Evaluation of the azoospermic patient

Characterization of patients presenting with male factor infertility in an equal access, no cost medical system

OBJECTIVES

Demographic information on patients presenting for the diagnosis and treatment of male factor infertility has been limited in the past by the paucity of subspecialty trained providers and concentrated sequential patient information. Previously reported studies looking at the characteristics of patients being evaluated for male subfertility may represent a selected subset of patients able to access these services. The changes in the diagnostic modalities available in the 1990s and new diagnostic categories may also affect the characterization of patients seen with the diagnosis of male factor infertility.

METHODS

A retrospective analysis was performed using a centralized database of patient records at a single military male infertility clinic. Seven hundred consecutive patients were studied to obtain information on patient and spouse age, race, length of subfertile period, medical history and examination, and laboratory evaluation. A single provider categorized the etiology of male factor infertility after the evaluation.

RESULTS

The mean patient age was 36 years (range 17 to 68). The mean spouse age was 31.2 years (range 19 to 50). The mean subfertile period was 5.5 years (range 0.5 to 35). Of the 700 patients, 51% were white, 10% African American, 2% Hispanic, and 37% other/unknown. Eleven percent of the patients were active smokers. The most common etiologic category groups describing male subfertility were previous vasectomy (56%), varicocele (14%), idiopathic infertility (8%), and nonobstructive azoospermia (6%).

CONCLUSIONS

An equal access, no cost medical system mirrors the demographics of the military population served. The clinical characteristics of patients presenting with male factor infertility have changed significantly during the past 30 years. Obstruction from a previous vasectomy is now the most common presenting complaint of patients visiting an infertility clinic. Vasectomy reversal may be more frequently requested when the cost is not a factor in providing fertility services. Idiopathic male factor infertility occurs in less than 10% of patients.

Microsurgical inguinal varicocele repair in azoospermic men

OBJECTIVES

To evaluate the efficacy of microsurgical inguinal varicocele repair in nonobstructive azoospermic men with palpable varicocele and to determine predictive parameters of outcome.

METHODS

After standard diagnostic evaluation, 24 pellet (-) completely azoospermic men and 14 pellet (+) virtually azoospermic men underwent microsurgical inguinal varicocele repair. Testicular core biopsy was also performed perioperatively in all patients. The outcome was assessed in terms of improvement in semen parameters and spontaneous pregnancy.

RESULTS

After a mean follow-up of 13.4 +/- 4.7 months, motile sperm in the ejaculate could be identified in 5 (21%) of the completely azoospermic patients, and these patients were rescued from invasive sperm extraction techniques when referred to intracytoplasmic sperm injection. Testicular histopathology of these patients with postoperative improvement revealed maturation arrest at spermatid stage (n = 3), Sertoli-cell-only (SCO) pattern with focal spermatogenesis (n = 1), and hypospermatogenesis (n = 1). None of the patients with pure SCO pattern or maturation arrest at spermatocyte stage had improvement after varicocele repair. However, improvement in semen parameters was observed in 12 (85.7%) patients with virtual azoospermia, 4 (28.6%) achieved a total motile sperm count greater than 5 million, and spontaneous pregnancy occurred with 3 (21.4%) of them.

CONCLUSIONS

Microsurgical inguinal varicocele repair offers completely azoospermic men the chance to provide motile sperm via ejaculate in 21%. Moreover, 28.6% of virtually azoospermic men are rescued from ICSI procedures as an initial treatment modality. Results of varicocele repair in azoospermic men also reveal that a certain threshold of spermatogenesis, requiring the presence of at least spermatids, is necessary for effective varicocele repair.

Microsurgical vasoepididymostomy with sperm cryopreservation for future assisted reproduction

BACKGROUND

Although obstructive azoospermia is treatable with microscopic seminal reconstruction, the number of patients who choose to undergo vasoepididymostomy is limited because of recent advances in assisted reproductive technology (ART). We attempted to define the outcome of surgical reconstruction in patients with suspected epididymal obstruction and no previous history of vasectomy.

METHODS

We described 40 eligible end-to-side vasoepididymostomy procedures performed on 24 azoospermic patients who had either bilateral or unilateral epididymal obstruction.

RESULTS

The overall patency rate following surgery was 54% (13/24) and for four patients (17%), natural intercourse resulted in pregnancy. Two pregnancies were initiated with intracytoplasmic sperm injections using frozen sperm collected during vasoepididymostomy.

