Imaging of obstructive azoospermia

Development of a multivariable prediction model for congenital unilateral absence of the vas deferens in male partners of infertile couples

BACKGROUND

Congenital unilateral absence of vas deferens has been diagnosed in fertile and normozoospermic males and is associated with the risk of unilateral renal absence or cystic fibrosis transmembrane conductance regulator mutations; but no prediction model currently exists to diagnose this condition.

OBJECTIVES

The study aims to identify clinical and biological variables that may have a predictive value for the diagnosis of congenital unilateral absence of vas deferens in male partners of infertile couples MATERIALS AND METHODS: We designed a retrospective, cross-sectional, case-control study on electronic health records of a single tertiary-care andrological centre collected between 1998 and 2018. We included all subjects diagnosed with congenital unilateral absence of vas deferens using combined scrotal and transrectal ultrasounds. Controls were confirmed free of congenital unilateral absence of vas deferens by the same way. Both groups received standardised exploration procedures. Multivariable logistic regression model was built in a backward stepwise manner. Model performance and calibration were assessed. The study is reported according to TRIPOD statement.

RESULTS

We included 69 congenital unilateral absence of vas deferens cases and 78 controls. Cases had a lower semen volume than controls. The congenital unilateral absence of vas deferens risk was associated with history of cryptorchidism and both levels of semen fructose and α-glucosidase. These predictors were confirmed by a random forest algorithm. The area under the curve was 0.886 (95% interval: 0.81-0.92). Calibration was performed with the Hosmer-Lemeshow test (p = 0.88).

DISCUSSION AND CONCLUSION

History of cryptorchidism, semen fructose and α-glucosidase were identified as relevant and independent predictors for the diagnosis of congenital unilateral absence of vas deferens. The model enables to identify male patients with a high risk of congenital unilateral absence of vas deferens to whom a transrectal ultrasounds would be proposed to confirm the diagnosis, whatever their semen parameters. It will also help to address the risks of unilateral renal absence and of cystic fibrosis transmembrane conductance regulator mutations carrying during the management of infertile couples.

Congenital absence of the vas deferens: Cystic fibrosis transmembrane regulatory gene mutations

Congenital absence of the vas deferens (CAVD) is a rare genetic condition first discovered in the mid-18th century related to mutations in the cystic fibrosis transmembrane regulatory genes. The condition is typically found during work-up of male infertility, and the majority of cases can be diagnosed with complete history and physical examination and pertinent investigations. The condition can be separated into three subcategories, and genetic advances have led to a much better understanding behind the disease, its pathogenesis, and options for treatment. In this review, we discuss the genetics, pathogenesis, embryology, and diagnosis of treatment of CAVD. Future work in this area likely will aim to better understand the epigenetic factors that influence the development of the condition in order to identify potential upstream therapeutic targets.

A modified single-armed microsurgical vasoepididymostomy for epididymal obstructive azoospermia: intraoperative choice and postoperative consideration

Background

To evaluate the clinical outcomes and the duration required for the sperm to return to the ejaculate after a modified single-armed 2-suture longitudinal intussusception vasoepididymostomy (SA-LIVE).

Methods

From March 2015 to December 2018, 134 patients with epididymal obstruction azoospermia underwent the modified single-armed vasoepididymostomy at Shanghai General Hospital. The outcomes and clinical findings were documented and evaluated. The mean follow-up period was 17 (range: 3–36) months.

Results

Patency was assessed by the return of sperm in the ejaculate. The overall patency rate was 55.2%, and the patency rates were 58.9, 40.7, 36.4, and 58.9% for bilateral surgery, unilateral surgery, proximal anastomosis, and distal anastomosis, respectively. The average time to achieve patency was 4.11 ± 2.74 months. In the first 6 months, 87.8% (65/74) patency patients reported sperm in the ejaculate. The overall pregnancy rate was 40.9% (29/66) at the follow-up of 3–36 months, and the natural pregnancy rate was 30.3% (20/66). The natural pregnancy rate was 32.1% post-bilateral surgery and 33.3% for the site of distal anastomosis; surprisingly, it was 0% for the site of proximal anastomosis.

