Fertiliteitsdiagnostiek anno 2011Fertiliteitsdiagnostiek anno 2011

Willem OmbeletGenk

Willem OmbeletGenk

Gent, 12-05-2011Gent, 12-05-2011

10-15 % van de koppels met kinderwens hebben 10-15 % van de koppels met kinderwens hebben fertiliteitsproblemenfertiliteitsproblemen

Oorzaken Oorzaken 30% man30% man 30% vrouw30% vrouw 30% man & vrouw30% man & vrouw 10% onbekend10% onbekend

Spermatogenesis

Female Male

Serum: infections, hormonal, thyroid, AMH Serum: infections, hormonalSemen sample

FSHPrl

HSGHysteroscopy

E2, Prog, LH

PCT

US uterus & ovaries

E2, Prog

0menses

2-3 14 28

Outpatient

LaparoscopyCT, MRI, ... Treatment

repeat semen sample US + Doppler scrotumGenetics

Oorzaken: vrouwOorzaken: vrouw

BaarmoederhalsfactorBaarmoederhalsfactor zz zz ImplantatiestoornisImplantatiestoornis

Syndr v AshermanSyndr v Asherman Poliepen, myomen, infectiesPoliepen, myomen, infecties

EileiderfactorenEileiderfactoren SterilisatieSterilisatie post-infectiepost-infectie erge endometrioseerge endometriose

EisprongstoornissenEisprongstoornissen PCOPCO hyperprolactinemiehyperprolactinemie

Andere afwijkingenAndere afwijkingen Post-heelkundePost-heelkunde

Meest frequente vrouwelijke factorAnovulatie

Meest frequente vrouwelijke factorAnovulatie

Oligomenorree (cyclus > 35 d)

Amenorree Primair (XO - syndr v Turner)Primair (XO - syndr v Turner) SecundairSecundair

normogonadotroop (hyperprolactinemie) hypogonadotroop hypergonadotroop (PCO – syndroom)

Hypogonadotrope amenorreeHypogonadotrope amenorree

stress, vermagering, sportstress, vermagering, sport

Simple weight loss amenorreeSimple weight loss amenorree

Exercise-associated amenorreeExercise-associated amenorree

Psychogene hypothalame amenorreePsychogene hypothalame amenorree

Lage E2, laag FSH en LH, hoog cortisolLage E2, laag FSH en LH, hoog cortisol

Hyperprolactinemie

Oligo- of anovulatie

Hyperandrogenisme

PCO-echografisch

PCO - Syndroom

Cyclus > 35 dagen

Hirsutisme, haaruitvalAcne

testosterone

12 follikels < 10mm – bilatOf

Ovarieel volume > 10 ml( 0.5233 x L x B x H )

Ovariële reserveOvariële reserve

Pro

po

rtio

n o

f p

oo

r q

ual

ity

oo

cyt

es(%

)102

103

104

105

106

Nu

mb

er o

f fo

llicl

es

107

0 10 20 30 40 50 60

50

75

100

25

Age (years)

Optimalfertility Declining

fertility End of fertility

Irregularcycles

Number of follicles

Proportion of poor quality oocytes

Menopause

100

Female Age (yrs)

