Sensitivity and Specificity of Ultrasonography in Predicting Etiology of Azoospermia

Differentiation between nonobstructive azoospermia and obstructive azoospermia: then and now

Male infertility has seen an increase in prevalence with cases of azoospermia estimated to affect 10%-15% of infertile men. Confirmation of azoospermia subsequently necessitates an early causal differentiation between obstructive azoospermia (OA) and nonobstructive azoospermia (NOA). Although less common when compared to NOA, OA can represent upward 20%-40% of cases of azoospermia. While there are a multitude of etiologies responsible for causing NOA and OA, correctly distinguishing between the two types of azoospermia has profound implications in managing the infertile male. This review represents an amalgamation of the current guidelines and literature which will supply the reproductive physician with a diagnostic armamentarium to properly distinguish between NOA and OA, therefore providing the best possible care to the infertile couple.

Advanced Sonographic Techniques in the Comprehensive Evaluation and Diagnosis of Male Infertility

Background Infertility affects many couples, with male factors being responsible for over half of the cases. Male infertility can arise from various testicular illnesses, such as varicocele and cryptorchidism, as well as posttesticular disorders, like ejaculation abnormalities. Infertility is defined as the inability to conceive after 12 months of unprotected sexual activity or after six months for women over 35. Diagnostic techniques such as semen analysis and scrotal ultrasonography are done to evaluate conditions like varicocele and epididymo-orchitis. This study aims to assess the diagnostic utility of ultrasonography for male infertility and compare its findings with those from surgery and clinical care. Methodology All patients were referred to the Department of Radiology, Tertiary Care Hospital, South India, for transrectal and scrotal ultrasonography, using a high-frequency transducer with a frequency of 7.5 MHz and a color Doppler when necessary. The study included all male patients with infertility and abnormal semen analysis, as well as those with infertility accompanied by scrotal abnormalities detected during clinical examination. Patients were placed in the left lateral decubitus position for the transrectal ultrasonography examination. The testes and epididymis were thoroughly examined on both sides and compared regarding symmetry, size, texture, and vascularity. Results Varicocele was the most frequent anomaly detected by both clinical examination and ultrasonography. Ultrasound detected 30 cases of varicocele, whereas clinical examination diagnosed 15 cases. Hydrocele was identified in eight cases through clinical examination and in 15 cases through ultrasound. Epididymal cysts were found in five cases via clinical examination, while both clinical examination and ultrasonography discovered epididymitis in 10 cases. Overall, the number of anomalies detected by ultrasound was significantly higher than those found by physical examination, with a statistically significant p value of 0.001. Conclusion Transrectal ultrasound provides high-resolution imaging of the prostate, seminal vesicles, and distal vas deferens, which aids in diagnosing obstructive azoospermia. Imaging is a valuable supplement to clinical examination and laboratory studies for accurately identifying anatomy and abnormalities. Both transrectal and scrotal ultrasonography offer crucial information in diagnosing male infertility. Ultrasonography is more effective in identifying pathological abnormalities than clinical palpation.

Ultrasound-Based Technologies for the Evaluation of Testicles in the Dog: Keystones and Breakthroughs

Ultrasonography is a valuable diagnostic tool extensively used in the andrology of human and domestic animals, including dogs. This review aims to provide an overview of various technologies based on ultrasound, from the basic B-Mode ultrasonography to the more recent advancements, such as contrast-enhanced ultrasonography (CEUS) and ultrasound elastography (UEl), all of which are utilized in the evaluation of canine testicles. The review outlines the principles behind each of these technologies and discusses their application in assessing normal and abnormal testicular conditions. B-mode canine testicular ultrasonography primarily focuses on detecting focal lesions but has limitations in terms of objectivity. Other technologies, including Doppler ultrasonography, B-Flow, and CEUS, allow for the characterization of vascular patterns, which could be further measured using specific applications like spectral Doppler or quantitative CEUS. Additionally, ultrasound elastography enables the assessment of parenchyma stiffness both qualitatively and quantitatively. These ultrasound-based technologies play a crucial role in andrology by providing valuable information for evaluating testicular function and integrity, aiding in the identification of pathological conditions that may impact the health and quality of life of male dogs.

