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ANDROLOGY ABSTRACTS
Year : 2015  |  Volume : 7  |  Issue : 5  |  Page : 24-37  

Andrology Abstracts


Date of Web Publication20-Mar-2015

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How to cite this article:
. Andrology Abstracts. Urol Ann 2015;7, Suppl S1:24-37

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. Andrology Abstracts. Urol Ann [serial online] 2015 [cited 2020 Aug 5];7, Suppl S1:24-37. Available from: http://www.urologyannals.com/text.asp?2015/7/5/24/153732

Clinical varicocele negatively influences serum testosterone, and varicocele repair improves serum testosterone among hypogonadal infertile men

Taha A. Abdel-Meguid*, Hasan Farsi, Hisham Mosli, Abdulmalik Tayib, Ahmad Al-Sayyad, Abdulghafour Halawani


King Abdulaziz University, Jeddah, Saudi Arabia

Purpose: To determine the impact of clinical varicocele on serum total testosterone (T), and the effect varicocele correction on T in infertile men; and to identify variables correlating with T changes.

Methods: This 4-group prospective, controlled, nonrandomized study involved 165 adult men. 66 infertile men who underwent varicocelectomy comprised the VIT (varicocele infertile treatment) group. 33 varicocele-infertile control men (VIC) and 33 varicocele-fertile control men (VFC) were observed only. Normal-control (NC) group included 33 fertile men without varicocele. Varicocele men were stratified at baseline into hypogonadal (T <300 ng/dL) or eugonadal (T ≥300 ng/dL) subgroups. Main outcome measurements were between-group baseline T differences; and within-group T changes at 6- and 12-month follow-ups of men with varicocele. Two-tailed P < 0.05 was considered significant.

Results: Means (SD) of baseline T in VIT, VIC, VFC, and NC were 347.4 (132.1), 339.7 (125.8), 396.6 (164.9), and 504.8 (149.7) ng/dL, respectively. The baseline T levels of varicocele groups were comparable, whereas they were significantly low compared with NC group. At 6-month follow-up, VIT demonstrated significant T improvements (mean change = 44.7 ng/dL; 12.9%; P < 0.0001). T changes were more remarkable among baseline hypogonadals (mean change = 93.7 ng/dL; 40.1%; P < 0.0001) compared with eugonadals (mean change = 8.6 ng/dL; 2.01%; P = 0.1223). These improvements were persistent at 12-month follow-up. Contrariwise, VIC and VFC exhibited non-significant T changes. Post-varicocelectomy T changes correlated significantly and inversely with baseline T (r = −0.689; P < 0.0001). This correlation was stronger and more significant among hypogonadals (r = −0.528; P = 0.004) than eugonadals (r = −0.400; P = 0.013). T improvements also exhibited significant positive correlations with preoperative and postoperative sperm concentrations. No other variable demonstrated significant correlation.

Conclusion: Baseline T was significantly low in men with varicocele compared with normal men. Varicocelectomy yielded significant T improvements among hypogonadal men but insignificant changes in eugonadals. Testosterone level changes after varicocelectomy significantly correlated inversely with baseline serum testosterone, and positively with sperm concentrations. Improved serum testosterone may have a role in predicting improvement of sperm concentration after varicocele repair. Should low testosterone be considered as a standalone indication for varicocelectomy remains to be determined.

Clomiphene citrate and human chorionic gonadotrophin are good alternative therapy to testesterone in hypogonadal men seeking fertility

Mohammed Habous


Elaj Medical Centers, United Arab Emirates

Background and Objectives: Secondary, or late onset, hypogonadism (LOH) is a common problem in the ageing male population. It is significantly associated with various comorbidities such as obesity, diabetes, hypertension, and osteoporosis.The standard therapy for hypogonadism is testesterone (T) which is not suitable for men seeking fertility - a major problem in many men from the Gulf States. We wished to compare the efficacy of single agent clomiphene citrate (CC), human chorionic gonadtrophin (HCG), and a combination of the two in symptomatic patients of LOH wishing to preserve fertility.

