Scrotal US for Evaluation of Infertile Men with Azoospermia

1. Scrotal US for Evaluation of Infertile Men with Azoospermia From the Departments of Radiology (M.H.M., J.Y.C.), Urology (J.T.S.), and Pathology (Y.K.C.), Samsung Cheil Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Radiology, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea (S.H.K.). Received February 17, 2005; revision requested April 14; revision received May 10; final version accepted June 13. Address correspondence to S.H.K.(e-mail: kimsh @radcom.snu.ac.kr). RSNA, 2006 Radiology: 168-173 Volume 239: Number 1—April 2006 Presented by Intern 黃俊肇

2. Introduction • WHO:Infertility: inability to initiate a pregnancy after 1 year of unprotected intercourseIn approximately 50%, male factors5-10%: azoospermia: absence of sperm 1.Non-obstructive: such as primary testicular failure advanced assisted reproductive technique (intracytoplasmic sperm injection) 2.Obstructive: amenable to interventional correction

3. Introduction • Transrectal US • Absence of the vas deferens • Obstruction in the ejaculatory duct • Scrotal US • Nonpalpable varicocele • Distinguish Testicular failure from obstruction1.abnormality in the proximal genital duct2.secondary changes of proximal genital duct due to distal genital duct obstruction • Goal: evaluate scrotal US to distinguish obstructive from nonobstructive azoospermia in infertile menthe standard reference: histologic findings

4. Materials • Study population: • October 2003 ~ January 2005 • 20 infertitle men with azoospermia • Mean age: 34.7 (21~44y/o) • Retrograde ejaculation were excluded by postejaculation urine analysis

5. Methods • US technique: • Investigator with 8 years experience in GU US • HDI 5000 with a 5~12MHz linear-array transducer • Patient: supine, scrota were supported by a towel between the thighs • Testicular volume: formula of Lambert: L x W x H x 0.71 • Testis and paratesticular area were checked • Valsava maneuver or upright position for venous evaluation if needed

6. Methods • Image interpretation • Without knowledge of histologic findings • Testis: Normal Abnormal: anechoic tubular structure or cystsectasia of the rete testis • Paratesticular area (epididymis): • Head: normal, absent, tubular ectasia, inflammatory masslike lesion • Body: normal, absent, tapering, inflammatory masslike lesion • Tail: Normal, absent, inflammatory masslike lesion • Vas deferens: not evaluate due to unreliably identified by scrotal US

7. Methods • Standard reference • 19/20 pt receive biopsy of the testis • Histologic resultes were provided by each of five staff pathologist (14, 28, 22, 14, 7 years) • Obstructive azoospermia: • Normal spermatogenesis, mild hypo • Nonobstructive azoospermia: • Severe hypo, maturation arrest, germ cell aplasia

8. Methods • Statistical analysis: • (SPSS, version 10.0, SPSS, Chicago, III) • Fisher exact test for assessing the difference of proximal duct • Wilcoxon signed rank sum test for assessing difference of testicular volume • P<=0.05 was significant

9. Results • Study group, by histologic prove:

10. Results • US findings in obstructive azoospermia (24/28 (86%) abnormal)

11. Epididymal abnormality Tubular ectasia, head Inflammatory mass, head

12. Tapering, body Tapering, body Inflammatory mass, body Inflammatory mass, tail

13. Results • US findings in nonobstructive azoospermia • 1/12 abnormal: multiple cysts in the mediastinum testis • The testis seemed to be smaller than in obstructive azoospermia

14. Testicular size Ejaculatory duct obstruction, multiple cysts Klinefelter syndrome, cyst

15. Results By epididymis abnormality: Sensitivity:82.1%, specificity: 100%, accuracy: 87.5%

16. Discussion • Azoospermic patient • Obstructive: • Surgical correction (vasoepididymostomy) • Lower cost • Natural pregnancy may filter some chromosomal or genetic abnormality • Prevent epididymal damage during sperm retrieval • Intracytoplasmic sperm injection • Single small testis biopsy is adequate • Nonobstructive: • Intracytoplasmic sperm injection • Multiple or larger sampling are needed

17. Previous evaluation tools • Vasography has been the reference standard • For distal genital duct • Invasiveness • Risk of genital duct scarring • Transrectal US • Easily depict the distal genital duct • Noninvasive • Low cost • Anatomic abnormalities (except CBAVD) don’t have a consistent causal relationship with obstructive azoospermia • The proximal genital duct cannot be evaluated

18. Advance in Scrotal US • Scrotal US • Traditionally only for nonpalpable varicocele • Recent advances in US equipment • Detailed anatomic evaluation for proximal genital duct • Also can predict distal genital duct due to the pathologic change at more proximal genital duct

19. Limitation • The results are limited by the small number of patients but it confirmed previous reports regarding pathologic changes of the proximal genital duct in the obstructive azoospermia • Although not all known causes for azoospermia are included  The scrotal US is still a possible tool for distinguish obstructive/nonobstructive azoospermia

20. Conclusion • Epididymal abnormalities depicted with scrotal US are significantly associated with obstructive azoospermia (P<.001) • Testicular volume is higher in obstructive azoospermia • Evaluate epididymis and testicular volume with scrotal US are important in distinguish obstructive from nonobstructive azoospermia