rates for men with OA using ICSI are excellent (96% 100%) regardless of the cause of the obstruction

11 Tecnica di prelievo e sede di ostruzione nessun impatto su SRR MESA: maggior numero di spz ma più invasiva Spz epididimo = spz testicolo Fresh = frozen spz

12 Conclusions: TESE with multiple samples > FNA SCO: MicroTESE > TESE Safety: MicroTESE >FNA >TESE

13 There is insufficient data from randomized trials to recommend any particular surgical spermretrieval 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

14

15

16 Conclusions MicroTESE > TESE in SCO No clinical predictors of SRR

17 MANCATO RECUPERO DI SPERMATOZOI: UTILE RIPETERE TESE/MICROTESE?

18 Vernaeve V et al, Hum Reprod 2006; 21: Ramasamy R et al, J Urol 2011; 185: Talas H et al, Asian J Androl 2007; 9:

19

20 SRR e TESE/microTESE: fattori predittivi?

21 792 men with NOA enrolled from 1997 to 2006 SR - SR + FSH level (miu/ml) 20.0 ( ) 18.8 ( )

22 1026 pz mtese

23 SR + SR - Testicular volume (mean + SD) ml ml

24

25 SRR e microtese: effetto della terapia ormonale

26 Hormonal treatment Authors No patients Treatment Outcome Shinjo et al, Andrology 2013; 1: Shiraishi et al, Hum Reprod 2012; 27:331-9 Hussein et al, BJU int 2013 ;111:E110-4; 20 with failed microtese 48 with failed microtese 612 pz CC treated 116 untreated hcg hcg/hcg +FSH (28 pz) No treatment (20 pz) 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) SR 3/20 (15% )in pz with pre-treatment low ITT SR 6/28 (21,4%) of treated SR 0/20 untreated 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: 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%

27 S. di Klinefelter e azoospermie postchemioterapia

28 Sperm retrieval rate 42.9% Fertilization rate 57.1% Pregnancy rate 50% Live birth rate 42%

29 2 TESE with prior hcg treatment in 6 pz SR in 2/6 pz (33%) Sperm retrieval rate 42% Pregnancy rate 27% Live birth rate 19%

30 Klinefelter syndrome: an argument for early aggressive hormonal and fertility management. Fert Steril 2012; 98:

31

32 Klinefelter vs NOA Yarali, Reprod Biomed Online 2009 Bakircioglu, Fert Ster 2011 Sabbaghian Urology 2014 Klinefelter NOA Klinefelter NOA Klinefelter NOA SRR (%) Fert Rate (%) * 28 21* Clin PR (%) Impl R (%) Live BR (%) *

33 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 CI )

34 Exclusion criteria: age > 50 years, HH, Y microdeletion, chemotherapy, hormonal treatment, drug/alchool abuse, > 40 cigarettes/die

35 Multiple site-bilateral TESE, sperm cryopreservation # Ejaculate * * * #

36

37 ICSI con spermatozoi testicolari: fresh or frozen?

38 Fertil Steril 2014; 101:344-9

39

40

41 ICSI e criptozoospermia: spermatozoi da eiaculato o testicolari?

42

43

44 Conclusioni OA > NOA PR e LBR? RCT! OA = NOA = OAS dati perinatali e malformazioni? RCT! MicroTESE> TESE e mtese/tese > FNA: RCT! KS e criptorchidismo predittivi di SRR in NOA Spermatozoi testicolari: fresh = frozen Spermatozoi testicolari > eiaculato?

45