Methods: In this unblinded multicentre RCT, a total of 287 hypogonadal patients were randomly enrolled 2:2:1 into three groups. Group A (n = 88) were given HCG 5000 international units (i.u) intramuscularly once a week; group Group B (n = 82) took CC 50 mg daily, and group C (n = 41) took both HCG and CC (our previous standard treatment) A non-randomised control group of consecutive patients (D: n = 76) who did not wish to preserve fertility were commenced on Testosterone depot (Nebido). All patients had physical examination, T measurements and glycosylated haemoglobin (HbA1c) at baseline,1 month and 3 months, as were Quantitative ADAM questionnaire (qADAM) scores. LH and FSH levels were checked at baseline, after 1-month and 3 months.

Results: The average age of patients were 42 being 47 for TU group, 40 for HCG, 38 for CC and 41 for combination group. All three treatments increased serum testosterone levels as shown in Table 1. Significant improvements were seen in the ADAM score in all groups. Improvements were seen in HbA1c and BMI in all groups, although not always reaching significance.

Conclusion: CC and HCG alone or in combination are good alternative therapy to T with comparable results and rapid onset subjectively and objectively in most hypogonadal men irrespective of their age but the outcome is less in obese patients.



Evaluation of radiological haemodynamic characteristics in the determination of clinically significant varicoceles

S. Abumelha, T. L. Yap, F. A. Al Mashat, A. Raheema, F. De Luca, N. Christopher, G. Garraffa, M. Walkden, D. Ralph, S. Minhas


Department of Andrology, University College London Hospitals, London, UK

Introduction and Objectives: The diagnostic radiological criteria utilised to define a clinically significant varicocele are not standardized and surgical intervention is often undertaken based on the use of nonstandardized ultrasonic parameters, which are largely operator dependent. The aim of this study was to determine whether venous diameter and venous reflux on colour Doppler ultrasonography correlated to reflux at venography in men with a clinically significant varicocele.

Materials and Methods: A case note review of men presenting to a tertiary referral centre for pain or fertility evaluation was undertaken retrospectively. 95 patients with a clinical varicocele (defined as grade II or III) underwent testicular ultrasound scanning and the haemodynamic parameters of venous diameter and reflux were assessed. Venous diameter was sub-divided into those varicoceles of <2.5 mm, 2.5-3 mm, 3-4 mm and >4 mm. Sensitivity and specifity of venous diameter and its association with reflux were analysed. A subset of patients that had ultrasound scanning performed underwent venography (n = 65) at the time of embolisation to assess venous incompetence and the ultrasonic haemodynamic parameters were correlated with reflux in this cohort.

Results: The mean age of patients was 37 years (range: 21-62). The mean maximum venous diameter of the varicoceles was 3.6 mm (range: 2-7 mm), with a mean of 3.9 mm (range: 2.5-7 mm) in those with reflux and 2.5 mm (range: 2-3.3 mm) in those without (significant difference, P < 0.001). Sensitivity and specifity of an ultrasound threshold of 3mm in detecting reflux was 78% and 95% respectively with a likelihood ratio of 16 [AUC = 0.94, P < 0.001, Graph 1] indicating that this cut off can significantly distinguish patients with reflux. A cut-off value for venous diameter of 3mm was significantly associated with presence of Doppler reflux (Fisher's exact test, P < 0.001). Venography confirmed reflux in 85% of those with USS diagnosed reflux and 88% in those with USS diameters >3 mm alone. A multiple regression analysis revealed that varicoceles size >3 mm was the strongest predictor of venography detected reflux (P = 0.002).

Conclusions: An ultrasound measured venous diameter greater than 3 mm was accurate (88% for USS), sensitive and specific at detecting reflux in clinical varicoceles. This cut off alone was more sensitive than Doppler detected reflux when the gold standard technique of venography was used to confirm the presence of reflux. Therefore an ultrasonic detected varicocele size of >3 mm appears to be the most appropriate objective haemodynamic parameter in determining patients suitable for varicocele intervention.



