Monday, 23 September 2019

Azospermia how best to find out the etiology.


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?  

The Other algorithm based on FSH level
If the male partner declines to undergo clinical examination or the doctor do not feel comfortable to examine him then we usually first estimate the serum FSH and frame the future investigations accordingly.
A)     Very high FSH: - Possibly primary testicular failure: - This is NOA(no-obstructive Azoo) – routine genetic  analysis is more relevant in these cases and such tests are also relevant in severe OAT. In fact it is often quoted that 5% of all infertile male have somatic karyotypic disorders and if such tests are limited to azoospermic males than he prevalence of peripheral karyotypic disorders will be as high as 15%!  At this juncture one should consul about different options like ICSI/ Donor Insemination/ Adoption/ accepting the philosophy remaining childless. Needless to mention that ICSI, if acceptable to couple should be counselled for genetic testing for routine karyotyping & Yq deletions, Even in cases where, genetic abnormalities have been reasonably ruled out àICSI procedure in cases with high FSH should be ideally done by an experienced Andrologist-Trial testàwithout any definite assurance to couple à Trial  Bilateral multiple testicular micro biopsies.
B)      Borderline FSH: - We usually prefer Needle biopsies. --> To clarify for further stepsà AID/Adoption/ ICSI.
C)      Normal FSH: - usually Implies Obst. Azoo. à Needle biopsyà
D)  1) Sperms retrievatedà May opt for Cryopreservationà  If thawed cryopreserved sperms are nonviable then one have again try for TESE.PESA/ICSI/rarely repair of obstruction---tedious reconstructive surgical procedures possibly with more uncertainties.2) No sperms retrievable by needle biopsyà Counsel for DI/ Adoption/ Top of Form
In In Nonobstructive Azoospermia since non obstructive ,could be testicular or pre testicular. Assess LH, FSH levels .if very high then testosterone has no role


  
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