Genetic concerns for the subfertile male in the era of ICSI

The treatment of severe male factor infertility has seen remarkable advances in the last five years with the introduction and widespread use of intracytoplasmic sperm injection (ICSI). Although ICSI represents one of the most important advances in the treatment of the subfertile male, significant concerns exist regarding the potential for transmission of abnormal genes to the offspring because many of the natural barriers to conception have been bypassed. Because these couples were not able to conceive prior to ICSI, the long-term genetic consequences in these offspring are largely undefined at this time. Genetic abnormalities related to male infertility need to be considered in terms of being (1) causative for male infertility and (2) potentially transmissible to the offspring. Reasons for pursuing a genetic evaluation include (1) establishing a diagnosis, (2) establishing a possible genetic origin, (3) clarifying the pattern of inheritance, and (4) providing information on natural history, variation and expression. The three most common known genetic factors related to male infertility are cystic fibrosis gene mutations leading to congenital absence of the vas deferens, Y-chromosome microdeletions leading to spermatogenic impairment, and karyotype abnormalities. When congenital bilateral absence of the vas deferens with azoospermia is encountered, cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations are commonly the underlying cause. When testicular failure is manifest by azoospermia or severe oligoszoospermia, Y-chromosome microdeletions may be present in approximately 10-15 per cent of otherwise normal appearing men. Karyotyping can uncover potentially transmissible genetic abnormalities in the infertile male including structural chromosomal disorders such as Klinefelter's (classic 47,XXY), mixed gonadal dysgenesis, chromosomal translocations and XYY syndromes. Finally, potential male infertility genes in animal models are reviewed. Without question, advances in clinical and basic research raise scientific and social issues that must be addressed.

Pathological epididymal obstruction unrelated to vasectomy: results with microsurgical reconstruction

PURPOSE

We determine the success of end-to-side epididymovasostomy in patients presenting with obstructive azoospermia from primary epididymal obstruction and identify prognostic factors that could predict a successful outcome.

MATERIALS AND METHODS

Of 256 consecutive patients undergoing end-to-side epididymovasostomy 49 had primary epididymal obstruction unrelated to prior vasectomy. Patients were excluded from study if they had a history of vasectomy, microsurgical reconstruction or ejaculatory duct obstruction.

RESULTS

Followup was available in 43 of the 49 patients (88%). Patency rates were 87% in the bilateral epididymovasostomy group, 69% in the unilateral group and 81% overall. Pregnancy rates were 43% in the bilateral and 23% in the unilateral group. While higher patency rates were observed for proximal anastomoses, higher pregnancy rates were observed for distal anastomoses. Intraoperative epididymal fluid quality correlated with patency, that is motile sperm in the epididymal aspirate correlated with postoperative patency (p <0.05). There was no correlation between fluid quality and pregnancy rates. Postoperative semen analyses demonstrated higher sperm density and higher motility in the pregnant versus nonpregnant groups.

CONCLUSIONS

Epididymovasostomy may be performed in patients with obstructive azoospermia unrelated to vasectomy with high patency and good pregnancy rates. Intraoperative epididymal fluid quality can be predictive of patency. There was a trend towards higher pregnancy rates for distal anastomosis. There were no pregnancies when anastomosis was at the caput epididymis on both sides.

Total protein and acid phosphatase concentrations in prostatic fluid from patients with BPH compared to carcinoma

OBJECTIVE

To obtain evidence of metabolic changes in the human prostate associated with prostate pathology, in particular carcinoma of the prostate, by identifying and evaluating associated changes in prostatic secretory products.

METHODS

Expressed prostatic fluid (EPF) from 36 patients with carcinoma, 128 with BPH histologically confirmed, and 148 with clinical BPH was subjected to determination of protein (Lowry; UV 280 nm absorption), enzymatic (DMA modified Row procedure) acid phosphatase (AcP), and immunologically identified (Tandem-PAP immunoenzymatic assay) prostatic acid phosphatase (PAP) concentration.