Conclusion

Modified SA-LIVE is safe and may achieve favorable patency and pregnancy rates. When double-armed sutures are not accessible, single-armed may be preferable. The expected patency time was within 1 year. Moreover, because of the low natural pregnancy rate for proximal anastomosis, sperm banking is preferred to SA-LIVE.

Male partners of infertile couples with congenital unilateral absence of the vas deferens are mainly non-azoospermic

BACKGROUND

Men with congenital unilateral absence of vas deferens were reported to be mainly azoospermic, with both unilateral renal absence and mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) but some have neither.

OBJECTIVES

To assess whether in infertile couples the male partners with congenital unilateral absence of vas deferens are mainly azoospermic men.

MATERIAL AND METHODS

Retrospective study in a unique university hospital; reproductive, clinical, CFTR analysis and seminal data of male partners of infertile couples (from 1998 to 2018) were analysed. Diagnosis of congenital unilateral absence of vas deferens was based on transrectal ultrasounds (TRUS): complete or partial absence of one vas deferens with complete contralateral vas deferens confirmed in 63 men. Distribution of sperm count in three classes: azoospermia, oligozoospermia or normozoospermia. Ultrasound determination of renal status; seminal biomarkers assays; and search for CFTR mutations.

RESULTS

Among the 63 men, 39.7% displayed azoospermia, 27% oligozoospermia and 33.3% normozoospermia; 42% of the non-azoospermic men (16/38) had previously obtained a natural pregnancy. We found unilateral renal absence in 17/59 patients (29%). Among 50 men with CFTR testing, five carried an allele associated with cystic fibrosis belonging to the 29 men without renal anomalies, indicating a high allelic frequency (8.6%). The 63 patients displayed high rates of surgical histories for undescended testicles or inguinal hernia, low values of semen volume and of total seminal glycerophosphocholine.

CONCLUSIONS

Our results indicate that men with congenital unilateral absence of vas deferens mainly display oligozoospermia or normozoospermia and that they were previously fertile. They clearly confirm, first, that CFTR testing is recommended in congenital unilateral absence of vas deferens men and it should be mandatory for those with normal kidneys; and, second, that TRUS is needed for the diagnosis of congenital unilateral absence of vas deferens. As congenital unilateral absence of vas deferens may be present whatever the sperm count, biological warnings are represented by semen volume and seminal epididymal markers and clinical warnings by surgical histories of undescended testes or inguinal hernia.

Update in the evaluation of the azoospermic male

Approximately 1% of all men in the general population suffer from azoospermia, and azoospermic men constitute approximately 10 to 15% of all infertile men. Thus, this group of patients represents a significant population in the field of male infertility. A thorough medical history, physical examination and hormonal profile are essential in the evaluation of azoospermic males. Imaging studies, a genetic workup and a testicular biopsy (with cryopreservation) may augment the workup and evaluation. Men with nonobstructive azoospermia should be offered genetic counseling before their spermatozoa are used for assisted reproductive techniques. This article provides a contemporary review of the evaluation of the azoospermic male.

Imaging of male infertility: pictorial review

OBJECTIVE

This article will review the workup of infertility in a male. The imaging of common conditions associated with infertility, including varicocele, ejaculatory duct obstruction, seminal vesicle agenesis, and undescended testis, will be shown, as well as other conditions that can be incidentally seen.

CONCLUSION

The analysis of infertility in males has become more common in recent years. The practicing radiologist should be familiar with the evaluation of the infertile man and the common radiologic findings and disease processes associated with infertility.

Imagerie et fertilité, quelles conséquences pour l’andrologue ? Imagerie du scrotum vue par le radiologue

L’échographie scrotale fournit à l’andrologue des informations iconographiques, susceptibles de changer fondamentalement la prise en charge du patient hypofertile. La recherche de signes d’obstruction canalaire, la détection de pathologies testiculaires infracliniques et l’évaluation de la perfusion testiculaire sont les véritables challenges pour le radiologue. L’échographie du contenu scrotal doit être proposée à tout patient qui consulte pour infertilité, au même titre que le bilan biologique et spermiologique, car elle oriente le diagnostic clinique, permet la détection de pathologie occulte et influence la stratégie thérapeutique.

