Consequences of bilateral cryptorchidism in adults.

Bilateral cryptorchidism treatment results are often shadowed by the majority of unilateral cases. We report the long-term follow-up results of boys treated for bilateral cryptorchidism during childhood. Patients treated in two main paediatric surgery centres were selected from medical registries and invited for a clinical examination including scrotal ultrasound, salivary testosterone measurement and a semen sample. Thirty-six men (38.3%) replied to the written invitation, and 21 agreed to be examined. The mean age at orchidopexy was 74 months (range 24-138). Sperm count was 0.42 × 106 (SD ± 0.64 × 106 ) ml-1 . The correlation between total testicular volume and total sperm count was statistically significant (r = 0.481; P = 0.032). These results show that surgical treatment of bilateral cryptorchidism after the age of 2 years does not prevent infertility. Sperm count and endocrine evaluation advocated after the treatment of bilateral cryptorchidism in all adult patients.

Decreased expression of genes associated with memory and x-linked mental retardation in boys with non-syndromic cryptorchidism and high infertility risk.

An elevated odds ratio for low IQ has been found for cryptorchid boys. Furthermore, poor school performance has been observed in cryptorchid boys with impaired mini-puberty. Gene expression analysis, qPCR and immunohistology were performed on testicular biopsies from 7 boys who underwent orchiopexy and had testicular histology typical of a high risk of infertility (HIR). The results were compared with 12 biopsies from cryptorchid boys with a low risk for developing infertility. The following genes associated with mental retardation were identically expressed: GDI1, OPHN1, PAK3, ARHGEF6, IL1RAPL, ACSL4, MECP2, RPS6KA3, ARX, and ATRX. However, boys in the HIR group had low or no expression of EGR4, FMR2 (AFF2) and VCX3A. In conclusion, impaired expression of genes known to encode proteins involved in signaling pathways that regulate cytoskeletal organization, synaptic vesicle transport and the establishment of connections between neuronal cells may contribute to reduced intellectual and cognitive functioning in infertile cryptorchid males.

Complete testis-epididymis nonfusion anomaly: a typical association with cryptorchid testis.

INTRODUCTION: Fusion anomalies of the testis and epididymis are associated with cryptorchidism. We present an analysis of the fusion anomalies of the epididymis in cryptorchid boys. PATIENTS AND METHODS: We performed a retrospective review of patients presenting with undescended testes between 1986 and 1993. Patients were stratified among four groups based on the degree of testis-epididymis nonfusion. RESULTS: A total of 880 testes were eligible for review, of which 93% (815/880) had normal fusion, 3.6% (32/880) had epididymal head nonfusion, 2% (19/880) had epididymal tail nonfusion, and 1.6% (14/880) had complete nonfusion. Increasing degree of nonfusion was associated with higher perioperative testes position. Head and tail nonfusion were observed together with a contralateral descended testis, but less frequently than in bilateral undescended testes (p = 3.89 × E-10). Complete nonfusion was not observed in the contralateral descended testes in unilateral cryptorchid boys. CONCLUSIONS: Different degrees of fusion anomalies of the epididymis are associated with unilateral and bilateral undescended testis, indicating that nonfusion anomalies interact with epididymal-testicular descent because of impaired epididymal function.

Testicular gene expression in cryptorchid boys at risk of azoospermia.

Despite timely and successful surgery, 32% of patients with bilateral and 10% with unilateral cryptorchidism will develop azoospermia. Cryptorchid boys at risk of azoospermia display a typical testicular histology of impaired mini-puberty at the time of the orchidopexy. During mini-puberty increased gonadotropin and testosterone secretion stimulate transformation of gonocytes into Ad spermatogonia. In the azoospermia risk group this transformation is to a great extent impaired. This study aimed to analyze data on whole genome expression signatures of undescended testes at risk of developing azoospermia. Twenty-three testicular biopsies from 22 boys were analyzed (19 testes from 18 boys with cryptorchidism and 4 contralateral descended testes from patients with testicular agenesis). Expression profiling identified 483 genes not or under-expressed in the azoospermia risk group compared with the control and low risk for azoospermia (LAZR) groups. Annotated loci were associated with spermatogenesis. Other significant genes were cellular defense response genes and hormone-controlled loci involved in spermatogenesis. Some genes transcribed in normal adult meiotic and post-meiotic germ cells are activated in healthy juvenile Ad spermatogonia. Thus, molecular events initiating the testicular expression program at the onset of puberty and maintaining it during adulthood occur very early in prepubertal testes. This molecular event is to a great extent impaired in the high risk for azoospermia (HAZR) group lacking Ad spermatogonia (stem cells for spermatozoa) indicating impaired mini-puberty.

