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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
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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
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Not every ejaculate is semen
Some men do not reach orgasm Collect urethral secretions instead Azoospermia; fructose negative
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Not every ejaculate is semen
Prolonged stimulation
of the glans with a
high amplitude vibrator
induces orgasm
and ejaculation
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Azoospermia does not always mean azoospermia
Transient azoospermia Fluctuating counts Cryptozoospermia
Multiple reports over time
Centrifuge sample, examine pellet
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Fructose matters
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Fructose matters
Fructose NEGATIVE Vas Aplasia (CBAVD) Ejaculatory Duct Obstruction (EDO)
Fructose POSITIVE Primary Testicular Failure Obstructive Azoospermia
- block at epididymis or vas
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Test for fructose
Standard Seliwanoff method5 ml resorcinol soln. + 0.5 ml semen
Modified Seliwanoff method1 ml resorcinol soln. + 0.1 ml semen
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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)
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Its all in the genes 10% - chromosomal numerical abn. >15% - Yq deletions
Screening required prior to TESE
Counseling about genetic risk
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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
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Testicular failure need not mean no sperm
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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
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One biopsy is not enough
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New approach to testicular biopsies in the ICSI era
Multiple instead of Single
Testicular Mapping Biopsies- multiple : 4 - 6
- bilateral
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Testicular Biopsy : NAB technique
Needle
Aspiration
Biopsy
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No Vasography
Fructose TRUS
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Microsurgical VEA Vas mucosa to epid.
ductule
with 10-0 nylon 25x magnification
VAS
EPID.
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ICSI for obstructive azoospermia
Ejaculated, epididymal or testicular spermgive comparable pregnancy rates after ICSI
- Nagy et al.Fertil Steril 1995
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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
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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
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Azoospermia, Fructose positive
Clinical Examination & F.S.H.Clinical Examination & F.S.H.
Obstructive EquivocalP.T.F.
Obstructive EquivocalP.T.F.
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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
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Azoospermia, Fructose positive
Clinical Examination & F.S.H.Clinical Examination & F.S.H.
Obstructive EquivocalP.T.F.
Obstructive EquivocalP.T.F.
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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
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Azoospermia, Fructose positive
Clinical Examination & F.S.H.Clinical Examination & F.S.H.
Obstructive EquivocalP.T.F.
Obstructive EquivocalP.T.F.
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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
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In Summary Confirm proper ejaculation Cryptozoospermia Fructose FSH & Physical Examination Testicular biopsy – multiple? Reconstructive surgery ART – PESA/TESE –ICSI Genetic studies