1. EOFF 2012, Dubai, Nov 24th
Sandro Esteves, MD, PhD
Director, ANDROFERT
Center for Male Reproduction and Infertility
Campinas, BRAZIL

2. 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
2
Esteves

3. Esteves, SC; EOFF 2012
Review this lecture at:
http://www.androfert.com.br/review

4. Medical Therapy for Male Infertility
Overview
Specific Non-specific
Therapy Therapy
Empirical
Genital tract treatment for
infection idiopathic male
infertility
Endocrine
disorders
Antioxidants Aromatase
inhibitors
Ejaculatory
disorders
4
Esteves

5. Medical Therapy for Male Infertility
Non-specific
 Androgens Therapy
 hCG/HMG
 FSH Empirical
 Anti-estrogens treatment for
idiopathic male
 Bromocriptine infertility
 Alpha-blockers
 Systemic corticosteroids No demonstrable
cause for abnormal
semen parameters;
~44% infertile men
5
Esteves

6. Empirical Medical Treatment
for Idiopathic Male Infertility
In general, NOT
EFFECTIVE.
Selected cases
may benefit of FSH
and anti-estrogens
Guidelines on Male Infertility.
6 European Association of Urology 2012
Esteves

7. Hypogonadotropic Hypogonadism
Clinical Features Endocrine Lab Main Causes
• Absent/low virilization • Abnormal low levels • Congenital:
• Hypotrophic testes of FSH, LH and • Kallman syndrome
• Azoospermia testosterone • Prader-Willi
• Acquired:
• Pituitary tumor
• Steroid abuse
• Testosterone
replacement therapy
MRI
7
Esteves

8. Adult onset hypo-hypo:
Medical therapy aimed to restore
spermatogenesis and
androgenic status
Classic Treatment:
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
8
Esteves

9. Adult onset Hypo-hypo:
hCG Preparations
LH activity Ampoule/ % Protein Source Technology Route of
(IU/ampule vial filling contamination administration
or vial) method
Urinary hCG 1,000- Filled-by- <5% Urine Chemical IM
10,000 bioassay extraction
Recombinant 250µg Filled-by- Negligible Transfected Recombinant SC
hCG mass CHO cells DNA
(FbM)
9
Esteves

10. Clinical Efficacy, Safety and Tolerability of Recombinant
hCG to Restore Spermatogenesis and Androgenic
Status of Hypogonadotropic Hypogonadism Males
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)
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
Restoration of spermatogenesis and androgen production: 10/11 men; No side-effects
Baseline Posttreatment
10
Esteves SC, Papanikolaou V; Fertil Steril 2011; Vol 96: S230
Esteves

11. Specific and Non-Specific Medical
Treatment of Male Infertility
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) .
11
Esteves

12. Oxidative Stress
An emerging
explanation
30%-80% of infertile men have for several
elevated markers of OS
Agarwal et al., Urology 2006
cases of male
infertility
Seminal
Reactive Oxygen Species (ROS)
(Log ROS + 1; cpm)
2,5
2
1,5
1
0,5
0
Fertile Infertile
Pasqualotto et al., Fertil Steril 2000
12
Esteves

13. Reactive Oxygen Species (ROS)
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)
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
13
Lampiao et al., Oxidative stress. In: Male Infertility. Parekattil & Agarwal (eds) 2012, pp.225-35
Esteves

14. 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)
14
Esteves

15. Oral Antioxidants
Cochrane Review 2011
Outcome N N Effect size
studies participants (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 6-16 242-700 No effect
count, sperm motility
Adverse effects 6 426 No effect
Improve the outcomes of live birth and pregnancy rate for
subfertile couples undergoing ART cycles
15 Showell MG et al. Antioxidants for male subfertility.
Esteves Cochrane Database Syst Rev 2011 Jan 19;(1):CD007411.

