Testicular Biopsy

Touch print smear of testicular tissue with thionine stain for intraoperative diagnosis in azoospermic men

PURPOSE

To compare the diagnostic value of testicular tissue touch print smear (TPS) conducted on azoospermic patients with results obtained from histopathology and in vitro fertility (IVF) lab findings.

METHODS

Microdissection testicular sperm extraction was performed on a group of 148 azoospermic patients and testicular samples obtained intraoperatively. Using TPS, the samples were smeared onto a sterile slide, followed with staining using thionine. The testis tissue bulk samples were also transferred to the IVF lab, and determinations of sperm presence or absence obtained from IVF lab tests were compared with the TPS sample results. Needle testis biopsy was separately performed on a group of 360 azoospermic patients, and results of pathohistology review on the biopsies were further compared with determinations of spermatogenesis stage obtained from TPS for those patients.

RESULTS

When compared with IVF lab results, TPS was found to have 100% (126/126) positive predictive value and 95.5% (25/26) negative predictive value for predicting sperm presence or absence, respectively. Furthermore, TPS was further found to have a 93.6% correlation (337 of 360 biopsies) with results of histological diagnoses performed by needle biopsy. Results from histology and TPS for the detection of sperm presence were concordant in 96.1% (346/360) of biopsies. Diagnosis of SCO by TPS shows the highest correlation with histopathology (98.6%), followed by complete spermatogenesis (97.5%), early maturation arrest (78.9%), and late maturation arrest (27.3%).

CONCLUSIONS

The results support the continued use of TPS in testicular tissue analysis for more rapid assessment of spermatogenesis and for detection of spermatozoa in azoospermic subjects.

Evaluation of the azoospermic male: a committee opinion

The purpose of this document is to review the current methods of diagnosis and evaluation for men with azoospermia.

An easy, reproducible and cost-effective method for andrologists to improve the laboratory diagnosis of nonobstructive azoospermia: a novel microcentrifugation technique

This study describes a new method of microcentrifugation as an improved, viable, cost-effective option to the classical Cytospin apparatus to confirm azoospermia. Azoospermic semen samples were evaluated for cryptozoospermia by a centrifugation method similar to that of World Health Organization guidelines (2010; entire specimen centrifuged at 3000g for 15 min, and aliquots of the pellet examined). Then, if no sperm were detected, the pellet from that procedure was resuspended in culture medium, centrifuged (2000g for 15 min), and the entire pellet spread on a 4 X 6mm area of a slide and stained using the Christmas tree method (Nuclear-Fast solution and picric acid). The entire stained area was examined for the presence or absence of sperm. A total of 148 azoospermic samples (after standard WHO diagnosis) were included in the study and 21 samples (14.2%) were identified as sperm-positive. In all microcentrifugation slides, intact spermatozoa could be easily visualized against a clear background, with no cellular debris. This novel microcentrifugation technique is clearly a simple and effective method, with lower cost, increasing both sensitivity and specificity in confirming the absence or presence of spermatozoa in the ejaculate. It may represent a step forward of prognostic value to be introduced by andrology laboratories in the routine evaluation of patients with azoospermia in the initial semen analysis.

UK practice regarding reversal of vasectomy 2001-2010: relevance to best contemporary patient management

Study Type - Practice trends (survey) Level of Evidence 2c What's known on the subject? and What does the study add? Approximately 6% of men who have had a vasectomy subsequently decide to have it reversed. For such men there are various options available, including vasal reconstruction, surgical sperm retrieval with assisted reproductive techniques, use of donated sperm or adoption. The decision-making process with regard to the most appropriate management is challenging and the urologist requires both an intimate knowledge of the advantages and disadvantages of each of the available options and the opportunity to counsel a couple appropriately. The study confirms that patient management after previous vasectomy is a complex process, demanding detailed knowledge about the availability and outcomes of alternatives to vasectomy reversal. It recommends that couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome and the available management options and their costs. Urologists should also have appropriate facilities to offer intra-operative demonstration of and, potentially, storage of sperm.

