Zero Sperm Count - What the Gynecologist Should Know by Dr Rupin Shah, MD
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Transcript of Zero Sperm Count - What the Gynecologist Should Know by Dr Rupin Shah, MD
Management of Azoospermia-what every gynecologist should
know
Rupin Shah M.S., M.Ch.(Urology)
Consultant Andrologist & Microsurgeon
Lilavati Hospital & Research Centre, Mumbai
54th AICOG, 2011
Basic questions Obstructive or non-obstructive If obstructive – operable; success?
- surgery or PESA-ICSI If non-obstructive
- any treatment?
- any sperm for ICSI
DIAGNOSTIC ALGORITHM
Not every ejaculate is semen
Some men do not reach orgasm Collect urethral secretions instead Azoospermia; fructose negative
Not every ejaculate is semen
Prolonged stimulation
of the glans with a
high amplitude vibrator
induces orgasm
and ejaculation
Azoospermia does not always mean azoospermia
Transient azoospermia Fluctuating counts Cryptozoospermia
Multiple reports over time
Centrifuge sample, examine pellet
Fructose matters
Fructose matters
Fructose NEGATIVE Vas Aplasia (CBAVD) Ejaculatory Duct Obstruction (EDO)
Fructose POSITIVE Primary Testicular Failure Obstructive Azoospermia
- block at epididymis or vas
Test for fructose
Standard Seliwanoff method5 ml resorcinol soln. + 0.5 ml semen
Modified Seliwanoff method1 ml resorcinol soln. + 0.1 ml semen
Normal FSH does not necessarily mean normal spermatogenesis
Normal FSH = Normal spermatogenesis
Not necessarily true
Many men with PTF will have normal FSH Normal FSH : inconclusive
- normal / abnormal spermatogenesis High FSH = Testicular Failure
(focal spermatogenesis may be present)
Its all in the genes 10% - chromosomal numerical abn. >15% - Yq deletions
Screening required prior to TESE
Counseling about genetic risk
Testicular failure need not mean no sperm
P.T.F. Patchy spermatogenesis Obstruction
P.T.F. with areas of spermatogenesis
no sperm many spermfew sperm
Testicular failure need not mean no sperm
Testicular failure need not mean no sperm
Some of these sperm can be
retrieved through multiple biopsies
and used for ICSI in 20% of men with Sertoli cell only in 20% of men with atrophy in 40% of men with maturation arrest
One biopsy is not enough
New approach to testicular biopsies in the ICSI era
Multiple instead of Single
Testicular Mapping Biopsies- multiple : 4 - 6
- bilateral
Testicular Biopsy : NAB technique
Needle
Aspiration
Biopsy
No Vasography
Fructose TRUS
Microsurgical VEA Vas mucosa to epid.
ductule
with 10-0 nylon 25x magnification
VAS
EPID.
ICSI for obstructive azoospermia
Ejaculated, epididymal or testicular spermgive comparable pregnancy rates after ICSI
- Nagy et al.Fertil Steril 1995
Obstructive Azoospermia- VEA or PESA-ICSI
VEA is preferred in younger couples ICSI is preferred in:
- when fast results are required
- older couples
- social pressures
- when VEA has poor chances
- filariasis, TB, hydrocelectomy
Varicocele matters - sometimes
Surgery for large varicoceles in azoo. men
-15/22 sperm appeared (mean 2.2 mill/ml)- - Goldstein 1998, Fertil Steril
-7/15 sperm + (1.8 – 7.9 mil/ml)- Pasqualotto 2003, Hum Reprod
Azoospermia, Fructose positive
Clinical Examination & F.S.H.Clinical Examination & F.S.H.
Obstructive EquivocalP.T.F.
Obstructive EquivocalP.T.F.
Azoospermia, obvious obstructiveAzoospermia, obvious obstructive
Direct exploration
- VEA/VVA
- no prior vasography
- vas patency checked during surgery
Direct exploration
- VEA/VVA
- no prior vasography
- vas patency checked during surgery
Needle biopsy
Proceed with VEA
or PESA-ICSI
Needle biopsy
Proceed with VEA
or PESA-ICSI
Needs confirmation of spermatogenesis
Needs confirmation of spermatogenesis
Azoospermia, Fructose positive
Clinical Examination & F.S.H.Clinical Examination & F.S.H.
Obstructive EquivocalP.T.F.
Obstructive EquivocalP.T.F.
Azoospermia, obvious PTFAzoospermia, obvious PTF
DI
Adoption
DI
AdoptionConsidering ICSIConsidering ICSI
Biopsy is not required for diagnosis Discuss options
Biopsy is not required for diagnosis Discuss options
Genetic studiesGenetic studies
Trial TESE – multiple SSTTrial TESE – multiple SST
Sperm absent Sperm present
Cryopreserve wife stimulatedICSI
Sperm absent Sperm present
Cryopreserve wife stimulatedICSI
Azoospermia, Fructose positive
Clinical Examination & F.S.H.Clinical Examination & F.S.H.
Obstructive EquivocalP.T.F.
Obstructive EquivocalP.T.F.
Azoospermia, Equivocal findings T.B. is needed for differential diagnosis Azoospermia, Equivocal findings T.B. is needed for differential diagnosis
NormalNormal P.T.F. - No SpermP.T.F. - No Sperm
TESE-ICSI
(fresh biopsy at
time of ICSI)
TESE-ICSI
(fresh biopsy at
time of ICSI)
Bilateral, multiple, micro- biopsies
proper interpretation
Bilateral, multiple, micro- biopsies
proper interpretation
PTF - Focal spermPTF - Focal sperm
VEA
(or ICSI )
VEA
(or ICSI )DI
Adoption
DI
Adoption
In Summary Confirm proper ejaculation Cryptozoospermia Fructose FSH & Physical Examination Testicular biopsy – multiple? Reconstructive surgery ART – PESA/TESE –ICSI Genetic studies