Center for Male Reproduction

Campinas, Brazil

Center for Male Reproduction

Campinas, Brazil
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Tiseo B.C.,University of Sao Paulo | Esteves S.C.,Center for Male Reproduction | Cocuzza M.S.,University of Sao Paulo
Asian Journal of Andrology | Year: 2016

The objective of this review was to summarize the evidence concerning the benefit of varicocele treatment to improve natural fertility in subfertile males. We also analyzed the effect of varicocele treatment on conventional semen parameters and sperm functional tests. An electronic search to collect the data was performed using the PubMed/MEDLINE databases until July 2015. Data pooled from a variety of study designs indicate that varicocelectomy improves semen parameters in the majority of the treated men with clinical varicocele and abnormal semen parameters regardless of the chosen surgical method. Surgical varicocele repair was beneficial not only for alleviating oxidative stress-associated infertility but also to improve sperm nuclear DNA integrity. However, given the low magnitude of the effect size in sperm DNA integrity, further research is needed to elucidate its clinical significance. Conflicting results on the effect of varicocele treatment on natural fertility seem to be due to heterogeneous study designs and, more importantly, patient selection criteria. When these issues are controlled, current evidence indicates that treatment of subclinical varicocele is not warranted, as it does not seem to improve fertility. On the contrary, fair evidence indicates that varicocele treatment should be offered to infertile patients with palpable varicocele and abnormal semen parameters. This evidence supports the current guidelines issued by the American Urological Association and European Association of Urology, which state that varicocele treatment should be offered to male partners of infertile couples presenting for evaluation with clinical varicocele and semen parameters alterations. © 2016 AJA, SIMM & SJTU.

Roque M.,Center for Reproductive Medicine | Esteves S.C.,Center for Male Reproduction
Asian Journal of Andrology | Year: 2016

A systematic review was conducted to identify and qualitatively analyze the methods as well as recommendations of Clinical Practice Guidelines (CPG) and Best Practice Statements (BPS) concerning varicocele in the pediatric and adolescent population. An electronic search was performed with the MEDLINE, EMBASE, Science Direct, and Scielo databases, as well as guidelines′ Web sites until September 2015. Four guidelines were included in the qualitative synthesis. In general, the recommendations provided by the CPG/BPS were consistent despite the existence of some gaps across the studies. The guidelines issued by the American Urological Association (AUA) and American Society for Reproductive Medicine (ASRM) did not provide evidence-based levels for the recommendations given. Most of the recommendations given by the European Association of Urology (EAU) and European Society of Pediatric Urology (ESPU) were derived from nonrandomized clinical trials, retrospective studies, and expert opinion. Among all CPG/BPS, only one was specifically designed for the pediatric population. The studied guidelines did not undertake independent cost-effectiveness and risk-benefit analysis. The main objectives of these guidelines were to translate the best evidence into practice and provide a framework of standardized care while maintaining clinical autonomy and physician judgment. However, the limitations identified in the CPG/BPS for the diagnosis and management of varicocele in children and adolescents indicate ample opportunities for research and future incorporation of higher quality standards in patient care. © 2016 AJA, SIMM & SJTU.

Esteves S.C.,Center for Male Reproduction | Roque M.,Center for Reproductive Medicine | Agarwal A.,American Center for Reproductive Medicine
Asian Journal of Andrology | Year: 2016

Varicocele affects approximately 35%-40% of men presenting for an infertility evaluation. There is fair evidence indicating that surgical repair of clinical varicocele improves semen parameters, decreases seminal oxidative stress and sperm DNA fragmentation, and increases the chances of natural conception. However, it is unclear whether performing varicocelectomy in men with clinical varicocele prior to assisted reproductive technology (ART) improve treatment outcomes. The objective of this study was to evaluate the role of varicocelectomy on ART pregnancy outcomes in nonazoospermic infertile men with clinical varicocele. An electronic search was performed to collect all evidence that fitted our eligibility criteria using the MEDLINE and EMBASE databases until April 2015. Four retrospective studies were included, all of which involved intracytoplasmic sperm injection (ICSI), and accounted for 870 cycles (438 subjected to ICSI with prior varicocelectomy, and 432 without prior varicocelectomy). There was a significant increase in the clinical pregnancy rates (OR = 1.59, 95% CI: 1.19-2.12, I2 = 25%) and live birth rates (OR = 2.17, 95% CI: 1.55-3.06, I2 = 0%) in the varicocelectomy group compared to the group subjected to ICSI without previous varicocelectomy. Our results indicate that performing varicocelectomy in patients with clinical varicocele prior to ICSI is associated with improved pregnancy outcomes. © 2016 AJA, SIMM & SJTU.

