Male infertility: the role of imaging in diagnosis and management

Future prospects for the advancement of treatment of men with NOA: focus on gene editing, artificial sperm, stem cells, and use of imaging

Nonobstructive azoospermia (NOA) affects about 60% of men with azoospermia, representing a severe form of male infertility. The current approach to manage NOA primarily involves testicular sperm retrieval methods such as conventional testicular sperm extraction (c-TESE) and microdissection testicular sperm extraction (micro-TESE). While combining testicular sperm retrieval with intracytoplasmic sperm injection (ICSI) offers hope for patients, the overall sperm retrieval rate (SRR) stands at around 50%. In cases where micro-TESE fails to retrieve sperm, limited options, like donor sperm or adoption, can be problematic in certain cultural contexts. This paper delves into prospective treatments for NOA management. Gene editing technologies, particularly clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated (Cas) protein 9 (CRISPR/Cas9), hold potential for correcting genetic mutations underlying testicular dysfunction. However, these technologies face challenges due to their complexity, potential off-target effects, ethical concerns, and affordability. This calls for research to address key challenges associated with NOA management within the clinical settings. This also necessitate ongoing research essential for developing more sensitive diagnostic tests, validating novel treatments, and customizing current treatment strategies for individual patients. This review concluded that the future of NOA management may entail a combination of these treatment options, tailored to each patient's unique circumstances, providing a comprehensive approach to address NOA challenges.

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.

Mechanistic Insights into Bisphenol A-Mediated Male Infertility: Potential Role of Panax Ginseng Extract

Male infertility is identified by the inability of a man to successfully impregnate his fertile female partner, even following a year of regular unprotected sexual intercourse. About half of all infertility cases are attributed to what is known as "male factor" infertility. The escalating prevalence of male infertility in the contemporary era across the globe can be largely attributed to environmental pollution, which is the common etiological factor due to the ubiquitous presence of the environmental contaminants. Bisphenol A is recognized as an endocrine-disrupting chemical that has adverse effects on both male and female reproductive systems. On the other hand, numerous studies have demonstrated that Panax ginseng possessed the potential to improve male infertility parameters; promote spermatogenesis, recover the quality and motility of sperm and enhance testicular functions as it acted as a natural androgen supplement. The objective of this review is to offer a summary of the findings obtained from the current research data on the insult of bisphenol A (BPA) on male infertility and its supposed mode of action, as well as shed light on the potent ameliorative role of Panax ginseng extract, with a special focus on the mechanism behind its action. This review delivers a clear understanding of BPA mechanism of action on male infertility and the presumed risks deriving from its exposure. Also, this review provides evidence for the functional role of Panax ginseng extract in restoring male fertility.

Understanding seminal plasma in male infertility: emerging markers and their implications

Infertility affects a significant proportion of the reproductive-aged population, with male-associated factors contributing to over half of the cases. However, current diagnostic tools have limitations, leading to an underestimation of the true prevalence of male infertility. While traditional semen parameters provide some insights, they fail to determine the true fertility potential in a substantial number of instances. Therefore, it is crucial to investigate additional molecular targets responsible for male infertility to improve understanding and identification of such cases. Seminal plasma, the main carrier of molecules derived from male reproductive glands, plays a crucial role in reproduction. Amongst its multifarious functions, it regulates processes such as sperm capacitation, sperm protection and maturation, and even interaction with the egg's zona pellucida. Seminal plasma offers a non-invasive sample for urogenital diagnostics and has shown promise in identifying biomarkers associated with male reproductive disorders. This review aims to provide an updated and comprehensive overview of seminal plasma in the diagnosis of male infertility, exploring its composition, function, methods used for analysis, and the application of emerging markers. Apart from the application, the potential challenges of seminal plasma analysis such as standardisation, marker interpretation and confounding factors have also been addressed. Moreover, we have also explored future avenues for enhancing its utility and its role in improving diagnostic strategies. Through comprehensive exploration of seminal plasma's diagnostic potential, the present analysis seeks to advance the understanding of male infertility and its effective management.

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.

Integrative Assessment of Seminal Plasma Biomarkers: A Narrative Review Bridging the Gap between Infertility Research and Clinical Practice

Infertility represents a significant global health challenge impacting millions of couples worldwide. Approximately half of all infertile couples exhibit compromised semen quality, indicative of diminished male fertility. While the diagnosis of male infertility traditionally relies on semen analysis, its limitations in providing a comprehensive assessment of male reproductive health have spurred efforts to identify novel biomarkers. Seminal plasma, a complex fluid containing proteins, lipids, and metabolites, has emerged as a rich source of such indicators. Reproduction depends heavily on seminal plasma, the primary transporter of chemicals from male reproductive glands. It provides a non-invasive sample for urogenital diagnostics and has demonstrated potential in the identification of biomarkers linked to illnesses of the male reproductive system. The abundance of seminal proteins has enabled a deeper understanding of their biological functions, origins, and differential expression in various conditions associated with male infertility, including azoospermia, asthenozoospermia, oligozoospermia, teratozoospermia, among others. The true prevalence of male infertility is understated due to the limitations of the current diagnostic techniques. This review critically evaluates the current landscape of seminal plasma biomarkers and their utility in assessing male infertility. Βy bridging the gap between research and clinical practice, the integrative assessment of seminal plasma biomarkers offers a multimodal approach to comprehensively evaluate male infertility.

