Reappraisal of the value of testicular biopsy in the investigation of infertility

Histopathological patterns of testicular biopsy in male infertility: A retrospective study from a tertiary care center in the western part of Saudi Arabia

OBJECTIVE

To identify and categorize various pathological changes seen in testicular biopsies of males with infertility and to compare the results with data from other local and international studies.

MATERIALS AND METHODS

All testicular biopsies from males with infertility received by the Pathology Department of King AbdulAziz University Hospital, Jeddah, in the period from January 2004 until May 2010 are reviewed and histopathologically classified into seven categories as follows : Normal spermatogenesis, hypospermatogenesis, germ cell maturation arrest (GCMA), Sertoli cell only syndrome, seminiferous tubule hyalinization, mixed and discordant patterns.

RESULTS

One hundred testicular biopsies were identified in the computerized records of the Department of Pathology of King AbdulAziz University Hospital in the studied period. The age ranged from 22 to 70 years with a mean age of 24.5 years. The histopathological patterns were as follows: 14 (14%) cases were reported as normal spermatogenesis;(29, 29%) cases as hypospermatogesis; and 12 (12%) cases were reported as GCMA, mostly at the level of primary spermatocytes. The Sertoli cell only syndrome and the seminiferous tubule hyalinization categories were each reported in 16 cases (16%). Nine cases (9%) showed a mixed pattern. Discordant pattern was seen in 5 (5%) cases.

CONCLUSION

Our study showed that hypospermatogenesis is the commonest pattern in testicular biopsies taken from males with infertility in our region. This study supports the recommendation of bilateral testicular biopsies when investigating male infertility.

Overexpression of epidermal growth factor induced hypospermatogenesis in transgenic mice

The in vivo role of epidermal growth factor (EGF) is not well defined even though its effects on culture cells were well studied. To understand the developmental, physiological, and pathological roles of EGF, we have generated transgenic mice widely expressing human EGF with the use of the beta-actin promoter. EGF and transforming growth factor alpha (TGFalpha) bind with equal affinity to the EGF receptor, a transmembrane tyrosine kinase, to trigger various biological responses. EGF and TGFalpha signaling are implicated in the development of the reproductive system. EGF also plays a physiological role in reproduction. Removal of the salivary gland in rodents, which reduces circulating EGF, reduces spermatogenesis, which can be corrected by EGF replacement. Here we show that in our transgenic males, only few post-meiosis II gametes were found, and the mice were sterile. This resembles a common cause of infertility in humans. Furthermore, the transgenic males had reduced serum testosterone. Our findings contrast the previous report on transgenic mice overexpressing TGFalpha in testis, which showed normal spermatogenesis. These data suggest that EGF is the active ligand for EGF receptor reported in germ cells, and proper EGF expression is important for completion of spermatogenesis.

Presence of mature sperm in testicular parenchyma of men with nonobstructive azoospermia: prevalence and predictive factors

OBJECTIVES

Hitherto, patients with testicular dysfunction and azoospermia had to resort to adoption, donor sperm insemination, or child-free living. The realization that a proportion of such men harbor spermatozoa in their testicular parenchyma, combined with the ability of intracytoplasmic sperm injection (ICSI) to effect pregnancy with single sperm, has prompted male infertility clinicians to explore testicular sperm extraction (TESE) in this patient population. We sought to investigate the likelihood of finding spermatozoa during TESE from men presenting with nonobstructive azoospermia and to define if any factors existed that were predictive of eventual sperm presence or absence.

METHODS

Thirty patients with nonobstructive azoospermia underwent TESE and simultaneous formal testis biopsy, cytologic analysis, and wet preparation analysis. Tissue obtained from TESE was analyzed according to a rigorous protocol, followed by exhaustive searching by trained embryologists.

RESULTS

Twenty-one patients (70%) had spermatozoa found on testicular tissue analysis. Neither patient age nor follicle-stimulating hormone (FSH) level was predictive of the ability to find sperm. With regard to histologic pattern, 50% of men with Sertoli cell-only, 75% of patients with maturation arrest, and 100% of patients with spermatids seen on histologic analysis had sperm retrieved from their testicular tissue during TESE. Absence of sperm on cytologic smear and wet preparation analysis failed to predict the presence of sperm on formal testicular tissue analysis in 40% of patients.

CONCLUSIONS

Men with nonobstructive azoospermia may have mature spermatozoa present within their testicular parenchyma. Relying on these data, patients should not be excluded from TESE based on serum FSH level, age, prior histopathologic pattern, or cytology/wet preparation results. These figures will allow clinicians to counsel patients with nonobstructive azoospermia informatively regarding TESE and their chances of having testicular sperm retrieved.