RESULTS

The important EPF findings are the following: (1) Protein concentrations (Lowry and UV determinations) are significantly increased in carcinoma as compared to histologic BPH, (2) AcP and PAP secretions remain stable in carcinoma versus BPH, and (3) AcP and PAP/Lowry protein ratios are significantly lower with carcinoma.

CONCLUSIONS

These findings of increased protein and the decreased relative secretions of AcP and PAP to total protein (ratio) in EPF from patients with carcinoma compared to BPH support and help to characterize the diffuse metabolic alteration in the prostate associated with prostate carcinoma. EPF observations identify potential metabolic changes occurring in prostate carcinoma that may have potential clinical and investigative relevance.

Image analysis assessment of testicular touch preparation cytologies effectively quantifies human spermatogenesis

PURPOSE

We have recently demonstrated that computer assisted image analysis of paraffin embedded testicular tissue based on deoxyribonucleic acid content and morphology characteristics is an effective method for the quantitative assessment of spermatogenesis. We assess the use of testicular touch preparation image analysis as a technique for quantification of spermatogenesis.

MATERIALS AND METHODS

Air dried, touch imprints of testicular tissue from obstructed azoospermic and severely oligozoospermic patients were obtained at the time of biopsy. Image analysis using a filter based on deoxyribonucleic acid content and cellular morphological characteristics was performed on Feulgen stained touch preparation imprints as well as paraffin embedded sections.

RESULTS

Image analysis of 52 testicular touch preparations from 48 azoospermic or severely oligozoospermic men revealed significant differences (p < 0.05) in the percentages of spermatid and spermatozoa, and 2N and 4N cells among seminiferous tubules exhibiting the 5 diagnostic categories of obstruction with normal spermatogenesis, maturation arrest at the spermatocyte stage, maturation arrest at spermatid stage, hypospermatogenesis and Sertoli cell only. Similar differences were observed in the image analysis data of the corresponding paraffin embedded testicular sections.

CONCLUSIONS

Computer assisted image analysis of testicular touch preparation is an effective quantitative method of spermatogenesis evaluation.

Varicocelectomy improves sperm strict morphology and motility

PURPOSE

We prospectively examined the effect of varicocelectomy on standard semen parameters and Kruger strict morphology, including site of specific sperm defect.

MATERIALS AND METHODS

Kruger strict morphology and routine semen analysis were performed in a blinded fashion before and a minimum of 4 months after varicocelectomy in 61 subfertile men with a primary diagnosis of varicocele.

RESULTS

Sperm motility, total number of motile sperm, and percentage and total number of sperm with normal strict morphology were significantly increased after varicocele repair. Average density was also increased, while volume and forward progression were unchanged. The percentage of normal head strict morphology was significantly improved, whereas tail and neck morphology did not reflect similar changes.

CONCLUSIONS

Varicocele repair in subfertile men improves Kruger strict morphology. In addition, motility and total motile sperm are significantly improved after repair. Since the stoichiometry of the sperm head is crucial to egg and sperm interaction, this decrease in head defects may be partially responsible for the increase in pregnancy rates after varicocele repair.

Sperm pellet analysis: a technique to detect the presence of sperm in men considered to have azoospermia by routine semen analysis

PURPOSE

In men considered to have azoospermia by routine semen analyses sperm may be identified after centrifuging the semen. Because these sperm may be used for intracytoplasmic sperm injection, we describe our technique and findings of sperm pelleting.

MATERIALS AND METHODS

Semen centrifugation for sperm pellet analysis was performed in 140 consecutive men in whom no sperm was identified on routine semen analysis and who were categorized as having obstructive or nonobstructive azoospermia. Obstructive azoospermia was defined as failed vasectomy reversal, failed reconstruction for congenital vasal or epididymal occlusion, or an acquired obstruction unrelated to ejaculatory duct obstruction. Patients with congenital absence of the vas deferens or who had undergone vasectomy were not included in the study. Nonobstructive azoospermia was defined as moderate to severe testicular atrophy with markedly elevated serum follicle-stimulating hormone (greater than 3 times normal), or a testicular biopsy that revealed maturational arrest, severe hypospermatogenesis or the Sertoli-cell-only pattern. Obstructive and nonobstructive azoospermia were present in 70 men who provided 109 samples and 70 who provided 103, respectively.