0

50

25

75

41 51 6121

Cu

mu

lati

ve %

31

Men

opa

use

On

set

Irre

gu

lari

ty

Ste

rilit

y

Su

bfe

rtili

ty

46

Website: www.fvvo.beBroekmans, FV&V in ObGyn, 2009, 2, 79-89

Accuracy Non Pregnancy prediction

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

1 - Specificity

Se

ns

itiv

ity

sROC curve AFC sROC curve AMH sROC curve FSHAFC studiesAMH studiesFSH studies

Accuracy Poor Response prediction

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

1 - Specificity

Se

ns

itiv

ity

sROC curve AFC

sROC curve AMH

AFC studies

AMH studies

Broekmans, FV&V in ObGyn, 2009, 2, 79-89

Cavum- en tubapathologieCavum- en tubapathologie

Female Male

Serum: infections, hormonal, thyroid Serum: infections, hormonalSemen sample

FSHPrl

HSGHysteroscopy

E2, Prog, LH

PCT

US uterus & ovaries

E2, Prog

0menses

2-3 14 28

Outpatient

LaparoscopyCT, MRI, ... Treatment

repeat semen sample US + Doppler scrotumGenetics

HSG: unicornuate uterus, patent tube

MRI: unicornuate uterus

MRI: ectopic ovary anterior to the

external iliac vessels

Ombelet et al., N Engl J Med, 348, 667, 2003

Diagnostische Hysteroscopie Diagnostische Hysteroscopie

LaparoscopieLaparoscopie

Female Male

Serum: infections, hormonal, thyroid Serum: infections, hormonalSemen sample

FSHPrl

HSGHysteroscopy

E2, Prog, LH

PCT

US uterus & ovaries

E2, Prog

0menses

2-3 14 28

Outpatient

LaparoscopyCT, MRI, ... Treatment

repeat semen sample US + Doppler scrotumGenetics

WHO 1987: 3555 men with male factorWHO 1987: 3555 men with male factor

Normaal : ≥20 mill / ml

Oligozoospermie : < 20 mill / ml

Asthenozoospermie : < 25 % grade a< 50 % grade a + b

Teratozoospermie : < 30 % < 14 % (strict criteria)

WHO 1999 : “authority-based” // not “evidence-based”

Case-control studyCase-control study

143 fertile

Men from pregnant women < 20 weeks

144 subfertileExclusion: tubal factor & anovulation

ProspectiveProspectivestudystudy

Statistics: ROC analysis

W Ombelet et al, Hum Reprod, 12, 987-993, 1997

ResultsResultsResultsResults

Area (ROC)Area (ROC) Cut-off ROCCut-off ROCP10 (F)P10 (F)

Count 69.4 34 14.3

Motility (a+b) 60.9 45 28

Morphology 77.7 10 5

WHO 2010

4500 men / TTP< 12 months/ P4500 men / TTP< 12 months/ P55

VolumeVolume < 1.5 ml< 1.5 ml

Sperm concentrationSperm concentration < 15 million spermatozoa/ml< 15 million spermatozoa/ml

Total Sperm numberTotal Sperm number < 39 million spermatozoa< 39 million spermatozoa

MotilityMotility (grade A+B) (grade A+B) < 32 % progressive motile< 32 % progressive motile

MorphologyMorphology < 4 % normal< 4 % normal

VitalityVitality < 58 %< 58 %

Cooper et al., HRU, 16, 231-245, 2010

TUNEL assay. TUNEL-positive nuclei (with double-strand nuclear DNA fragmentation) of spermatozoa as represented by the intense (A) and dull (B) Texas red fluorescence in

the nuclear region. The healthy nuclei (without DNA fragmentation) are stained blue with DAPI (C) used as counterstain.

Angelopoulou et al., Reprod Biol Endocrinol, 5, 36, 2007

Sperm Chromatin Structure Assay – SCSA

100

1000

Gre

en

Flu

ore

scen

ce

Evenson et al., 1980

200 cells /minute5000 cells analysed/sample

Denatured ss DNA: red fluorescence

Tubal Factor No Tubal Factor

IMC< 1 million

Morphology < 4%

ICSI

IVF

IMC< 1 million

Morphology >= 4%

IMC>= 1 million

Washingprocedure

IMC< 1 million

Morphology < 4%

ICSI

IUI 4 x

IMC< 1 million

Morphology >= 4%

IMC>= 1 million

Washing procedure

Initial SemenSample

Algorithm for male subfertility treatment

< 30% or no fertilisation

< 30% or no fertilisation

ICSI

IVF

Semen profile in a general population Aim: to investigate sperm quality in a general populationAim: to investigate sperm quality in a general population