Hydroxyurea as a reversible cause of azoospermia in sickle cell anemia

Hamad Alakrash, Mohammed Kattan,

Mohammad Al Ghusin, Naif Al Hathal


Prince Sultan Military Medical City, Riyadh, Saudi Arabia

In this study we report a case of Sickle cell disease patient on hydroxyurea presented with primary infertility and non-obstructive azoospermia. The patient semen analysis records showed sperm count of 20 million/ml 2 years before this presentation. Intracytoplasmic sperm injection was planned and showed complete absence of mature sperms and microsurgical testicular sperm extraction showed no recovered spermatozoa. Surprisingly after only 3 months of the cessation hydroxyurea semen analysis showed sperm count of 4.25 million/mL and 53% motility, intracytoplasmic sperm injection was rescheduled.

Key Words: Azoospermia, hydroxyurea, sickle cell disease

INTRODUCTION


0Hydroxyurea has been reported to impair spermatogenesis in animal studies, resulting in testicular atrophy, [1] reversible decrease in sperm count, [2] abnormal sperm morphology, [3,4] and motility. [1] Furthermore, the chromatin structure of germ cells is also affected, mainly in preleptotene spermatocytes [2,3] and increased apoptosis in spermatogonia and early spermatocytes [5] while stem spermatogonia do not seem to be affected, resulting in the possibility of repopulation of seminiferous tubules. Hereby, we report a case of reversible azoospermia after cessation of hydroxyurea in a patient with sickle cell anemia.

CASE REPORT

0A 30-year-old gentleman who is a known case of hepatitis C virus and sickle cell disease. The patient was started on hydroxyurea treatment 1-year ago for recurrent attacks of sickle cell crisis. He does not have any other medical problem and is currently not on any treatment other than hydroxyurea.

The patient is being followed in our IVF Clinic as a case of primary infertility and non-obstructive azoospermia. Interestingly, his sperm count was 20 million/mL 2 years before presentation.

His physical exam showed 18 cc bilateral testes with no evidence of varicocele. Laboratory data showed FSH 11.1 IU/L, testosterone level 21.4 nmol/L.

So, the patient was planned for intracytoplasmic sperm injection (ICSI) using fresh testicular sperm extraction (TESE) since it is our IVF laboratory restrictions that we do not freeze testicular tissue of patients with Hepatitis or HIV in case we plan TESE or micro-TESE before date of ICSI.

At time of ICSI, his semen analysis (including post wash) showed again complete absence of mature sperms. Hence, the patient underwent immediate bilateral TESE. Unfortunately, No spermatozoa were recovered and consequently the IVF cycle was cancelled.

So, the case was thoroughly discussed with his haematologist to stop hydroxyurea and revaluate semen analysis after 3 months based on few case reports and series on the literature reporting recovery of spermatozoa after cessation of hydroxyurea treatment. The patient was seen 3 months after cessation of his hydroxyurea treatment. Surprisingly, his semen analysis showed sperm count of 4.25 million/mL and 53% motility. The couples at this stage were scheduled for ICSI using ejaculate sperms. He was also advised to perform sperm banking.

RESULTS

0After stopping hydroxyurea on a sickle cell patient; azoospermia was reversed and sperm count increased by 5 million over a period of 3-month.

DISCUSSION

0In this study in our hospital King Faisal Specialist Hospital and Research Centre, Riyadh, we report this case of sickle cell disease patient on HU treatment that presented with infertility. The investigation showed improvement in sperms numbers after cessation of HU and this impressive recovery of sperms occurred rapidly within less than 4 months. A study by [6] showed that treatment of adult normal male mice (ICR strain) with a clinically relevant dose of HU (30 mg/kg) for 30 days had significantly reduced testis weight, sperm density and progressive motility. Testis weight and stored sperm parameters were not reversed even at the 4 th month post with drawal of HU treatment. This is the only designed study that showed a clinically relevant dose of HU used for the treatment of SCD albeit conducted in normal mice, adversely affects testis and epididymal function. Consequently, the use of an appropriate transgenic SCD animal model for the determination of the link between SCD and HU treatment on male fertility indices is warranted.