RESULTS

Motile and nonmotile sperm was identified in 13 of the 70 patients (18.6%) with obstructive and in 16 of the 70 (22.8%) with nonobstructive azoospermia. Pellet variability, that is the absence of sperm in 1 specimen and its presence in another from the same patient, was noted in 7 of the 17 men (41.2%) with obstructive and 2 of the 17 (11.8%) with nonobstructive azoospermia (not statistically significant). Motile sperm was present in the pellets of 6 of the 70 men (8.6%) with obstructive and 15 of the 70 (21.4%) with nonobstructive azoospermia. The median number of motile sperm was lower in the obstructive than in the nonobstructive group (0 sperm in 17 samples versus 5 sperm in 41 samples, p <0.001). The median value of 0 in the obstructive azoospermia group reflects the finding that 9 of the 17 samples did not contain motile sperm. Similarly the median number of nonmotile sperm was lower in the obstructive than in the nonobstructive group (5 versus 8 sperm).

CONCLUSIONS

We demonstrated the presence of motile and nonmotile sperm in a significant number of men considered to have azoospermia by routine semen analysis. Semen centrifugation (sperm pelleting) should be performed in all men considered to have this condition by routine semen analysis, especially those with testicular failure and those in whom intracytoplasmic sperm injection is possible.

Comparison of tunica albuginea substitutes for the treatment of Peyronie's disease

PURPOSE

Peyronie's disease is a connective tissue disorder resulting in fibrotic plaque formation on the tunica albuginea of the penis. One approach to repair consists of plaque excision and patching with one of many potential patch materials. Because the optimal patch material for covering the resultant defect has not been determined, this study compares histological and cavernosometric changes in the penis as a result of the placement of three different types of patch grafts used in surgery for Peyronie's disease.

MATERIALS AND METHODS

Eleven mongrel dogs were divided into three groups, each receiving a different patch material (superficial dorsal penile vein, silicone fabric, and dermabraded preputial flap). Each dog had dynamic infusion cavernosometry (DIC) performed prior to placement of the patch over a 6 x 3 mm. defect surgically created in the tunica albuginea. Three months later, DIC was repeated prior to sacrifice. Histology of the penis was examined using Masson's trichrome, and hematoxylin and eosin stains.

RESULTS

The only difference among the cavernosometric parameters (preop versus postop) was a higher initial pressure in the dermabraded preputial flap group postoperatively. The dogs undergoing vein patch had moderate fibrosis with apparent reformation of the tunica albuginea over the patch site. The normal venous architecture of the graft was no longer recognizable. Those dogs receiving a silicone patch had moderate fibrosis with a fibrous sheath of compressed histiocytes and fibroblasts enveloping the graft site. Finally, the dermabraded preputial flap patch group had mild-moderate fibrosis with focal loss of the cavernosal space underlying the flap.

CONCLUSIONS

We feel that continued use of the vein patch for repair of Peyronie's disease is warranted.

Absence of cyclic adenosine 3':5' monophosphate responsive element modulator expression at the spermatocyte arrest stage

OBJECTIVE

To test the hypotheses that variations in the expression of adenosine 3':5' monophosphate (cAMP) responsive element modulator are found in human seminiferous epithelium in men with impaired testicular function and subsequent infertility and that variations in apoptosis frequency are associated with differential cAMP responsive element modulator expression in male infertility states.

DESIGN

Standard immunohistochemical staining using a rabbit polyclonal antibody against the tau isoform of the cAMP responsive element modulator protein was performed on 5-microM sections of Bouin's fixed, paraffin-embedded testicular tissue obtained from azoospermic or severely oligozoospermic men for routine clinical purposes. Histologic diagnosis was confirmed with computerized image analysis of Feulgen-stained sections.

SETTING

Tertiary male infertility referral center at a medical school.

PATIENT(S)

Forty-eight testis biopsies were performed in 38 azoospermic or severely oligozoospermic males.

INTERVENTION(S)

Rabbit polyclonal cAMP responsive element modulator tau antibody was applied to the paraffin-embedded testis sections.