Yoga and Lifestyle Changes: A Path to Improved Fertility - A Narrative Review

Infertility, a widespread medical condition affecting numerous couples globally, persists as a challenge despite advances in assisted reproductive technologies (ARTs), often burdened by financial, physical, and emotional strains. Complementary and alternative approaches, notably yoga, have garnered attention for potentially enhancing fertility outcomes. Studies reveal yoga's influence on factors contributing to infertility, including reduced oxidative stress (OS) and oxidative DNA damage (ODD). OS, linked to mutagenic base formation, higher malondialdehyde levels, abnormal methylation, and altered gene expression, can impair sperm genome integrity. Yoga's efficacy is evident in lowering OS, positively affecting signal transmission, gene expression, and physiological systems. Furthermore, yoga has a positive impact on addressing the dysregulation of apoptosis, resulting in improved processes such as spermatogenesis, sperm maturation, and motility, while also reducing DNA fragmentation. OS correlates with genome-wide hypomethylation, telomere shortening, and mitochondrial dysfunction, contributing to genome instability. Yoga and meditation significantly reduce OS and ODD, ensuring proper reactive oxygen levels and preserving physiological systems. The review explores potential mechanisms underlying yoga's positive impact on infertility, including enhanced blood flow, reduced inflammation, relaxation response, and modulation of the hypothalamic-pituitary-adrenal axis. Furthermore, a comprehensive review of the literature reveals substantial evidence supporting the positive effects of yoga on infertility factors. These include oxidative stress (OS), oxidative DNA damage (ODD), epigenetic changes, hormonal balance, ovarian function, menstrual irregularities, and stress reduction. In summary, yoga emerges as a promising adjunctive therapy for infertility, demonstrating the potential to mitigate key factors influencing reproductive success. Although preliminary evidence indicates the positive effects of yoga on infertility, further clinical research is imperative to define specific benefits, molecular mechanisms associated, optimal protocols, and long-term effects in infertility treatment plans.

A Rare Case of Penoscrotal Webbing and Extensive Hernias: An Anatomical Report With Genetic Insights

During a routine anatomical dissection of an 81-year-old male cadaver received through the Gift Body Program of Saint Louis University School of Medicine (SLU SOM), a massive bulging in the abdominal area was observed that was consistent with numerous hernia repairs noted in the donor's self-reported medical history. Gross anatomical dissection of the cadaveric body revealed extensive herniation of portions of the small intestine and peritoneal sac along the costal margin and extending to the left aspect of the abdomen. Additionally, an uncircumcised phallus was buried within the suprapubic fat pad and demonstrated simple, grade III penoscrotal webbing (PSW), creating an impression of micropenis presence. To gain additional insights into the current case, analysis of the coding regions (exomes) of DNA procured from the body for putative genetic variants was performed using next-generation sequencing (NGS) technology. This analysis revealed 110 rare (minor allele frequency (MAF) ≤ 0.01), pathologic/deleterious genetic mutations. The most relevant variants to this case were the ones associated with male sexual development, BMP1 and BMP4; connective tissue development, COL3A1 and COL5A3; cilia morphogenesis and function, DNAH5 and MAPK15; as well as hormonal homeostasis, ESR1. Direct involvement of BMP1 both in male sexual development and hernia genesis makes it a strong candidate for linking the two pathologies, PSW and multiple hernias, observed in the present case. Yet the presence of a group of mutated genes linked to myopathies (ITGA7, NRAP, POLM, SCN5A, XIRP2) and muscular dystrophy (ITGA7) raises a question about the involvement of these muscular pathologies in hernia genesis and unsuccessful hernia repairs associated with the current case.

Diffusion-weighted magnetic resonance imaging and magnetic resonance spectroscopy for non-invasive characterization of azoospermia: A prospective comparative single-center study

BACKGROUND

Azoospermia affects about 15% of childless males. The differential diagnosis between subtypes of azoospermia is the initial step in its management.

OBJECTIVES

To investigate the role of diffusion-weighted magnetic resonance imaging and proton magnetic resonance spectroscopy in distinguishing obstructive azoospermia from non-obstructive azoospermia and predicting sperm retrieval together with histological alterations in men with non-obstructive azoospermia.

MATERIALS AND METHODS

This prospective comparative study involved 60 men with obstructive azoospermia (group A) and 60 men with non-obstructive azoospermia (group B). Scrotal proton magnetic resonance spectroscopy and diffusion-weighted magnetic resonance imaging were conducted for all participants to respectively evaluate testicular metabolites and normalized apparent diffusion coefficient 1 week before sperm retrieval.