Coordinate developmental control of the meiotic cell cycle and spermatid differentiation in Drosophila males

Wild-type function of four Drosophila genes, spermatocyte arrest, cannonball, always early and meiosis I arrest, is required both for cell-cycle progression through the G2/M transition of meiosis I in males and for onset of spermatid differentiation. In males mutant for any one of these meiotic arrest genes, mature primary spermatocytes with partially condensed chromosomes accumulate and postmeiotic cells are lacking. The arrest in cell-cycle progression occurs prior to degradation of cyclin A protein. The block in spermatogenesis in these mutants is not simply a secondary consequence of meiotic cell-cycle arrest, as spermatid differentiation proceeds in males mutant for the cell cycle activating phosphatase twine. Instead, the arrest of both meiosis and spermiogenesis suggests a control point that may serve to coordinate the male meiotic cell cycle with the spermatid differentiation program. The phenotype of the Drosophila meiotic arrest mutants is strikingly similar to the histopathological features of meiosis I maturation arrest infertility in human males, suggesting that the control point may be conserved from flies to man.

Physiopathology of spermatogenic arrest

OBJECTIVE

To review the world literature on the etiology, physiopathology, and treatment of spermatogenesis arrest.

STUDY SELECTION

All the pertinent literature on spermatogenic arrest has been selected. Most studies related to this topic have been identified through Medline and through published literature.

PATIENTS

Spermatogenic arrest has been diagnosed by testicular biopsy in men of reproductive age who had either severe oligospermia (partial arrest) or azoospermia (complete arrest), normal testicular volume, and depending on the etiology normal, high, or low levels of gonadotropins.

INTERVENTIONS

The effects of heat, radiotherapy, and chemotherapy have been reported. Depending on the etiology of spermatogenic arrest, different hormonal treatments have been tested.

MAIN OUTCOME MEASURE

Level of interruption of germ cell differentiation in testicular biopsy have been determined. Improvement of the sperm count or appearance of mature sperm after an hormonal treatment have been observed.

RESULTS

Spermatogenic arrest can occur at spermatogonial level in case of gonadotropin insufficiency or after germ cell damage due to chemotherapy or radiotherapy. The arrest is most frequently observed at primary spermatocyte level. Reversible arrest at that level can be due to heat, infections, hormonal and nutritional factors. Irreversible arrest at primary spermatocyte or spermatid level have a genetic origin due to chromosomes anomalies either in somatic cells or in germ cells.

CONCLUSIONS

Spermatogenic arrest is usually due to genetic factors resulting in irreversible azoospermia. However some cases may be consecutive to hormonal, thermic, or toxic factors and may be reversible either spontaneously or after a specific treatment.

Testicular cytology in azoospermia

Two hundred-seventy-five azoospermic males were subjected to fine-needle aspiration (FNA) cytologic study of testis with the aim of determining the cause of azoospermia; 534 aspirates from these patients were classified as follows: normal spermatogenesis (162), hypospermatogenesis (mild, moderate, or severe, 226), absence of spermatogenesis (130), maturation arrest (36), Sertoli-cell-only syndrome (14), and Leydig-cell hyperplasia (3). The morphology of cells was excellent in the cytologic preparations and various spermatogenic cells and Sertoli cells were easily recognized. Leydig cells were uncommonly seen, except in cases of Leydig-cell hyperplasia. Degenerative changes, possibly due to obstruction, were seen in 104 cases. The procedure was well tolerated by the patients. We conclude that FNA cytology is a useful investigative modality in the evaluation of azoospermic males.

Cellular relationship impairment in maturation arrest of human spermatogenesis: an ultrastructural study

Ultrastructural examination of testicular biopsies from cases of maturation arrest showed that there were characteristic abnormalities of the Sertoli cell junctional connections. These abnormalities together with the meiotic failure afford an explanation for the severe oligospermia or azoospermia noted in patients with maturation arrest. Premature setting up of ectoplasmic specializations in front of early spermatids and/or spermatocytes were also observed.

Correlation between spermatozoon numbers in spermiogram and seminiferous epithelium histology in testicular biopsies from subfertile men

A new method for correlating testicular biopsies and spermiograms is proposed. The number of spermatogonia, round spermatids, and elongated spermatids per cross-sectioned tubule were calculated in the testes from 33 subfertile men and in 10 control normal testes. According to these quantitations, the testes in subfertile men were classified as testes with maturation arrest of spermatogenesis, testes with hypospermatogenesis, and testes with associated maturation arrest and hypospermatogenesis. A power regression curve correlating the number of elongated spermatids and sperm numbers in the spermiogram was performed.

The role of testicular biopsy in the investigation of male infertility

Sixty-five testicular biopsies from infertile men were assessed retrospectively. In 21 patients infertility was attributed to varicoceles. In the remaining cases the testicular histology was classified into 3 major groups. Normal, hypospermatogenesis and germ cell aplasia. These histological categories were correlated with serum gonadotrophic hormone levels and sperm counts. All cases of germ cell aplasia showed azoospermia or severe oligospermia, but sperm counts alone were not reliable indicators of spermatogenesis. Patients with very low sperm counts and raised levels of serum FSH invariably had germ cell aplasia. These patients made up a group in whom testicular biopsies were of limited value in assessment. In all other instances the testicular biopsy was still an important tool in the assessment and prognostication for fertility in the subfertile male.