Scrotal US for Evaluation of Infertile Men with Azoospermia Radiology: 168-173 Volume 239: Number 1—April 2006 Presented by Intern 黃俊肇 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

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

Introduction Transrectal US Scrotal US Absence of the vas deferens Obstruction in the ejaculatory duct Scrotal US Nonpalpable varicocele Distinguish Testicular failure from obstruction 1.abnormality in the proximal genital duct 2.secondary changes of proximal genital duct due to distal genital duct obstruction Goal: evaluate scrotal US to distinguish obstructive from nonobstructive azoospermia in infertile men the standard reference: histologic findings

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

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

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

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

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

Results Study group, by histologic prove: Obstructive 14 Congenital bilateral absence of the vas deferens(CBAVD): 9 Inflammatory-associated obstruction: 5 Nonobstructive 6 Klinefelter syndrome: 1 Y microdeletion: 1 Unexplained testicular failure: 4

Results Epididymis Head (61%) Body (64%) Tail (71%) Mediastinum testis US findings in obstructive azoospermia (24/28 (86%) abnormal) Epididymis Head (61%) Tubular ectasia (11) Absence (4) Inflammatory masslike lesion (2) Body (64%) Tapering (8) Absence (7) Inflammatory masslike lesion (3) Tail (71%) Absence (15) Inflammatory masslike lesion (5) Mediastinum testis (10%) Multiple cysts (3)

Epididymal abnormality Tubular ectasia, head Inflammatory mass, head

Tapering, body Tapering, body Inflammatory mass, body Inflammatory mass, tail

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

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

Results Epididymis Head 17(61) <.001 Body 18(64) Tail 20(71) US Abnormalities Obstructive Azoospermia (n=28) Nonobstructive Azoospermia (n=12) PValue Epididymis Head 17(61) <.001 Body 18(64) Tail 20(71) Overall* 23(82) Testis Mediastinum 3(11) 1(8.3 ) NS Volume(cm3) 7.7~25.8 (11.6) 1.2~16.4 (8.3) <.05 By epididymis abnormality: Sensitivity:82.1%, specificity: 100%, accuracy: 87.5%

Discussion Azoospermic patient Obstructive: Nonobstructive: 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: Multiple or larger sampling are needed

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

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

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

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