EGR4 is a master gene responsible for fertility in cryptorchidism.

The purpose of early medical or surgical treatment of boys with undescended testes is to prevent the development of infertility. However, early and successful surgery cannot prevent infertility in cryptorchid boys who lack type A dark (Ad) spermatogonia. The aim of this study was to compare the gene expression pattern of patients with completed transformation of gonocytes into Ad spermatogonia, associated with low infertility risk, with patients that had failed to undergo this process and had a high infertility risk. Genes expressed in the 16 cryptorchid testes were estimated using Affymetrix whole-genome microarray and compared to the expression profiles from four contralateral gonads of boys with unilateral testicular agenesis. Whole-genome expression profiling showed that boys in the high infertility risk group according to testicular histology, showed decreased or lack of expression of most of the genes essential for hypothalamo-pituitary-testicular axis function relative to low or intermediate risk group as well as controls. In particular, EGR4, which is involved in regulating the secretion of luteinizing hormone, was virtually not expressed. Thus, we found multiple differences in gene expression between the high and low infertility risk groups, confirming the importance of an intact hypothalamo-pituitary testicular axis and EGR4 in fertility development.

Differences in testicular development between 5alpha-reductase 2 deficiency and isolated bilateral cryptorchidism.

PURPOSE: We demonstrated that infertility develops in most patients with steroid 5alpha-reductase 2 deficiency. MATERIALS AND METHODS: We compared the testicular histopathology of boys with steroid 5alpha-reductase 2 deficiency to that of boys with isolated bilateral cryptorchidism. RESULTS: Testes with steroid 5alpha-reductase 2 deficiency lacked spermatocytes but had Ad spermatogonia and a normal germ cell count. In contrast, bilateral cryptorchid testes had severe germ cell depletion and the majority lacked Ad spermatogonia. CONCLUSIONS: In patients with steroid 5alpha-reductase 2 deficiency the impaired second step of germ cell maturation results in defective transformation of spermatogonia into spermatocytes. The position of the undescended testis appears to have no major pathological impact on the development of germ cells in patients with steroid 5alpha-reductase 2 deficiency.

Testicular histology related to fertility outcome and postpubertal hormone status in cryptorchidism.

BACKGROUND: Early surgical correction of an undescended testis is performed to prevent the development of male infertility. However, in boys with cryptorchidism early successful surgery cannot prevent infertility if they lack Ad spermatogonia. In this study, sperm concentrations and postpubertal hormone levels were correlated to bilateral testicular histology. The aim was to define the risk of future infertility via a testis biopsy program for boys with cryptorchidism. METHODS: Eighty-nine boys who had an orchidopexy were subjected to bilateral testicular biopsy. Histological analysis of 178 biopsies indicated three groups of high, intermediate, and low risk of infertility according to the presence of Ad spermatogonia. After puberty, sperm concentrations were analysed and correlated with plasma gonadotropin and testosterone levels. FINDINGS: In patients with unilateral cryptorchidism 70% of scrotal testes had an impaired transformation of Ad spermatogonia, indicating that cryptorchidism is a bilateral disease. Sperm concentrations correlated to the number of Ad spermatogonia found at the time of orchidopexy (p<0.001). All males in the high risk of infertility group were oligospermic (mean: 8.9 x 10 (6) sperm/ejaculate) and 20% were azoospermic. These patients had 25 times less sperm compared to the group with presence of Ad spermatogonia in both testes (p<0.001). Correlations between testicular histology and postpubertal hormone levels confirmed a relative gonadotropin deficiency in the majority of males with cryptorchidism. INTERPRETATIONS: Ad spermatogonia proved to be a discriminating factor for the fertility outcome in cryptorchidism. Gonadotropin treatment following orchidopexy should be considered in cryptorchidism when no Ad spermatogonia are found in undescended gonads and scrotal testis have Ad germ cell counts <0.005 per tubule.

