1. 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
2. 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 - 411 004
Cell - 09822012166, Tel. 020-40151777
5. Diagnostic TESA
What Do We Diagnose ?
1. Presence of Sperm in Testis
2. Histopathological picture to explain the
Azoospermia
3. Carcinoma In Situ (C.I.S.)
Dr. Anand K Shinde
6. 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
9. Mixed Phenotypes
SCO + Normal Heterogenous Tubules
High chance of success at TESE ShowingTesticularDamage
10. 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…
11. Klinefelter’s Syndrome can have Sperms !
(E) The typical appearance of a biopsy from a man with Klinefelter’s syndrome is
shown composed of seminiferous tubule hyalinization (arrows), aggregations of LC
and occasional tubules with Sertoli cells only. This pattern is not diagnostic of
Klinefelter’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 full
spermatogenesis surrounded by aggregations of LC (×25). All tissues are fixed in GR
fixative, except F, which is fixed in Cleland’s fixative, and all are haematoxylin–eosin
(HE) stained. R.I.McLachlan et al.
14. 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
15. 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
16. 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
17. Indications of Tesicular Biopsy
(in general are as follows…)
4. Failure of prolonged Gonadotrophin therapy in
Hypogonadotrophic Hypogonadism
If 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
18. TESA Efficacy & Ease
TESA : Sperms Recovery TESE : Sperms Recovery
OA 100% 100%
NOA Let us see ! Let us see !
Dr. Anand K Shinde
19. TESA Efficacy
Study No of Sperm Sperm P
Men Recovery by Recovery by
TESE TESA
Rosenlund 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) NS
Aridogan et al(2003) 38 (76) 40.8%(31) 39.5% (30) NS
Hauser (2006) 87 (167) 62.1% (54) 24.1% (21) <0.001 †
20. Efficacy of TESA
How much tissue is obtained ?
How many sperms are recovered ?
Parameters Compared TESE TESA P
Quantity 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 testis
No. of locations with motile sperm 0.9 ± 1.1 0.3 ± 0.8 <.001†
cells per testis
No. 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
21. Efficacy of TESA
Do we get sufficient material for
Histopath Exam by TESA ?
Yes, if multifocal TESA is
performed, on both testes.
Dr. Anand K Shinde
22. How can CIS be picked up by blind TESA ?
Testicular Biopsy is important in the evaluation of men at
risk of CIS or Testicular cancer.
TESA is not the ideal way.
Open procedures with magnification to look for
micronodules are better suited
Towards a non –invasive method for early detection
C.E. Hoei-Hansen, N.E.Skakkebaek ,
Human Reproduction Vol 22 No.1 (2007)
27. If in azoospermic man percutaneous TESA, HPE shows
Sertoli 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 59
Ultrasound nodule 10 1
Nodule removed 9 0
Maligmant neoplasm 2
Leydig cell tumour 3
Leydig cell hyperplasia 4
In - situ carcinoma 2
M.Mancini et al , Human Reproudction Vol.22 (2007)
28. Take Home messages
1) Diagnostic TESA is important as it gives
Sperms for freezing, tissue for
Histopathology which helps in
Prognostication for ICSI
Dr. Anand K Shinde
29. Take Home messages
1) 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
31. 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 !.
32. Take Home messages
Lower FSH (< 10 mIu / ml)
Larger Testis Vol ( > 10 ml)
means TESA will be
satisfactory
otherwise TESE is better.
33. Take Home messages
TESA may be less disruptive for testis
- Hematoma,
- infarcts,
- raised LH, FSH &
- lowered Testosterone
than open Biopsies.
35. Thank you !
Dr. Anand K. Shinde
M.D (Gyn)
• IVF - Consultant at IVF Pune,
DMH Pune - 4
• Director Andrology IVF Pune,
Deenanath Mangeshkar Hospital
Pune - 411 004
