Idications for testicular biopsy or exploration in azoospermia

Appropriate cut-off value for follicle-stimulating hormone in azoospermia to predict spermatogenesis

BACKGROUND

This study was undertaken to determine the optimal cut-off value for FSH to predict the presence of spermatogenesis in patients with non-obstructive azoospermia.

METHODS

A total of 206 non-obstructive azoospermic men were enrolled in this prospective study. By using receiver operating characteristic (ROC) curves, we determined the optimal cut-off value for FSH and evaluated whether the test could adequately predict successful sperm retrieval.

RESULTS

There were 108 non-obstructive azoospermic patients who had evidence of spermatogenesis (group A) and achieved success in sperm retrieval. Another 98 non-obstructive azoospermic patients (group B) failed in sperm retrieval. The mean value of serum FSH in group B was significantly higher than in group A (28.03 +/- 14.56 mIU/mL vs 7.94 +/- 4.95 mIU/mL, p < 0.01; respectively). The area under the receiver operating characteristic curves were 0.939 +/- 0.02 and a cut-off value of 19.4 mIU/mL discriminated between group A and B with a sensitivity of 70%. The positive predictive value for failed sperm retrieval (group B) can reach 100%.

CONCLUSIONS

Elevated plasma levels of FSH of more than 19.4 mIU/mL could be used as a reliable criterion for a trial of sperm retrieval from testes in artificial reproductive techniques.

Fine-needle aspiration cytology of the testis: can it be a single diagnostic modality in azoospermia?

PURPOSE

The aim of this study was to determine whether fine-needle aspiration cytology (FNAC) of testis alone is sufficient to diagnose testicular function and whether follicle-stimulating hormone (FSH) estimation can be safely eliminated from the evaluation protocol of the azoospermic subject.

MATERIALS AND METHODS

We studied 46 adult azoospermic males who were infertile for more than 2 years following marriage. Hormonal profile was done in all. Later all 46 patients were subjected to bilateral FNAC of the testes. The cytological findings were correlated with histological findings.

RESULTS

We found 95.65% agreement between FNAC and testicular biopsy. Though serum FSH estimation was done in all patients in this series, in none of the cases did it affect overall management.

CONCLUSION

FNAC is a quick, safe and minimally invasive modality. Following a well-performed semen analysis in an azoospermic subject, it appears that FNAC may be the only investigation needed. It provides a reliable diagnosis in patients with either obstructive or non-obstructive azoospermia. Routine estimation of FSH can be omitted from the investigative protocol in these patients.

Torsion-induced injury in rat testes does not affect mitochondrial respiration or the accumulation of mitochondrial mutations

Male rats were subjected to 1 h testicular torsion of the spermatic cord or 1 h torsion followed by detorsion and recovery up to 4 weeks. The extent of tissue damage was evaluated by a testicular biopsy score count and mitochondrial function. Torsion for 1 h followed by detorsion induced significant morphological damage, which became more severe with longer periods of recovery. This morphological damage could not be correlated with mitochondrial damage as assessed by measuring the 4834 bp mitochondrial DNA 'common deletion' using a quantitative competitive polymerase chain reaction (PCR) assay. Mitochondrial respiratory chain activity, as measured by mitochondrial oxygen consumption using an oxygen electrode, did not vary between the treated animals and the controls. We conclude that the common mitochondrial DNA deletion and oxygen consumption are not good indicators of testicular damage induced by torsion.

Significance of serum FSH levels and testicular morphology in infertile males

OBJECTIVES

To determine the relationship between plasma levels of FSH and testicular spermatogenic patterns.

METHODS

Testicular biopsies were obtained from 99 infertile men. Biopsies were performed either in order to distinguish the type of azoospermia (obstructive/non-obstructive) or because of severely subnormal semen variables. Serum FSH was measured by immunoassay (normal range is less than 7 mIU/ml).

RESULTS

Statistically significant difference was detected between patients with Sertoli cell only syndrome and normal spermatogenesis, hypospermatogenesis and maturation arrest (p<0.01, p<0.01, p<0.05, respectively). No statistically significant differences were found between normal spermatogenesis, hypospermatogenesis and maturation arrest.

CONCLUSION

Our study revealed that elevation of serum FSH correlates only with the appearance of Sertoli cell only syndrome. We think that azoospermic or severely oligoasthenoteratozoospermic patients with highly elevated plasma FSH levels (three times the normal) could be excluded from separate testicular biopsy, because these patients are not suitable for conventional treatments. If he is willing to undergo an IVF program the sperm will often be present, no matter what the testicular histology is to be used for assisted reproductive techniques, particularly ICSI.

Clinical aspects associated with Sertoli-cell-only histology

OBJECTIVE

To assess the clinical features found in infertile men in whom the histological diagnosis of Sertoli-cell-only (SCO) was made on testicular biopsy.