Few reports showed that all sperm parameters might to be affected in semen samples collected during HU treatment, and this impairment occurred within 6 months. [7]

A case study reported follow-up semen analyses for a 29-year-old SCD patient under HU treatment. [8] A normal semen analysis at the beginning of therapy and 1-month later, the patient became azoospermic at 6 months. Ten months after the cessation of HU treatment, another semen analysis showed partial recovery of spermatogenesis. Thus an adverse effect of HU was suspected in this case of transient and partially reversible azoospermia.

Despite the previously mentioned few case reports on the adverse effects of hydroxyurea on sperm parameters, fertility maybe preserved in young men with sickle cell anemia on HU treatment. One study showed that the rates of miscarriage and pregnancies resulted in normal births to be within the range among a cohort of patients taking HU. In a multicenter study on HU, two pregnancies established while the male partners were on HU treatment which led to the birth of healthy babies. [9]

CONCLUSION

0This case shows the important side effect of HU on male fertility in patients with sickle cell anemia. HU can exacerbate the condition of infertility and hypogonadism that is already prevalent in patients with SCD by reversible inhibition of spermatogenesis. [10] So, we believe that all patients being treated with HU should be counselled for the possibility of sub/infertility. In case of HU induced azoospermia, a drug holiday can cause recovery of spermatozoa.

REFERENCES

01. Ficsor G, Ginsberg LC. The effect of hydroxyurea and mitomycin C on sperm motility in mice. Mutat Res 1980;70:383-7.

2. Wiger R, Hongslo JK, Evenson DP, De Angelis P, Schwarze PE, Holme JA. Effects of acetaminophen and hydroxyurea on spermatogenesis and sperm chromatin structure in laboratory mice. Reprod Toxicol 1995;9:21-33.

3. Evenson DP, Jost LK. Hydroxyurea exposure alters mouse testicular kinetics and sperm chromatin structure. Cell Prolif 1993;26:147-59.

4. Wyrobek AJ, Bruce WR. Chemical induction of sperm abnormalities in mice. Proc Natl Acad Sci U S A 1975;72:4425-9.

5. Shin JH, Mori C, Shiota K. Involvement of germ cell apoptosis in the induction of testicular toxicity following hydroxyurea treatment. Toxicol Appl Pharmacol 1999;155:139-49.

6. Kopsombut P, Mukherjee S, Roa DP, Turner EA, Powell A, Ademoyero AA, et al. Hydroxyurea and indices of male fertility. Adv Reprod 2000;4:9-32.

7. Berthaut I, Guignedoux G, Kirsch-Noir F, de Larouziere V, Ravel C, Bachir D, et al. Influence of sickle cell disease and treatment with hydroxyurea on sperm parameters and fertility of human males. Haematologica 2008;93:988-93.

8. Garozzo G, Disca S, Fidone C, Bonomo P. Azoospermia in a patient with sickle cell disease treated with hydroxyurea. Haematologica 2000;85:1216-8.

9. Charache S, Terrin ML, Moore RD, Dover GJ, Barton FB, Eckert SV, et al. Effect of hydroxyurea on the frequency of painful crises in sickle cell anemia. Investigators of the Multicenter Study of Hydroxyurea in Sickle Cell Anemia. N Engl J Med 1995;332:1317-22.

10. Masood J, Hafeez A, Hughes A, Barua JM. Hydroxyurea therapy: A rare cause of reversible azoospermia. Int Urol Nephrol 2007;39:905-7.

Lenghthening phalloplasty using multimodality surgical technique

Ayman Helmi, Talal Merdad 1


Prince Sultan Military Medical City, 1 Man Clinic, Riyadh,

Saudi Arabia

Introduction: Lengthening phalloplasty is an operation that aims at increasing the length of the penile shaft. This procedure has been gaining popularity with different surgical techniques being described to achieve the desired results.

Aim: We are advocating a unique modified surgical technique with high success rate. Our technique differs as it involves urological as well as plastic surgical principles. The technique will be illustrated by intra-operative edited photos.

Methods: A retrospective study including consecutive male patients presenting for penile lengthening over the last 9 years. Patients underwent pre-operative andrology and psychological evaluation. The procedure was performed by the same urologist and plastic surgeon simultaneously. A successful surgical outcome is defined as: Achieving a lengthening of equal to or more than 3.0 cm.