RESULTS

Apparent diffusion coefficient was significantly higher in group B as compared to group A (0.47 ± 0.11 vs. 0.29 ± 0.05; and 0.46 ± 0.14 vs. 0.28 ± 0.02) for the right and left testis, respectively. Conversely, testicular choline and lipids were significantly higher in group A as compared to group B. Normalized apparent diffusion coefficient, choline, and lipids at cut-off levels of 0.353, 0.31, and 0.725 could differentiate between obstructive azoospermia and non-obstructive azoospermia (area under the curve = 0.963; confidence interval = 0.939-0.986, area under the curve = 0.985; confidence interval = 0.974-0.997, and area under the curve = 0.970; confidence interval = 0.940-0.999, respectively). Regarding the prediction of sperm retrieval in the non-obstructive azoospermia group, choline levels had the highest area under the curve (0.923), and its cut-off level was 0.195. The normalized apparent diffusion coefficient was significantly lower in men with positive sperm retrieval as compared to men with unsuccessful retrieval. Finally, it was revealed that all magnetic resonance imaging parameters except creatine could independently predict testicular histology in men with non-obstructive azoospermia. The highest prediction was 95% in normal spermatogenesis, and the least prediction was 40% in spermatid arrest. Regression analysis was used to detect final predictors and extrapolate an equation that could be used to predict testicular pathology CONCLUSIONS: Normalized apparent diffusion coefficient and proton magnetic resonance spectroscopy are helpful in differentiating obstructive azoospermia from non-obstructive azoospermia and predicting sperm retrieval and related histological alterations in men with non-obstructive azoospermia.

Imaging in Male Infertility

Infertility is defined as inability to conceive despite regular unprotected sexual intercourse for greater than 1 year. Conditions involving the male partner accounts for the infertility in approximately 50% of cases. The goals of imaging in male infertility are to detect treatable/ reversible causes, imaging for sperm retrieval from testis or epididymis for assisted reproductive techniques like in vitro fertilization or intracytoplasmic sperm injection and to provide appropriate genetic counselling for prevention of occurrence of disease in future offspring. The purpose of this article is to describe imaging features in various causes of male infertility to acquaint radiologists with various imaging appearances of causes of male infertility to avoid missing these pathologies.

Management of small testicular masses: outcomes from a single-centre specialist multidisciplinary team

OBJECTIVES

To report the management outcomes of men with ≤20-mm small testicular masses (STMs) and to identify clinical and histopathological factors associated with malignancy.

PATIENTS AND METHODS

A retrospective analysis of men managed at a single centre between January 2010 and December 2020 with a STM ≤20 mm in size was performed.

RESULTS

Overall, 307 men with a median (interquartile range [IQR]) age of 36 (30-44) years were included. Of these, 161 (52.4%), 82 (26.7%), 62 (20.2%) and 2 men (0.7%) underwent surveillance with interval ultrasonography (USS), primary excisional testicular biopsy (TBx) or primary radical orchidectomy (RO), or were discharged, respectively. The median (IQR) surveillance duration was 6 (3-18) months. The majority of men who underwent surveillance had lesions <5 mm (59.0%) and no lesion vascularity (67.1%) on USS. Thirty-three (20.5%) men undergoing surveillance had a TBx based on changes on interval USS or patient choice; seven (21.2%) were found to be malignant. The overall rate of malignancy in the surveillance cohort was 4.3%. The majority of men who underwent primary RO had lesions ≥10 mm (85.5%) and the presence of vascularity (61.7%) on USS. Nineteen men (23.2%) who underwent primary TBx (median lesion size 6 mm) had a malignancy confirmed on biopsy and underwent RO. A total of 88 men (28.7%) underwent RO, and malignancy was confirmed in 73 (83.0%) of them. The overall malignancy rate in the whole STM cohort was 23.8%. Malignant RO specimens had significantly larger lesion sizes (median [IQR] 11 [8-15] mm, vs benign: median [IQR] 8 [5-10] mm; P = 0.04).

CONCLUSIONS

Small testicular masses can be stratified and managed based on lesion size and USS features. The overall malignancy rate in men with an STM was 23.8% (4.3% in the surveillance group). Surveillance should be considered in lesions <10 mm in size, with a TBx or frozen-section examination offered prior to RO in order to preserve testicular function.

Is testis sparing surgery safe in patients with incidental small testicular lesions referring to a fertility center? A retrospective analysis reporting factors correlated to malignancy and long-term oncological outcomes

PURPOSE

To define predictors of malignancy after Testis sparing surgery (TSS) in patients referring to a fertility center with incidental small testicular lesions. Sub analyses were performed to assess predictors of Leydig cell hyperplasia and Leydig cell tumor.

MATERIALS AND METHODS

We performed a retrospective analysis of a single institutional database including patients treated with TSS between 2002 and 2020. All patients who underwent TSS as a first line surgical approach for incidentally detected lesions found during fertility evaluation were included.

RESULTS

Data of 64 patients were collected. The median follow up was 58 months and no recurrences were observed. At univariable logistic regression multifocal lesions, hypervascularization, microlithiasis, age and lesion size were significantly associated with malignancy. At multivariable logistic regression lesion dimension, hypervascularization and multifocal lesions were predictors of malignancy. Lesions smaller than 5 mm proved to be benign in 96.6% of the cases (32/33). Intraoperative color of the lesion and US pattern of vascularization were predictors at multivariable logistic regression for Leydig cell hyperplasia and Leydig cell tumor.

CONCLUSION

Ultrasonographic characteristics and intraoperative appearance of the lesion can predict the malignant nature of small testicular lesions, guiding their surgical management in patients referring to a fertility center. Based on our experience, clinicians may safely perform TSS in carefully selected patients.