CONCLUSIONS

In the era of modern ART, microsurgical vasoepididymostomy with cryopreservation of sperm collected during the operation is recommended for patients with epididymal obstructions.

Testicular biopsy in patients with obstructive azoospermia

The present report studies the testicular biopsy lesions (histologic and semiquantitative) in a series of 48 patients with obstructive azoospermia of known etiology (vasectomy, congenital absence of vas deferens, herniorrhaphy, hydrocelectomy, Young's syndrome, and ejaculatory duct obstruction) in order to establish objective testicular data that permit the pathologist to diagnose an obstructive process, which should not be mistaken with a primary testicular lesion. The semiquantitative study included determinations of the average numbers of spermatogonia, primary spermatocytes, young spermatids (Sa + Sb), and differentiated spermatids (Sc + Sd). According to this study, the testes were classified into the following groups: (1) normal testes whose germ cell numbers were within normal limits (27 testes); (2) testes with lesions in the adluminal compartment; these lesions comprise two subgroups: (2a) late sloughing of primary spermatocytes (both spermatid types were greatly reduced in number while the other germ cell types were in normal numbers) (45 testes); and (2b) early sloughing of primary spermatocytes (normal spermatogonial number, reduced number of spermatocytes, and scanty spermatids) (9 testes); and (3) lesions in the basal compartment; these lesions comprise two subgroups: (3a) pure hypospermatogenesis (a proportionate decrease in the numbers of all germ cell types) (8 testes); and (3b) hypospermatogenesis associated with sloughing of primary spermatocytes (decreased numbers of all germ cell types with a very scanty number spermatids) (4 testes). Two testes appeared hyalinized and one testis was removed owing to cryptorchidism. The most frequent testicular lesion observed (alteration in the adluminal compartment of seminiferous tubules) seems to be related to the increase in hydrostatic pressure in the tight compartment formed by seminiferous tubules, rete testis, efferent ducts, the epididymal duct, and the initial portion of the vas deferens. The severity of the lesions is probably related to the cause and span of the obstruction. In addition, two azoospermic men without obstructive azoospermia and whose testicular biopsy study revealed meiotic anomalies (with the subsequent bad prognosis) were also studied for comparison. The semiquantitative study of these patients permitted the differential diagnosis between two lesion types. Testes with meiotic anomalies had a disproportionately elevated number of primary spermatocytes, and an extremely low number of young spermatids.

Transurethral resection of partially obstructed ejaculatory ducts: seminal parameters and pregnancy outcomes according to the etiology of obstruction

PURPOSE

We determine how transurethral resection of the ejaculatory ducts performed for infertility affects seminal parameters and pregnancy outcomes in patients with partial ejaculatory duct obstruction due to a congenital or acquired etiological factor.

MATERIALS AND METHODS

Based on history and physical examination, hormonal profiles, semen analyses, transrectal ultrasonography and vasography findings partial ejaculatory duct obstruction was diagnosed in 14 men a mean of 30 years old who presented for infertility evaluation. Patients were grouped according to congenital or acquired cause of obstruction. Transurethral resection of the ejaculatory ducts was performed using the standard resectoscope loop technique. Clinical outcome was assessed by postoperative analyses of seminal parameters and pregnancy reports.

RESULTS

Transurethral resection of the ejaculatory ducts significantly improved semen quality (ejaculate volume and percentage of sperm motility) in all patients in the congenital group, while all but 1 (83%) had an improved sperm count. Pregnancy was achieved via sexual intercourse by 66% of the patients an average of 5.7 months postoperatively. Of the acquired etiological factor group 37.5% had improved semen quality after transurethral resection of ejaculatory duct and 12.5% achieved pregnancy via sexual intercourse. Postoperative complications occurred at a similar rate in each group (33%). However, complications in the congenital etiology group were minor, while 25% of the men in the acquired group had significant impairment of seminal parameters after transurethral resection of the ejaculatory ducts.

CONCLUSIONS

Semen quality improvement and pregnancy outcome after transurethral resection of the ejaculatory ducts for partial ejaculatory duct obstruction differ significantly according to the main etiological cause of obstruction. An equivocal diagnosis of partial obstruction and technical problems during transurethral resection of the ejaculatory ducts may contribute to failure. However, in some cases the reason for failure remains unclear.