Testicular ultrasound examination and hemodynamics of patients with azoospermia

The most difficult form of male infertility to treat is azoospermia. Azoospermia is defined as the complete absence of spermatozoa in the ejaculate. The age of the patients who underwent clinical and diagnostic studies varied between 22 and 45 years. Among 119 examined patients with azoospermia, 58.0% were diagnosed with secretory infertility. In 42.0% patients, the presence of spermatogenesis in excretory-obturational infertility was established. Among 69 patients with secretory infertility, 23 had azoospermia in the absence of spermatozoa and spermatogenic cells, which accounted for 33.3% of all patients with secretory infertility (in particular, 2 with leukocytospermia, which indicated damage to the tubular apparatus as a result of previous orchitis). In 66.6% patients, azoospermia was observed in the absence of spermatozoa, but in the presence of precursor cells of spermatogenesis. 11.5% patients out of 69 (group 1) were diagnosed with concomitant diseases. We see that arterial hypertension, diseases of the gastrointestinal tract, liver, and kidneys occur. Hereditary diseases were not detected in the examined patients. Pain of varying intensity was found in 6.7% of patients, varying degrees of testicular hypoplasia were found in 7.6%, dysuria in 13.4%, epididymitis in history 8.4%; history of epidemic mumps 6.7%; 12.6% had depression, restlessness, sleep disorders, and 21.0% had erectile dysfunction. According to clinical examination and ultrasound, chronic prostatitis is suspected in 19.2% of patients. An increase in the number of leukocytes in the blood was found in 13.2% patients. According to ultrasound, 60.5% of the patients with azoospermia had normal testicular sizes, and 39.5% had reduced testes. The volume of the testicles in the control group was 22.3 ± 2.1 cm³ on average, varying from 18.3 to 25.1 cm³. In the group with azoospermia, the volume of the testicles was on average 16.7 ± 1.7 cm³ and varied from 8.2 to 21.1 cm³, that is, the volume of the testicles in patients with azoospermia was on average 1.3 times smaller compared to normozoospermia. In the obstructive form of azoospermia, diffuse changes were detected in both testicles, probably obturational changes. Hypoplasia of the left testicle and increased echogenicity were observed in the non-obstructive form of azoospermia. The veins of the spermatic cord were moderately dilated. There was a normal amount of free fluid in the scrotum. According to elastography, the elasticity of the testicles was above normal. Obturational processes in the testicles were suspected. The hemodynamic parameters of testicular parenchymal blood flow in infertile men obtained by ultrasound dopplerography are of important diagnostic value. The average value of the linear blood flow velocity in the arteries of the parenchyma in men with normozoospermia was 0.107 ± 0.015 m/s on the right, and 0.103 ± 0.012 m/s on the left. With azoospermia, the average value of the linear velocity of blood flow on the right was 0.086 ± 0.012 m/s, and on the left – 0.084 ± 0.008 m/s. Thus, the hemodynamic indicators of the scrotum show that the most pronounced changes are found in men with azoospermia in the absence of spermatogenesis.

CF and male health: Sexual and reproductive health, hypogonadism, and fertility

Over 30,000 people in the United States are diagnosed with cystic fibrosis (CF), and over 50% of those with CF are male. Men with CF face specific and sometimes difficult sexual and reproductive health (SRH) issues, including infertility and hypogonadism. Male infertility affects over 95% of men with CF, with obstructive azoospermia resulting from congenital bilateral absence of the vas deferens being the primary cause of infertility. SRH education for males with CF represents an important opportunity for clinical improvement, as the majority of men with CF know that their disease impacts their fertility, however the depth of this understanding varies significantly. Hypogonadism is a clinical syndrome that affects men with low testosterone level, a common finding among men with CF that has clinical implications and can significantly affect quality of life. Better understanding of SRH attitudes, the prevalence of hypogonadism, and management of infertility in men with CF should remain future research priorities.

Protein markers of spermatogenesis and their potential use in the management of azoospermia

INTRODUCTION

Azoospermia, absence of sperm in the ejaculate is classified as obstructive (OA) and non-obstructive azoospermia (NOA). In OA, sperm are produced, but due to physical obstruction in the male reproductive tract, they are not released in the ejaculate. NOA, on the other hand, is defined as the absence of sperm in the ejaculate due to testicular dysfunction. In NOA, spermatogenesis is frequently preserved in specific sites, and proteomics studies have been employed in order to identify men with preserved spermatogenesis.