PATIENTS AND METHODS

A retrospective review was carried out of the seminal fluid analysis, testis size and follicle-stimulating hormone (FSH) levels of 72 men who had bilateral testicular biopsies due to infertility when one (30) or both (42) of bilateral testicular biopsies showed tubules containing only Sertoli cells. In a subgroup of 15 men, the biopsies were re-examined to correlate the morphological features with the plasma FSH level.

RESULTS

When both biopsies showed bilateral SCO the patient had azoospermia (86%) or oligozoospermia (14%); the testicular size was normal in 36% and the FSH level was normal (43%), raised (21%) or grossly elevated (more than twice normal, 36%). When one biopsy showed SCO, the opposite testis showed appearances which varied from grossly impaired spermatogenesis to almost normal spermatogenesis. The clinical findings were also very variable.

CONCLUSIONS

The clinical features associated with the histological diagnosis of SCO are extremely variable. Biopsy evidence of bilateral SCO cannot be relied upon to indicate a total absence of spermatogenesis in the testes.

The relationship between plasma levels of gonadotropins, androgens, and prolactin in azoospermic men with their testicular spermatogenic pattern

OBJECTIVE

To assess the relationship between plasma levels of gonadotropins, androgens, and PRL with testicular spermatogenic pattern.

DESIGN

Patient series.

SETTING

University affiliated medical center.

PATIENTS

One hundred twenty azoospermic infertile men.

INTERVENTIONS

Testicular fine needle aspirations and determination of plasma levels of FSH, LH, T, free T, and PRL.

MAIN OUTCOME MEASURES

Gonadotropins, androgens, and PRL plasma levels as a diagnostic criterion of testicular spermatogenic patterns.

RESULTS

No statistically significant differences were detected in plasma levels of LH, androgens, and PRL among patients with Sertoli cell only, spermatogenic arrest, or full spermatogenesis. Elevated plasma levels of FSH threefold above the upper normal limit preclude, with a probability of 95%, the existence of full testicular spermatogenesis, but are not valid for the diagnosis of either Sertoli cell only syndrome or spermatogenic arrest.

CONCLUSIONS

Luteinizing hormone, androgens, and PRL plasma levels are of no diagnostic value in predicting any specific spermatogenic pattern, and plasma FSH levels can not be used for diagnosing Sertoli cell only syndrome.

Effects of ischaemia on the caput epididymis and its relationship to higher epididymal obstruction: a qualitative study in the ram

The objective of this study was to determine if localized ischaemia of the caput epididymis in the ram causes morphological changes similar to those characteristic of higher epididymal obstruction in humans. This was tested by performing unilateral occlusion of the superior epididymal artery in 10 rams. At the end of 4 (n = 5) or 28 weeks (n = 4), rams were castrated and the testes and epididymides were weighed. Analysis of histological sections at the light microscope level provided quantitative data on lumen diameter and epithelial cell height of the efferent ducts. Qualitative analysis and specific histochemical stains for identification of lipofuscin pigment provided further information on tissue changes. Electron microscopy was performed on the efferent ducts to assess ultrastructural changes. The results revealed that localized ischaemia of the proximal epididymis caused a dramatic change in tubule calibre of the efferent ducts and initial segment resulting in obstruction of the distal lumina. These changes were more severe following 28 weeks of arterial occlusion. The epithelial cells of the proximal region showed an increase in the number of lysosomes and they became active in phagocytosis of spermatozoa. Lipofuscin pigment accumulated within the epithelial cells and also in macrophage-like cells that had invaded the lumina, interstitium and intra-epithelial regions of the ducts. On the basis of these observations we conclude that the tissue changes which occur in the ram epididymis as a result of localized ischaemia show a striking similarity to those seen in men exhibiting higher epididymal obstruction. This suggests the possible implication of vascular disorders in the aetiology of obstructive azoospermia in men.

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.

Deoxyribonucleic acid flow cytometry and semiquantitative histology of spermatogenesis: a comparative study

OBJECTIVE

To compare deoxyribonucleic acid (DNA) flow cytometry with a semiquantitative histologic method for the assessment of spermatogenesis and to investigate the influence of various preparative techniques on the results of DNA measurements.

DESIGN

Testicular tissue from 52 autopsies was examined for spermatogenesis by DNA flow cytometry and by conventional semiquantitative histology. Flow cytometry was performed on single nuclei suspensions from fine needle aspiration biopsies, resuspended imprints, as well as on specimens obtained by mechanical disaggregation of surgical biopsies of the same testis.

RESULTS

In all cases, flow cytometry revealed a characteristic distribution pattern of haploid (n), diploid (2n), and tetraploid (4n) cells independent of the preparation technique used. The percentage of haploid cells of the testes showed statistically highly significant correlations (P = 0.0002) with the results of semiquantitative histology. Fine needle aspiration biopsy always contained more haploid cells compared with resuspended imprints and mechanically disaggregated samples.