MAIN OUTCOME MEASURE(S)

Testis immunoreactivity to polyclonal cAMP responsive element modulator tau antibody and apoptotic indices.

RESULT(S)

Although cAMP responsive element modulator immunoreactivity was present in the round spermatid stage of meiosis in testis biopsy specimens showing normal spermatogenesis, spermatid maturation arrest, and hypospermatogenesis, there was complete absence of expression in biopsy specimens from patients with Sertoli cell only and spermatocyte maturation arrest states. In addition, significantly increased apoptotic indices were observed in the spermatocyte maturation arrest state in comparison with normal spermatogenesis and Sertoli cell only pattern.

CONCLUSION(S)

These data suggest that cAMP responsive element modulator may be important for spermatid development and a stage-specific regulator of human spermatogenesis. Absence of cAMP responsive element modulator may be a cause of testicular failure in various types of male infertility.

Unilateral testicular injury from external trauma: evaluation of semen quality and endocrine parameters

PURPOSE

Because few studies have described the impact of unilateral testicular trauma on fertility parameters, we review the experience at the Ben Taub General Hospital during a 16-year period. Semen and endocrine profiles were analyzed to evaluate the influence on the outcomes of orchiectomy versus testicular salvage.

MATERIALS AND METHODS

From 1979 to 1995, 67 patients were identified who sustained unilateral testicular trauma. Of these patients 12 were located and 10 agreed to be evaluated. Injuries included gunshot wounds, stab wounds and blunt trauma, and treatment consisted of unilateral orchiectomy or testicular repair. The study protocol comprised a history and physical examination, routine semen analysis, determination of semen and serum antisperm antibody titers (Immunobead* assay) and a modified gonadotropin stimulation test. Results were compared with a group of semen donors with proved fertility.

RESULTS

In the 7 patients who underwent unilateral orchiectomy mean sperm density was normal but significantly decreased compared with that of the fertile controls (81.6 versus 132.6 x 10(6)/ml., p = 0.04). Sperm motility was not significantly affected. Baseline follicle-stimulating hormone (FSH) and luteinizing hormone (LH), and post-stimulation LH were significantly increased in this group compared with controls (p < 0.01). In the group that underwent testicular repair sperm density, motility, and baseline and post-stimulation FSH and LH levels were not significantly different from controls. In all patients in both groups testosterone levels and contralateral testicular size were normal. Only 1 patient in the repair group had an elevated serum and semen antisperm titer.

CONCLUSIONS

While the testicular salvage group had no significant seminal or endocrine abnormality, the orchiectomy group had a significant decrease in sperm density and elevation of baseline FSH and LH. These preliminary data suggest that testicular salvage is more protective of overall testicular function than orchiectomy.

The prevalence of cystic abnormalities of the prostate involving the ejaculatory ducts as detected by transrectal ultrasound

PURPOSE

To determine the prevalence of cystic lesions of the prostate involving the ejaculatory ducts using transrectal ultrasound (TRUS).

MATERIALS AND METHODS

The prevalence of cystic lesions of the prostate involving the ejaculatory ducts was determined in a prostate cancer screening group and also in an "at risk" population of men with infertility.

RESULTS

Cystic lesions of the prostate involving the ejaculatory ducts as detected by TRUS were detected in 5.0% (20 of 400 consecutive men) in a prostate cancer screening population. In contrast, these abnormalities were present in 17.0% (23/135) of the "at risk" infertile men who had TRUS performed.

CONCLUSIONS

This is the largest series to date defining the prevalence of TRUS-identified cystic lesions of the prostate in a non-infertility population. While cystic lesions of the prostate involving the ejaculatory duct are uncommon in an otherwise healthy and fertile male, their prevalence increases in infertile men whose examination and semen analyses make them "at risk" for having ductal obstruction.

