EVALUATION OF EPIDIDYMAL AND TESTICULAR SPERM ASPIRATION IN AZOOSPERMIC INFERTILE MALES IN BASRAH

This study aimed to evaluate the safety and efficacy of percutaneous epididymal and testicular sperm aspiration as a diagnostic technique to confirm sperm production and as a therapeutic technique to harvest sperms for use in the intracytoplasmic sperm injection and the indications for performing testicular biopsy in azoospermic infertile males. Thirty married patients were included in this prospective study from February 2011 to December 2012 seen in Basrah General Hospital. Their age ranged from 20 to 40 years. All patients underwent full medical examination with laboratory tests which included seminal fluid analysis, serum leutinising hormone (LH), follicular stimulating hormone (FSH), testosterone, and prolactin in addition to color Doppler ultrasonography of the scrotum. Patients with history of undescended testes, varicocele, & testicular pathology were excluded from this study. All patients showed normal physical examination with normal secondary sexual characters. The external genitalia were normal with normal sizes of their testes. The percutaneous epididymal and testicular sperm aspirations were positive in 12 out of 30 patients (40%). The rest had negative aspirations (60%). The testicular biopsy which performed in the patients with negative aspiration showed normal germinal epithelium with mature spermatozoa in only 5 patients out of 18 (28%) while the rest 13 patients had spermatogenic arrest (72%). In conclusion, percutaneous epididymal and testicular sperm aspiration has been found helpful as a diagnostic technique for patients with non-reconstructable azoospermia. It is a minimally invasive sperm retrieval technique and appears to be an effective alternative to microsurgical epididymal sperm aspiration, which is more invasive and costly. It is less invasive than testicular biopsy and preferably performed as a first step procedure in an attempt to obtain sperms for both diagnostic and therapeutic purposes. Introduction nfertility is the inability of a sexually active, non-contracepting couple to achieve pregnancy in one year 1 . Conception is normally achieved within 12 months in 80 to 85% of couples who are not using contraceptive measures 2 . Infertility affects both men and women. Male causes for infertility are found in 50% of these couples. In many couples, however, male and female factors are present. In case of a single factor, the fertile partner may compensate for the less fertile partner. Infertility then usually becomes manifest if both partners are subfertile; this explains why in infertile couples there is often a coincidence of male and female factors. Reduced male fertility can be the result of congenital and acquired urogenital abnormalities, infections of the male accessory glands, increased scrotal temperature (varicocele), endocrine disturbances; genetic abnormalities and immunological factors. In 40–60% of cases there is abnormal seminal analysis and there is no relevant history or abnormality on physical examination and endocrine laboratory testing (idiopathic male infertility) 1 . I Evaluation of Epididymal and Testicular Sperm Aspiration Murtadha Al-Musafer & Safaa Al-Maatooq Bas J Surg, December, 20, 2014 82 primary spermatogenic failure is defined as impaired spermatogenesis originating from causes other than hypothalamicpituitary diseases. The severe forms of primary spermatogenic failure have a clinical presentation as non-obstructive azoospermia. Typical findings from the physical examination of a patient with spermatogenic failure may be abnormal secondary sexual characteristics, gynaecomastia and low testicular volume and/or consistency. Follicle Stimulating Hormone (FSH) may be elevated (Hypergonadotrophic hypogonadism) or normal. Obstructive azoospermia means the absence of both spermatozoa and spermatogenic cells in semen and postejaculate urine due to bilateral obstruction of the seminal ducts 1 . Intratesticular obstruction has been reported in 15% of obstructive azoospermia 3 and is usually caused by post-inflammatory obstruction of the retetestis. Epididymal obstruction is the most common cause of obstructive azoospermia; affecting 30-67% of azoospermic men 4 . Congenital forms of obstruction (disjunction between efferent ductules and corpus epididymis, agenesis/atresia of a short part of the epididymis) are rare. Young’s syndrome, characterised by proximal epididymal obstruction and chronic sinopulmonary infections 5 , results from a mechanical blockage due to debris within the proximal epididymal lumen. Among the acquired forms, those secondary to acute (gonococcal) and subclinical (e.g. chlamydial) epididymitis are considered to be the most frequent 6 . Azoospermia caused by surgery may occur after bilateral epididymal cyst removal. Vas deferens obstruction following vasectomy is the most frequent cause of acquired obstruction. About 2– 6% of these men request vasectomy reversal. Of those undergoing