The male infertility evaluation still matters in the era of high efficacy assisted reproductive technology

Today's reproductive endocrinology and infertility providers have many tools at their disposal when it comes to achieving pregnancy. In the setting of highly efficacious assisted reproductive technology, it is natural to assume that male factor infertility can be overcome by acquiring sperm and then bypassing the male evaluation. In this review, we go through guideline statements and a stepwise male factor infertility evaluation to propose that a thorough male evaluation remains important to optimize pregnancy and live birth. The foundation of this parallel evaluation is referral to a reproductive urologist for the optimization of the male partner, for advanced diagnostics and interventions, and for the detection of other underlying male pathology. We also discuss what future developments might have an impact on the workup of the infertile male.

Testicular haemodynamics, plasma testosterone and oestradiol concentrations, and serum nitric oxide levels in the Egyptian buffalo bull after a single administration of human chorionic gonadotropin

This current study aimed for the first time to evaluate the effect of a single intravenous administration of human chorionic gonadotropin hormone (hCG) on the testicular artery haemodynamics measurements (resistance [RI], and pulsatility indices [PI]), plasma steroids (estradiol-17β and testosterone) and nitric oxide (NO) levels in buffalo bulls. Twelve Egyptian buffalo bulls weighted 450 ± 20 kg were randomly divided into the hCG group (n = 6) and injected a single dose with Ovogest (EPIFASI; 5,000 IU, iv), whereas the others (n = 6) were injected with normal saline and served as controls. Doppler evaluation and blood sampling were performed just before the administration (hour 0) and at 1, 2, 4, 6, 8, 10, 24 and 28 hr after administration. Bulls in the control group did not show any alterations in hormonal levels and blood flow parameters (p > .05). In the hCG group, RI was declined (p < .05) in 6 hr post-administration (0.31 ± 0.01 versus 0.45 ± 0.01), while PI was declined (p < .05) later in 10 hr (0.74 ± 0.01 versus 1.23 ± 0.02). Additionally, testicular blood flow was increased (p < .05) 8 hr (42.02 ± 1.02 ml/min/100 g versus 31.34 ± 0.88 ml/min/100 g) after administration. Testosterone and NO levels were (p < .05) increased at 4 and 6 hr post-administration (3.55 ± 0.03 ng/ml versus 2.84 ± 0.01 ng/ml, and 55.32 ± 4.25 µmol/L versus 32.21 ± 1.55 µmol/L), whereas oestradiol levels were elevated (p < .05) in 6 hr (31.25 ± 0.08 pg/ml) only post-administration then declined. In conclusion, the single intravenous administration of hCG triggered many alterations in the supratesticular artery vascularization and hormonal profile that could affect positively on steroidogenesis and testicular function in buffalo bull.

Functional histology of human scrotal wall layers and their overlooked relation with infertility: a narrative review

Male infertility currently contributes to nearly half of the reported infertility cases. Scrotal wall layers play a cardinal role in regulating testicular physiology. However, few studies have focused on the functional histology of these layers and their relations with infertility in humans. The objective of the present narrative review is to collate novel insights into the functional histology of the human scrotal wall layers and their relation with infertility. The data was extracted from articles published between 1946 and 2021. The study was performed between January and December 2021. 71 original studies have been included in this review. Despite the fact that few studies have presented detailed functional histology of the human scrotal wall layers, this narrative review elucidates the possible influence of scrotal histology on infertility. Scrotal wall layers-associated pathologies may induce infertility by various mechanisms. They can impose mechanical forces that may affect the testicular histology and stimulate testicular inflammation. Moreover, they may induce testicular hyperthermia. Various unanswered clinical questions have been identified in this narrative review. More clinical studies are needed to assess the effect of alterations in the components of the scrotal wall layers on fertility (e.g., due to the exposure to metabolic and/or psychological stressors). In addition, testing the effectiveness of various pharmacological/surgical interventions to treat scrotal wall layers-associated pathologies will provide more insights into infertility treatment.

Reproductive function in men conceived with in vitro fertilization and intracytoplasmic sperm injection

OBJECTIVE

To determine the semen quality and reproductive hormones of men conceived by in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) compared with men conceived without assisted reproductive technology (ART).

DESIGN

Cohort study.

SETTING

IVF centers in Victoria and the Western Australian Raine Study.

PATIENT(S)

Men conceived with IVF/ICSI and men conceived without ART aged 18-25 years.

INTERVENTION(S)

Clinical review.

MAIN OUTCOME MEASURE(S)

The primary outcome was the prevalence of severe oligozoospermia (sperm concentration, <5 million/mL). The secondary outcomes were total sperm count, total and progressive motility, total motile count, normal morphology, and serum testosterone, luteinizing hormone (LH) and follicle-stimulating hormone (FSH).

RESULTS

There was no difference in the prevalence of severe oligozoospermia between 120 men conceived with IVF/ICSI and 356 men conceived without ART (9% vs. 5.3%). Men conceived with IVF/ICSI had similar sperm concentration, total sperm count, and total motile count but lower mean total (55.3% vs. 60.6%) and progressive (44.7% vs. 53.9%) sperm motility with higher mean normal morphology (8.5% vs. 5.4%). Differences in progressive motility (ß, -9.9; 95% confidence interval [CI], -16.7 - -3.0), normal morphology (ß, 4.3; 95% CI, 3.0-5.7), and proportion with abnormal morphology (adjusted odds ratios, 0.1; 95% CI, 0.04-0.5) remained significant after adjusting for confounders. Men conceived with IVF/ICSI had lower mean FSH (3.3 IU/L) and LH (3.9 IU/L) levels and higher mean testosterone levels (19.1 nmol/L) than controls (4.2 IU/L, 11.0 IU/L, and 16.8 nmol/L).

