Algorithm / standard flow chart of
investigation of Azoospermia:-
When a report comes with azoospermia,
we the clinicians usually, step A) enquire details of “Semen collection errors” . We, like all
other ART centers, also routinely ask for repeat analysis with a telephonic
request to the pathologist concerned about insisting on step B)
high speed
centrifugation and looking for presence of sperms in the centrifuge deposits/
pellets. If that too is negative we usually again approach the concerned
male about anejaculation ( for post-orgasmic) step
C) post
void urine centrifugation –looking for sperms. Unfortunately these procedures
though adopted routinely in ART clinics but in Medical Colleges where rush of
patients is too much –these two essential steps are sometimes missed even by
the consultants. This has happened many a times. Urine for presence of sperms in case of anejacuatory disorders though
in the present state of knowledge we do not encourage such cumbersome tests
,Instead we proceed for ICSI procedures.
Post void urine centrifugation
–looking for sperms. Unfortunately these procedures though adopted routinely in
ART clinics but in Medical Colleges where rush of patients is too much –these
two essential steps are sometimes missed even by the consultants. This has
happened many a times. step
D Don’t
add more trauma psychologically
traumatized male step
E so that he keeps coming, Counsel the male
with respect :Encourage
him that It is a
correctable diosrders.It (azoo) is not cancer . There will be some methods available
for you, my dear son, Another thing, I have witnessed that there are many drop outs in this cumbersome
procedure in a psychologically shocked male partner. He, in many cases
stops coming to hospital. Possibly it also happens in established reputed
clinics too. The couple have a preformed notion that azoospermia is
uncorrectable and has no treatment. They equate this pathological observation
with sterility. I have a feeling that if these procedures (initial semen
report, subsequent procedures including hormone assay) could have been carried
out in the same floor of a particular building, I feel that the dropout rates
would have been less. I do not know how other doctors feel about this – i.e.
handling a psychologically traumatized male patient roaming from Pathology
Deptt àto endocrine deptt àand then to surgical wingà back to infertility OPD. Here is the flow chart which we
follow in our Medical College. Admittedly, this algorithm should not be
considered as standard, and has some
limitations
Step
F Clinically examine
the concerned male partner and try to correlate with the lab Reports-. For instance clinical examination
can also estimate size and consistency
of testis, retractile tests, Cryptorchidism, large varicocele, tubercular
epididymitis/ previous scrotal surgery and other epididymal diseases. It cost
nothing but male partner feels that he is duly cared in the concerned
institution. Because by the time report (azoospermia) is in his hands he gets
tremendous psychological trauma which all of us are aware but possibly cannot
analyze the magnitude of shock which accompanies with such report. Simple
clinical local exam of male partner will paves the path for trust between male
partner and doctor which eases obstacles/ barriers of subsequent investigations
of male partner. Therefore I reiterate that all cases of Azoo should be
clinically examined which is often omitted and therefore some obvious causes
are missed. This applies to OAT cases too.
This algorithms based
on clinical examination : Vas pupation.(described
below) the other way is to stepwise proceed as per
A)
Step
G If, clinically vas cannot be palpated (vasal aplasia)
- one should try
excluding CABV (congenital absence of
bilateral vas) – we straightaway refer to another nearby ART centre for
further evaluation in such a situation ideally
CFTR gene assessment will be prudent and if negative for mutation then
PESA/ICSI may be considered. If mutation
is + then also one can proceed in the same way but ICSI -ET programme but ET
should be preceded by PGD. (Though there are some imitations of PGD).
B)
Step
G :- Vas presentàis their presence of Fructose in routine semen
analysis? - If yes
then it is usually (but not always) unlikely to be a case of Obst.
Azoo. Such persons are more likely to be primary Testicular disease/H-P Axis disorder. So for fructose +
persons next step will be estimation of FSH as a
minimum.
C)
A) If
FSH is high then it is likely to be a case of Primary Testicular
failure (primary disease of testis= what Andrologist designate as Primary
testicular Failure). High FSH, hopefully, excludes any Hypo/Pit disorder. In
such settings one should ideally proceed
for
D)
Y Q deletion and other chromosomal abnormalities
preferably in consultation with the clinical geneticist. If they
approve then only one should proceed for multiple bilateral testicular micro biopsies.
Fructose amount can be estimated by biochemistry Deptt. Good fructose implies
healthy & functional seminal vesicles.
E)
step G :-If Fructose +, and
FSH normalà then needle biopsy without karyotyping—If sperm are retrievable then one
can proceed for PESA, ICSI, or
Microsurgery(VEA). Only if no sperm could be extracted then one can counsel for
DI/ Adoption.
step
H:- Fructose negative
Azoospermia: -
ejaculatory duct obstruction has to be confirmed by adopting imaging
modalities. One can opt for localizing the site of Obstruction especially by
rectal USG (TR USG). If seminal vesicles are dilated then TUR by urologist may
open the obstructed Ejaculatory Duct.
If USG reveals normal size seminal vesicles- then in all
probability the degree of obstruction is usually INOPERABLE BLOCK- --one can opt for PESA/ICSI in
consultation with Andrologist. It is also said that fertilization rates are
higher in vases of Obstructive Azoo than
NOA – though maternal age is an important factor. to workup for obstructive vs non obstructive. What is semen
pH? What is the volume? Semen fructose - quantitative analysis? Seminal vesicle
dilated?
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