Identification of spermatozoa and round spermatids in the ejaculates of men with spermatogenic failure

OBJECTIVES

As many as 10% of infertile men have azoospermia caused by spermatogenic failure or ductal obstruction. The histologic diagnoses associated with spermatogenic failure--Sertoli cell-only syndrome, maturation arrest, and hypospermatogenesis--do not necessarily represent global changes in the affected testis, as occasional seminiferous tubules may still produce mature germ cells. Intracytoplasmic sperm injection (ICSI) allows individual sperm that have been isolated from testicular tissue to fertilize oocytes. This study assessed whether mature germ cells (either round spermatids or spermatozoa) were present in the ejaculates of patients with spermatogenic failure.

METHODS

All semen analyses performed at our tertiary care institution from January 1993 through December 1995 were reviewed to identify azoospermic men with spermatogenic failure. During this period, our laboratory employed Nuclear-Fast Red and picroindigocarmine staining (NF-PICS) of cytospin slides to identify rare spermatozoa and spermatids in otherwise azoospermic ejaculates.

RESULTS

Of 3005 analyses reviewed, 20 azoospermic men whose infertility was solely attributable to spermatogenic failure were identified. The histologic diagnoses were germinal cell aplasia (n = 7), complete maturation arrest (n = 6), incomplete maturation arrest (n = 3), and hypospermatogenesis (n = 4). Using the NF-PICS technique, mature germ cells were identified in the ejaculates of 15 men (75%), and 9 men (45%) had fully formed spermatozoa present.

CONCLUSIONS

In the clinical management of azoospermic infertile men, the NF-PICS technique may be used to identify men who have some degree of testicular spermatogenesis. This might obviate the need for the purely diagnostic testis biopsy that is performed before therapeutic biopsy for testicular sperm extraction in conjunction with ICSI.

The Turner biopsy needle facilitates seminal vesicle aspiration

Transrectal ultrasonography and seminal vesicle aspiration with or without vesiculography have become an integral part of the evaluation and management of the infertile male with ejaculatory duct obstruction. We have found that the Echo Tip Turner Biopsy Needle used in conjunction with ultrasound guidance greatly facilitates these transrectal procedures.

Quality of semen obtained by penile vibratory stimulation in men with spinal cord injuries: observations and predictors

OBJECTIVES

To study the semen quality and to examine prognostic factors that may affect semen quality in men with spinal cord injuries (SCI) who respond to penile vibratory stimulation (PVS).

METHODS

Fifty-one PVS responders were prospectively examined. Penile vibratory stimulation was induced with optimized vibration parameters. Semen quality was characterized by semen analysis. The gel agglutination test for the presence of antisperm antibodies and serum hormone assays were performed. Characteristics of the spinal lesions, type of bladder management, and hormone assays were compared to semen quality and incidence of azoospermia or total lack of motility.

RESULTS

The mean semen parameters were: volume-1.9 mL (range 0.2 to 7.0); total sperm-457 million (range 0 to 10,900); motility-12.6% (range 0% to 55%); total motile sperm-39.3 million (range 0 to 401); normal morphology-50.1% (range 0% to 90%). Better sperm motility was seen in men with cervical lesions versus those with thoracic lesions (16% versus 7%) and incomplete versus complete lesions (19% versus 10%). There was a higher incidence of azoospermic specimens in men with thoracic lesions versus cervical level (26% versus 3%) and a lower incidence of finding any motile sperm in the specimen (47% versus 81%). Men voiding without catheters had a lower incidence of azoospermia (3% versus 28%). Abnormalities of hormone and antibody tests were rare.

CONCLUSIONS

Better sperm specimens from PVS of men with SCI may be expected from men with higher neurologic level, incomplete lesions, and those voiding without the use of a catheter. Hormonal abnormalities and immunologic causes do not explain the poor sperm quality seen in men with SCI.

The Use of Ultrasonograhy in the Evaluation and Management of Male Infertility

Although many causes of male infertility are not easily managed, in a significant number of cases a correctable factor is identified. This review article looks at the important role sonography plays in the evaluation and management of two such disorders—varicocele and obstruction of the ejaculatory ducts.

Diagnosis of vasal obstruction with seminal vesiculography: an alternative to vasography in select patients

OBJECTIVES

To determine whether the pelvic and inguinal portion of the vas deferens can be visualized during seminal vesiculography.

DESIGN

Retrospective review of the seminal vesiculograms performed in six patients to determine the frequency of visualization of the vas deferens. A prospective evaluation to determine the amount of contrast necessary to visualize the vas deferens was performed in three patients.