Results: A total of 85 patients have been included. The age ranged from 27 to 45 years with a median of 33 years. Marital status: 80% have been married for 5 years or more. The range of pre-operative penile length in flaccid status was 4.0 to 7.0 cm with an average of 6.5 cm. While the range of pre-operative penile length in erect status was 9.0-11.0 cm (average: 10.0 cm). The average penile lengthening achieved post-operatively was: 4.35 cm. with a range of 3.8-4.9 cm. There was no major complications or failure of the procedure observed. One patient suffered partial wound dehiscence following return to sexual activity 2 weeks after surgery. Patients' satisfaction with the outcome 6 months following surgery reached 44/45 with one case of dissatisfaction owing to the residual scar.

Discussion: The most popular surgical method used for penile lengthening is release of the suspensory ligament. Our technique differs as follows: It involves urological as well as plastic surgical principles. It combines fat reduction, vertical skin lengthening and retro positioning of the skin fold of the root of the penis proximally in order to therefore, we are able to achieve the maximum length with the safest optimum outcome.

Conclusion: Using our multimodality technique phalloplasty is a safe procedure with 100% surgical success rate in regard to desired length gain. Overall patient satisfaction rate of 97% which exceeds the standard procedure.

Microdissection TESE in men with maturation arrest; an outcome analysis

T. L. Yap., S. Abumelha, F. A. Al Mashat, A. Raheema, F. De Luca, N. Christopher, G. Garraffa, D. Ralph, S. Minhas


Department of Andrology, University College London Hospitals, London, UK

Introduction and Objectives: There is a paucity data reporting on the outcome of men with maturation arrest (MA) and mTESE. The aim of this study was to report on the outcome of this unique subset of patients and determine prognostic factors for sperm retrieval.

Materials and Methods: The records of patients with bilateral maturation arrest on testicular biopsies performed during microdissection TESE were retrospectively identified. Testicular size was measured by ultrasound scan (normal 3.5 cm and above) and FSH and LH levels were measured. All patients underwent a genetic evaluation and had a negative analysis, including karyotype and Y-deletion. All men underwent a microdissection sperm retrieval using a standard technique.Testicular biopsies were characterised according to the level of maturation arrest (early MA in case of Johnsen score (JS) ≤5 and late MA if JS >5). The mean and maximum JS, FSH, LH, testosterone, testicular size and the sperm retrieval rates were analysed.

Results: In total 97 patients were diagnosed with bilateral MA. Mean age of patients was 40 (range: 23-67) years. The mean FSH and LH levels were 16.4 IU/L (range: 1.6-67) and 8.1 IU/L (range: 1.4-28) respectively. Overall sperm retrieval rates were 30%. Patients with early MA had significantly higher FSH and lower sperm retrieval rates than those with bilateral late or mixed MA [Table 1, P < 0.05]. However, multiple regression analysis revealed that neither type of maturation arrest nor hormone levels or mean and maximum Johnsen score was significantly associated with a successful sperm retrieval (P all >0.05), although late MA and maximum Johnsen score had a closer association than other parameters (P = 0.07).

Conclusions: In patients with maturation arrest sperm retrieval rates are low compared to other histopathological diagnoses with over 70% of patients having a negative mTESE. Although there is a better prognostic outcome in late MA, the overall sperm retrieval outcome in general for maturation arrest is poor.

The clinical value of assessing sperm chromosomal aneuploidy in couples undergoing failed intracytoplasmic sperm injection and its correlation with semen parameters

F. A. Almashat, T. Yap, S. A. Bora 1 , G. Rozis 1 ,

S. Abumelha, H. Abdulla 1 , M. Y. Thum 1 , S. Minhas


Department of Andrology, University College London Hospital, 1 Lister Fertility Clinic, Department of Assisted Reproduction, London, UK

Introduction and Objectives: Chromosome abnormalities in embryos may be a major cause of fertilisation/implantation failure and miscarriage after ICSI. However, the role for determining sperm aneuploidy rate (AR) in couples failing ICSI remains controversial with no clinical guidance on the indications for its use and value in the clinical setting. The aims of this study were to determine the incidence of sperm chromosomal aneuploidy in couples undergoing failed ICSI and to determine whether sperm concentration and morphology correlated with aneuploidy rates.