AREAS COVERED

Differential protein expression in patients with male infertility is an indicator of impaired spermatogenesis. Here, we reviewed proteins with a potential role as biomarkers of spermatogenesis that could help in the management of non-obstructive and obstructive azoospermia. The following keywords were used for bibliographic research: seminal plasma, proteomics, male infertility, nonobstructive, obstructive, azoospermia, oligospermia.

EXPERT OPINION

Biopsy is an invasive and potentially harmful technique for detecting spermatogenesis in men with OA and NOA. Seminal plasma proteins are highly promising as biomarkers for spermatogenesis. Current literature presents a number of potential candidate biomarkers for determining preserved spermatogenesis.

MRI in the evaluation of the azoospermic male

PURPOSE We aimed to show the usefulness of magnetic resonance imaging (MRI) in the evaluation of infertile men and its ability to distinguish obstructive from nonobstructive azoospermia. METHODS Between April 2015 and February 2018, 45 azoospermic men underwent scrotal MRI. We evaluated the images with an emphasis on signal characteristics of the testis and morphologic changes typical for obstruction. Testicular volume (TV), apparent diffusion coefficient (ADC) value, T1 and T2 signal ratios (testis/muscle) were measured for every testis. On the basis of histologic results, patients were divided into two groups: obstructive azoospermia (OA) and nonobstructive azoospermia (NOA). RESULTS Testes of patients in the OA group had significantly lower ADC values (mean 0.876±101 ×10-3 mm2/s) than in the NOA group (mean, 1.114±147 ×10-3 mm2/s). TV was significantly higher in patients with OA (median, 17.61 mL; range, 11.1-38.4 mL) than in those with NOA (median, 10.5 mL; range, 5.2-22.2 mL). ROC analysis showed that both TV and ADC values were highly predictive for distinguishing between OA and NOA patients, with an area under the ROC curve of 0.82 and 0.92 respectively. A cutoff value of ≥12.4 mL could distinguish obstructive from nonobstructive azoospermia with a sensitivity of 92% and specificity of 63%, whereas for ADC measurements a cutoff value of ≥0.952 ×10-3 mm2/s exhibited a sensitivity of 81% and specificity of 90% There was no statistically significant difference in T1 and T2 signal ratios between both groups. Abnormalities typical for obstruction of the male reproductive tract (e.g., dilatation of ejaculatory ducts, prostatic or seminal vesicle cysts) were found in 78% of patients (14/18) in the obstructive group. CONCLUSION Scrotal MRI is a very effective tool for the evaluation of azoospermic men and may provide important information facilitating interventional treatment of infertility.

Should Scrotal Color Doppler Ultrasound Be Routinely Indicated in Fertility Evaluation of Non-Azoospermic Men?

Objective

Scrotal ultrasound is not a routine investigation in the clinical approach to male infertility analysis. This study aims to identify the role of testicular Doppler ultrasound in male infertility assessment and its relation to semen parameters in non-azoospermic men.

Methods

Cross-sectional descriptive analysis of 558 men from infertile couples were examined at the Hue Center for Reproductive Endocrinology and Infertility, Hue University Hospital from June 2016 to May 2018. Some cohort characteristics, semen analysis and testicular Doppler ultrasound were analyzed. Men with acute systemic diseases, acute urinary tract infection, hepatic dysfunction, malignant diseases, retrograde ejaculation, cryptorchidism or azoospermia were excluded.

Results

The mean volumes of the right and left testicles were 8.87 and 8.77 ml, respectively. The total volume of the 2 sides was 17.63 ± 4.34 ml (95% confidence interval 17.27-18.00 ml). The mean right resistive index (RI) was 0.61 ± 0.23, and the mean left RI was 0.59 ± 0.01. The rate of normal semen quality was 23.2% in group with varicocele and 30.6% in group with non-varicocele. The ultrasound results from the normal semen group were much different from those of the abnormal semen group regarding testicular volume: mean right testis volume: 9.67 ± 1.88 vs. 8.75 ± 2.34 ml, p = 0.0096; mean left testis volume: 9.54 ± 1.78 vs. 8.51 ± 2.44 ml, p = 0.0047; mean total volume of 2 sides: 19.21 ± 3.60 vs. 17.26 ± 4.59 ml, p = 0.005 (varicocele group); mean right testis volume: 9.21 ± 2.21 vs. 8.63 ± 2.21 ml, p = 0.029 (non-varicocele group). The other indexes of color Doppler ultrasound (peak systolic velocity, end diastolic velocity, RI) were not found to correlate with semen quality.

