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Azoospermia Causes and Treatments
- 1. 1 Dept of Urology Govt Royapettah Hospital and Kilpauk Medical College Chennai AZOOSPERMIA
- 2. Moderators: Professors: • Prof. Dr. G. Sivasankar, M.S., M.Ch., • Prof. Dr. A. Senthilvel, M.S., M.Ch., Asst Professors: • Dr. J. Sivabalan, M.S., M.Ch., • Dr. R. Bhargavi, M.S., M.Ch., • Dr. S. Raju, M.S., M.Ch., • Dr. K. Muthurathinam, M.S., M.Ch., • Dr. D. Tamilselvan, M.S., M.Ch., • Dr. K. Senthilkumar, M.S., M.Ch. Dept of Urology, GRH and KMC, Chennai. 2
- 3. 3 Definition • Azoospermia is the complete absence of sperm in the semen • Centrifuge the semen specimen • Presence of any sperm in the pellet -evaluate for oligospermia Dept of Urology, GRH and KMC, Chennai.
- 4. 4 CLASSIFICATION Non Obstructive Azoospermia – Production Problem Obstructive Azoospermia – Delivery Problem Dept of Urology, GRH and KMC, Chennai.
- 5. 5 Non Obstructive Azoospermia A. Hypogonadotropic hypogonadism 1. Kallmann syndrome 2. Pituitary tumor B. Spermatogenic abnormalities 1. Chromosomal abnormalities 2. Y-chromosome microdeletions 3. Gonadotoxins 4. Varicocele 5. Viral orchitis 6. Torsion 7. Idiopathic Primary testicular failure Secondary testicular failure Testes : Small Firm Testes : Small Soft Dept of Urology, GRH and KMC, Chennai.
- 6. 6 Obstructive Azoospermia 1. Post surgical obstructions 2. Post infective causes 3 Post vasectomy 4. CBAVD 5. Ejaculatory duct obstructions Dept of Urology, GRH and KMC, Chennai.
- 7. 7 Klinefelter’s syndrome • Most common chromosomal anomaly in azoospermic men • Phenotypic male with small firm testes, gynecomastia, elevated gonadotropins • Seminiferous tubular sclerosis • Occasional tubules with Sertoli cells and spermatozoa • No therapy to improve spermatogenesis Non- mosaic pattern TESE , ICSI with IVF Mosaic pattern (Oligospermia) ICSI with IVF Dept of Urology, GRH and KMC, Chennai.
- 8. 8 Kallman Syndrome • Congenital hypogonadotropic hypogonadism • Cryptorchidism, micropenis • hallmark - delay in pubertal development • Anosmia • Craniofacial asymmetry, cleft palate, harelip, color blindness • Congenital deafness, renal anomalies Androgens - virilization Gonadotropin therapy - fertility • hCG 2000 IU sc 3 times a week • Addition of FSH – for completion of spermatogenesis Dept of Urology, GRH and KMC, Chennai.
- 9. 9 Other chromosomal disorders • Y Chromosome Microdeletions – Deletion of AZFa, AZFb, AZFc – Inconsistent testes biopsy – TESE/ ICSI - IVF • XX Male (sex reversal syndrome) – Small firm testes – Sperm retreival- unsuccessful • XYY Syndrome – TESE/ ICSI - IVF • Noonan’s Syndrome Dept of Urology, GRH and KMC, Chennai.
- 10. 10 Other non-obstructive causes • Cryptorchidism • Testicular Torsion • Varicocele • Sertoli Cell–Only Syndrome • Orchitis • Myotonic Dystrophy Dept of Urology, GRH and KMC, Chennai.
- 11. 11 Other non-obstructive causes • Chemotherapy – Permanent sterility- 80% -100% - MOPP/COPP – Sperm banking • Radiation – > 65cGy – Azoospermia - 2.5 - 7.5 months after irradiation • Gonadotoxins: – Medications : Spironolactone, CCB, Cimetidine – Chronic Alcoholism – Cigarrete • Idiopathic Dept of Urology, GRH and KMC, Chennai.
- 12. 12 Obstructive causes CBAVD • Most common Obstructive cause • Abnormality in the cystic fibrosis transmembrane conductance regulator (CFTR) gene • normal spermatogenesis Sperm retrieval , ICSI, IVF Dept of Urology, GRH and KMC, Chennai.