CONCLUSION

This study of men conceived with IVF/ICSI found similar sperm output to men conceived without ART. Overall, the results are reassuring.

Noninvasive Differentiation of Obstructive Azoospermia and Nonobstructive Azoospermia Using Multimodel Diffusion Weighted Imaging

RATIONALE AND OBJECTIVES

To evaluate the diagnostic performance of parameters derived from multimodel diffusion weighted imaging (monoexponential, stretched-exponential diffusion weighted imaging and diffusion kurtosis imaging [DKI]) from noninvasive magnetic resonance imaging in distinguishing obstructive azoospermia (OA) from nonobstructive azoospermia (NOA).

MATERIALS AND METHODS

Forty-six patients with azoospermia were prospectively enrolled and classified into two groups (21 OA patients and 25 NOA patients). The multimodel parameters of diffusion-weighted imaging (DWI; apparent diffusion coefficient [ADC], distributed diffusion coefficient [DDC], diffusion heterogeneity [α], diffusion kurtosis diffusivity [D_app], and diffusion kurtosis coefficient [K_app]) were derived. The diagnostic performance of these parameters for the differentiation of OA and NOA patients were evaluated using receiver operating characteristic analysis. The area under the curve (AUC) was calculated to evaluate the diagnostic accuracy of each parameter.

RESULTS

All the parameters (ADC, α, DDC, D_app, and K_app) values were significantly different between OA and NOA (P < 0.001 for all). For the differentiation of OA from NOA, K_app showed the highest AUC value (0.965), followed by DDC (0.946), D_app (0.933), ADC (0.922), and α (0.887). K_app had a significantly higher AUC than the conventional ADC (P < 0.05).

CONCLUSION

Parameters derived from multimodels of DWI have the potential for the noninvasive differentiation of OA and NOA. The K_app value derived from the DKI model might serve as a useful imaging marker for the differentiation of azoospermia.

Ulva lactuca methanolic extract improves oxidative stress-related male infertility induced in experimental animals

AIM

This study designated to investigate and compare the therapeutic effect of Ulva lactuca methanolic extract against oxidative stress (OS)-infertility induced by naturally occurring prooxidants (gossypol) and selenium- vitamins A, C, and E (selenium-ACE) drug.

METHODS

Male infertility was induced in rat by intraperitoneal injection of 5 mg/kg gossypol eight times then the treatment was carried out with 100 mg/kg ulva methanolic extract oral administration for one or two weeks, after this period OS, and male infertile markers were detected in blood and/or testes.

RESULTS

Gossypol stimulated male infertility by increasing testicular OS markers and decreasing semen quality, hyaluronidase enzyme activity, and blood testosterone level. The treatment with ulva methanolic extract improved gossypol related adverse effects. The treatment period for two weeks with extract was the most potent one.

CONCLUSIONS

Ulva methanolic extract could be considered as good antioxidant therapeutic candidate for OS linked male infertility.

Real-time transrectal ultrasound-guided seminal vesiculoscopy for the treatment of patients with persistent hematospermia: A single-center, prospective, observational study

This study aimed to describe endoscopic anatomy of the seminal tract and summarize our experience of transutricular seminal vesiculoscopy (TSV) guided by real-time transrectal ultrasonography (TRUS) in managing persistent hematospermia. A total of 281 consecutive patients with persistent hematospermia who underwent TSV with or without real-time TRUS were enrolled in this single-center, prospective, observational study. The median follow-up period was 36.5 (range: 8.0–97.5) months. TSV was successfully performed in 272 (96.8%) patients. The approach of a 4.5/6 F rigid vesiculoscope entering the seminal tract was categorized into four types on the basis of endoscopic presentation of the ejaculatory duct orifice and verumontanum. Seven (2.6%), 74 (27.2%), 64 (23.5%), and 127 (46.7%) patients had Types I (through the ejaculatory duct in the urethra), II (through the ejaculatory duct in the prostatic utricle), III (transutricular fenestration through a thin membrane), and IV (real-time transrectal ultrasound-guided transutricular fenestration) approach, respectively. In patients who successfully underwent surgery, bleeding occurred in the seminal vesicle in 249 (91.5%) patients. Seminal vesiculitis, calculus in the prostatic utricle, calculus in the ejaculatory duct, calculus in the seminal vesicle, prostatic utricle cysts, and seminal vesicle cysts were observed in 213 (78.3%), 96 (35.3%), 22 (8.1%), 81 (29.8%), 25 (9.2%), and 11 (4.0%) patients, respectively. Hematospermia was alleviated or disappeared in 244 (89.7%) patients 12 months after surgery. Fifteen patients had recurrent hematospermia, and the median time to recurrence was 7.5 (range: 2.0–18.5) months. TSV guided by TRUS may contribute to successful postoperative outcomes in managing persistent hematospermia.