RESULTS

The vas deferens was visualized down to the level of the scrotum in four of the six initial studies examined retrospectively. The vas deferens was visualized adequately after the infusion of > or = 10 mL of contrast in all three studies performed prospectively.

CONCLUSION

Seminal vesiculography is a minimally invasive diagnostic alternative to vasography that can be used to document the patency of the pelvic and inguinal portions of the vas deferens in select patients.

The value of transrectal ultrasonography in the diagnosis and treatment of partial obstruction of the seminal duct system

We report a case of male subfertility with ejaculate volume less than 1 cc and moderate oligoasthenozoospermia. Partial obstruction of the seminal duct system was suspected and transrectal ultrasonography revealed a müllerian duct cyst. We confirmed the diagnosis with transperineal puncture and contrast filling of the cyst and seminal vesicles. This procedure allowed us to avoid scrotal vasostomy and perform conventional vasography as well as to measure the distance between the ceiling of the cyst and the urethra, which facilitated subsequent transurethral surgery.

Epididymovasostomy

There are a variety of causes of epididymal obstruction, but the most frequent indication for epididymovasostomy today is obstruction following vasectomy. We have seen significant advances over the last few decades in our techniques for reconstructing the proximal excurrent ductal system in order to restore sperm to the ejaculate and fertility in men with azoospermia secondary to epididymal obstruction. The patency rates for epididymovasostomy have improved significantly with the use of microsurgical techniques and specific tubule anastomosis. The level of anastomosis plays a crucial role in eventual fertility. These microsurgical techniques are tedious and difficult to master but practice and meticulous attention to detail are rewarded by excellent results.

Seminal vesicle aspiration in the management of patients with ejaculatory duct obstruction

Ejaculatory duct obstruction is a rare but significant cause of male factor infertility. Vasography is the current gold standard for the diagnosis of complete obstruction of the ejaculatory ducts. However, there is currently no reliable method to diagnose partial obstruction. We performed seminal vesicle aspiration under transrectal ultrasonographic guidance in 11 infertile men to assess the use of this diagnostic test in the evaluation and management of patients with ejaculatory duct obstruction. The absence of sperm within the seminal vesicle aspirate from 8 patients who had sperm in the ejaculate demonstrates that sperm are not normally present within the seminal vesicles. Numerous motile sperm were observed in the seminal vesicle aspirate from an azoospermic patient in whom vasography documented complete ejaculatory duct obstruction, demonstrating that sperm can reflux into the seminal vesicles in patients with distal obstruction. Two patients with suspected partial ejaculatory duct obstruction had sperm in the seminal vesicles. In conclusion, sperm are not normally present within the seminal vesicles and ejaculatory duct obstruction should be suspected in any patient with numerous sperm within the seminal vesicles.

New indication of testis biopsy for azoospermia: a clinical study in Japanese patients

Because of the progress made with assisted reproductive techniques, we decided to clarify the indication for testis biopsy in Japanese azoospermic patients. A total of 88 azoospermic patients were recruited with testis histologies obtained by bilateral biopsy. Testicular histology was evaluated using Johnsen's score count. Patients with at least 1 testis containing sperm were assigned to the active spermatogenesis group. Patients whose testes had no sperm were assigned to the hypospermatogenesis group. Differences in terms of the clinical data between the 2 groups were analyzed. Clinical data consisted of past history, physical examination and hormone concentrations. The unpaired t test was generally used to examine the statistical significance of any differences between the 2 groups. 1) There were significant differences between the 2 groups in the levels of serum testosterone and luteinizing hormone. 2) There were markedly significant differences between the 2 groups in terms of testis volume and the concentration of serum follicle-stimulating hormone (FSH). 3) The smallest testis volume and the highest serum FSH value in the active spermatogenesis group were 7 ml and 32.7 mlU/ml (normal range 2.9-8.2), respectively. In conclusion, although the presence or absence of active spermatogenesis can be accurately predicted by measuring the testis volume and serum FSH, testis biopsy should be carried out in patients with a testis volume greater than 7 ml or a serum FSH less than 4 times normal when the use of assisted reproductive techniques are planned.