vasovasostomy, 5–10% will also have an epididymal blockage due to tubule rupture, making vasoepididymostomy mandatory 7 . Congenital bilateral absence of the vas deferens (CBAVD) is found in 1:1600 men and in all men with cystic fibrosis. Men with CBAVD appear to have mutations of the cystic fibrosis gene in 85% of the cases. CBAVD can therefore be considered a genital form of cystic fibrosis 8 . Ejaculatory duct obstruction is found in about 1–3% of obstructive azoospermia 9 . These obstructions can be classified as cystic or post-inflammatory. Cystic obstructions are usually congenital (Müllerian duct cyst or urogenital sinus/ejaculatory duct cysts) and are medially located in the prostate between the ejaculatory ducts. In urogenital sinus anomalies, one or both ejaculatory ducts empty into the cyst, while in Müllerian duct anomalies, ejaculatory ducts are laterally displaced and compressed by the cyst 10 . Post-inflammatory obstructions of the ejaculatory duct are usually secondary to urethroprostatitis 11 . Congenital or acquired complete obstructions of the ejaculatory ducts are commonly associated with low semen volume, decreased or absent seminal fructose and acid pH. The seminal vesicles are usually dilated (anteriorposterior diameter >15 mm) on transrectal ultrasound 12 . Typical clinical findings in men with obstructive azoospermia are a normal testicular volume, enlarged and hardened epididymis, nodules in the epididymis or vas deferens, absence or partial atresia of the vas deferens, signs of urethritis or prostatitis and Prostatic abnormalities on rectal examination. Obstructive lesions of the seminal tract should be suspected in azoospermic or severely oligozoospermic patients with normal-sized testes and normal endocrine parameters 1 . Percutaneous epdidymal and teticular aspirations were first described in 1928 by Huhner as a diagnostic technique for cases Evaluation of Epididymal and Testicular Sperm Aspiration Murtadha Al-Musafer & Safaa Al-Maatooq Bas J Surg, December, 20, 2014 83 of infertility 1 . Since then, the pathological findings of percutaneous epididymal and testicular aspirations have been shown to correlate with open testicular biopsies in 87 to 94% of cases. Using 20 to 23 gauge needles, this diagnostic procedures have been performed with few complications or adverse effects 2-4 . Aim of the study The aim of this study is to evaluate the *safety and *efficacy of percutaneous epididymal and testicular sperm aspiration as a diagnostic technique to confirm sperm production and as a therapeutic technique to harvest sperms for their subsequent use in the intracytoplamic sperm injection (ICSI), and the indications for performing testicular biopsy. * Regarding post-aspiration complications * Sperm retrieval rate in comparison with the standard testicular biopsy Patients & Methods Thirty married patients with azoospermia were included in this comparative study from February 2011 to December 2012 in Basrah General Hospital. All patients underwent epididymal and testicular aspirations initially. Those with negative aspiration (no sperms in the aspirate) were subjected to the standard testicular biopsy procedure. Their age ranged from 20 to 40 years. All patients underwent full medical examination with laboratory tests which included two seminal fluid analysis, post ejaculate urine for sperms, serum Leutinising Hormone (LH), Follicule Stimulating Hormone (FSH), testosterone, and prolactin in addition to color doppler ultrasonography of the scrotum. Transrectal ultrasound (TRUS) not available in Basrah center. Patients have no past history of: Crypto-orchidisim, Testicular pathology (torsion or trauma), Infection (tuberculosis or mumps orchitis), Chemotherapy/Radiotherapy, Surgery (orchidopexy, retroperi-toneal/pelvic, herniorrhaphy, prostatic surgery) Retrograde ejaculation. All patients showed normal physical examination with normal secondary sexual characters and no gynaecomastia. The external genitalia were normal with normal sizes of their testes, and normal endocrine parameters which include (serum LH, FSH, testosterone, and prolactin). Method of epididymal sperm aspiration After obtaining patient's consent, the aspirations were performed in a minor procedure room in Basrah general hospital and Al-manar fertility center with the patient under local anesthesia (spermatic cord block which was performed by injecting 5cc of 1% lidocaine into the spermatic cord at the pubic tubercle area bilaterally). Before aspiration, patients received a single intravenous dose of a broad-spectrum antibiotic (1gram of cefotaxime). The epididymis was immobilized by the first assistant who stabilized the inferior two-thirds of the testicle. The scrotum overlying the epididymis was pulled taut. The superior pole of the testicle was presented to the operating surgeon who grasped the epididymis carefully between the thumb and index finger. A 23 gauge butterfly needle was directed into the caput of the epididymis and suction was applied by pulling back on the p