New Sperm Morphology Analysis in Equids: Trumorph® Vs Eosin-Nigrosin Stain

The evaluation of the male fertility potential is based on the analysis of the basic spermatic characteristics of concentration, motility and morphology. Thus, the study of sperm morphology is a fundamental element in the seminal analysis, but its real meaning has been biased by the techniques used for its evaluation. These techniques involve dehydration phases and subsequent staining, which involves the production of artifacts. The aim of the study is to compare two methods for equid semen morphology evaluation, Trumorph^® using living sperm vs. eosin-nigrosine stain. A total of 49 ejaculates from stallions and donkeys were used. After semen collection and dilution, an aliquot was placed on the slide and introduced in the Trumorph^® device. Then observation was made with a 40x objective and negative phase-contrast microscope. Another aliquot was stained using eosin-nigrosine stain and viewed using 100× magnification. Well-formed sperm were observed, and different abnormalities were identified using Trumorph^®. The use of eosin-nigrosin staining method and Trumorph^® led to the same results and both techniques can be used for stallion and donkey sperm morphological analysis. However, considering the fact that Trumorph^® uses living sperm helps prevent sperm cell alteration during sample preparation. Therefore, Trumorph^® can be a good alternative to the conventional staining method, which provides a quick test on live sperm.

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.

Obstructive oligospermia: the role of interventional radiology in its diagnosis and treatment

Purpose

According to the latest World Health Organization guidelines (2010), oligo-sperm it is due to a sperm concentration of less than 15 million/ml of seminal fluid. The cause can be obstructive and non-obstructive. Interventional radiology allows diagnosis and, in some cases, minimally invasive treatment.

Case presentation

A 28-year-old man with oligospermia (7 million/ml of seminal fluid), surgically treated 2 years ago for clinical grade III bilateral varicocele (according to Dubin’s classification), was admitted to the Urology Department for suspected accidental surgical ligation of the left vas deferens. The patient underwent several diagnostic tests including phlebography of the left pampiniform plexus, bilateral vesico-deferentography. The steno-occlusion of the ejaculatory ducts was diagnosed, which was resolved through an innovative interventional radiology treatment.

Conclusions

Interventional radiology has played a decisive role in the diagnosis and treatment of the causes of male infertility. In our experience, it has considerable potential in the minimally invasive treatment of steno-obstructive pathologies of the vesico-deferential system.

Male infertility

It is estimated that infertility affects 8-12% of couples globally, with a male factor being a primary or contributing cause in approximately 50% of couples. Causes of male subfertility vary highly, but can be related to congenital, acquired, or idiopathic factors that impair spermatogenesis. Many health conditions can affect male fertility, which underscores the need for a thorough evaluation of patients to identify treatable or reversible lifestyle factors or medical conditions. Although semen analysis remains the cornerstone for evaluating male infertility, advanced diagnostic tests to investigate sperm quality and function have been developed to improve diagnosis and management. The use of assisted reproductive techniques has also substantially improved the ability of couples with infertility to have biological children. This Seminar aims to provide a comprehensive overview of the assessment and management of men with infertility, along with current controversies and future endeavours.

The first magnetic resonance imaging-detected case of bilateral seminal vesicle duplication: An illustrative case report

Given the increasing use of prostate magnetic resonance imaging (MRI) for imaging suspected cancer and male infertility, understanding imaging features of congenital anomalies of the seminal vesicles (SVs) is of clinical importance. This case presents the first MRI-detected case of bilateral SV duplication with an isolated right SV cyst in the absence of other congenital genitourinary anomalies. In addition to illustrating imaging features of this rare anomaly, this case provides an overview of the role of MRI in providing accurate diagnosis and guiding management options of the most common SV anomalies.

Diagnosis and hormonal treatment of male infertility

Male infertility is a frequently observed medical condition that is related to the functioning of extremely complex organs such as the pituitary gland and the gonads. The diagnosis and proper management of infertile men is challenging for modern medicine, given the high expectations and demands of current patients, mainly due to the economic and emotional expenses aroused by this "relationship issue". In many cases, patients should receive therapies aimed at improving the functioning of that complex hormonal axis, instead of treating their underlying problem; thus, seeking to optimize the production of gametes with better conditions and improve fertilization rates without requiring assisted procedures.

The role of color Doppler in assisted reproduction: A narrative review

Color Doppler of perifollicular vascularity is a useful assessment tool to predict the growth potential and maturity of Graafian follicles. Power Angio is independent of the angle of insonation and morphometry and provides reliable clues to predict the implantation window of the endometrium. Color Doppler can be used for the prediction of ovarian hyperstimulation syndrome. It can also be used to identify the hyper responder and gonadotropin-resistant type of polycystic ovaries. The secretory scan of corpus luteum can accurately predict its vascularity and functional status. A corpus luteum with decreased blood flow is a very sensitive and specific indicator of threatened and missed abortions. Color Doppler and Power Angio need to be standardized and identical settings should be maintained if different patients, or if changes over time within the same patient are to be compared.

