Update in the evaluation of the azoospermic male

Approximately 1% of all men in the general population suffer from azoospermia, and azoospermic men constitute approximately 10 to 15% of all infertile men. Thus, this group of patients represents a significant population in the field of male infertility. A thorough medical history, physical examination and hormonal profile are essential in the evaluation of azoospermic males. Imaging studies, a genetic workup and a testicular biopsy (with cryopreservation) may augment the workup and evaluation. Men with nonobstructive azoospermia should be offered genetic counseling before their spermatozoa are used for assisted reproductive techniques. This article provides a contemporary review of the evaluation of the azoospermic male.

Meaning Touch Imprint and Testicular Sperm Extraction(TEST) in Azoospermia Patients during Testis Biopsy / 대한비뇨기과학회지

PURPOSE: Because testicular biopsy traditionally has been performed as a separate operation, there are some needs for immediate interpretation of the testicular biopsy specimen in obstructive azoospermia patients. The realization that a proportion of patients with nonobstructive azoospermia harbor spermatozoa in their testicular parenchyma, combined with the ability of intracytoplasmic sperm injection(ICSI) to effect pregnancy with single sperm, has prompted clinicians to explore testicular sperm extraction(TESE) in these patients. We performed this study to investigate the meaning of touch imprint and TESE. MATERIALS AND METHODS: Fifty-two patients with azoospermia underwent touch imprint, TESE and simultaneous formal testicular biopsy. Testicular biopsy tissue was touched on a slide and stained using a Diff-Quik method. Tissue obtained from TESE was analyzed by intensive searching to find spermatozoa. RESULTS: Twenty-nine patients were determined as obstructive azoospermia including two cases of hypospermatogenesis, all patients had sperm seen on touch imprint and TESE. The other patients were diagnosed as nonobstructive azoospermia, testicular histology was divided into two main patterns: Sertoli cell only syndrome, spermatocytic arrest. Touch imprint failed to show sperm, but three of twenty patients(15%) with Sertoli cell only syndrome had sperm present during TESE. CONCLUSIONS: Touch imprint provides high quality cellular detail for immediate review, which can minimize the intraoperative time required to decide upon the appropriateness of correcting the ductal obstruction in obstructive azoospermia patients. Men with nonobstructive azoospermia may have mature spermatozoa present within their testicular parenchyma. Therefore intensive searching for presence of spermatozoa should be performed in tissue obtained from TESE by trained specialist.

Clinical significance of GnRH stimulation test in male infertility / 대한비뇨기과학회지

GnRH stimulation test has been used to distinguish patients with hypogonadotropic hypogonadism of pituitary origin from those with hypothalamic disease. GnRH stimulation test also has been used to identify early stage of Sertoli cell insufficiency and to know the subtle abnormalities or spermatogenesis. Some investigators reported that exaggerated FSH response after GnRH stimulation means the same diagnostic meaning as basely elevated FSH level and this in turn reflects Sertoli cell insutriciency or may help to identify patients with isolated primary germ cell failure in azoospermic patients. So they suggested the possibility that GnRH stimulation test can replace testis biopsy in male infertility. To define the normal range of the gonadotropin response after GnRH stimulation and to know the indications for GnRH stimulation test if it is useful as an evaluation method for spermatogenesis, and especially to test the possibility whether GnRH stimulation test may replace testis biopsy, we performed GnRH stimulation test in 118 infertile men and 20 fertile adult male volunteers and compared the results with testicular histology. Normal basal serum levels for LH, FSH, testosterone were 1.4-18.3( mean 9.9) mIU/ml, 2.8-18.4 (mean 10.0) mIU/ml, 2.0-9.1 (mean 5.0)ng/ml respectively, and 95% confidence intervals for the peak responses to an intravenous bolus injection of 100ug GnRH were 360-1950{mean 1098)% of the basal serum LH level, and 111-318(mean 225)% of the basal FSH level in 20 rertile adult male volunteers. The results of the FSH response in GnRH stimulation test were not helpful in distinguishing patients with bad testicular histology from those with good ones in 118 infertile men. So we came to the conclusion that GnRH stimulation test can not replace testis biopsy as an evaluation method for spermatogenesis in the majority of infertile patients.