High-resolution sonography of the normal extrapelvic vas deferens

OBJECTIVE

The purpose of this study was to determine the reliability of sonographic visualization of the normal extrapelvic vas deferens and to analyze its appearance and dimensions.

METHODS

Scans of the scrotum and spermatic cords were obtained in 25 fertile volunteers. Identification of the vas deferens was attempted bilaterally in the scrotal, suprascrotal, and prepubic segments in all volunteers. When possible, the total thickness and the diameter of the lumen were measured. Visualization and dimensions were correlated with the body mass index (BMI) and abstinence interval.

RESULTS

All segments of the vas deferens were identified bilaterally in all volunteers. In all cases, it appeared as an anechoic or very hypoechoic tubular structure that was noncompressible and contained no detectable blood flow. It was convoluted inferiorly and became straight as it progressed from the scrotum to the suprascrotal and prepubic segments. The lumen was seen in the suprascrotal segment in all of the volunteers except the one with the highest BMI. The total thickness of the vas ranged from 1.5 to 2.7 mm (mean, 1.89 mm). The lumen of the vas ranged from 0.2 to 0.7 mm (mean, 0.43 mm). There was no correlation between the luminal diameter and the abstinence interval.

CONCLUSIONS

The extrapelvic portion of the vas deferens is reliably visualized sonographically. Its appearance is characteristic and reproducible. The lumen can be measured in almost all cases.

Clinical and radiological evaluation of ejaculatory duct obstruction

Ejaculatory duct obstruction (EDO) is a rare but surgically correctable cause of male infertility. With the advent and increased use of transrectal ultrasonography and magnetic resonance imaging, abnormalities of the ejaculatory duct (ED) related to infertility have been diagnosed more frequently. Recently, with the increased awareness of functional obstruction of ED, reports have been focusing on the diagnosis of partial or functional EDO. We present 2 review of the ED pathologies, imaging modalities and treatment options.

Inflammatory disorders of the prostate and the distal genital tract

Inflammatory disease of the prostate and distal genital tract is emerging as a major health problem because it is estimated that up to 15% of adult men may be affected at some point in their lives. Clinically, the diagnosis of "prostatitis" refers to multiple disorders that cause pelvic pain and discomfort, ranging from acute bacterial infection to complex conditions that may not necessarily be caused by prostatic inflammation. Because the traditional etiology-based classification system did not always correlate with symptoms and therapeutic efficacy, a new classification of prostatitis has been suggested by the National Institutes of Health. New imaging techniques such as high-resolution transrectal ultrasonography (TRUS) and MR imaging provide exquisite anatomic detail and often play a crucial role in the evaluation of these patients.

Normal and variant appearances of the adult epididymis and vas deferens on high-resolution sonography

PURPOSE

To describe the appearance, anatomic position, and size of the normal adult epididymis and vas deferens using high-resolution sonography.

METHODS

The sonographic appearance, anatomic position, and size of the epididymal head (EH), epididymal body (EB), epididymo-deferential loop (EDL), and vas deferens (VD) were evaluated in 112 consecutive infertile men (infertile group), and the data were compared with those from 84 consecutive men without history of infertility (reference group).

RESULTS

Compared with the testis, the EH was isoechoic, the EB hypoechoic, and the VD anechoic. In 88.4% of cases in the infertile group and 97.6% of cases in the reference group, the EH was located above the upper pole of the testis, with the EB lateral to the testis and the EDL below the lower pole of the testis. In 9% of cases in the infertile group and 6% of cases in the reference group, the EB was located posterior to the body of the testis, with the EDL inverted and the VD anterior to the ET. In 11.6% of cases in the infertile group and 2.4% of cases in the reference group, the epididymis was inverted, with the EH located below the lower pole of the testis. The mean (+/-SD) normal sizes were as follows: EH, 7.6 +/- 1.6 mm; EB, 3.2 +/- 0.8 mm; EDL, 7.7 +/- 1.3 mm; VD, 1.9 +/- 0.2 mm. No statistically significant differences in size were found between the 2 groups.

CONCLUSIONS

We describe the normal and variant appearance, position, and size of the adult epididymis and VD on high-resolution sonography.

