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Step-by-Step Guide to Managing Azoospermia: From Diagnosis to Treatment
- 1. AZOOSPERMIA Management Made Simple : “Stepwise approach” DR SHARDA JAIN DR JYOTI AGARWAL
- 2. Azoospermia does not mean no child. 70 to 80% can father there own child
- 3. AZOOSPERMIA • Complete absence of sperm in the ejaculate • 1% of General population • 10% of infertile males • All gynaecologist should understand & manage appropriately
- 4. AZOOSPERMIA MALE PRELIMINARY MANAGEMENT • Confirm diagnosis (Centrifuge sample) • Counselling • Evaluation
- 5. WHO • Centrifuge 15 mt at speed 3000 • Examine the pellet • Again repeat after gap of 6 to 12 weeks
- 6. AZOOSPERMIA CAUSES • Pre – Testicular (Hypo – Hypo) • Testicular Failure (NOA) • Post – Testicular (Obstructive)
- 7. AZOOSPERMIA DIAGNOSIS – 3 STEP PROCESS • Detailed history • Detailed examination • Basic Investigations (FSH & T)
- 8. HISTORY
- 9. AZOOSPERMIA MALE EVALUATION Detailed History Undescended testis Viral Orchitis CBAVD Operation – bilateral inguinal hermia
- 10. DRUGS IMPAIRING MALE INFERTILITY Mechanism Examples Gonadotoxins (impair spermatogenesis) • Sulfasalazine • Methotrexate • Cytotoxic Chemotherapy • Colchicine • Nitrofuradantin Erectile dysfncton • Beta – blockers • Thiazide diuretics Ejaculaory failure • Alpha – blockers • Anti depressants Antiadrogenic • Spironolactone • Cimetidine Hypothalamic – pituitary Suppression • Testosteone • Anabolic steroid Drugs – Increase prolactin GnRH analogues Drugs of misuse • Cannabis • Heroin Cocaine
- 11. EXAMINATION
- 12. AZOOSPERMIC MALE – STEP 2 DETAILED CLINICAL EXAMINATION CLINICAL Examination • General health • Hair distribution • Body proportion • Voice
- 13. AZOOSPERMIA MALE – STEP 2 DETAILED CLINICAL EXAMINATION GENITAL EXAMINATION Testis – size & consistency epididymis – size Vas present / absent Other specific points
- 15. ASSESSMENT GENERAL INVESTIGATION TESTIS EPIDIDYMIS HYPOGONADOTROPIC HYPOGONADISM VARIABLE COLLAPSED TESTICULAR SMALL & SOFT COLLAPSED OBSTRUCTIVE NORMAL NORMAL
- 16. GENITAL EXAMINATION SPEAKS WHAT IS THE CAUSE OF AZOOSPERMIA no sperm many spermfew sperm Testicular Failure Obstructive Azoospermia Patchy spermatogenesis
- 17. INVESTIGATIONS
- 18. AZOOSPERMIA MALE – STEP 3 BASIC INVESTIGATIONS • FSH • Testosterone • Genetic Tests if required
- 19. ASSESSMENT FSH Testosterone Hypogonadotropic Hypogonadism Low Low Testicular High Low / Normal Obstructive Normal Normal GENERAL INVESTIGATION +
- 20. TESTESTERONE MEASUREMENT • Early morning sample • Fasting sample
- 21. ADDITIONAL TESTS Need for FRUCTOSE , TRUS , FNAC, TESTICULAR BIOPSY Is usually not there
- 23. Pre- Gonadal – Hypothalamic Pituitary Disorders HYPO HYPO CAUSES CONGENITAL ACQUIRED • KALLMANN SYNDROME • IHH • PITUITARY TUMOURS • HYPOTHALAMIC TUMOURS • DRUGS
- 25. Hypo HypoAzoospermia Management Medical Management Gonadotropins (both LH & FSH) • HCG injection till T Level normal , then • add FSH for Several months for spermatogenesis
- 26. NON – OBSTRUCTIVE AZOOSPERMIA (TESTICULAR FAILURE)
- 27. TESTICULAR FAILURE • FSH high • Testes small in size • Epididymis collapsed
- 28. Primary Gonadal Disorders CONGENITAL ACQUIRED Y-CHROMOSOME ABNORMALITY VIRAL ORCHITIS EPIDIDYMO ORCHITIS KLINEFELTER SYNDROME DRUGS / TOXINS CRYOPTORCHIDISM RADIATION TRAUMA / TORSION SYSTEMIC ILLNESS
- 29. Risk of transmitting genetic / fertility problems from the father to the male offspring
- 30. Chromosomal Abnormalities Population Infertile men Sex Chromosomal 0.23 2.24 Autosomal 0.57 1.14 All 0.80 3.65 VAN Assche at ., 1996
- 33. Y chromo- Micro Deletion • Counselling is very important as 100% is passed onto boys (not daughters) • Prognostic Value of test AZF c Sperm Can be recovered AZF a or b – no Sperm
- 34. Oligosoermia ≤ 5 million/ml & NOA of unknown cause • Chromosomes • Y deletions
- 36. AZOOSPERMIA MANAGEMENT • Keep it simple • Diagnosis : by history , examination & basic tests • Obstructive – PESA , if failed PESA then TESE / TESA • Testicular failure – *Random biopsy TESE *Micro TESE