Effects of hormonal treatment on the contralateral descended testis in unilateral cryptorchidism.

OBJECTIVE: One of the therapeutic options in the treatment of cryptorchidism is hormonal therapy with luteinizing hormone releasing hormone (LHRH) and/or human chorionic gonadotropin (HCG); concerns have, however, been raised regarding its safety. The purpose of this study was to demonstrate that hormonal therapy improves the abnormal histology of the contralateral descended testis without harming the germ cells. METHOD: Patients with unilateral cryptorchidism were randomized into two groups: those treated with orchiopexy alone and those treated with LHRH long acting analog and HCG. Biopsies taken from contralateral descended testes were analyzed and compared with controls. RESULTS: The number of germ cells per tubule in contralateral testes of patients treated with orchiopexy alone is significantly lower than the number of germ cells in testes of patients with spontaneously descended testes (P<0.0001). Hormonal therapy did not have any adverse effect upon the histology of the contralateral testis, but in fact improved it. Seven weeks of hormonal therapy induced a rise in the number of germ cells per tubule (P<0.05). It was also beneficial for the number of adult dark spermatogonia per tubule and the number of primary spermatocytes, although these differences did not reach statistical significance. CONCLUSION: The contralateral testis in patients with unilateral cryptorchidism is abnormal. Hormonal therapy improves the histopathology of the contralateral testis without harming the germ cells.

Antibodies against human tissue transglutaminase and endomysium in diagnosing and monitoring coeliac disease.

BACKGROUND: Coeliac disease (CD) patients often present a variety of uncharacteristic symptoms and therefore sensitive and specific screening tests are needed as an aid in making an accurate diagnosis. A recently developed ELISA, using human recombinant tissue transglutaminase (tTG) as antigen, was evaluated for its significance in the diagnosis of CD. The patient's compliance to a gluten-free diet and the serological reaction during gluten challenge were also monitored. The results were compared with IgA-endomysium antibody (EMA) results. METHODS: Sera previously collected from 365 patients (0.4-76 years) with jejunal biopsy on a gluten-containing diet and from 41 patients on a gluten-free diet or challenge were tested for IgA anti-human tTG antibodies (IgA tTG ab) with Celikey (Pharmacia Diagnostics). The study population comprised 208 CD patients and 157 controls. The diagnostic performance and cut-off for the assay were estimated with ROC analysis. EMA was analysed by indirect immunofluorescence microscopy on cryostat sections of monkey oesophagus. RESULTS: 200/208 patients with CD had positive IgA tTG ab (median >100 U/ml), while only 1/157 of the control patients were positive (median 1.67 U/ml). The area under the ROC curve was 98.3% and the sensitivity and specificity of the test were 96% and 99% for the study population. Only 4/365 patients (1%) presented discordant IgA tTG ab and EMA results, 2 of them had only IgA tTG ab and 2 only EMA. The IgA tTG ab levels and the EMA titres were closely correlated to the duration of gluten-free diet and gluten challenge, respectively. CONCLUSION: IgA tTG ab can be used as an accurate observer-independent alternative to EMA in diagnosing or monitoring CD.

The importance of both an early orchidopexy and germ cell maturation for fertility.

Delayed orchidopexy for undescended testes has been associated with abnormal testicular histology, but the effect on later fertility is unknown. We aimed to establish the importance of the first postnatal maturational step-ie, the transformation of gonocytes into Ad (dark) spermatogonia on fertility. We matched histological findings of the testes from 31 patients who had undergone an early orchidopexy with their total number of sperm. If Ad spermatogonia were present, 17 (94%) of 18 (95% CI 72.7-99.9) of the men had a total sperm count of 40 x 10(6)/ejaculate or greater. By contrast, despite successful early surgery, if Ad spermatogonia were absent, 12 (92%) of 13, (64.0-99.8) patients had abnormal spermiograms. Thus, the transformation of gonocytes into Ad spermatogonia is crucial for male fertility.