Testicular Biopsy: Comparison of Open Surgical and Percutaneous Needle Biopsy Techniques / 대한비뇨기과학회지

Testicular biopsy has been known as very useful diagnostic procedure for the male infertility. For the past 9 months percutaneous testicular biopsy procedures were attempted on 64 patients with azoospermia or atrophic testis using a new Tru-Cut biopsy needle. In addition surgical testicular open biopsy procedure on one side and percutaneous testicular needle biopsy procedure on the other side were performed in comparison with two techniques. Biopsy specimens were fixed in Bouin solution. They were stained and histologically examined. Results were summarized as follows: Numbers of seminiferous tubules obtained by needle biopsy technique were found to be fewer than that of the tubules obtained by open biopsy technique. But diagnostic accuracy was not compromised by the needle biopsy technique. There was no bleeding either from the testis or scrotum, no extusion of testicular tissue from the puncuate site. In conclusion percutaneous testicular biopsy using Tru-Cut biopsy needle has been proved to be simple, time saving, less expensive and accurate method for testicular biopsy.

Clinical Investigation in Husbands of Infertile Couples / 대한비뇨기과학회지

A clinical investigation was undertaken on Infertile males who seen our department during the period from 1978 to 1982. The results obtained sub as follows : 1. A total of 275 Infertile male corresponds to 1.8% of total male out-patients for the period of 5 years. 2. Numbers of Infertile male patients are increasing yearly. 3. Duration of infertile marital life ranged the mean being 3.8 years. It was 6.10% of the total infertile males that the patient had been visited psycho-dept because of neurosis(94%) 4. Susceptive etiological factors in the oligospermia, azoospermia are listed as follow : 1) epididymitis, 16.4% 2) cryptorchidism, 5.6% 3) Varicocele, 2.8% 4) Undetermined, 70.9% It was 35.9% of the total undetermined cases(l51 cases) that the past history of patient had suffered from prostatitis, urethritis. 6. Judging from the results of semen analysis(265 cases) is azoospermia was found in 21.5% oligospermia, in 58.5%, normospermia, in 20.0% 7. Findings of testicular biopsies of azoospermias(25 cases) showed that spermatogenic arrest was found in 32%, germ cell aplasia; in 24% hypospermatogenesis ; in 20% , peritubular or tubular fibrosis ; in 12%.

Testis Biopsy in Infertile Men with Azospermia / 대한비뇨기과학회지

Concepts regarding the evaluation and management of the infertile male have evolved during the past decade primarily because of the development of new methodology. Nevertheless, the causes of male infertility is often obscure, and the clearly defined causes are infrequent or rare. Testicular biopsy findings are basic and very important in evaluating the causes of infertility. The testis biopsy findings of 30 azoospermic patients were evaluated and it was observed in aspect of testicular size and past history. Following results were obtained. 1. Among the 91 patients who underwent semenalysis, 30 cases (33%)were azospermia. 2. In testicular biopsy findings hypospermatogenesis was the most frequent finding and the more severe hypospermatogenesis was the more atrophic the seminiferous tubule is and showed frequent Leydig cell hyperplasia. 3. Testicular biopsy findings revealed no specific correlation between small testis and normal testis patients. 4. In aspect of past history 2 epididymal tubercu1osis patients showed normal biopsy findings which suggest obstruction of sperm route and one cryptorchism and one varicocele patients showed hypospermatogenesis. 5. By testicular biopsy most of the cause of infertility was testicular and 3 cases were posttesticular.