Conclusions

Testicular volume which has a close relation to the semen parameters could be used as a clinical prediction factor for the quality of semen.

Male reproductive health in cystic fibrosis

The impact of cystic fibrosis (CF) on male reproductive health is profound. The vast majority of men with CF are infertile due to obstructive azoospermia. Multiple factors associated with CF contribute to an increased prevalence of testosterone deficiency, which adversely affects muscle mass, bone density, and quality of life. This article reviews the pathophysiology, diagnosis, and management of infertility and testosterone deficiency that occur in men with CF. With improving survival of CF patients, these topics are becoming more significant in their clinical care.

Clinical Consultation Guide on Imaging in Male Infertility and Sexual dysfunction

Imaging can benefit clinicians in evaluating men with infertility or sexual dysfunction by giving an overview of a patient's overall clinical condition before undertaking an invasive procedure. An understanding of the limitations and advantages of image modalities used in clinical practice will ensure that clinicians can optimize patient care with imaging when necessary. PATIENT SUMMARY: The objective of this article was to review the current literature on imaging modalities used for the diagnosis and management of male infertility and sexual dysfunction. An understanding of the advantages and limitations of these imaging modalities will ensure that clinicians can optimize patient care with imaging when necessary.

Scrotal ultrasonographic findings in obese infertile patients and their correlations to semen and hormonal profile

OBJECTIVE

The aim of this prospective study was to compare scrotal ultrasonographic findings in obese and normal weight infertile men and correlate these findings with semen parameters and hormonal profile.

MATERIAL AND METHODS

A total of 188 men presented for infertility evaluation were included in this study. They were divided according to body mass indices into obese (n=96) and normal weight infertile patients (n=92). Basic infertility evaluation, semen analysis and scrotal duplex ultrasound examination in addition to measurement of serum levels of follicular stimulating hormone, testosterone and estradiol were done for all cases. The ratio between testicular size measured by scrotal ultrasound and body mass index were calculated.

RESULTS

Any significant differences were not observed in semen parameters, serum levels of follicular stimulating hormone and testosterone between obese and normal weight infertile men (p>0.05). Serum estradiol level was significantly higher in obese than normal weight infertile men (p<0.001). There is significant increase in subclinical varicocele, hydrocele and testicular microlithiasis detected by scrotal ultrasound in obese infertile men than nonobese patients (p<0.05). Despite having comparable testicular size detected on scrotal ultrasound, infertile obese men had significantly lower total testicular volume to body mass index ratio and this ratio correlated positively with semen volume, sperm concentration, total sperm count and serum testosterone but negatively with serum follicular stimulating hormone and estradiol levels.

CONCLUSION

We therefore conclude that the incidence of subclinical varicocele, hydrocele and testicular microlithiasis was higher in obese infertile patients and the ratio between testicular volume assessed by scrotal ultrasound and body mass index may be a new parameter that correlates with subfertility status in these men.

Differential Diagnostic Value of Obstructive and Nonobstructive Azoospermia by Scrotal Ultrasound

Our objective was to assess the differential diagnostic value of classification of obstructive versus nonobstructive azoospermia by scrotal ultrasound. Forty patients with azoospermia were selected for our study (ages, 23-35; average, 29 ± 5.34 years). Patients were divided into the obstructive (17) or nonobstructive (23) azoospermia category. Twenty "healthy" volunteers were selected for the control group. We observed the testis, epididymis, and vas deferens in all subjects. Testicular volumes were calculated and compared with the control group for both obstructive and nonobstructive groups. Cystic or tubular dilation of the epididymis was found in all patients with obstructive azoospermia. The patients with nonobstructive azoospermia had no significant abnormalities of the epididymis. There was no difference in the testicular volumes between the patients with obstructive azoospermia and healthy controls (P > 0.05). However, the testicular volumes of patients with nonobstructive azoospermia were smaller than those of healthy volunteers (P < 0.05). It is helpful to identify obstructive and nonobstructive azoospermia by scrotal ultrasound, because it is a less invasive method that can be used to isolate probable treatment options.