Advances in the evaluation and treatment of the infertile man

Numerous advances in technology have been made in the last several years in the diagnosis and treatment of the infertile man. Using case presentations, this article highlights these important new developments and reviews the basics of a comprehensive male infertility evaluation. The use of ultrasound as a critical, indispensable, yet noninvasive tool in the evaluation of possible male reproductive tract obstruction is discussed. Since assisted reproductive techniques (ARTs) have become increasingly important in the management of the otherwise untreatable infertile man, specialized testing of sperm function, e.g., the sperm penetration assay (SPA), and strict morphology assessment are often useful prior to the initiation of some of these assisted reproductive procedures such as intrauterine insemination (IUI) or in vitro fertilization (IVF). Testicular touch preparation cytology and image analysis are also important additions to routine testicular biopsy for quantifying the extent of spermatogenesis. Finally, the revolutionary micromanipulation procedure of intracytoplasmic sperm injection (ICSI) has forever changed the practice of andrology by enabling men previously thought to be irreversibly infertile the chance to initiate their own biologic pregnancy.

In situ end-labeling of human testicular tissue demonstrates increased apoptosis in conditions of abnormal spermatogenesis

OBJECTIVE

To determine, using an in situ end-labeling technique, whether the frequency of apoptosis is increased in testis biopsy specimens that demonstrate abnormal spermatogenesis.

DESIGN

Immunohistochemical analysis was performed on archived paraffin-embedded testis biopsy specimens. Apoptotic indices, defined as the number of apoptotic bodies per the total number of cells or the number of Sertoli cells, were calculated after counting all the intratubular spermatogenic cells and Sertoli cells in 20 tubules.

SETTING

Major academic male factor infertility clinic.

PATIENT(S)

Forty-eight testis biopsy specimens were obtained for routine clinical purposes from 38 men with azoospermia or severe oligozoospermia.

INTERVENTION(S)

In situ end-labeling was performed on archived paraffin-embedded testis biopsy specimens using terminal deoxynucleotidyl transferase.

MAIN OUTCOME MEASURE(S)

Apoptotic indices.

RESULT(S)

Significantly increased apoptotic indices were observed in patients with spermatocyte arrest, spermatid arrest, and hypospermatogenesis compared with patients with normal spermatogenesis and the Sertoli cell-only pattern.

CONCLUSION(S)

In situ end-labeling of testis biopsy specimens from infertile men demonstrates increased apoptosis in maturation arrest and hypospermatogenesis states compared with normal spermatogenesis and the Sertoli cell-only pattern. This unique observation implicates a prominent role for this form of programmed cell death in the pathophysiology of maturation arrest and hypospermatogenesis states.

Apoptotic frequency is increased in spermatogenic maturation arrest and hypospermatogenic states

PURPOSE

Increased testicular apoptosis has been observed in maturation arrest and hyposper-matogenesis states in rodent models, but this process has not yet been characterized in humans. We hypothesized that increased cell death present with accelerated apoptosis is significant in pathophysiology of many male infertility states associated with abnormal spermatogenesis. We examined frequency of apoptotic bodies in human testis biopsy specimens from infertile men using morphometric analysis of hematoxylin and eosin stained paraffin sections.

MATERIALS AND METHODS

Testis biopsy specimens were obtained for routine clinical purposes from azoospermic and severely oligozoospermic men and were stained with hematoxylin and eosin. Apoptotic bodies were identified using established morphometric criteria. Apoptotic indexes, defined as apoptotic bodies per total number of cells and per Sertoli cells, were calculated after counting all intratubular spermatogenic cells and Sertoli cells in 20 tubules.

RESULTS

A total of 51 biopsies was performed in 50 men. Significantly increased apoptotic body per total cell and apoptotic body per Sertoli cell ratios were observed in maturation arrest and hypospermatogenesis states in comparison to Sertoli cell only and normal spermatogenesis (p < 0.05, Mann-Whitney test).

CONCLUSIONS

Increased apoptosis in maturation arrest and hypospermatogenesis states compared to normal but obstructed spermatogenesis and Sertoli cell only were observed, indicating a prominent role for this form of programmed cell death in human male infertility.

Results of laser tissue soldering in vasovasostomy and epididymovasostomy: experience in the rat animal model

The use of microsurgical techniques (vasovasostomy and epididymovasostomy) for vasectomy reversal has now enabled surgeons to perform both procedures with certainly acceptable success rates. However, these operations are technically demanding and require special training in microsurgery.