Esteves S.C.,Center for Male Reproduction | Agarwal A.,Cleveland Clinic
International Braz J Urol | Year: 2011

Extraordinary advances have been achieved in the field of male infertility in the last decades. There are new concepts in sperm physiology and several modern tools for the assessment of spermatogenesis kinetics in vivo. New tests using molecular biology and DNA damage assays allow the clinician to correctly diagnose men so far classified as having idiopathic male infertility. In the field of treatment, microsurgery has increased success rates either for reconstruction of the reproductive tract or the retrieval of spermatozoa for assisted conception. Emerging evidence suggests that life-style and environmental conditions are of utmost importance in male fertility and subfertility. This review discusses several concepts that have changed over the last years, such as the duration of the spermatogenic cycle in humans, Y-chromosome infertility, the reproductive potential of non-mosaic Klinefelter syndrome men, the impact of paternal age and sperm DNA in male infertility, the role of antioxidants in the treatment of infertile men, the predictive factors and techniques for sperm retrieval in non-obstructive azoospermia, and the microsurgical treatment of clinical varicoceles. Whenever possible, levels of evidence are provided as suggested by the Oxford Center of Evidence-based Medicine.

Cho C.-L.,Kwong Wah Hospital | Esteves S.C.,Center for Male Reproduction | Agarwal A.,American Center for Reproductive Medicine
Asian Journal of Andrology | Year: 2016

Varicocele has been associated with reduced male reproductive potential. With the advances in biomolecular techniques, it has been possible to better understand the mechanisms involved in testicular damage provoked by varicocele. Current evidence suggests the central role of reactive oxygen species (ROS) and the resultant oxidative stress (OS) in the pathogenesis of varicocele-associated male subfertility although the mechanisms have not yet been fully described and it is likely to be multifactorial. Excessive ROS is associated with sperm DNA fragmentation, which may mediate the clinical manifestation of poor sperm function and fertilization outcome related to varicocele. Testing of ROS/OS and DNA fragmentation has the potential to provide additional diagnostic and prognostic information compared to conventional semen analysis and may guide therapeutic management strategies in individual patient. © 2016 AJA, SIMM & SJTU.

Introduction: Rare foci of sperm production may be found in up to 60% of men with nonobstructive azoospermia (NOA). Sperm production, if present, is minimal for sperm appearance in the ejaculate. Given that there are no treatment options to restore fertility, sperm retrieval is the only alternative to find testicular sperm than then can be used for in vitro fertilization (IVF). Among sperm acquisition methods, micro-TESE has higher success rates at obtaining sperm compared with testicular sperm extraction and testicular sperm aspiration. Materials and Methods: This video describes the operative aspects of micro-TESE, performed on an outpatient basis, in a man with NOA and history of cryptorchidism in whom orchidopexy was performed at age 6. The concept of micro-TESE is to identify areas of sperm production within the testes with the aid of optical magnification (15-25X) and based on the size and appearance of the seminiferous tubules (ST). Results: Intraoperative findings revealed homogeneous pattern of collapsed STs in which an area containing dilated STs was clearly identified and extracted. Testicular tissue was then processed in the IVF laboratory to allow sperm search. In this case, micro-TESE was successful at obtaining testicular sperm for intracytoplasmic sperm injection (ICSI). Surplus retrieved testicular spermatozoa not used for ICSI was cryopreserved. The operative time was 120 minutes, and intraoperative blood loss was negligible. Postoperatively, the patient recovered to his normal activities within 5 days and no complications were recorded except for minor testicular pain and scrotal swelling. Conclusion: Micro-TESE allowed the identification and extraction of sperm-containing STs with minimum tissue excision and marked reduction in time processing of testicular specimens for sperm injection.

