Dr. Anand K Shinde MD (Gyn)• Director Andrology @ ‘IVF-Pune’ Deenanath Mangeshkar Hospital Pune• President Elect POGS (PUNE OBGYN SOCIETY )• Founder Member Indian Menopause Society• Member Safe Motherhood Committe FOGSI• Consultant & P.G. Teacher Dept OBGYN D.M.H
Welcome to S I G A SIGA - ANDROMEDA Greetings for 2010 ! Dr. Anand K Shinde MD (Gyn) Director Andrology ‘IVF-Pune’ Deenanath Mangeshkar Hospital Pune - 411 004Cell - 09822012166, Tel. 020-40151777
Diagnostic TESA What Do We Diagnose ?1. Presence of Sperm in Testis2. Histopathological picture to explain the Azoospermia3. Carcinoma In Situ (C.I.S.) Dr. Anand K Shinde
TESA TESA as a method to retrieve sperms in Azoospermia ( For ICSI = Yes ! ) but...TESA as a method of Testicular Biopsy ? Yes it is possible to get Testicular Biopsy by TESA ! (Diagnostic use ? ) Dr. Anand K Shinde
Mixed Phenotypes SCO + Normal Heterogenous TubulesHigh chance of success at TESE ShowingTesticularDamage
Sertoli Cell Only Syndrome SCOS as in Idiopathic infertility, Y Microdeletions, Orchitis, Chemo/Radiotherapy, Embryonal failure of Germ Cell migration to the Gonadal Ridge…. TESE -25% successful..due to mixed variants…
Klinefelter’s Syndrome can have Sperms !(E) The typical appearance of a biopsy from a man with Klinefelter’s syndrome isshown composed of seminiferous tubule hyalinization (arrows), aggregations of LCand occasional tubules with Sertoli cells only. This pattern is not diagnostic ofKlinefelter’s syndrome and can result from a range of pathological processes (×10).(F) A biopsy from a man with Klinefelter’s syndrome illustrating a tubule showing fullspermatogenesis surrounded by aggregations of LC (×25). All tissues are fixed in GRfixative, except F, which is fixed in Cleland’s fixative, and all are haematoxylin–eosin(HE) stained. R.I.McLachlan et al.
Indications of Tesicular Biopsy (in general are as follows…)1. Detection of severity & type of Spermatogenic falilure A. Prognostic factor for subsequent ICSI B. Phenotyping in clinical research. Dr. Anand K Shinde
Indications of Tesicular Biopsy (in general are as follows…)2. Differentiating Obstructive Azoospermia (OA)from Non-obstructive Azzospermia (NOA) A. Equivocal Endocrine (FSH, inhibin B) B. Equivocal Clinial findings (Testicular Vol.) C. Prior to reconstructive surgery for OA Dr. Anand K Shinde
Indications of Tesicular Biopsy (in general are as follows…)3. Evaluation for Testicular Neoplasia / CIS A. At Pubertal / Adult Orchiopexy B. For at Risk Population - NOA - H/O Cryptorchidism - Scrotal USG - Microlithiasis - In Ca Testis case for other side Dr. Anand K Shinde
Indications of Tesicular Biopsy (in general are as follows…)4. Failure of prolonged Gonadotrophin therapy inHypogonadotrophic HypogonadismIf Testicular Biopsy for diagnosis(and subsequent Rx) is so important….. Is TESA the best way to do it ? Let us see ….. Dr. Anand K Shinde
TESA Efficacy & Ease TESA : Sperms Recovery TESE : Sperms RecoveryOA 100% 100%NOA Let us see ! Let us see ! Dr. Anand K Shinde
TESA Efficacy Study No of Sperm Sperm P Men Recovery by Recovery by TESE TESARosenlund et al(1998)21 gauge* 12 (17) 50% (6) 16.7% (2) …19 gauge* 10 (16) 70% (7) 60% (6) …Ezeh et al (1998) 35 63% (22) 14% (5) <.0001†Freodler et al (1997) 37 43% (16) 11% (4) .02‡Tournaye (1999) 14 64.3% (9) 7.1% (1) …Qublan et al (2002) 27 33% (9) 30% (8) NSAridogan et al(2003) 38 (76) 40.8%(31) 39.5% (30) NSHauser (2006) 87 (167) 62.1% (54) 24.1% (21) <0.001 †
Efficacy of TESA How much tissue is obtained ? How many sperms are recovered ? Parameters Compared TESE TESA PQuantity of sperm cells (Scale of 1.1 ± 1.1 0.5 ± 0.5 <.001†1-3)*No. of locations with 1.3 ± 1.3 0.7 ± 1.0 <.001†spermatogenesis per testisNo. of locations with motile sperm 0.9 ± 1.1 0.3 ± 0.8 <.001†cells per testisNo. of frozen straws per subject 4.4 ± 5.4 0.6 ± 1.1 <.001† RON HAUSER, et al (2006) J of Andrology Vol. 27 No. 1 2006
Efficacy of TESADo we get sufficient material for Histopath Exam by TESA ? Yes, if multifocal TESA isperformed, on both testes. Dr. Anand K Shinde
How can CIS be picked up by blind TESA ?Testicular Biopsy is important in the evaluation of men atrisk of CIS or Testicular cancer.TESA is not the ideal way. Open procedures with magnification to look formicronodules are better suitedTowards a non –invasive method for early detectionC.E. Hoei-Hansen, N.E.Skakkebaek ,Human Reproduction Vol 22 No.1 (2007)
If in azoospermic man percutaneous TESA, HPE showsSertoli Cell only (SCO) pattern & if Clinical exam & / or USG Scrotum shows micronodule, you must go for open TESE 97 Azoospermic Sertoli cell-only No Sertoli cell-only biopsies syndrome (Group A) syndrome (Group B)Patients 38 59Ultrasound nodule 10 1Nodule removed 9 0Maligmant neoplasm 2Leydig cell tumour 3Leydig cell hyperplasia 4In - situ carcinoma 2 M.Mancini et al , Human Reproudction Vol.22 (2007)
Take Home messages1) Diagnostic TESA is important as it gives Sperms for freezing, tissue for Histopathology which helps in Prognostication for ICSI Dr. Anand K Shinde
Take Home messages1) In Azoospermic men think of CIS testis & do not forget Clinical exam for nodules & ultrasound for testicular microlithiasis (Prevalence 1:250). Addition of Immunohistochemistry helps the pickup rate Dr. Anand K Shinde
M.Mancini et al , Human Reproudction Vol.22 (2007)
Take Home messages Percutaneous TESA needs to be multifocal & bilateral before you resort to TESE. Andrologists prefer GA while Uro-Surgeons may manage with Local Anaesthesia !.
Take Home messagesLower FSH (< 10 mIu / ml)Larger Testis Vol ( > 10 ml) means TESA will besatisfactory otherwise TESE is better.
Take Home messagesTESA may be less disruptive for testis - Hematoma, - infarcts, - raised LH, FSH & - lowered Testosteronethan open Biopsies.