Transrectal ultrasound in the evaluation of men with low volume azoospermia

The evaluation of the subfertile man has changed with the advent of noninvasive imaging techniques. We used high resolution transrectal ultrasound early in the evaluation of 25 men 24 to 35 years old with probable ductal obstruction represented by azoospermia or severe oligospermia (less than 1 million sperm per cc) and low volume ejaculate. Of these patients 13 were found to have a post-testicular obstructive cause including ejaculatory duct obstruction (5), voluminous seminal vesicle dilatation with obstruction (3), seminal vesicle aplasia (2), nonpalpable vas (2) or epididymal obstruction (1). The other 12 men had either a varicocele (8) or testicular failure (4). Except for vasal or epididymal pathology, the other causes of post-testicular azoospermia presented with an ejaculate volume consistently less than 1.0 cc. All 10 patients with low volume and an abnormal ultrasound had normal follicle stimulating hormone levels and testicular biopsy findings. Sonography not only was helpful in establishing the diagnosis but also in determining the distal extent of the obstruction. Transrectal ultrasound is an important noninvasive diagnostic tool that minimizes the need for more invasive studies in the evaluation of azoospermia, particularly when associated with low ejaculate volume.

Transrectal ultrasound and partial ejaculatory duct obstruction in male infertility

Partial ejaculatory duct obstruction, due to either a congenital or an acquired cyst or ejaculatory duct stenosis secondary to calcification, chronic inflammation, can produce a wide spectrum of seminal fluid abnormalities. Sperm density may range from azoospermia to normospermia while ejaculate volume can be low to normal. Sperm motility is consistently diminished (less than 30%). We have treated 2 patients with ejaculatory duct stenosis whose diagnosis was accurately made with transrectal ultrasonography (TRUS). We now suggest that TRUS be used when there is a low semen volume (less than 1.0 cc), or low motility (less than 30%), or oligospermia (less than 20 million sperm/mL), and normal findings on physical examination with normal serum gonadotropin values in the absence of any other explanation.

The neodymium:YAG laser recanalization in a patient with azoospermia due to ejaculatory duct agenesis

A 32-year-old man with azoospermia is presented. Transperineal echographically guided vesiculography of the vas deferens showed absence of the ejaculatory duct and presence of a cystic müllerian duct in which both enlarged seminal vesicles joined. Transurethrally, by means of a contact tip over the verumontanum a new channel was created by neodymium:YAG laser irradiation at 25 watts every 2 seconds. The patient had 32.10(6) spermatozoa per ml. with good quality on semen analysis 10 months later.

Transrectal ultrasound of the ejaculatory apparatus

Most interest in transrectal ultrasound (US) of the prostate has concentrated on its role in the diagnosis and management of prostatic cancer. The increasingly detailed investigation of male patients with infertility has recently led to interest in the use of US in investigating the structure and function of the ejaculatory ducts and seminal vesicles. The anatomy and pathology of the ejaculatory ducts and seminal vesicles as demonstrated by transrectal US are discussed and illustrated.

Melatonin and aromatase stimulating activity of human seminal plasma

Melatonin concentrations and aromatase stimulating activity were determined in human seminal plasma and correlated with sperm density and motility. Aromatase stimulating activity was determined with an in vitro rat granulosa cell system and melatonin by radioimmunoassay. Compared to normal semen, aromatase stimulating activity was lower in azoospermic individuals, while melatonin was higher in oligospermic and azoospermic samples. Aromatase stimulating activity correlated positively with sperm concentrations and a negative correlation was found between melatonin and sperm progression. These findings suggest that low sperm production is associated with low aromatase stimulating bioactivity in seminal plasma; and melatonin may have an effect upon both sperm production and motility.

Transrectal ultrasonography in the evaluation of the infertile man: a report of 3 cases

The traditional evaluation of the infertile man with azoospermia or low ejaculate volume includes determination of serum testosterone and follicle-stimulating hormone levels, a seminal fructose test, post-ejaculate urinalysis and, sometimes, vasography. Transrectal ultrasonography, a technique currently familiar to most urologists, recently has been added to our diagnostic armamentarium. This office-based imaging procedure provides an accurate assessment of the prostate, ejaculatory ducts and seminal vesicles, which can be helpful in the evaluation of certain infertile patients. We describe 3 patients who presented with either azoospermia or decreased ejaculate volume in whom transrectal ultrasonography had a critical role in the fertility evaluation. The clinical indications for and interpretation of transrectal ultrasonography in the infertile population are described. Transrectal ultrasonography currently is the most accurate, inexpensive and readily available noninvasive imaging technique used to diagnose obstruction of the ejaculatory ducts in the infertile patient with either azoospermia or low ejaculate volume.