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
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/
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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