PURPOSE

A new method of performing these procedures using laser tissue soldering is described and results are evaluated. Laser tissue soldering is different from laser welding in that it involves the laser activation of a protein solder with a dye specific for the specific wavelength of laser light; therefore, surrounding tissue is not affected by the laser.

MATERIALS AND METHODS

Ten rats underwent bilateral vasovasostomy and eleven underwent bilateral epididymovasostomy. In each rat, a sutured anastomosis was performed on one side while laser tissue soldering was performed on the other. Animals were sacrificed after one month and anastomoses were evaluated for patency and presence of sperm granulomas. Histologic analysis was also performed.

RESULTS

Patency rates were 8/10 (80%) for sutured vasovasostomy versus 9/10 (90%) for the laser technique. Epididymovasostomy patency rates were 8/11 (73%) for sutured versus 9/11 (82%) for the laser technique. Mean operative times were significantly shorter for lasered anastomoses when compared to controls. The frequency of granuloma formation did not significantly differ between laser and control groups.

CONCLUSIONS

Laser tissue soldering resulted in similar patency when compared to a conventional 2 layered sutured anastomosis while decreasing operative time. In addition, since fewer sutures are placed, the laser method is less technically demanding.

Image analysis assessment of the abnormal testis biopsy in male infertility

PURPOSE

We previously demonstrated that testis biopsy image analysis is an effective method for quantifying intratubular spermatogenic cells in the obstructed testis with normal spermatogenesis. As an extension of the initial report, we describe using the quantitative ploidy and morphological characteristics of cells counted with image analysis in abnormal testis biopsies obtained for a male infertility evaluation.

MATERIALS AND METHODS

Image analysis using a specifically designed filter was performed on Feulgen stained 5 microns, sections of paraffin embedded testicular tissue. Archival testicular tissue had been obtained using standard biopsy techniques from patients with azoospermia or severe oligospermia. Qualitative classification was based on standard evaluation of hematoxylin and eosin processed tissue.

RESULTS

There were 62 biopsies performed in 58 men. Significant differences in the intratubular content of haploid (spermatozoa and spermatids), diploid and tetraploid cells were found among the 5 categories of abnormalities: the Sertoli-cell-only syndrome, spermatocyte arrest, spermatid arrest, hypospermatogenesis and normal spermatogenesis. Moderate variability was found in the proportion of cell types in spermatid arrest and hypospermatogenesis.

CONCLUSIONS

Testis biopsy image analysis provides a quantitative method for categorizing abnormalities of intratubular cell content present in male infertility states by using deoxyribonucleic acid content and morphology characteristics. The limitations of the present qualitative analysis system are emphasized by the moderate variability evident within the current categories of spermatid arrest and hypo-spermatogenesis states.

Intracytoplasmic sperm injection for treatment of the infertile male

Intracytoplasmic sperm injection (ICSI) with in vitro fertilization represents one of the most significant advances in fertility technology. In this relatively new procedure, a single viable sperm is microinjected into an oocyte that has been extracted transvaginally. After fertilization occurs, the embryo is transferred into the uterus. This procedure now affords men who were previously thought to be irreversibly infertile the chance to initiate their own biologic pregnancy. However, because of the procedure's significant costs and its potential risk to the mother, careful selection of couples following a thorough male factor evaluation is mandatory.

Advances in the treatment of organic erectile dysfunction

Nonsurgical measures have replaced penile prostheses as first-line treatment. In addition to intracavernous injection therapy and vacuum/constriction devices, options now include urethral suppositories.

Testis biopsies frequently demonstrate sperm in men with azoospermia and significantly elevated follicle-stimulating hormone levels

PURPOSE

Men with azoospermia, markedly elevated serum follicle-stimulating hormone levels and testicular atrophy were previously considered irreversibly infertile. Thus, testicular biopsy in this patient population was considered unnecessary. However, presently men with even the most severe infertility disorders are potentially able to initiate a pregnancy with intracytoplasmic sperm injection provided sperm can be recovered in even relatively few numbers directly from the testicular tissue. For these reasons we sought to reevaluate the findings from testicular biopsies in these men in the era of advanced micromanipulation techniques.