Esteves S.C.,Center for Male Reproduction
Asian Journal of Andrology | Year: 2015

The clinical management of men with nonobstructive azoospermia (NOA) seeking fertility has been a challenge for andrologists, urologists, and reproductive medicine specialists alike. This review presents a personal perspective on the clinical management of NOA, including the lessons learned over 15 years dealing with this male infertility condition. A five-consecutive-step algorithm is proposed to manage such patients. First, a differential diagnosis of azoospermia is made to confirm/establish that NOA is due to spermatogenic failure. Second, genetic testing is carried out not only to detect the males in whom NOA is caused by microdeletions of the long arm of the Y chromosome, but also to counsel the affected patients about their chances of having success in sperm retrieval. Third, it is determined whether any intervention prior to a surgical retrieval attempt may be used to increase sperm production. Fourth, the most effective and efficient retrieval method is selected to search for testicular sperm. Lastly, state-of-art laboratory techniques are applied in the handling of retrieved gametes and cultivating the embryos resulting from sperm injections. A coordinated multidisciplinary effort is key to offer the best possible chance of achieving a biological offspring to males with NOA. © 2015 AJA, SIMM & SJTU. All rights reserved 1008-682X.

Esteves S.C.,Center for Male Reproduction | Bento F.C.,Center for Male Reproduction
Reproductive BioMedicine Online | Year: 2013

This article describes how Androfert complied with the Brazilian Cells and Germinative Tissue Directive with regard to air quality standards and presents retrospective data of intracytoplasmic sperm injection (ICSI) outcomes performed in controlled environments. An IVF facility, composed of reproductive laboratories, operating room and embryo-transfer room, was constructed according to cleanroom standards for air particles and volatile organic compounds. A total of 2060 couples requesting IVF were treated in the cleanroom facilities, and outcome measures compared with a cohort of 255 couples treated at a conventional facility from the same practice before implementation of cleanrooms. No major fluctuations were observed in the cleanroom validation measurements over the study period. Live birth rates increased (35.6% versus 25.8%; P = 0.02) and miscarriage rates decreased (28.7% versus 20.0%; P = 0.04) in the first triennium after cleanroom implementation. Thereafter, the proportion of high-quality embryos steadily increased whereas pregnancy outcomes after ICSI were sustained despite the increased female age and decreased number of embryos transferred. This study demonstrates the feasibility of handling human gametes and culturing embryos in full compliance with the Brazilian directive on air quality standards and suggests that performing IVF in controlled environments may optimize its outcomes. © 2012, Reproductive Healthcare Ltd.

Esteves S.C.,Center for Male Reproduction | Varghese A.C.,Montreal Reproductive Center
Journal of Human Reproductive Sciences | Year: 2012

Spermatozoa from azoospermic males can be retrieved from either the epididymis or the testis, depending on the type of azoospermia, using different surgical methods such as percutaneous epididymal sperm aspiration (PESA), testicular sperm aspiration (TESA), testicular sperm extraction (TESE), and microsurgical testicular sperm extraction (micro-TESE). After collecting the epididymal fluid or testicular tissue, laboratory techniques are used to remove contaminants, cellular debris, noxious microorganisms, and red blood cells. Processed spermatozoa may be used for intracytoplasmic sperm injection or eventually be cryopreserved. However, spermatozoa collected from either the epididymis or the testis are often compromised and more fragile than ejaculated ones. Therefore, sperm processing techniques should be used with great caution to avoid jeopardizing the sperm fertilizing potential in treatment cycles. In this review, we describe the current methods for processing surgically-retrieved specimens, either fresh or frozen-thawed, and provide the tips and pitfalls for facilitating the handling of such specimens. In addition, we present the available laboratory tools to aid in the identification of viable immotile spermatozoa to be used in conjunction with assisted reproductive techniques. Review of the literature was carried out using PubMed and Science Direct search engines.

Miyaoka R.,Center for Male Reproduction | Esteves S.C.,Center for Male Reproduction
Advances in Urology | Year: 2012

Varicocele is a major cause of male infertility, as it may impair spermatogenesis through several distinct physiopathological mechanisms. With the recent advances in biomolecular techniques and the development of novel sperm functional tests, it has been possible to better understand the mechanisms involved in testicular damage provoked by varicocele and, therefore, propose optimized ways to prevent and/or reverse them. Up to now, there is still controversy involving the true benefit of varicocele repair in subfertile men as well as in certain specific situations such as concomitant contralateral subclinical varicocele or associated nonobstructive azoospermia. Also, with the continued development of assisted reproductive technology new issues and questions are emerging regarding the role of varicocelectomy in this context. This paper reviews the most recent data available on the pathogenesis, diagnosis, and management of varicocele with regard to male infertility. Copyright © 2012 Ricardo Miyaoka and Sandro C. Esteves.

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