OBJECTIVES

To review the management of men presenting for reversal of vasectomy amongst consultant members of the British Association of Urological Surgeons (BAUS) between 2001 and 2010. • To make recommendations for contemporary practice.

SUBJECTS AND METHODS

Three consecutive questionnaire-based surveys were undertaken by BAUS consultant members in 2001, 2005 and 2010. • Standard questionnaires were sent on each occasion asking urologists about their counselling of couples regarding options in achieving a conception, expectation of outcome from reconstructive surgery and the techniques of vaso-vasostomy used. • In 2005 additional information was obtained about the availability of fertility treatments and sub-specialization of the urologist and in 2010 about the eligibility criteria for in-vitro fertilization (IVF) treatment and synchronous sperm retrieval.

RESULTS

Overall there was a 47% response rate with >80% of respondents still performing vaso-vasostomy. • More than 75% of respondents were doing <15 procedures a year and <50% of respondents counselled couples about other management options. • Only 41% gave their personalized outcomes from vaso-vasostomy, whilst >80% were using some form of magnification intra-operatively. • Members of the BAUS section of andrology were more likely to discuss options for becoming a parent and criteria for IVF treatment, to present their individualized outcomes from vaso-vasotomy and to carry out >15 procedures a year than urologists with no andrological affiliation.

CONCLUSIONS

• Patient management after previous vasectomy is a complex process necessitating detailed knowledge concerning the availability and outcomes of alternatives to vaso-vasostomy. • Couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome. • Vaso-vasostomy should no longer be seen as a procedure within the remit of any adequately trained urologist but as one option to be considered by a sub-specialist with access to appropriate micro-surgical training and assisted reproductive technologies.

Early versus late maturation arrest: reproductive outcomes of testicular failure

PURPOSE

There is a paucity of data characterizing infertile men with maturation arrest. We hypothesized that men with early stage maturation arrest could be clinically distinguished from men with late maturation arrest and would have worse reproductive outcomes.

MATERIALS AND METHODS

We retrospectively reviewed the records of all patients with nonobstructive azoospermia and cryptozoospermia who underwent testis mapping and sperm extraction from 2002 to 2009 and for whom histopathological findings were available. Patients had uniform maturation arrest if multiple biopsies revealed maturation arrest at the spermatogonia/spermatocyte (early maturation arrest) or the spermatid (late maturation arrest) stage. Clinical parameters and pregnancy outcomes of in vitro fertilization/intracytoplasmic sperm injection were examined. Statistical analysis consisted of univariate and multivariate analysis.

RESULTS

Uniform maturation arrest was identified in 49 of 219 men (22.3%) undergoing testicular sperm extraction. On multivariate analysis men with maturation arrest had significantly larger testes (p=0.01), decreased follicle-stimulating hormone (p=0.05) and more detectable genetic abnormalities (p=0.01) than men with other histopathological conditions. Men with late maturation arrest had decreased follicle-stimulating hormone (p=0.02), increased testosterone (p=0.03) and a higher sperm retrieval rate at testicular sperm extraction (p=0.01) than men with early maturation arrest. Predictors of successful sperm retrieval were larger testes, cryptozoospermia, late maturation arrest and hypospermatogenesis (each p≤0.05). Pregnancy outcomes for men with maturation arrest were not significantly different from those for men with other histopathological conditions.

CONCLUSIONS

Maturation arrest is a common, diverse histopathological subtype of severe male infertility. Compared to men with late maturation arrest those with early maturation arrest have increased follicle-stimulating hormone, decreased testosterone and a decreased probability of mature spermatozoa. In vitro fertilization/intracytoplasmic sperm injection outcomes were similar when spermatozoa were discovered during testicular sperm extraction.

Evaluation of the azoospermic male

The purpose of this Technical Bulletin is to review the current methods of diagnosis and strategies for treatment of men with azoospermia.