Importance of early postnatal germ cell maturation for fertility of cryptorchid males.

PATIENTS/METHOD: Twenty-seven adults who underwent an orchidopexy before 2 years of age have recently had their spermiograms analyzed. RESULTS: Sixty-three percent of them had a normal sperm count; their germ cells had undergone the second stage of maturation and adult dark (Ad) spermatogonia were present at the time of surgery 20-25 years earlier. In contrast, 37% of them were infertile despite a seemingly successful orchidopexy; they had impaired second-step germ cell maturation and Ad spermatogonia were absent at orchidopexy. CONCLUSIONS: Transformation of gonocytes into Ad spermatogonia is crucial for fertility. This underscores the importance of a testicular biopsy at orchidopexy in order to identify those who could benefit from early LH-RH treatment after orchidopexy.

Fertility potential: a comparison of intra-abdominal and intracanalicular testes by age groups in children.

We compared a group of intra-abdominal (IA) with intracanalicular (IC) testes of the same age in order to see if there were differences in the fertility potential of the testes in these two locations. We also wished to determine at what age, if any, differences became apparent. Semithin (1 microm thick) sections of 54 IA and 103 IC testes between the ages of 3 months and 5 years were evaluated and the spermatic index (SI) calculated for each. The two groups were compared using mathematical models to describe the relationship between age and SI. Models of both IA and IC testes show a sharp decline in the SI during the first 1.8 years of life and remain near zero thereafter. The models are statistically indistinguishable, suggesting there is no detectable difference in the fertility potential of IA and IC testes up to 5 years. The SI appears to reach a critically low value in both groups between 8 and 9 months of age, suggesting that surgical intervention would be appropriate before this time.

A novel syndrome involving primary skeletal growth and retardation in siblings.

An identical pattern of malformations was found in two brothers both having microcephaly and severe developmental delay. Additionally, they had hypotelorism, epicanthic folds, and convergent strabismus. There was shortening of either the radius or the tibia and shortening of the first metacarpals. Persistently dorsally flexed fingers and toes were noted, all of which are unusually long. Both boys had a high-pitched voice and were unable to communicate verbally at the age of 4.5 years. They both developed short stature. One brother has anal atresia; the other had a pulmonary artery atresia, VSD, ASD, and an over-riding aorta. This apparently new syndrome is possibly an autosomal, or a X-linked recessive trait.

Elevated placental estradiol: a possible etiological factor of human cryptorchidism.

PURPOSE: It has been convincingly argued that the increasing incidence of reproductive abnormalities in human males may be associated with increased estrogen exposure during gestation. We documented the expression of estradiol in the syncytiotrophoblast and placenta of males born with cryptorchidism and normal genitalia, respectively. MATERIALS AND METHODS: Tissue from newborn placentas was fixed in glutaraldehyde and embedded in ePON for immunohistological procedures. Cryptorchidism was unilateral in 6 males and bilateral in 1. Semithin histological sections of placental biopsies of these 7 males and 7 randomly selected, normal male placentas were analyzed immunohistochemically with a polyclonal anti-estradiol-17 beta, 6-keto antibody. RESULTS: The weak expression of estradiol in the placentas of normal males was localized predominantly at the basal part of the syncytiotrophoblast in the terminal placental villi. In contrast, all placentas of cryptorchid males had strong expression of estradiol at the basal portion of the syncytiotrophoblast. CONCLUSIONS: The increased expression of estradiol in the syncytiotrophoblast may have an impact on testicular descent.

An unusual subset of cryptorchidism: possible end organ failure.

