1. Scrotal US for Evaluation of Infertile Men with Azoospermia
Radiology: 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 , 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.( RSNA, 2006

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. Epididymal abnormality
Tubular ectasia, head
Inflammatory mass, head

12. Tapering, body
Tapering, body
Inflammatory mass, body
Inflammatory mass, tail

13. 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

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

15. 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%

16. 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

17. 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

18. 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

19. 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

20. 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