Management of Azoospermia-what every gynecologist should

know

Rupin Shah M.S., M.Ch.(Urology)

Consultant Andrologist & Microsurgeon

Lilavati Hospital & Research Centre, Mumbai

54th AICOG, 2011

Basic questions Obstructive or non-obstructive If obstructive – operable; success?

- surgery or PESA-ICSI If non-obstructive

- any treatment?

- any sperm for ICSI

DIAGNOSTIC ALGORITHM

Not every ejaculate is semen

Some men do not reach orgasm Collect urethral secretions instead Azoospermia; fructose negative

Not every ejaculate is semen

Prolonged stimulation

of the glans with a

high amplitude vibrator

induces orgasm

and ejaculation

Azoospermia does not always mean azoospermia

Transient azoospermia Fluctuating counts Cryptozoospermia

Multiple reports over time

Centrifuge sample, examine pellet

Fructose matters

Fructose matters

Fructose NEGATIVE Vas Aplasia (CBAVD) Ejaculatory Duct Obstruction (EDO)

Fructose POSITIVE Primary Testicular Failure Obstructive Azoospermia

- block at epididymis or vas

Test for fructose

Standard Seliwanoff method5 ml resorcinol soln. + 0.5 ml semen

Modified Seliwanoff method1 ml resorcinol soln. + 0.1 ml semen

Normal FSH does not necessarily mean normal spermatogenesis

Normal FSH = Normal spermatogenesis

Not necessarily true

Many men with PTF will have normal FSH Normal FSH : inconclusive

- normal / abnormal spermatogenesis High FSH = Testicular Failure

(focal spermatogenesis may be present)

Its all in the genes 10% - chromosomal numerical abn. >15% - Yq deletions

Screening required prior to TESE

Counseling about genetic risk

Testicular failure need not mean no sperm

P.T.F. Patchy spermatogenesis Obstruction

P.T.F. with areas of spermatogenesis

no sperm many spermfew sperm

Testicular failure need not mean no sperm

Testicular failure need not mean no sperm

Some of these sperm can be

retrieved through multiple biopsies

and used for ICSI in 20% of men with Sertoli cell only in 20% of men with atrophy in 40% of men with maturation arrest

One biopsy is not enough

New approach to testicular biopsies in the ICSI era

Multiple instead of Single

Testicular Mapping Biopsies- multiple : 4 - 6

- bilateral

Testicular Biopsy : NAB technique

Needle

Aspiration

Biopsy

No Vasography

Fructose TRUS

Microsurgical VEA Vas mucosa to epid.

ductule

with 10-0 nylon 25x magnification

VAS

EPID.

ICSI for obstructive azoospermia

Ejaculated, epididymal or testicular spermgive comparable pregnancy rates after ICSI

- Nagy et al.Fertil Steril 1995

Obstructive Azoospermia- VEA or PESA-ICSI

VEA is preferred in younger couples ICSI is preferred in:

- when fast results are required

- older couples

- social pressures

- when VEA has poor chances

- filariasis, TB, hydrocelectomy

Varicocele matters - sometimes

Surgery for large varicoceles in azoo. men

-15/22 sperm appeared (mean 2.2 mill/ml)- - Goldstein 1998, Fertil Steril

-7/15 sperm + (1.8 – 7.9 mil/ml)- Pasqualotto 2003, Hum Reprod

Azoospermia, Fructose positive

Clinical Examination & F.S.H.Clinical Examination & F.S.H.

Obstructive EquivocalP.T.F.

Obstructive EquivocalP.T.F.

Azoospermia, obvious obstructiveAzoospermia, obvious obstructive

Direct exploration

- VEA/VVA

- no prior vasography

- vas patency checked during surgery

Direct exploration

- VEA/VVA

- no prior vasography

- vas patency checked during surgery

Needle biopsy

Proceed with VEA

or PESA-ICSI

Needle biopsy

Proceed with VEA

or PESA-ICSI

Needs confirmation of spermatogenesis

Needs confirmation of spermatogenesis

Azoospermia, Fructose positive

Clinical Examination & F.S.H.Clinical Examination & F.S.H.

Obstructive EquivocalP.T.F.

Obstructive EquivocalP.T.F.

Azoospermia, obvious PTFAzoospermia, obvious PTF

DI

Adoption

DI

AdoptionConsidering ICSIConsidering ICSI

Biopsy is not required for diagnosis Discuss options

Biopsy is not required for diagnosis Discuss options

Genetic studiesGenetic studies

Trial TESE – multiple SSTTrial TESE – multiple SST

Sperm absent Sperm present

Cryopreserve wife stimulatedICSI

Sperm absent Sperm present

Cryopreserve wife stimulatedICSI

Azoospermia, Fructose positive

Clinical Examination & F.S.H.Clinical Examination & F.S.H.

Obstructive EquivocalP.T.F.

Obstructive EquivocalP.T.F.

Azoospermia, Equivocal findings T.B. is needed for differential diagnosis Azoospermia, Equivocal findings T.B. is needed for differential diagnosis

NormalNormal P.T.F. - No SpermP.T.F. - No Sperm

TESE-ICSI

(fresh biopsy at

time of ICSI)

TESE-ICSI

(fresh biopsy at

time of ICSI)

Bilateral, multiple, micro- biopsies

proper interpretation

Bilateral, multiple, micro- biopsies

proper interpretation

PTF - Focal spermPTF - Focal sperm

VEA

(or ICSI )

VEA

(or ICSI )DI

Adoption

DI

Adoption

In Summary Confirm proper ejaculation Cryptozoospermia Fructose FSH & Physical Examination Testicular biopsy – multiple? Reconstructive surgery ART – PESA/TESE –ICSI Genetic studies