- 37. Testicular Sperm Recovery -NOA • Testicular Sperm Aspiration (TESA) • Random Testicular Sperm Extraction (TESE) • Microdissection TESE
- 38. Testicular Failure – Histology • Hypo spermatogenesis eg Maturation arrest ( early /late ) • Sertoli cell – only syndrome testicular Failure Sertoli cell – only syndrome Levin 1979
- 39. Role of Diagnostic Biopsy • Value debated (outside should not be done if no embryologist + freezing facilities ) • Focal spermatogenesis is quite often seen. • T .Biopsy can itself be Therapeutic Testicular Bipsy pic
- 40. Testicular Sperm Aspiration (TESA) • Very poor sperm recovery rates • Multiple fine needle aspirates from testis El-Haggar et al .,2006 • 19-guage needle better then 21-guage Rosenlund et al ., 1998
- 42. Testicular sperm Extraction Random Biopsy TESE Multiple Biopsy under sedation & local inguinal block 3-9 biopsy attempted to locate focal spermatogenesis Craft et al 1993
- 43. Testicular Sperm Extraction Random Biopsy TESE • Sperm recovery rate 20 – 60% • Simple case procedure-- can be undertaken in all centres Deveroey et al ,1994
- 45. Random TESE complications • Haematoma formation • Infection • Testicular atrophy Deroyver et ai 2014
- 46. Random TESE advantages • No learning curve • No operating microscope needed • Can be done at all centres Uma Gordon (Bristol) 3 rd FERTICON 2019
- 47. Microdissection Testicular Sperm Extraction (Micro TESE) is the latest option for the worst Azoospermia Scenerios
- 48. Microdissection TESE • Sperm recovery rate improved from • 43 to 63 % • Sampling of selected regions Schlegel 1999
- 49. Microdissection TESE • Under operating microscope • Learning curve involved • Offered in specialist centre only • Best for patchy spermatogenesis (Sartoli Cell Only Syndrome)
- 50. Testicular Failure --gap for next biopsy • Random TESE to micro TESE • Minimum 6 months gap To allow for testicular tissue recovery Generally earlier positive cases only come for second request
- 52. OBSTRUCTIVE AZOOSPERMIA • Normal FSH & T • Testis normal size • Epididymis full
- 53. PESA – PERCUTANEOUS EPIDIDYMAL SPERM ASPIRATION √
- 54. Percutancous Epidiymal sperm aspiration (PESA) • Very simple procedure • Sedation & local anaesthesia – inguinal & scrotal block • Sperm can be recovered for 3-6 ICSI cycles
- 55. Microsurgical epididymal Sperm Aspiration (MESA) • No place for MESA • Open / invasive procedures , long operating time in microsurgical procedure. • Failed PESA – move to TESA/TESE x
- 56. MESA (Microsurgical Epididymal Sperm Aspiration)
- 57. CBAVD & Cystic Fibrosis screening • CFTR gene mutation carrier • Screen wife also • If wife is carrier : *Preimplantation genetic diagnosis * Donor sperm / egg from screened donor
- 58. CBAVD Screening • CFTR gene mutation – negative • Screening for renal abnormalities
- 59. DEVELOPING TECHNIQUES • Tissues perfusion mapping Herwig et al 2007 • Narrow Band imaging Enatsu et al 2015 • FFOCT (full field optical coherent tomography) Ramasamy et al 2012
- 60. AZOOSPERMIA MANAGEMENT • Keep it simple • Diagnosis : by history , examination & basic tests • Obstructive – PESA , if failed PESA then TESE / TESA • Testicular failure – *Random biopsy TESE *Micro TESE
- 61. Role of HORMONAL supplementation • Anti – androgen ,Aromitase inhibitors , gonadotropins • Evidence not absolute. • Improvement of testosterone level Uma Gordon 2019 3rd Ferticon 2019 International conference cum workshop
- 62. Azoospermia Male collaborative approach • Reproductive specialists • Urologists • Clinical geneticists
- 63. QUESTION ??
- 64. ADDRESS 11 Gagan Vihar, Near Karkari Morh Flyover, Delhi - 51 CONTACT US 9650588339 9599044257 011-22414049 WEBSITE : www.lifecareivf.in www.lifecarecentre.in www.lifecareabs.in ISO 14001:2004 (EMS) …..Caring hearts, healing hands ISO 9001:2008 Helpline : 9599044257 Web.www.lifecareivf.in Helpline : 9910081484 29 Year In your service