Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

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

21,653 views

Published on

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

Published in: Health & Medicine

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>

×