Semen profile in a general population Aim: to investigate sperm quality in a general populationAim: to investigate sperm quality in a general population

Website: www.fvvo.beOmbelet et al., FV&V in ObGyn, 2009, 1, 18-26

Azoospermia: etiologyAzoospermia: etiologyAzoospermia: etiologyAzoospermia: etiology

Non-obstructive

Maturation arrest Idiopathic, cryptorchidism, Idiopathic, cryptorchidism,

mumps, drugs …mumps, drugs …

Sertoli cell only Idiopathic, irridiation, Idiopathic, irridiation,

drugs …drugs …

Seminiferous tubular sclerosis

Genetic, Klinefelter, Genetic, Klinefelter, testicular torsion, …testicular torsion, …

Obstructive

Epididymal obstruction Post-infective, post-surgery,

…

Vas deferens obstruction CBAVD, post-vasectomy ..

Ejaculatory duct obstruction

Prostatic cysts, post-surgical, post-infective

Azoospermia: diagnosisAzoospermia: diagnosisAzoospermia: diagnosisAzoospermia: diagnosis

Non-obstructive

Genetic testingGenetic testing

FSH, FSH, inhibine Binhibine B

testicular volumetesticular volume

Obstructive

Genetic testingGenetic testing

FSH, inhibine B: nlFSH, inhibine B: nl

testicular volume: nltesticular volume: nl

KaryotypeKaryotype

Count < 5 millCount < 5 mill

Yq deletionsYq deletions13% if nonobstructive azoospermia13% if nonobstructive azoospermia3 - 7% with severe oligozoospermia3 - 7% with severe oligozoospermia““Transmitted to male offspring”Transmitted to male offspring”

AZFa, AZFb,AZFa, AZFb, AZFb +c,AZFb +c, YqYq deletionsdeletions

All azoospermicAll azoospermicNone with sperm onNone with sperm on

diagnostic biopsy or TESEdiagnostic biopsy or TESE

AZFc deletionsAZFc deletions27/42 severely oligospermic27/42 severely oligospermic

9/20 (45%) with sperm on biopsy9/20 (45%) with sperm on biopsy9/12 (75%) had sperm at TESE9/12 (75%) had sperm at TESE

Hopps et al, HR, 18, 1660, 2003

EVALUATION OF AZOOSPERMIAEVALUATION OF AZOOSPERMIAEVALUATION OF AZOOSPERMIAEVALUATION OF AZOOSPERMIA

AzoospermiaAzoospermia

VasectomyVasectomy EndocrineEndocrineevaluationevaluation

<< 15 years 15 years

Vas reversalVas reversal

HypogonadotropicHypogonadotropichypogonadismhypogonadism

Semen volumeSemen volume< 1 cc< 1 cc

GonadotropinsGonadotropins TRUSTRUS

Semen volumeSemen volume>> 1 cc 1 cc

Dilated SV’sDilated SV’s

Testis biopsy/Testis biopsy/sperm retrievalsperm retrieval

NormalNormalspermatogenesisspermatogenesis ICSIICSI

Vasogram/Vasogram/SV gramSV gram

EjaculatoryEjaculatoryductduct

obstructionobstruction

TUREDTUREDballoon dilationballoon dilation

FSHFSH< 2x normal< 2x normal

FSHFSH>> 2x normal 2x normal

GeneticGeneticevaluationevaluation

Testis biopsy/Testis biopsy/sperm retrievalsperm retrieval

No spermNo sperm Decreased spermDecreased spermproductionproduction

NormalNormalspermatogenesisspermatogenesis

TIDTIDadoptionadoption

TESE/ICSITESE/ICSI VasogramVasogramSpermSperm

retrieval/retrieval/ICSIICSI

EpididymalEpididymalexploration/VEexploration/VE

+/- sperm+/- spermretrievalretrieval

> 15 years> 15 years

Sperm retrieval/Sperm retrieval/ICSIICSI

CBAVDCBAVD

CF testingCF testing

Sperm retrieval/Sperm retrieval/ICSIICSI

Kolettis PN. J Androl 23:293-305, 2002.Kolettis PN. J Androl 23:293-305, 2002.