CONCLUSION

Our results confirm the suitability of DNA flow cytometry as a fast and reliable quantitative method for the assessment of spermatogenesis and demonstrate its optimal feasibility in combination with fine needle aspiration biopsy.

Clinical, endocrinological and histopathological evaluation of male infertility

In the years 1980-1988, 135 infertile males, 38 azoospermic and 98 oligozoospermic patients were studied. Physical findings, hormonal (FSH, LH, testosterone and prolactin) estimations were carried out. After doing testicular biopsies, all findings were evaluated.

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.

Incidence of aetiological factors in testicular obstructive azoospermia

Testicular exploration was performed in 225 azoospermic men with normal sized testes and normal serum levels of FSH. Thirty-one men had impaired spermatogenesis and the cause of obstruction was found in 46% of the subjects. Thirty-two men had a history of genital tract infection while 18 had a history of genital or inguinal surgery. A history of chest disease was noted in 25 men with obstructive azoospermia. Aplasia of the vasa was present in 9.3% of the group. The epididymis was the site of obstruction in 63% of patients but the cause of epididymal obstruction was unknown in 81 of the 141 men.

Vasography, its indications and complications

A retrospective study was undertaken of the results of vasography in 440 male partners of infertile marriages who had undergone scrotal exploration and in a group of 42 men with a variety of genital tract disorders. Abnormalities were observed in 10% of 265 azoospermic men and in 4% of 175 other men with infertility. There was no evidence that vasography caused damage to the vas deferens and no oligozoospermic man became azoospermic. A high incidence radiological of abnormalities was seen in haemospermia but the incidence of abnormalities in selected men with ejaculatory problems or testicular pain was low.

Young's syndrome. Obstructive azoospermia and chronic sinopulmonary infections

We studied 29 men with Young's syndrome, a combination of obstructive azoospermia and chronic sinopulmonary infections. Men with this syndrome have only mildly impaired respiratory function and normal spermatogenesis; the azoospermia is due to obstruction of the epididymis by inspissated secretions. The diagnosis is based on the occurrence of chronic sinopulmonary infections, persistent azoospermia, normal spermatogenesis, and characteristic epididymal findings, as well as exclusion of cystic fibrosis and the immotile-cilia syndrome. The sperm themselves appear to be normal in Young's syndrome. Pregnancies had occurred in five couples; in three paternity was documented by genotyping. Thus, improved microsurgical and medical therapy might restore fertility. We suggest that Young's syndrome has a prevalence comparable to that of Klinefelter's syndrome and is a common cause of both chronic sinopulmonary infection and azoospermia.

The long-term results of surgery for obstructive azoospermia

Thirty azoospermic patients with normal testes and normal serum FSH levels had scrotal exploration with photographic record of the appearance of the epididymes and vasography; bilateral epididymovasostomies were done is possible, with vasovasostomies if they were coexisting vasal blocks. Follow-up studies showed no success when the epididymes were empty (Type 1), when the vasa were absent or malformed (Type 2), or when tubular dilatation was confined to the heads of the epididymes; all of the latter cases had coexisting sinusitis, bronchitis or bronchiectasis (Type 4--Young's syndrome). Five patients with post-inflammatory disease had epididymes distended down to their tails (Type 3), and 3 also had vasal blocks. Three achieved sperm counts greater than 10 million per ml and impregnated their wives. Ten of 16 vasectomy reversals done by a similar side-to-side technique were successful. A simple classification of obstructive azoospermia is described and it is concluded that in about 50% of cases the underlying cause of failure in sperm transport remains obscure.

Endocrine assessment of the subfertile male

Sixty-three male (XY) patients attending a subfertility clinic with average sperm density under 40 million/ml were studied by testicular biopsy and multiple basal estimations of plasma LH, FSH, testosterone as well as LHRH (50 micrograms i.v.) stimulation. A further forty patients with similar sperm densities also had testicular biopsy but only single estimations of the three hormones. A single basal FSH was found to be the best discriminator of testicular histologies. Patients with testicular biopsies showing germ cell aplasia in some or all seminiferous tubules (grades 3 and 4) had significantly higher basal FSH than those with hypospermatogenesis, germ cell arrest or normal appearance (grades 1 and 2). Basal FSH also showed a linear trend rising with decreasing sperm density but only rose above the normal range when sperm densities fell below 1 million/ml. When basal FSH, testicular histology and sperm density were considered together in the whole group (n = 100), high levels of FSH accurately indicated the presence of germ cell aplasia in some or all seminiferous tubules in azoo- and oligospermic men with sperm density under 5 million/ml. Normal FSH and azoospermia is diagnostic of obstruction in the excurrent ducts, and further investigation is undertaken if surgical correction of the obstruction is contemplated. Hormone estimations are not helpful in oligospermic patients with average sperm density over 5 million/ml. On the basis of these findings it is suggested that there is little place for the LHRH test in the routine assessment of male subfertility. Testicular biopsy is indicated only in oligospermic patients with average sperm density under 5 million/ml and normal basal FSH.