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

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What every gynecologist needs to know about azoospermia - Dr Rupin Shah provides a clear guide

What every gynecologist needs to know about azoospermia - Dr Rupin Shah provides a clear guide

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  • 1. 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
  • 2. 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
  • 3. Not every ejaculate is semen
    • Some men do not reach orgasm
    • Collect urethral secretions instead
    • Azoospermia; fructose negative
  • 4. Not every ejaculate is semen
    • Prolonged stimulation
    • of the glans with a
    • high amplitude vibrator
    • induces orgasm
    • and ejaculation
  • 5. Azoospermia does not always mean azoospermia
    • Transient azoospermia
    • Fluctuating counts
    • Cryptozoospermia
    • Multiple reports over time
    • Centrifuge sample, examine pellet
  • 6. Fructose matters
  • 7.  
  • 8. Fructose matters
    • Fructose NEGATIVE
      • Vas Aplasia (CBAVD)
      • Ejaculatory Duct Obstruction (EDO)
    • Fructose POSITIVE
      • Primary Testicular Failure
      • Obstructive Azoospermia
      • - block at epididymis or vas
  • 9. 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
  • 10. 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)
  • 11. Its all in the genes
    • 10% - chromosomal numerical abn.
    • >15% - Yq deletions
    • Screening required prior to TESE
    • Counseling about genetic risk
  • 12. 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
  • 13. Testicular failure need not mean no sperm
  • 14. 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
  • 15. One biopsy is not enough
  • 16. New approach to testicular biopsies in the ICSI era
    • Multiple instead of Single
    • Testicular Mapping Biopsies
    • - multiple : 4 - 6
    • - bilateral
  • 17. Testicular Biopsy : NAB technique
    • N eedle
    • A spiration
    • B iopsy
  • 18. No Vasography
    • Fructose
    • TRUS
  • 19. Microsurgical VEA
    • Vas mucosa to epid. ductule
    • with 10-0 nylon
    • 25x magnification
    VAS EPID.
  • 20. ICSI for obstructive azoospermia
    • Ejaculated, epididymal or testicular sperm
    • give comparable pregnancy rates
    • after ICSI
    • - Nagy et al.Fertil Steril 1995
  • 21. 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
  • 22. 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
  • 23. Azoospermia, Fructose positive Clinical Examination & F.S.H. Obstructive Equivocal P.T.F.
  • 24. 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
  • 25. Azoospermia, Fructose positive Clinical Examination & F.S.H. Obstructive Equivocal P.T.F.
  • 26. 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
  • 27. Azoospermia, Fructose positive Clinical Examination & F.S.H. Obstructive Equivocal P.T.F.
  • 28. 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
  • 29. In Summary
    • Confirm proper ejaculation
    • Cryptozoospermia
    • Fructose
    • FSH & Physical Examination
    • Testicular biopsy – multiple?
    • Reconstructive surgery
    • ART – PESA/TESE –ICSI
    • Genetic studies