Sandro Esteves, MD, PhD
Director, ANDROFERT
Center for Male Reproduction and Infertility
Campinas, BRAZIL
EOFF 2012, Dubai, Nov 24th
Learning Objectives
How to revert male hypogonadism and infertility by specific medical therapy
Oral antioxidant therapy is a hot topic: what you need to know in 2012
Obesity is a risk factor for male infertility: how to use aromatase inhibitors to increase sperm
production
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Review this lecture at:
http://www.androfert.com.br/review
Esteves, SC; EOFF 2012
Medical Therapy for Male Infertility Overview
Non-specific Therapy
Empirical treatment for
idiopathic male infertility
Specific Therapy
Genital tract infection
Endocrine disorders
Ejaculatory disorders
Antioxidants Aromatase inhibitors
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Medical Therapy for Male Infertility
Non-specific Therapy
Empirical treatment for
idiopathic male infertility
Androgens
hCG/HMG
FSH
Anti-estrogens
Bromocriptine
Alpha-blockers
Systemic corticosteroids No demonstrable
cause for abnormal
semen parameters;
~44% infertile men
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Empirical Medical Treatment
for Idiopathic Male Infertility
Guidelines on Male Infertility.
European Association of Urology 2012
In general, NOT EFFECTIVE.
Selected cases may benefit of FSH and anti-estrogens
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MR
I
Hypogonadotropic Hypogonadism
Clinical Features
• Absent/low virilization
• Hypotrophic testes
• Azoospermia
Endocrine Lab
• Abnormal low levels of FSH, LH and testosterone
Main Causes
• Congenital: • Kallman syndrome
• Prader-Willi
• Acquired: • Pituitary tumor
• Steroid abuse
• Testosterone replacement therapy
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Urinary hCG 1,000-2,000 UI IM injections; twice or t.i.w;
minimum 12 weeks
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12 Maintenance
Adult onset hypo-hypo:
Medical therapy aimed to restore spermatogenesis and androgenic status
Classic Treatment:
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Adult onset Hypo-hypo: hCG Preparations
LH activity
(IU/ampule
or vial)
Ampoule/
vial filling
method
% Protein
contamination
Source Technology Route of
administration
Urinary hCG 1,000-
10,000
Filled-by-
bioassay
<5% Urine Chemical
extraction
IM
Recombinant
hCG
250µg Filled-by-
mass
(FbM)
Negligible Transfected
CHO cells
Recombinant
DNA
SC
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Pretreatment
Abnormal virilization
Posttreatment
Normal hair distribution
Pretreatment
Hypotrophic scrotum/reduced testes
Posttreatment
Normal scrotum and testes
Figure 2. Photographs illustrating a patient with gigantism associated with a pituitary tumor secreting growth hormone and prolactin cured by
transsphenoidal hypophysectomy. Secondary hypo-hypo was treated with rec-hCG leading to a marked improvement in virilization and testicular
volume (with patient permission).
Baseline Posttreatment
Clinical Efficacy, Safety and Tolerability of Recombinant
hCG to Restore Spermatogenesis and Androgenic
Status of Hypogonadotropic Hypogonadism Males
Esteves SC, Papanikolaou V; Fertil Steril 2011; Vol 96: S230
Series of 11 azoospermic males with adult onset hypo-hypo
Pituitary tumor, Steroid abuse, Testosterone replacement therapy, Encephalic trauma
Once a week SC self-administration of 250µg rec-hCG (ready-to-use prefilled syringe)
Restoration of spermatogenesis and androgen production: 10/11 men; No side-effects
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12 Evaluation
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1. There is little scientific
evidence for an empirical
medical treatment in idiopathic
male infertility.
2. Medical treatment is
recommended in cases of
Hypogonadotropic Hypogonadism (GR-A) .
Specific and Non-Specific Medical Treatment of Male Infertility
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0
0,5
1
1,5
2
2,5
Fertile Infertile
Seminal Reactive Oxygen Species (ROS)
(Log ROS + 1; cpm)
Pasqualotto et al., Fertil Steril 2000
Oxidative Stress An emerging
explanation
for several
cases of male
infertility
30%-80% of infertile men have
elevated markers of OS Agarwal et al., Urology 2006
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Chemical species with unpaired electron capable to oxidize lipids, proteins and nucleic acids:
Superoxide anion (•O-2) Hydroxyl radical (•OH) Hydrogen peroxide (H2O2) Peroxyl radical (ROO•) Hypochlorite ion (OCl-)
Generated from aerobic metabolism in mitochondria.
