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

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

  1. 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. 2. Basic questions <ul><li>Obstructive or non-obstructive </li></ul><ul><li>If obstructive – operable; success? </li></ul><ul><li>- surgery or PESA-ICSI </li></ul><ul><li>If non-obstructive </li></ul><ul><li>- any treatment? </li></ul><ul><li>- any sperm for ICSI </li></ul><ul><li>DIAGNOSTIC ALGORITHM </li></ul>
  3. 3. Not every ejaculate is semen <ul><li>Some men do not reach orgasm </li></ul><ul><li>Collect urethral secretions instead </li></ul><ul><li>Azoospermia; fructose negative </li></ul>
  4. 4. Not every ejaculate is semen <ul><li>Prolonged stimulation </li></ul><ul><li>of the glans with a </li></ul><ul><li>high amplitude vibrator </li></ul><ul><li>induces orgasm </li></ul><ul><li>and ejaculation </li></ul>
  5. 5. Azoospermia does not always mean azoospermia <ul><li>Transient azoospermia </li></ul><ul><li>Fluctuating counts </li></ul><ul><li>Cryptozoospermia </li></ul><ul><li>Multiple reports over time </li></ul><ul><li>Centrifuge sample, examine pellet </li></ul>
  6. 6. Fructose matters
  7. 8. Fructose matters <ul><li>Fructose NEGATIVE </li></ul><ul><ul><li>Vas Aplasia (CBAVD) </li></ul></ul><ul><ul><li>Ejaculatory Duct Obstruction (EDO) </li></ul></ul><ul><li>Fructose POSITIVE </li></ul><ul><ul><li>Primary Testicular Failure </li></ul></ul><ul><ul><li>Obstructive Azoospermia </li></ul></ul><ul><ul><li>- block at epididymis or vas </li></ul></ul>
  8. 9. Test for fructose <ul><li>Standard Seliwanoff method 5 ml resorcinol soln. + 0.5 ml semen </li></ul><ul><li>Modified Seliwanoff method 1 ml resorcinol soln. + 0.1 ml semen </li></ul>
  9. 10. Normal FSH does not necessarily mean normal spermatogenesis <ul><li>Normal FSH = Normal spermatogenesis </li></ul><ul><li>Not necessarily true </li></ul><ul><li>Many men with PTF will have normal FSH </li></ul><ul><li>Normal FSH : inconclusive </li></ul><ul><li>- normal / abnormal spermatogenesis </li></ul><ul><li>High FSH = Testicular Failure </li></ul><ul><li>(focal spermatogenesis may be present) </li></ul>
  10. 11. Its all in the genes <ul><li>10% - chromosomal numerical abn. </li></ul><ul><li>>15% - Yq deletions </li></ul><ul><li>Screening required prior to TESE </li></ul><ul><li>Counseling about genetic risk </li></ul>
  11. 12. Testicular failure need not mean no sperm <ul><li>P.T.F. Patchy spermatogenesis Obstruction </li></ul><ul><li>P.T.F. with </li></ul><ul><li>areas of spermatogenesis </li></ul>no sperm many sperm f e w spe r m
  12. 13. Testicular failure need not mean no sperm
  13. 14. Testicular failure need not mean no sperm <ul><li>Some of these sperm can be </li></ul><ul><li>retrieved through multiple biopsies </li></ul><ul><li>and used for ICSI </li></ul><ul><li>in 20% of men with Sertoli cell only </li></ul><ul><li>in 20% of men with atrophy </li></ul><ul><li>in 40% of men with maturation arrest </li></ul>
  14. 15. One biopsy is not enough
  15. 16. New approach to testicular biopsies in the ICSI era <ul><li>Multiple instead of Single </li></ul><ul><li>Testicular Mapping Biopsies </li></ul><ul><li>- multiple : 4 - 6 </li></ul><ul><li> - bilateral </li></ul>
  16. 17. Testicular Biopsy : NAB technique <ul><li>N eedle </li></ul><ul><li>A spiration </li></ul><ul><li>B iopsy </li></ul>
  17. 18. No Vasography <ul><li>Fructose </li></ul><ul><li>TRUS </li></ul>
  18. 19. Microsurgical VEA <ul><li>Vas mucosa to epid. ductule </li></ul><ul><li>with 10-0 nylon </li></ul><ul><li>25x magnification </li></ul>VAS EPID.
  19. 20. ICSI for obstructive azoospermia <ul><li>Ejaculated, epididymal or testicular sperm </li></ul><ul><li>give comparable pregnancy rates </li></ul><ul><li>after ICSI </li></ul><ul><li>- Nagy et al.Fertil Steril 1995 </li></ul>
  20. 21. Obstructive Azoospermia - VEA or PESA-ICSI <ul><li>VEA is preferred in younger couples </li></ul><ul><li>ICSI is preferred in: </li></ul><ul><li>- when fast results are required </li></ul><ul><li>- older couples </li></ul><ul><li>- social pressures </li></ul><ul><li>- when VEA has poor chances </li></ul><ul><li>- filariasis, TB, hydrocelectomy </li></ul>
  21. 22. Varicocele matters - sometimes <ul><li>Surgery for large varicoceles in azoo. men </li></ul><ul><li>-15/22 sperm appeared (mean 2.2 mill/ml) </li></ul><ul><li>- Goldstein 1998, Fertil Steril </li></ul><ul><li>-7/15 sperm + (1.8 – 7.9 mil/ml) </li></ul><ul><li>- Pasqualotto 2003, Hum Reprod </li></ul>
  22. 23. Azoospermia, Fructose positive Clinical Examination & F.S.H. Obstructive Equivocal P.T.F.
  23. 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
  24. 25. Azoospermia, Fructose positive Clinical Examination & F.S.H. Obstructive Equivocal P.T.F.
  25. 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
  26. 27. Azoospermia, Fructose positive Clinical Examination & F.S.H. Obstructive Equivocal P.T.F.
  27. 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
  28. 29. In Summary <ul><li>Confirm proper ejaculation </li></ul><ul><li>Cryptozoospermia </li></ul><ul><li>Fructose </li></ul><ul><li>FSH & Physical Examination </li></ul><ul><li>Testicular biopsy – multiple? </li></ul><ul><li>Reconstructive surgery </li></ul><ul><li>ART – PESA/TESE –ICSI </li></ul><ul><li>Genetic studies </li></ul>

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