Testicular Biopsy in Male Sterility / 대한비뇨기과학회지

Testicular biopsy is mandatory in azoospermic men with normal sized testes to distinguish between ductal obstruction and spermatogenic failure as the cause of azoospermia. In men with poor semen quality or azoospermia and small testes, the results of a pathologic evaluation will rarely if ever alter therapy. However, the biopsy often assists in making a definitive diagnosis which helps the physician in giving the patient a prognosis and avoiding unnecessary treatment in irredeemable situation. We performed 25 cases of testicular biopsy in infertile men, procuring the results as below: 1. Testicular biopsy specimen were classified into 5 group histopathologically: germ cell aplasia, 6 cases (24%); spermatogenic arrest, 8 cases (32%); hypospermatogenesis, 5 cases (20%); peritubular or tubular fibrosis, 3 cases (12%); normal or obstructive, 3 cases (12%). 2. In 25 cases, 18 cases were azoospermia and 7 cases were oligospermia. 3. In 13 cases (52%), the lesions were localized both in the seminiferous tubule and in the interstitial tissue and in 9 cases (36%), the lesions were localized only in the seminiferous tubule, and 3 cases (12%)were normal.

Testis Biopsy in lnfertile Men with Azoospermia / 대한비뇨기과학회지

Investigations into the pathogenesis of male infertility have relied predominantly on two types of analysis: histological evaluations of testicular biopsies and assays of these hormones thought to be responsible for the regulation of spermatogenesis. Other types of analysis such as chromosomal studies and biochemical determinations of ejaculate components have also played a role in characterizing male infertility. Testis biopsy findings of 54 cases with azoospermia were observed in aspect of testicular size and pastory and seminovesiculograms were performed in 3 cases with normal testis and 1 case with peritubular fibrosis and reduced spermatogenesis. The following results were obtained. 1) Among the 42 cases with normal sized testis, 12 cases (28.6%) of normal testis, 10 cases (23.8%) of peritubular fibrosis with reduced spermatogenesis, 11 cases (26. 2%) of reduced spermatogenesis, 1 case(2.4%) of maturation arrest at spermatid level, 6 cases (14.3%) of Sertoli cell only syndrome and 2cases (4.7%) of hyalinized tubule with Leydig cell hyperplasia were observed. 2) Among the 12 cases with small sized testis, 1 case (8.3%) of normal testis, 1 case (8.3%) of peritubular fibrosis with reduced spermatogenesis, 2 cases(16.7%) of reduced spermatogenesis, 5 cases(41.7%) of Sertoli cell only syndrome and 3 cases (25.O%) of hyalinized tubule with Leydig cell hyperplasia were observed. 3) Normal testis was observed in 4 of 9 cases with tuberculous epididymitis and 1 case with surgically corrected bilateral hydrocele on their past history. Peritubular fibrosis with reduced spermatogenesis was observed in 3 of 9 cases with urethritis, 2of3 cases with tuberculous epididymitis and 1 case with surgically corracted bilateral varicocele on their past history. 4) The observed in 3 cases of normal testis and 1 carmel testis and 1 case of peritubular fibrosis with reduced spermatogenesis on the seminovesiculogram.

Clinical Studies on 76 Cases of Varicocele / 대한비뇨기과학회지

A clinical study was made on seventy-six cases of varicocele during the period from July l976 to December 1978. The following results were obtained. 1. Incidence of varicocele was 76 cases (12.1%) to 627 total in-patient 2. The age distribution was between 14 and 47 years of age, showing the highest incidence in 21 to 30 years of age (91.5%). 3. Lateralization showed 93.4% in left, 5.l% in both, 1.5% in the right 4. Among the symptoms on admission. inguinal dragging pain was noticed in 65%, scrotal weight bearing sensation in 60.5%, walking disturbance in 11.2% and symptomless in 10% 5. Among l6 cases of conservative treatment, there were improvement of the symptoms in 68.7% but recurrence in 25%, no improvement of the symptoms and mass in 31.3%. 6. Local anesthesia was better than spinal anesthesia on performing 64 cases of inguinal varicocectomy because of short and comfortable postoperative courses. 7. Testicular biopsies of 10 cases disclosed premature sloughing of germinal epithelium in 6 cases.tubular thickening in 2 cases, decreased spermatogenesis in 7 cases and normal testicular pattern in 1 case.