The association between seminal vesicle size and duration of abstinence from ejaculation

There are few data describing the relationship between seminal vesicle (SV) size and duration of abstinence between ejaculations. This study evaluates the association between SV size and duration of abstinence from ejaculation using pelvic magnetic resonance imaging (MRI). Sexually active men 18-68 years old who underwent pelvic MRI for various medical indications were included. The date of last ejaculation was recorded, and the cross-sectional areas of the right and left seminal vesicles were calculated separately using mediolateral and anteroposterior measurements on T2-weighted MRI images. The association between SV area and duration of abstinence between ejaculations was determined via linear regression analysis. The study cohort consisted of 104 men with a mean age of 46.45 ± 11.4 (range 18-68) years old. Mean right and left SV cross-sectional areas were 744.1 ± 351.1 (range: 149.9-1794.7) mm² and 727.6 ± 359.2 (range 171.4-2248.4) mm² respectively. The mean duration of abstinence between ejaculations in the cohort was 3.6 ± 2.6 (range 1-15) days. Although no correlation between age and SV area was observed (r = .007, p = .947), linear regression analysis demonstrated a positive correlation between SV area and the duration of abstinence from ejaculation (r = .372, p = .0001). SV cross-sectional area increases with duration of abstinence from ejaculation and can be assessed using MRI. The use of SV size estimation may be applicable in diagnosis, risk stratification and treatment of urological diseases.

Ultrasonography in Diagnosis of Congenital Absence of the Vas Deferens

BACKGROUND Congenital absence of the vas deferens is an important cause of obstructive azoospermia, and the lack of an imaging diagnostic test is a critical problem. The aim of this study is to discuss the use of ultrasonography in congenital absence of vas deferens, including dysplasia of the epididymis and the seminal vesical. MATERIAL AND METHODS Five fresh spermatic cord specimens were detected by ultrasonography (US) to evaluate the image of the spermatic cord segment of the vas deferens. Fifty normal males had scrotal US to confirm whether the normal spermatic cord segment of the vas deferens can be detected and to measure the internal and external diameter on the long axis view. Forty-six males clinically diagnosed as having congenital absence of vas deferens underwent scrotal US to evaluate the spermatic cord segment of the vas deferens and the epididymis. The seminal vesicals were detected with transrectal ultrasonography. We evaluated images of the vas deferens, epididymis, and seminal vesical. RESULTS Scrotal ultrasonography can distinguish the vas deferens from the other cord-like structures in the spermatic cord, and the vas deferens has a characteristic image. Scrotal ultrasonography detected all 50 normal males and measured the diameter. No statistically significant difference was found between the left and right measurements. In the 46 patients, the following anomalies were observed: 1) 42 cases of congenital bilateral absence of vas deferens; 2) 2 cases of congenital unilateral absence of the vas deferens; and 3) 1 case of congenital segmental absence of the vas deferens. All 46 cases were accompanied with epididymis and seminal vesical anomalies. CONCLUSIONS The spermatic cord segment of the vas deferens can be detected by US, which is a valuable tool in diagnosis of congenital absence of the vas deferens. Seminal vesical and epididymis anomalies often associated with congenital absence of the vas deferens were revealed by ultrasonography.

Review of Azoospermia

Azoospermia is classified as obstructive azoospermia (OA) or non-obstructive azoospermia (NOA), each having very different etiologies and treatments. The etiology, diagnosis, and management of azoospermia were reviewed and relevant literature summarized. Differentiation between these two etiologies is of paramount importance and is contingent upon thorough history and physical examination and indicated laboratory/genetic testing. OA occurs secondary to obstruction of the male reproductive tract, and is diagnosed through a combination of history/physical examination, laboratory testing, genetics (CFTR for congenital OA), and imaging studies. NOA (which includes primary testicular failure and secondary testicular failure) is differentiated from OA by clinical assessment (testis consistency/volume), laboratory testing (FSH), and genetic testing (karyotype, Y chromosome microdeletion, or specific genetic testing for hypogonadotropic hypogonadism). For obstructive azoospermia, management includes microsurgical reconstruction when feasible using microsurgical vasovasostomy or vasoepididymostomy. Microsurgical epididymal sperm aspiration with in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) is utilized for those cases not amenable to reconstruction. NOA management includes medical management for congenital hypogonadotropic hypogonadism and microdissection testicular sperm extraction with IVF/ICSI for appropriate candidates based on laboratory/genetic testing. Overall, this important review provides an updated summary of the most recent available literature describing etiology, diagnosis, and management of azoospermia.