Transurethral seminal vesiculoscopy for recurrent hemospermia: experience from 419 cases

We summarized our experience in transurethral seminal vesiculoscopy (TSV) for recurrent hemospermia by introducing surgical techniques, intraoperative findings, and treatment outcomes. TSV was performed in 419 patients with an initial diagnosis of persistent hemospermia at Shanghai Changhai Hospital (Shanghai, China) from May 2007 to November 2015. TSV was successfully performed in 381 cases (90.9%). Hemospermia was alleviated or disappeared in 324 (85.0%) patients by 3 months after surgery. Common intraoperative manifestations were bleeding, obstruction or stenosis, mucosal lesions, and calculus. Endoscopic presentation of the ejaculatory duct orifice and the verumontanum was categorized into four types, including 8 (1.9%), 32 (7.6%), 341 (81.4%), and 38 (9.1%) cases in Types A, B, C, and D, respectively. TSV is an effective and safe procedure in the management of seminal tract disorders. This study may help other surgeons to become familiar with and improve this procedure. However, further multicentric clinical trials are warranted to validate these findings.

Ultrasound Evaluation of Testicular Volume in Patients with Testicular Microlithiasis

Purpose

Ultrasonography is a useful tool to measure testicular volume. According to the European Society of Urogenital Radiology, the combination of testicular atrophy and testicular microlithiasis (TML) is a risk factor for testicular cancer. Testicular atrophy is defined as a volume of less than 12 ml. The aim of this study was to compare testicular volume in patients with TML to patients with normal testicular tissue.

Materials and Methods

From 2013 to 2015 we included a total of 91 adult patients with TML, and 91 adult patients with normal testicular tissue as a control group. All patients underwent scrotal B-mode ultrasound investigation including measurement of width, length and height in both testicles. Testicular volume was calculated using the formula π/6×length×height×width.

Results

The median age for patients with TML was 48 years (range: 19-94 years), and 48 years (range: 20–75 years) in patients with normal tissue. No statistically significant difference was found between total testicular volume (both testes) >30 ml in patients with TML compared to patients without (OR 0.77 (95% CI 0.43-1.38, p=0.37). However, patients with TML tended to have lower testicular volume compared to patients without TML, when investigating testicular volume below 12 ml.

Conclusion

Overall, no association was found between testicular volume and TML, but there was a trend indicating that severe atrophy is often seen in patients with TML compared to patients without TML. However, a significant difference was only found in testicular volume ≤8 ml.

Sonography in male infertility: a look beyond the obvious

Infertility affects 15-20% of the reproductive age range population; the male factor accounts for up to 40-60% of these. With female factor infertility catching most of the limelight in research, diagnosis and treatment, the other half of the problem has not been duly addressed. Imaging has an important role to play in the evaluation of male infertility, especially to identify correctible (obstructive) causes. We review the scrotal, trans-rectal sonographic and Doppler findings in infertile men to aid in the accurate diagnosis and proper management of such patients.

Prevalence and Management of Incidental Small Testicular Masses Discovered on Ultrasonographic Evaluation of Male Infertility

PURPOSE

We report the safety of surveillance of small testicular masses incidentally discovered during evaluation of male infertility.

MATERIALS AND METHODS

We retrospectively reviewed a prospectively collected database to identify patients with male infertility found to have incidental small testicular masses (hypoechoic lesions less than 10 mm) on scrotal ultrasound. The men were offered close surveillance with interval imaging and office followup. Patient and imaging characteristics were collected to compare the surveillance and surgical groups with additional comparisons between benign and malignant pathologies to elucidate predictors of underlying malignancy.

RESULTS

Of 4,088 men in whom scrotal ultrasound was completed for male infertility evaluation 120 (2.9%) were found to have a subcentimeter testicular mass. Average followup was 1.30 years (range 0.1 to 16.9). A total of 18 men (15%) proceeded to extirpative surgery while 102 remained on surveillance at last followup. In those with at least 1 month of followup the mean lesion growth rate was -0.01 mm per year. Reasons for surgery included testicular exploration for infertility, mass growth, positive tumor markers, history of testis cancer, concerning imaging characteristics and patient choice. Six of the 18 men who underwent surgery were found to have malignancy, which was seminoma in all. All malignant lesions were greater than 5 mm on initial imaging and demonstrated vascularity, although size and vascularity were not significantly different from those of benign lesions on final pathology findings. No patients demonstrated advanced or recurrent disease.

CONCLUSIONS

Small testicular masses are not uncommon, especially in the infertile male population. Most of these masses do not show significant growth during long-term evaluation and can be safely surveilled with close followup.

Evaluation of the diagnostic efficacy of strain elastography in infertile population with normal and abnormal semen parameters

OBJECTIVE

The aim of the present study was to investigate the diagnostic value of strain elastography (SE) of testicular tissues in infertile population. We also evaluated the correlation between SE results with semen parameters and hormone profiles of the patients.

MATERIAL AND METHODS

A total of 61 patients and 122 testes were evaluated. Patients who were evaluated in an andrology outpatient clinic with the diagnosis of infertility and referred to radiology department for investigation of reproductive organs between June 2015 and January 2016 were included. Patients were divided into two groups according to semen analyses results as normal (Group 1) and abnormal (Group 2). Hormone profiles, semen analyses, B-mode, coloured Doppler ultrasonography and sonoelastography examinations were performed for each patient. Measurements of testicular volumes, resistive indices (RI) in intraparenchymal arteries, strain, strain ratio (SR) and presence of varicocele were recorded.