- 13. 13 Ejaculatory duct obstruction • Complete/ Partial • Azoospermia and decreased ejaculatory volume (<1.0 mL) • Acidic semen lacking fructose • P/R: palpable midline mass or dilated seminal vesicles • TRUS – cystic midline structure within the prostate • Vasography • Seminal Vesicle Aspiration and Seminal Vesiculography 6% of Azoospermic men – Jarrow et al Dept of Urology, GRH and KMC, Chennai.
- 14. 14 Examination and Investigations Serum hormone testing Testosterone, LH, FSH, and prolactin Genetic Testing 10%- 15% - karyotypic anomalies Presence of the vas deferens Testicular size Serum FSH Dept of Urology, GRH and KMC, Chennai.
- 15. 15 Radiological Investigations – TRUS • Low volume <1ml • Azoospermia /oligospermia<20 million/ml • Low sperm motility (30%) • N testes, N FSH, Testosterone – Scrotal USG – Vasography • Site of obstruction in Azoospermia • Time to do • Gold std for Ejaculatory duct obst • Equivocal TRUS findings – Seminal vesiculography • Midline cyst/ dilated SV in TRUS Normal Vasogram L ED Obstruction Dept of Urology, GRH and KMC, Chennai.
- 16. 16 ALGORITHM Dept of Urology, GRH and KMC, Chennai.
- 17. 17 Surgical management • Diagnostic procedures • Procedures to improve sperm production • Procedures to improve sperm delivery Dept of Urology, GRH and KMC, Chennai.
- 18. 18 Diagnostic procedures • Testicular Biopsy – Open testicular biopsy • Unilateral/bilateral, side, site – Percutaneous testicular biopsy • Direction, 8% failure • Testicular sperm aspiration (PESA) – Only cytologic, no histolgic information Dept of Urology, GRH and KMC, Chennai.
- 19. 19 Testicular Biopsy Patterns • Normal testes • Hypospermatogenesis • Maturation arrest • Germ cell aplasia – Sertoli cell only syndrome • End-stage testes Rarely pathognomonic of a single etiology Dept of Urology, GRH and KMC, Chennai.
- 20. 20 Procedures to improve sperm delivery Vasectomy reversal •Single layer/multilayer •Secondaryepididymal obstruction Dept of Urology, GRH and KMC, Chennai.
- 21. 21 Procedures to improve sperm delivery Inguinal Vasovasostomy •Injury/inflammation •High inguinal incision •Concomitant epididymal obstruction •Secondary obstruction – 3%-12% Dept of Urology, GRH and KMC, Chennai.
- 22. 22 Procedures to improve sperm delivery Vasoepididymostomy Epididymal obstruction Azoospermia Normal gonadotropin levels Semen volume more than 1.5 mL Normal-feeling vasa deferentia Normal-sized testes Palpably full / indurated epididymides Dept of Urology, GRH and KMC, Chennai.
- 23. 23 Vasoepididymostomy • End-to-End Technique • End-to-Side Technique • Intussusception Technique Anastamosis to be within the tunica vaginalis Dept of Urology, GRH and KMC, Chennai.
- 24. 24 Procedures to improve sperm delivery Crossover procedures Dept of Urology, GRH and KMC, Chennai.
- 25. 25 Sperm Retrieval for Obstructive Azoospermia • Vasal Aspiration of Sperm - anejaculation • Epididymal Aspiration of Sperm – sperm retreival for cryopreservation, IVF- ICSI • Microsurgical Epididymal Sperm Aspiration Dept of Urology, GRH and KMC, Chennai.
- 26. 26 Sperm Retrieval for Obstructive Azoospermia • Open Testis Biopsy – 4-6 sites • Testis Sperm Aspiration (TESA) and Needle Biopsy • Microsurgical Testicular Sperm Extraction (MESA) • – incision, tubule selection • Nonmicrosurgical Testicular Sperm Extraction Dept of Urology, GRH and KMC, Chennai.
- 27. 27 Ejaculatory duct obstruction Treatment • Transurethral Resection of the Ejaculatory Duct • Transurethral Balloon Dilation of the Ejaculatory Ducts • Antegrade seminal vesicle lavage • Laser drilling of the ejaculatory ducts • Transurethral incision Dept of Urology, GRH and KMC, Chennai.
- 28. 28 IVF with ICSI • Men with surgically unreconstructible obstruction • Men with nonobstructive azoospermia • Men with few viable sperm in the ejaculate • Azoospermic men with varicoceles Viable sperm injected directly into oocyte Fertility rates – 70% Delivery rates – 50% Treatment of choice for severe uncorrectable male factor infertility Dept of Urology, GRH and KMC, Chennai.
- 29. 29 Dept of Urology, GRH and KMC, Chennai.