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 54 th 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 method 5 ml resorcinol soln. + 0.5 ml semen
Modified Seliwanoff method 1 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 sperm f e w spe r m

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
N eedle
A spiration
B iopsy

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 sperm
give 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. Obstructive Equivocal P.T.F.

Azoospermia, obvious obstructive Direct exploration - VEA/VVA - no prior vasography - vas patency checked during surgery Needle biopsy Proceed with VEA or PESA-ICSI Needs confirmation of spermatogenesis

Azoospermia, obvious PTF DI Adoption Considering ICSI Biopsy is not required for diagnosis Discuss options Genetic studies Trial TESE – multiple SST Sperm absent Sperm present Cryopreserve  wife stimulated  ICSI

Azoospermia, Equivocal findings T.B. is needed for differential diagnosis Normal P.T.F. - No Sperm TESE-ICSI (fresh biopsy at time of ICSI) Bilateral, multiple, micro- biopsies proper interpretation PTF - Focal sperm VEA (or ICSI ) DI Adoption

In Summary
Confirm proper ejaculation
Cryptozoospermia
Fructose
FSH & Physical Examination
Testicular biopsy – multiple?
Reconstructive surgery
ART – PESA/TESE –ICSI
Genetic studies

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Zero sperm count what the gynecologist should know by dr rupin shah, md

by Aniruddha Malpani on Jan 27, 2011

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Zero sperm count what the gynecologist should know by dr rupin shah, md — Presentation Transcript