MATERIALS AND METHODS

Chart review identified men with azoospermia, confirmed on a pelleted specimen, and a serum follicle-stimulating hormone level of 3 or more times normal. Mature sperm in the touch preparation cytology and testis biopsy specimen were confirmed.

RESULTS

A total of 57 men, most with testicular atrophy, underwent a testicular biopsy and in 17 (30%) mature sperm were identified. The most common diagnosis in these men was severe hypospermatogenesis. Men without sperm most commonly had a pure Sertoli-cell-only pattern.

CONCLUSIONS

Men with azoospermia and testicular atrophy with significantly elevated follicle-stimulating hormone levels should undergo testicular biopsy if in vitro fertilization with intracytoplasmic sperm injection is an acceptable approach for the couple.

Testis biopsy image analysis effectively quantifies spermatogenic cell types

PURPOSE

Evaluation of the testis biopsy specimen in male infertility has been hampered by the qualitative rather than quantitative nature of routine histological techniques and interpretation. Although useful, flow cytometry has demonstrated significant limitations due to its inability to differentiate among haploid cell types, spermatozoa and spermatids. Thus, deoxyribonucleic acid image analysis was performed on testis biopsy specimens to combine the advantages of quantitative ploidy and morphological characteristics to develop a more effective quantitative system.

MATERIALS AND METHODS

Image analysis using a specifically designed filter was performed on Feulgen stained 5 microns. sections of paraffin embedded testicular tissue. The archival testicular tissue had been obtained using standard biopsy techniques from patients with azoospermia and normal spermatogenesis on routine hematoxylin and eosin processed tissue.

RESULTS

The overall findings (mean plus or minus standard deviation) in 20 biopsies from 18 men are haploid 54.2 +/- 5.6, diploid 31.2 +/- 5.2 and tetraploid 15.0 +/- 4.6%. Spermatozoa and spermatids contributed 23.2 +/- 5.7 and 30.9 +/- 7.6% to the total cell content, respectively. A mean of 2,462 +/- 254 cells were counted per case.

CONCLUSIONS

We used image analysis to evaluate testicular biopsies. This technique can quantitatively determine the percentages of various cell types within the seminiferous tubules. Furthermore, it can differentiate between spermatozoa and spermatids based on morphological characteristics. This technique, which combines ploidy and cell morphology characteristics, represents a significant advancement in the interpretation of the testicular biopsy, and has implications for redefining the presently used system of qualitative interpretative assessment.

Role of ultrasound in the assessment of male infertility

The use of ultrasonography has become an important component in the evaluation and treatment of male reproductive tract disorders. From the use of color flow Doppler ultrasonography for the assessment of varicoceles to transrectal ultrasonography combined with seminal vesiculography for the evaluation of ejaculatory duct obstruction, ultrasonography has practical clinical applications. In this article, the authors review the indications and use of ultrasonography in the assessment and treatment of the infertile male. The recent advances in diagnostic transrectal ultrasonography for ejaculatory duct obstruction, in particular, are emphasized.

Testicular touch preparation cytology

PURPOSE

The applications, technique and limitations of testicular touch preparation cytology in evaluation of the infertile man are described.

MATERIALS AND METHODS

The technique and histological results of testicular touch preparation cytology for normal specimens and various pathological conditions of male infertility are described in detail.

RESULTS

Testicular touch preparation cytology is able to differentiate between late spermatids and mature spermatozoa, as well as to identify other spermatogenic elements.

CONCLUSIONS

Touch preparation cytology has 2 important purposes: 1) distinguishing between maturation arrest at the late spermatid stage and normal spermatogenesis, and 2) determining whether obstruction is the cause of azoospermia. While testis biopsy is the gold standard, touch preparation cytology is an extremely important adjunct because of its ability to define whole sperm. The urologist and pathologist are better able to make a diagnosis when routine biopsy and touch preparation cytology are performed.