Quantitative testicular biopsy in congenital and acquired genital obstruction

Advances in the management of infertility in men with spinal cord injury

Couples with a spinal cord injured male partner require assisted ejaculation techniques to collect semen that can then be further used in various assisted reproductive technology methods to achieve a pregnancy. The majority of men sustaining a spinal cord injury regardless of the cause or the level of injury cannot ejaculate during sexual intercourse. Only a small minority can ejaculate by masturbation. Penile vibratory stimulation and electroejaculation are the two most common methods used to retrieve sperm. Other techniques such as prostatic massage and the adjunct application of other medications can be used, but the results are inconsistent. Surgical sperm retrieval should be considered as a last resort if all other methods fail. Special attention must be paid to patients with T6 and rostral levels of injury due to the risk of autonomic dysreflexia resulting from stimulation below the level of injury. Bladder preparation should be performed before stimulation if retrograde ejaculation is anticipated. Erectile dysfunction is ubiquitous in the spinal cord injured population but is usually easily managed and does not pose a barrier to semen retrieval in these men. Semen analysis parameters of men with spinal cord injury are unique for this population regardless of the method of retrieval, generally presenting as normal sperm concentration but abnormally low sperm motility and viability. When sperm retrieval is desired in this population, emphasis should be placed on initially trying the simple methods of penile vibratory stimulation or electroejaculation before resorting to more advanced and invasive surgical procedures.

Diagnostic value of differential quantification of spermatids in obstructive azoospermia

Testicular biopsies from 80 azoospermic young men were revised and the average numbers per cross-sectioned tubule of each germ cell type were calculated and compared with those of control normal testes. In 53 patients, azoospermia had an obstructive cause, and in 22 of those 53 patients more adult spermatids were found by testicular biopsy than young spermatids (over 100% in some testes), in one or both testes. However, in normal testes fewer mature spermatids than young spermatids (23.3%) were found. In the 22 patients, the causes of azoospermia were: vasectomy (7 patients), bilateral agenesis of the vas deferens (3 patients), Young syndrome (3 patients), bilateral cysts in the caput epididymidis (1 patient), bilateral inguinal herniorrhaphy (1 patient), left varicocele (1 patient), and unknown causes (6 patients). Biopsies were bilateral except for 3 cases (a vasectomized patient, a patient with Young syndrome, and a patient with obstruction due to an unknown cause). Hormonal levels were normal in the 22 patients. In addition, testicular biopsies of 3 twisted testes from 3 young adult men showing a number of adult spermatids higher than that of young spermatids were also included in the study. All testicular biopsies-including those of the twisted testes-showed an obstructive histologic pattern, consisting of a mosaic distribution of testicular lesions: mainly tubular ectasis and germ cell sloughing into the adluminal compartment of seminiferous tubules. The increase in the number of adult spermatids was bilateral in 1 of the 6 vasectomized men who underwent bilateral biopsy, and in 7 of the 11 bilaterally biopsied patients with obstructive azoospermia due to other causes. The most probable explanation for the increased number of adult spermatids is stagnation of testicular fluid, caused by sperm excretory duct obstruction. The unilateral increase in the number of adult spermatids in vasectomized men might be related to the occurrence of a spermatic granuloma (a frequent finding in vasectomy) in the proximal end of the sectioned ductus deferens ipsilateral to the testis with nonincreased adult spermatid numbers, and the absence of spermatic granuloma in the ductus deferens ipsilateral to the testis with increased adult spermatid numbers. This granuloma would produce, in addition to spermatozoon destruction, reabsorption of the testicular and epididymal fluids. The higher rate of bilateral increase, in the number of young spermatids observed in the patients with congenital lesions of the ductus deferens or the ductus epididymidis, might be related to the absence of spermatic granulomas in congenital obstructions.