PURPOSE: A paucity of germ cells exists in the cryptorchid gonad that usually correlates with a similar finding in the contralateral descended testis. However, we have noted a small number of boys with cryptorchidism in whom there is a significant difference between the histological evaluation of the cryptorchid testis and the normal descended testis that may indicate a different etiology. MATERIALS AND METHODS: From 1986 to 1991, 1,426 boys with unilateral cryptorchidism underwent orchiopexy, of whom 752 also underwent bilateral testicular biopsy. Testicular volume and position, and patency of the processus vaginalis were examined. Biopsies were fixed in 2% glutaraldehyde and embedded in Epon. Semithin tissue sections were analyzed by 2 independent investigators. The number of total germ cells, gonocytes, adult dark and pale spermatogonia, primary spermatocytes and Leydig cells was assessed. RESULTS: Of the 1,426 boys the undescended testis was on the right side in 726 and on the left side in 658 (52 versus 48%, p = 0068). Of the 752 boys who underwent bilateral biopsy 42 (5.6%) 1.1 to 16 years old (mean age plus or minus standard deviation 0 5.2 +/- 3.65) had a poor fertility index of less than 0.2 germ cell per tubule in the cryptorchid gonad, although the germ cell count in the descended testis was normal. Of the 42 testes in this special group of boys 30 (71%) were on the right side (Fisher's exact test p <0.23), including 16 (38%) in an intra-abdominal or high canalicular position. The processus vaginalis was patent in 86% of the intra-abdominal testes and in 100% of those located at the tubercle but in only 25% of those in a pre-scrotal position. While average germ cell count in the cryptorchid testis was 0.06 per tubule with abnormal germ cell maturation, number was normal (greater than 2 germ cells per tubule) in the contralateral descended testis with a normal distribution of adult dark and pale spermatogonia, and primary spermatocytes. Average volume of the cryptorchid testis was significantly less than that of the descended testis (1.20 +/- 0.35 versus 1.60 +/- 0.68 mm.3, p <0.0001). CONCLUSIONS: Based on the normal scrotal testis the fertility prognosis is good in this small subgroup of boys with cryptorchidism. Rather than the usual endocrinopathy of cryptorchidism, the undescended testis in these boys may be the result of end organ failure. These patients with favorable fertility potential may be recognized only if each testis is biopsied at unilateral orchiopexy.

Increased apoptosis in the contralateral testes of patients with testicular torsion as a factor for infertility.

PURPOSE: Unilateral testicular torsion is common and leads to bilateral testicular injury. Spermiography is abnormal in 70% of patients after testicular torsion. Histological changes in the contralateral testis at the time of torsion have been previously interpreted as the consequence of a predisposing testicular pathology or a noxious effect of the twisted testis. We hypothesized that increased apoptosis in the contralateral testis in unilateral testicular torsion is a consequence of a breakdown in the blood-testis barrier of the twisted testis, which may increase the risk of infertility. MATERIALS AND METHODS: A total of 17 patients 14 to 34 years old (mean age plus or minus standard deviation 20.7+/-6.1) underwent surgery to alleviate unilateral testicular torsion. Mean time from the first symptoms of torsion to surgery was 4.2+/-3.0 hours (range 0.5 to 11). Bilateral testicular biopsy was performed in all patients, and apoptosis was analyzed by terminal deoxynucleotidyl transferase mediated S-deoxyuridine triphosphate nick end labeling. RESULTS: Compared with controls, the incidence of apoptosis was increased in the contralateral testes in all patients. Apoptosis occurred predominantly in spermatocytes, early and late spermatids, and Sertoli's cells. In contrast, spermatogonia, peritubular connective tissue (fibroblasts and myofibroblasts) and endothelial cells seldom underwent apoptosis. Leydig cells were affected less often than spermatocytes. The extent of apoptosis and necrotic changes within the twisted testicle directly correlated with the duration of torsion. CONCLUSIONS: Extensive apoptosis is a phenomenon that occurs regularly in the germinal epithelium of the contralateral testis in testicular torsion. Specifically primary and secondary spermatocytes are predominantly affected. Notably spermatogonia, capillary endothelium, connective tissue and peritubular fibroblasts are rarely involved. A selection strategy has seemingly evolved that precludes the possibility of the perpetuation of genetic mutations. We hypothesize that trauma to the blood-testis barrier initiated by testicular torsion induces the release of apoptotic activating factors (cytokines), which subsequently cause extensive apoptosis in the germinal epithelium of the contralateral testis. Therefore, it is probable that repeat apoptotic episodes may explain the high incidence of infertility in these patients.