Sources: Leukocytes (extrinsic) Spermatozoa (intrinsic)
Lampiao et al., Oxidative stress. In: Male Infertility. Parekattil & Agarwal (eds) 2012, pp.225-35
Reactive Oxygen Species (ROS)
Sperm and Seminal Plasma Antioxidants:
Enzymatic (SOD, catalase, GPX): inactivate ROS (conversion into other substances) Non-enzymatic (ascorbic acid, alpha-tocopherol, carnitine, etc.): neutralize ROS
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Rationale for Oral Antioxidants in Male Infertility
AO classified according to
their mechanism of action:
Catalytic: enhances the
already present antioxidant
enzymes (Glutathione, NAC).
Scavenging:
Water soluble: react with
oxidants in the cytosol
(Vitamin C)
Lipid soluble: protect cell
membrane from lipid
peroxidation (Vitamin E)
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Oral Antioxidants Cochrane Review 2011
Outcome N
studies
N
participants
Effect size
(OR; 95% CI)
Live birth 3 214 4.85 [1.92, 12.24]
Pregnancy rate 15 964 4.18 [2.65, 6.59]
DNA fragmentation 1 64 -13.80 [-17.50, -10.10]
Miscarriage, sperm
count, sperm motility 6-16 242-700 No effect
Adverse effects 6 426 No effect
Improve the outcomes of live birth and pregnancy rate for
subfertile couples undergoing ART cycles
Showell MG et al. Antioxidants for male subfertility.
Cochrane Database Syst Rev 2011 Jan 19;(1):CD007411. Esteves
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Sperm DNA Fragmentation and
Assisted Conception
19%
1.5%
Normal Elevated
Live Birth Rates by Intrauterine Insemination
OR = 0.07
[95% CI: 0.01-0.48]
Adapted from Bungum et al., Hum Reprod 2007
26%
42%
IVF ICSI
Pregnancy by Method in Cases of Elevated Sperm DNA
Fragmentation
P <0.05
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Sperm DNA Fragmentation and
Miscarriage
Robinson L et al. Hum Reprod. 2012; 27(10): 2908-17
• Population: Meta-analysis of 16 cohort studies (2,969 couples),
14 prospective.
• Techniques for DNA integrity:
Acridine orange-based assays, TUNEL and COMET.
• Findings:
Significant increase in miscarriage rates in patients undergoing
IVF/ICSI with high sperm DNA damage compared with those
with low DNA damage.
Risk ratio (RR) = 2.16 (1.54, 3.03), P < 0.00001).
Miscarriage rates are positively correlated
with sperm DNA damage levels
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Oral Antioxidant Therapy
Controversies
Methodological weakness of antioxidants
trials make it difficult to determine “who”,
“how” and “for how long”
• Patient selection and controls
• Associated pathology
• Single or combination antioxidants
• Dosage & formulation
• Outcome measures
• Varying duration of treatment
• Lack of diagnostic markers for oxidative stress
• Presence of molecular and genetic differences
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Oral Antioxidants
in Male Infertility
No consensus yet.
Short-term use
appear to be safe.
Caution against
indiscriminate use
of high dosages for
long periods.
Beneficial
Kodama 1997
Dawson, 1992
Kessopoulou, 1995
Vezina, 1996
Vicari, 2001; 2002
Lenzi, 2003; 2004
Cavallini, 2004
Comhaire, 2005
Grecco 2005
Menezo 2007
Tremellen 2007
Piomboni 2008
Gil Villa 2009
No effect
Giovenco, 1987
Moilanen, 1993
Iwanier, 1995
Rolf, 1999
Sigman, 2006
Detrimental
long-term use and high doses;
increased mortality in cancer population-based studies.
Heinonen, 1994 Lonn, 2005
Bjelakovic, 2007
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Who are the candidates for Oral
Antioxidant Therapy?