The effect of experimental cryptorchidism on the phosphorus NMR spectrum of the rat testis

Magnetic resonance (MR) spectroscopy of the cryptorchid rat testis was used to test whether changes in the MR spectra of the rat testis might be a more sensitive indicator of changes in the metabolic status of germ cells in the testis rather than simply the cell types present. Testes of adult Wistar rats before and during 42 days of experimental cryptorchidism were investigated by in-vivo 31P MR spectroscopy. Results were compared to MR studies of the synchronized developing testis. The testicular phosphomonoester/ATP (PM/ATP) ratio was dependent only on the cell types present, and showed the same characteristics for each cell type present in the degenerating testis as in the developing testis. The testicular phosphodiester/ATP (PD/ATP) ratio decreased rapidly when the number of round and elongated spermatids was reduced. Similar effects, although less pronounced, were seen in the developing testis. The pH decreased rapidly after cryptorchidism, and was related inversely to the PM/ATP ratio, which was also observed in the developing testis. This study demonstrates that MR spectroscopy monitors the cell types present in the rat testis rather than its metabolic status.

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.

Evaluation and treatment of ejaculatory duct obstruction in the infertile male

OBJECTIVE

To evaluate the role of ejaculatory duct obstruction as a cause for male factor infertility and review the treatment of this condition.

DESIGN

A retrospective study was carried out involving male patients diagnosed as having ejaculatory duct obstruction as a contributing cause for their subfertility.

SETTING

Patients were evaluated and treated through a university-based male infertility clinic.

PATIENTS, PARTICIPANTS

Patients were evaluated for the presence of ejaculatory duct obstruction if they suffered from decreased ejaculate volume, sperm density, and sperm motility but had normal physical examinations and otherwise normal laboratory evaluations.

INTERVENTIONS

Patients were treated by transurethral resection of the ejaculatory ducts.

MAIN OUTCOME MEASURES

Results of semen analysis and pregnancy rates.

RESULTS

An alteration in semen quality was achieved in 79% of patients after transurethral resection. An increase in sperm density or motility was achieved in 50%, whereas 29% showed an increase in ejaculate volume only. Pregnancy rate postoperatively was 29%.

CONCLUSIONS

Ejaculatory duct obstruction as a cause of male infertility is more common than was previously recognized, especially among nonazoospermic patients. In properly selected patients, transurethral resection of the ejaculatory ducts can result in marked improvement in semen quality with subsequent pregnancy.

Acute experimental unilateral orchitis in the rabbit and its effect on fertility

We examined the nature of contralateral damage following unilateral orchitis to see if an immunologically mediated mechanism was present. Experimentally induced orchitis in 18 white New Zealand rabbits were examined and compared to 20 in the control groups. Serum antisperm antibody presence and bilateral testicular biopsies (Johansen biopsy score, mean seminiferous tubule diameter) were examined and pregnancy rates were noted. Acute orchitis seemed to be a causative factor in production of antisperm antibody and the presence of antisperm antibody caused histologic changes in contralateral testicles and therefore impaired fertility.

The progression of spermatogenesis in the developing rat testis followed by 31P MR spectroscopy

To evaluate the use of human testicular 31P MR spectroscopy as a diagnostic tool to differentiate between several stages of male infertility, we have studied the testicular levels of several phosphorus containing compounds in the rat in relation to the condition of spermatogenesis and the cell types present in the seminiferous tubules of the testis. During testicular maturation several characteristic changes occur in the 31P MR spectrum of the testis of male Wistar rats. The phosphomonoester/adenosine triphosphate (PM/ATP) ratio shows a decline from 1.61 to 1.02 between the age of 3 and 12 weeks, whereas the phosphodiester (PD)/ATP ratio increases from 0 to 0.72. The testicular pH increases in the same time from 7.06 to 7.32. Testicular MR data obtained after 12 weeks of age onward do not show significant change anymore. The high PM/ATP ratio is associated by a relative high amount of proliferating spermatogonia and spermatocytes during meiosis in the testis, whereas the PD peak seems to be correlated with the release and maintenance of spermatozoa. The MR spectra show a specific fingerprint in all developmental stages of the rat testis as a result of the different cell types in the testis.

