AZOOSPERMIA TREATMENT CHENNAI INDIA

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Consult with Dr Arun Muthuvel MS, MCh who is a specialist in Azoospermia at Iswarya Fertility centers in Chennai, India.

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AZOOSPERMIA SIMPLIFIED

INTRODUCTION

• Azoospermia is the medical term used when there are no sperm in the ejaculate.

• Rare (approximately 1% of all men [1]),

• Approx 10%–15% of all infertile men.

DIAGNOSIS OF AZOOSPERMIA

no sperm is identified in the centrifuged pellet of two separate semen samples.

AZOOSPERMIA CLASSIFICATION - ETIOLOGICAL

• Pre Testicular - hormonal

• Testicular - intrinsic failure

• Post Testicular - obstruction

AZOOSPERMIA CLASSIFICATION - CLINICAL

• Obstructive

• Non Obstructive

PRE TESTICULAR (HORMONAL)

• Genetic abnormality

  • Kallmann’s syndrome

  • Prader-Willi syndrome

• Idiopathic HH

• Isolated FSH / LH deficiency

• Prolactin excess - micro / macro

TESTICULAR (INTRINSIC FAILURE)

• Genetic abnormality –Klinefelter’s syndrome, XYY, 46 XX male syndrome, Yq AZF gene deletion

• Varicocele

• Bilateral anorchism, cryptorchidism

• Sertoli cell only syndrome

• Gonadotoxic therapy : drug, radiation, chemical

• Orchitis - mumps / Infections

OBSTRUCTIVE AZOOSPERMIA

Normal sperm production + obstruction

Causes

• Previous vasectomy

• Obstructions in Epididymis, Vas or Ejaculatory duct

• Infections

• Iatrogenic injuries during Scrotal/inguinal surgeries

• Congenital anomalies

NON OBSTRUCTIVE AZOOSPERMIA

Due to abnormal sperm production

Causes

• Sertoli cell only syndrome

• Maturation arrest

• Hypospermatogenesis

• Klinefelter’s syndrome

• Kallmann syndrome

• Y-Chromosome microdeletions

• Post mumps - orchitis, Post CT / RT

• Torsion - testis / Cryptorchidism

EVALUATION OF AZOOSPERMIA

• Semen Analysis - Repeat - Repeat ?

• Clinical History

• Physical exam - General & Local (vas*)

• Imaging (USG Scrotum / TRUS)

• Hormonal - FSH, LH, Total / Free Testosterone, Prolactin, Estradiol. FSH - >7.6 mIU/ml

• Genetic - Karyo, Ych micro

Diagnostic evaluation of the infertile male: Practice Committee of the American Society for Reproductive Medicine, 2014

NEXT STEPS IN AZOOSPERMIA EVALUATION

• Differentiate first

• Is it Obstructive or non Obstructive ?

How do we differentiate Obstructive vs Non Obstructive Azoospermia ?

Childhood and Developmental history

• Cryptorchidism, testicular torsion

• Mumps - orchitis

• Herniorrhaphy

• Onset of puberty

• Secondary sexual development

• Onset axillary, pubic hair, start of shaving

• Onset of masturbation

How do we differentiate azoospermia by clinical history ?

Medical history

• Systemic illness: hepatic, renal failure

• Gonadotoxic therapy - CT, RT, Steroids, Smoking, thermal, etc

Surgical history

• Herniorrhaphy, bladder neck, orchidectomy, retroperitoneal surgery

How do we differentiate (by Dr Arun Muthuvel MS, MCh - Azoospermia Treatment Chennai)

Physical examination

• General appearance

• Gynecomastia

• Axillary, pubic hair

• Testis volume, consistency

• Epididymis induration

• Varicocele

• Digital rectal examination

Semen analysis in Azoospermia

• Repeat - Repeat

• At least 2 times

• Inspect Pellet after centrifugation at 1,500-2,000 rpm for 10 min

• If ejaculatory vol < 1 ml – Postejaculatory urine should be examined

OBSTRUCTIVE AZOOSPERMIA

Semen Analysis

• Complete proper collection ?

• Semen Volume

• pH

• Fructose

• Post ejaculate urine analysis

Ultrasound scan in azoospermia diagnosis and treatments

Scrotal

• Testis volume / Varicocele / Testis tumor

TRUS - Transrectal USG

• r/o or to confirm level of obstruction

• Low volume azoospermia without absence of testicular atrophy

How do we differentiate ?

• Clinical history

• ExaminationTestis - N / smallVas, Epi N.Testis - N size

• Vas,Epi N/Absent.

• Semen analysis

• pH, Fructose, Volume normal.

• pH acidic ? Fructose absent ? Volume - low

Hormones

• Hyper-hypo / Hypo - hypo / normal

Histological patterns of spermatogenesis in Azoospermia testicular biopsy

• Tubular sclerosis - Absence of seminiferous tubules

• SCOS - No germ cells within the seminiferous tubules

• Spermatogenic arrest - Incomplete spermatogenesis, not beyond the spermatocyte stage

• Hypospermatogenesis - All germ cell stages present including spermatozoa with a decline in no of germ cells

• Normal spermatogenesis

• Mixed pattern - different stages of spermatogenesis

Sperm Retrieval rate in Non-obstructive Azoospermia

• Hypospermatogenesis 70-85%

• Maturation Arrest 35-47%

• Sertoli Cell-only 10-24%

Hormones - Non Obstructive Azoospermia

Clinical status

• Germ cell aplasia - FSH ↑, LH and Testosterone - Normal

• Testicular failure -  FSH ↑, LH ↑, Testosterone - Normal or Low

• Hypogonadotropic Hypogonadism -  FSH, LH, Testosterone all are low

Treatment options in Azoospermia

• 1. Obstructive vs Non obstructive

  2. Testicular biopsy

Diagnostic

• Diagnose Obstruction vs Non Obstruction

• Identification of mature sperm for ICSI

• Identification of malignancy

Therapeutic

• Harvesting of sperm for ICSI

Medical Treatment of Azoospermia

Hypogonadotropic hypogonadism

• HCG / HMG / FSH

• Combination / Step wise

• Sperm count increase observed in 3-24 months

Varicocelectomy for Azoospermia

• Only in clinically palpable cases

• Severe hypospermatogenesis

• ICSI vs varicocelectomy

Methods to Extract sperms in Azoospermia

• PESA / MESE

• TESA

• TESE

• Micro TESE

Conclusion

• Azoospermia - common in Fertility Setup

• Differentiate Obstruction vs Non obstruction Azoospermia

• Medical vs Surgical

• Right Surgical route

Consult with Dr Arun Muthuvel MS, MCh who is a specialist in Azoospermia in Chennai, India.

MICRO TESE PROCEDURE