Hematospermia: imaging findings

Hematospermia is an anxiety provoking but otherwise generally benign and self-limited condition that is infrequently associated with significant underlying pathology, and is most often considered to be idiopathic in nature. Management with routine clinical evaluation, watchful waiting, and reassurance generally suffice without further diagnostic workup or treatment. Noninvasive imaging may play an important role in the diagnostic workup of men with hematospermia, particularly in those who are >40 years old, have other associated symptoms or signs of disease, or have persistence of hematospermia. Many entities may be encountered in association with hematospermia at imaging, and specific therapeutic interventions may be used if certain treatable underlying pathologies are coincidentally detected. In this comprehensive review, we discuss the potential etiologies, diagnostic workup, imaging techniques, relevant male pelvic anatomy, imaging appearance of specific associated pathologies, and treatment for hematospermia.

Sonographic findings of the genital tract in boys with cystic fibrosis

This pictorial review illustrates the findings in the sonographic examination of the male genital tract in children with cystic fibrosis (from newborn to age 12 years). We illustrate the variability in appearance and discuss the differences in findings from those in adult males with cystic fibrosis.

Transrectal US–guided Seminal Vesiculography and Ejaculatory Duct Recanalization and Balloon Dilation for Treatment of Chronic Pelvic Pain

Ejaculatory duct obstruction (EDO) is an uncommon but correctable cause of infertility and male chronic pelvic pain. The condition is thought to be underdiagnosed, but the increased application of noninvasive imaging tools, specifically transrectal ultrasonography (US), has lead to greater recognition of EDO. Moreover, the development of minimally invasive therapies now offers comprehensive evaluation and treatment options with low morbidity for select patient groups. This report describes the technique of transrectal US-guided seminal vesiculography, percutaneous recanalization, and ejaculatory duct balloon dilation for EDO as a treatment for male chronic pelvic pain.

Transurethral resection of the ejaculatory ducts for treating ejaculatory symptoms

OBJECTIVES

To report our experience with transurethral resection of the ejaculatory ducts (TURED) in infertile men with symptomatic ejaculatory duct obstruction (EDO).

PATIENTS AND METHODS

Before surgery, all patients complained of a decrease in the volume of their ejaculate, 14 of 15 had a non-projectile ejaculation, nine had a genitourinary infection necessitating antibiotic treatment, and five had pain with orgasm. The mean ejaculate volume and total motile sperm count was 1.1 mL and 8.1 million sperm per ejaculate. After surgery, at a mean follow-up of 2 months, 10 men reported having projectile ejaculation, and eight reported a marked improvement in their sensation of orgasm. Overall, 14 men reported a subjective improvement in their ejaculation. The average postoperative ejaculate volume was 2.3 mL and the total motile sperm count was 38.1 million per ejaculate.

CONCLUSIONS

Men with symptomatic EDO who underwent TURED showed improvements in their ejaculation, sensation of orgasm, semen analysis values and fertility.

[The value of ultrasound in diagnosis of male infertility]

INTRODUCTION

The number of male patients with clinical presentation of infertility, especially secondary infertility after infections, is increasing every day. Contemporary urological standards in defining male infertility include ultrasound examination. Ultrasound examination of the scrotum using color doppler is of great importance.

DIAGNOSIS OF MALE INFERTILITY

Testicular atrophy, microlithiasis and varicocele are the most common causes of male infertility. Microlithiasis and classical testicular microlithiasis are not directly associated with infertility. Gray scale sonography is used in evaluation of the dilatation of the testicular veins, but color Doppler made a real contribution in revealing subclinical varicocele. Transrectal ultrasound is used in a number of pathological conditions of prostate, seminal vesicles and ducts. In cases of obstructive azoospermia it is important to find out the cause, such as focal prostatitis, cysts, ejaculatory ducts obstruction or absence of vas deferens.

CONCLUSION

Ulltrasound is a noninvasive method easy to perform, which provides information without postexamination consequences such as strictures or obstructions, which are possible after invasive deferentography. Ultrasound guided biopsy, provides a new minimally invasive diagnostic tool in current urology.