CF - 1/2500 births: carriers 1/25 CF - 1/2500 births: carriers 1/25

95% - “Wolffian duct abnormalities”95% - “Wolffian duct abnormalities”

CF - 1/2500 births: carriers 1/25 CF - 1/2500 births: carriers 1/25

95% - “Wolffian duct abnormalities”95% - “Wolffian duct abnormalities”

EVALUATION OF AZOOSPERMIAEVALUATION OF AZOOSPERMIAEVALUATION OF AZOOSPERMIAEVALUATION OF AZOOSPERMIA

AzoospermiaAzoospermia

VasectomyVasectomyEndocrineEndocrineevaluationevaluation

<< 15 years 15 years

Vas reversalVas reversal

HypogonadotropicHypogonadotropichypogonadismhypogonadism

Semen volumeSemen volume< 1 cc< 1 cc

GonadotropinsGonadotropins TRUSTRUS

Semen volumeSemen volume>> 1 cc 1 cc

Dilated SV’sDilated SV’s

Testis biopsy/Testis biopsy/sperm retrievalsperm retrieval

NormalNormalspermatogenesisspermatogenesis ICSIICSI

Vasogram/Vasogram/SV gramSV gram

EjaculatoryEjaculatoryductduct

obstructionobstruction

TUREDTUREDballoon dilationballoon dilation

FSHFSH< 2x normal< 2x normal

FSHFSH>> 2x normal 2x normal

GeneticGeneticevaluationevaluation

Testis biopsy/Testis biopsy/sperm retrievalsperm retrieval

No spermNo sperm Decreased spermDecreased spermproductionproduction

NormalNormalspermatogenesisspermatogenesis

TIDTIDadoptionadoption

TESE/ICSITESE/ICSI VasogramVasogramSpermSperm

retrieval/retrieval/ICSIICSI

EpididymalEpididymalexploration/VEexploration/VE

+/- sperm+/- spermretrievalretrieval

> 15 years> 15 years

Sperm retrieval/Sperm retrieval/ICSIICSI

CBAVDCBAVD

CF testingCF testing

Sperm retrieval/Sperm retrieval/ICSIICSI

Kolettis PN. J Androl 23:293-305, 2002.Kolettis PN. J Androl 23:293-305, 2002.

Grade I:

Grade II:

Grade III:

Testicular microlithiasisTesticular microlithiasis tumors tumors

varicocelevaricocele

Environmental factors

Male Fertility

Physicallighttemperatureradiationelectromagnetic fields

Socio-economicnutritionstarvationoccupationlife styleBehavioral

psychologic stressdrug addiction: coffee, smoking, alcoholextreme weight lossphysical stress: competitive sports

Biologicalinfections

viralbacterial....

Chemicalmedicationheavy metals

(Pb, Cd,...)pesticides

Occupational heat exposure and male fertility

Occupational heat exposure and male fertility

Cumulative conception rate according to the male partners

exposure to heat. Exposed = exposed to heat or

seated in a vehicle for more than 3 hours per day.

Thonneau et al, Lancet, 1996, 347, 204-5 and Bujan et al, 2000, Hum Reprod, 15, 1355 - 7.

Cell phones & oxidative stress

Agarwal, RBMOnline, 15, 266, 2007

ConclusieConclusie

Accurate diagnose blijft belangrijkAccurate diagnose blijft belangrijk AnamneseAnamnese Klinisch onderzoekKlinisch onderzoek Speciale onderzoekenSpeciale onderzoeken

Minimale onderzoeken // Maximaal rendementMinimale onderzoeken // Maximaal rendement

Infertiliteit Infertiliteit ≠ ≠ IVF & ICSIIVF & ICSI

Genk IVF team