31P magnetic resonance spectroscopy for diagnosing abnormal testicular function

OBJECTIVE

To determine if testicular 31P magnetic resonance (MR) spectroscopy can be of additional clinical value.

DESIGN

A controlled study in three selected subjects groups.

SETTING

All participants were referred to the outpatient clinic of our Department of Obstetrics and Gynecology.

PARTICIPANTS

Normal healthy volunteers (n = 13), oligozoospermic (n = 14), and azoospermic patients (n = 17; 6 with epididymal obstruction and 11 with severe germ cell depletion) were selected on the basis of semen analysis, hormone determinations, and, if necessary, on operative exploration.

INTERVENTIONS

Magnetic resonance spectroscopy was performed on a Philips Gyroscan S15 (Philips Medical Systems, Best, the Netherlands).

MAIN OUTCOME MEASURE(S)

The routine clinical analyses were compared with the outcome of testicular MR spectroscopy to test the hypothesis that MR spectroscopy can be of additional value in the diagnosis of idiopathic oligozoospermic or azoospermic patients.

RESULTS

The MR spectra of normal volunteers were significantly different from oligozoospermic patients (P less than 0.001), from azoospermic patients with germ cell depletion (P less than 0.001), and from azoospermic patients with an obstruction (P less than 0.05). Between the two azoospermic groups also a significant difference was found (P less than 0.001).

CONCLUSIONS

These results show that MR spectroscopy is a reliable technique to monitor the testicular function.

Role of testicular fine-needle aspiration biopsy in the evaluation of male infertility: cytologic and histologic correlation

A series of testicular fine-needle aspiration biopsy specimens from 272 infertile men with azoospermia were reviewed and categorized according to morphologic patterns. These included active spermatogenesis, 14 (5%); hypospermatogenesis, 106 (39%); Sertoli cells only, 70 (26%); atrophic pattern, 52 (19%); and maturation arrest, 1 (0.36%). In 29 cases (11%) the amount of material was insufficient for evaluation. The histologic and cytologic findings in 52 cases showing spermatogenesis correlated very well in 52 cases for which open testicular biopsy specimens were also available. These findings indicate that fine-needle aspiration biopsy of the testis is a reliable and useful technique for the investigation of patients with azospermia.

Fine-needle aspiration cytology in azoospermic males

Bilateral testicular fine-needle aspiration cytology (FNAC) was performed in 100 males, including 10 controls with normal fertility and 90 infertile azoospermic males. The various seminiferous tubular cells were easily identified in smears. It was possible to give a cytological diagnosis in histologic terms by analysis of the combinations of various cell types. The cytohistologic correlation in 25 cases was nearly 100%. FNAC is particularly useful in cases of obstructive azoospermia, where mature spermatozoa are seen in smears.

Evaluation of the azoospermic patient

Azoospermia is found in up to 10 to 20 per cent of the men who present to an infertility clinic. The main causes are testicular failure and ductal obstruction. Testicular biopsy remains the definitive test used to differentiate these 2 disorders. A retrospective study of 133 azoospermic men was performed to determine the accuracy and limitations of noninvasive variables in predicting testicular failure in an effort to limit the need for diagnostic testicular biopsy. Of 49 patients (37 per cent) with ductal obstruction a third had bilateral vasal agenesis. The remaining 84 azoospermic patients (63 per cent) had testicular failure. The results of the complete evaluation of these patients are described. Among the 101 patients with a testicular biopsy confirmed diagnosis there was a significant difference in testicular size (p less than 0.001), ejaculate volume (p less than 0.001) and serum follicle-stimulating hormone (p less than 0.001) between patients with testicular failure and those with ductal obstruction. The sensitivity and specificity of various parameters were determined. The best criteria to predict ductal obstruction preoperatively are a serum follicle-stimulating hormone level of less than 2 times greater than normal and the absence of bilateral testicular atrophy (100 per cent sensitivity and 71 per cent specificity). An algorithm for evaluation of the azoospermic patient is described such that all men with ductal obstruction and a minimal number with testicular failure undergo testicular biopsy.