16. Sperm DNA Fragmentation and
Assisted Conception
Live Birth Rates by Pregnancy by Method in Cases
Intrauterine Insemination of Elevated Sperm DNA
Fragmentation
42%
19%
P <0.05
26%
OR = 0.07
[95% CI: 0.01-0.48]
1.5%
Normal Elevated IVF ICSI
16 Adapted from Bungum et al., Hum Reprod 2007
Esteves

17. Sperm DNA Fragmentation and
Miscarriage
• 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
17 Robinson L et al. Hum Reprod. 2012; 27(10): 2908-17
Esteves

18. 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
18
Esteves

19. Oral Antioxidants
in Male Infertility
Beneficial No effect
Kodama 1997 Giovenco, 1987
Dawson, 1992 Moilanen, 1993
Kessopoulou, 1995 Iwanier, 1995  No consensus yet.
Vezina, 1996 Rolf, 1999
Vicari, 2001; 2002 Sigman, 2006  Short-term use
Lenzi, 2003; 2004 appear to be safe.
Cavallini, 2004
Comhaire, 2005 Detrimental  Caution against
Grecco 2005
long-term use and indiscriminate use
Menezo 2007 high doses;
Tremellen 2007
of high dosages for
increased mortality in long periods.
Piomboni 2008 cancer population-
Gil Villa 2009 based studies.
Heinonen, 1994
Lonn, 2005
Bjelakovic, 2007
19
Esteves

20. 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
20 Esteves et al. What the gynecologist should know about male infertility:
Esteves an update. Arch Gynecol Obstet 2012; 286(1): 217-29

21. Quick and Easy Tests for OS
Sperm DNA Fragmentation Reactive Oxygen Species
Sperm Chromatin Detection of Superoxide
Dispersion Test: Anion:
● Sperm with absent “halos” ● Reduction of Nitroblue Tetrazolium
have DNA strand breaks in Formazan (coloured intermediate)
● Semen/Spermatozoa ● Semen
● Quantitative ● Qualitative
21
Esteves

22. How to use Antioxidant Therapy
Treatment Strategy
Once OS is diagnosed,
Differentiate between
focus on identifying Select antioxidant
sperm and leukocyte
and controlling source formulation and dosage
source of ROS
of increased ROS
Varicocele Ascorbic acid (Vit. C)
Testing for - tocopherol (Vit. E)
Genital Infection Glutathione
Leukocytes in Semen N-acetyl-cysteine
Smoking
Carnitine
Medication Coenzyme Q10
Drug abuse Lycopene
Picnogenol
Systemic diseases Pentoxifylline
Pollution Selenium
Shao-Fu-Zhu-Yu-Tang
Radiation Astaxanthin
Lepidium meyenii
 -linolenic acid and lignans
Folic acid
22
Zinc
Esteves

23. Oral Antioxidants in Male
Our formula Infertility
Vitamin C 500mg
Vitamin E 400 mg
Folic acid 2 mg
Zinc 25 mg
Selenium 26 mcg
How long: minimum 2 months
From initiation of sperm production to ejaculation
Old concept ~80 days
New concept
Misell LM et al. J Urol. 2006
~60 days
23
Esteves & Agarwal. Novel concepts in male infertility. Int Braz J Urol 2011; 37 (1): 5-15
Esteves

24. Oral Antioxidant Therapy
for Male Infertility
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.
24
Esteves

25. 25
Esteves

26. Jensen et al. Fertil Steril 2004; 82: 863; Hammoud et al. Fertil Steril 2008; 90: 2222;
26 Kriegel et al. RBM Online 2009; 19: 660; Martini et al. Fertil Steril 2010; 94: 1739.
Esteves

27. Esteves, 27

28. 28
Esteves

29. Aromatase Inhibitors for
Infertile Obese Men
Serum Levels of Total
Testosterone and Estradiol
Normal > 10
T/E2 Ratio
𝟑𝟓𝟎 𝒏𝒈/𝒅𝑳
e.g.: 4.9 =
𝟔𝟐 𝒑𝒈/𝒎𝑳
T/E2 <10
Aromatase Hyperactivity
Anastrozole 1 mg
q1d 60-90 days
Zumoff et al. Reversal of the hypogonadotropic hypogonadism of obese men by administration of
29 the aromatase inhibitor testolactone. Metabolism 2003; 52: 1126. Raman & Schlegel Aromatase
inhibitors for male infertility. J Urol 2002; 167: 624.
Esteves

30. Aromatase Inhibitors for
Obesity-related Male Infertility
Anastrazole (1mg q1d for 3-6 months)
18
15.6 15.6
16
14 P <0.05
12
10
8
5.9 5.5
6
4 2.9 3.5
2
0
T/E ratio Ejaculate volume Sperm Count
(mL) (million/mL)
Pre-treatment Post-treatment
30 Raman JD, Schlegel PN. Aromatase inhibitors for male infertility. J Urol. 2002;167:624-9
Esteves

31. 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
31
fertility are still to be determined.
Esteves