Infertile men with OS
Diagnosis
Indirect Assessment
• Lipid Peroxidation (Malondialdehyde)
• Protein oxidation products (eg. 8-OHdG)
• Sperm DNA integrity
Direct Assessment
• Total Antioxidant Capacity
• Seminal ROS Levels
• Detection of Superoxide Anion
Esteves et al. What the gynecologist should know about male infertility:
an update. Arch Gynecol Obstet 2012; 286(1): 217-29 Esteves
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Sperm Chromatin Dispersion Test:
● Sperm with absent “halos” have DNA strand breaks
● Semen/Spermatozoa
● Quantitative
Sperm DNA Fragmentation
Detection of Superoxide Anion:
● Reduction of Nitroblue Tetrazolium in Formazan (coloured intermediate)
● Semen
● Qualitative
Reactive Oxygen Species
Quick and Easy Tests for OS
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How to use Antioxidant Therapy Treatment Strategy
Ascorbic acid (Vit. C)
- tocopherol (Vit. E)
Glutathione
N-acetyl-cysteine
Carnitine
Coenzyme Q10
Lycopene
Picnogenol
Pentoxifylline
Selenium
Shao-Fu-Zhu-Yu-Tang
Astaxanthin
Lepidium meyenii
-linolenic acid and lignans
Folic acid
Zinc
Select antioxidant formulation and dosage
Testing for
Leukocytes in Semen
Differentiate between sperm and leukocyte
source of ROS
Varicocele
Genital Infection
Smoking
Medication
Drug abuse
Systemic diseases
Pollution
Radiation
Once OS is diagnosed, focus on identifying
and controlling source of increased ROS
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Oral Antioxidants in Male
Infertility Our formula
Vitamin C 500mg
Vitamin E 400 mg
Folic acid 2 mg
Zinc 25 mg
Selenium 26 mcg
How long: minimum 2 months
Old concept ~80 days
New concept ~60 days
From initiation of sperm production to ejaculation
Misell LM et al. J Urol. 2006
Esteves & Agarwal. Novel concepts in male infertility. Int Braz J Urol 2011; 37 (1): 5-15 Esteves
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Oral Antioxidant Therapy
for Male Infertility
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1. Oxidative stress impairs sperm
function and is a risk factor for male infertility and miscarriage (GR-A) .
2. Current evidence suggest that OA
supplementation for subfertile males
improve the chances for pregnancy
and live birth for couples undergoing ART (GR-A).
3. Well-designed studies are needed to determine
the best candidates for AO therapy and which
formulation and dosages yield better results.
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Jensen et al. Fertil Steril 2004; 82: 863; Hammoud et al. Fertil Steril 2008; 90: 2222;
Kriegel et al. RBM Online 2009; 19: 660; Martini et al. Fertil Steril 2010; 94: 1739. Esteves
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Esteves, 27
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Aromatase Inhibitors for
Infertile Obese Men
Serum Levels of Total Testosterone and Estradiol
T/E2 Ratio Normal > 10
e.g.: 4.9 =𝟑𝟓𝟎 𝒏𝒈/𝒅𝑳
𝟔𝟐 𝒑𝒈/𝒎𝑳
Zumoff et al. Reversal of the hypogonadotropic hypogonadism of obese men by administration of
the aromatase inhibitor testolactone. Metabolism 2003; 52: 1126. Raman & Schlegel Aromatase
inhibitors for male infertility. J Urol 2002; 167: 624.
T/E2 <10
Aromatase Hyperactivity
Anastrozole 1 mg q1d 60-90 days
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Raman JD, Schlegel PN. Aromatase inhibitors for male infertility. J Urol. 2002;167:624-9
5.9
2.9
5.5
15.6
3.5
15.6
0
2
4
6
8
10
12
14
16
18
T/E ratio Ejaculate volume(mL)
Sperm Count(million/mL)
Anastrazole (1mg q1d for 3-6 months)
Pre-treatment Post-treatment
Aromatase Inhibitors for
Obesity-related Male Infertility
P <0.05
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Aromatase Inhibitors for Obesity-related Male Infertility
1. Obesity is a risk factor for male infertility (GR-B).
2. Peripheral androgen aromatization is enhanced in men with elevated BMI. Obese men show increased plasma estradiol and low testosterone levels (GR-B).
3. Lowering estradiol levels, by administration of AI, increases
LH and FSH levels by pituitary modulation, and increase testosterone levels (GR-A).
4. AI may stimulate sperm production (GR-C); effects upon
fertility are still to be determined.
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