RESULTS

Mean age of participants was 33.7±6.3 years. Mean testicular volumes (Group 1, 19.41±4.8 mL, and Group 2, 17.64±3.62 mL) were significantly different between groups (p=0.023). Mean SRs were also different between Groups 1 and 2 (0.12±0.08 vs. 0.22±0.18, p<0.001). Testicular volumes were directly proportional with SRs in Group 1. Strain values had inverse relationship with sperm concentration and total motile sperm counts in Group 2 (p=0.01). SRs were found to be positively correlated with RI and sperm morphology in Group 2 (p<0.05). Although FSH values showed significant difference among groups, any correlation between FSH and elastographic parameters could not be displayed.

CONCLUSION

Strain elastography results were found to be significantly different in patients with abnormal sperm counts. This technique may provide promising results, however, further large scale studies may help to clarify the value of this imaging modality in the assessment of male infertility.

[Rational diagnosis and treatment of male infertility]

Male infertility can be diagnosed by evaluation of the (female and) male history with respect to risk factors, and includes scrotal sonography, hormone and semen measurements. In severe male factor infertility, genetic testing is indicated. Treatment options vary between preventive, medical or surgical strategies depending on the underlying diagnosis. Assisted reproductive techniques may be applied as a consequence of the couple's infertility profile.

Potential role of imaging in assessing harmful effects on spermatogenesis in adult testes with varicocele

Varicocele is characterized by an abnormal dilatation and retrograde blood flow in the spermatic veins. Varicocele is the leading correctable cause of male infertility. Although it is highly prevalent in infertile men, it is also observed in individuals with normal fertility. Determining which men are negatively affected by varicocele would enable clinicians to better select those men who will benefit from treatment. To assess the functional status of the testes in men with varicocele, color Doppler sonographic parameters were evaluated. Testicular arterial blood flow was significantly reduced in men with varicocele, reflecting an impairment of spermatogenesis. An improvement in the testicular blood supply was found after varicocelectomy on spectral Doppler analysis. Testicular contrast harmonic imaging and elastography might improve our knowledge about the influence of varicocele on intratesticular microcirculation and tissue stiffness, respectively, providing possible information on the early damage of testicular structure by varicocele. Magnetic resonance imaging (MRI), with measurement of apparent diffusion coefficient has been used to assess the degree of testicular dysfunction and to evaluate the effectiveness of varicocele repair. Large prospective studies are needed to validate the possible role of functional sonography and MRI in the assessment of early defects of spermatogenesis in testes with varicocele.

Zinner syndrome: an uncommon cause of painful ejaculation

Zinner syndrome refers to the triad of ipsilateral renal agenesis, seminal vesicle cysts and ejaculatory duct obstruction. Ipsilateral renal agenesis may be associated with seminal vesicle cysts in 70% of cases, but a remnant ureteral bud has been shown to coexist in only 27% of these cases. While some patients may remain asymptomatic and are discovered incidentally, others present with symptoms related to seminal vesicle cysts or ejaculatory duct obstruction: voiding or ejaculatory difficulty or pain. The diagnosis is made with imaging findings, and differentiation from other pelvic cysts requires a multimodality approach. In this report, we present typical imaging findings of a patient who presented with painful ejaculation where there was a congenital seminal vesicle cyst with ipsilateral renal agenesis associated with a remnant ureteral bud draining into the seminal vesicle cyst and also associated with a cyst of the prostatic utricle. We discuss the relevant embryological basis for this unusual combination of findings.

Correlation between spermatogenesis disorders and rat testes CYP2E1 mRNA contents under experimental alcoholism or type I diabetes

PURPOSE

The aim of the study was to investigate the correlation between spermatogenesis disorders and CYP2E1 mRNA contents in testes of rats with experimental alcoholism or type I diabetes.

MATERIAL/METHODS

Two pathological states characterized by CYP2E1 induction were simulated on Wistar male rats: experimental alcoholism and type I diabetes. As controls for each state, equal number of animals (of the same age and weight) were used. Morphological evaluation of rat testes was carried out. The spermatogenic epithelium state was estimated by four points system. CYP2E1 mRNA expression was rated by method of reverse transcriptase polymerase chain reaction. Pearson correlation coefficients were used for describing relationships between variables.

RESULTS

The presence of alcoholism and diabetes-mediated quantitative and qualitative changes in male rat spermatogenic epithelium in comparison with norm has been demonstrated. The increased levels of testes CYP2E1 have been fixed simultaneously. CYP2E1 mRNA content negatively strongly correlated with spermatogenic index value (r=-0.99; P<0.001) and positively strongly correlated with epithelium desquamation occurrence (r=0.99; P<0.001) in testes of rats with chronic alcoholism. The strong correlation between CYP2E1 mRNA content and number of spermatogonia (r=0.99; P<0.001) and "windows" occurrence (r=0.96; P<0.001) has been fixed in diabetic rats testes.

CONCLUSIONS

Present investigation has demonstrated that the testicular failure following chronic ethanol consumption and diabetes type I in male rats accompanied CYP2E1 mRNA over-expression in testes. The correlation between the levels of CYP2E1 mRNA in testes and spermatogenesis disorders allow supposing the involvement of CYP2E1 into the non-specific pathogenetic mechanisms of male infertility under above-mentioned pathologies.