Materials and Methods: Sperm aneuploidy was determined in couples that failed at least one or more ICSI cycles (failures; fertilisations n = 2, implantations n = 109, miscarriages n = 5). AR of chromosomes 13, 18, 21, X/Y were assessed using fluorescence in situ hybridization (FISH). 56 patients had karyotyping performed. Standard semen parameters were correlated with sperm aneuploidy, and threshold values for semen parameters for measuring sperm aneuploidy were determined. Semen analysis was reported according to the WHO 2010 criteria.

Results: 116 patients underwent sperm aneuploidy assessment. Mean age of patients was 39.4 years (range: 27-73) in males and 36.2 years (range: 26-47) in females. Karyotyping was performed in 48.3% (n = 56) of male patients and was normal in all of them. The mean number of analysed spermatozoa was 2023 (range: 13922227) (n = 90). The mean sperm concentration was 31.05 (range: 0.2100). 37.1% of patients had a raised aneuploidy rate (>7%) and 15% had abnormal X/Y ratio (>1.1). The mean total aneuploidy rate (n = 116) was 6.71% (range: 1-28.2), with mean individual (n = 90) chromosomal aneuploidy rates of 2.38% Chr 13, 0.87% Chr 18, 1.1% Chr 21, 2.9% Chr X and Y and 0.84% diploid spermatozoa. The mean X/Y ratio was 1.04 (0.6-2.0). Total aneuploidy rates were significantly associated with male age and sperm concentration (P < 0.001) but not morphology (P = 0.09). The total aneuploidy rate in this cohort was significantly associated with aneuploidy rates in chromosomes 13 (P < 0.001), 21 (P < 0.03), X and Y (P < 0.001).

Conclusions: Over a third of patients who failed ICSI have a raised sperm aneuploidy rate and would suggest that patients who have failed ICSI should have sperm AR determined. Furthermore, male age and sperm concentration appear to be predictive of patients with raised AR. Both of these findings are of prognostic value in counselling patients undergoing ICSI treatment.

The prevalence of erectile dysfunction and its major risk factors among the Northern Saudi men with diabetes mellitus

Mohammed J. Alenzi, Abdullah W. ALdughiman 1 , Sultan J. Alanazi 1


Department of Urology, Aljouf University, 1 College of Medicine,

Aljouf University, Sakaka, Saudi Arabia.

Introduction: Diabetes mellitus (DM) is one of the most common chronic diseases in nearly all coun­tries and in Saudi Arabia in particular where it is close to be an epidemic (International Diabetes Federation. IDF Diabetes Atlas, 6 th edition. Brussels, Belgium: International Diabetes Federation, 2013). The high and increasing rates of DM in Saudi Arabia is reasoned to many factors; namely, high caloric intake, obesity and physical inactivity along with genetic predisposition {Alqurashi et al., 2011, Badran et al., 2012}. Diabetes is associated with sexual dysfunction (SD), where, a threefold increased risk of erectile dysfunction (ED) was documented in diabetic compared with non-diabetic men (Giugliano et al., 2010, Maiorino et al., 2014). Diabetic patients may present with several clinical conditions, including hypertension, overweight and obesity, metabolic syndrome, cigarette smoking, neuropathy, micro- and micro-angiopathy or atherogenic dyslipidemia, which are themselves risk factors for SD (Lewis et al., 2010). The age-adjusted risk of ED is doubled in diabetic men vs. non-diabetics (Johannes et al., 2000, Lewis et al., 2010). ED significantly associates each of the cardiovascular risk factors; diabetes, smoking, hypertension, hyperlipidemia, metabolic syndrome, as well as depression, lower urinary tract symptoms, and poor health state (Bortolotti et al., 2001, Giuliano et al., 2004, Ponholzer et al., 2005, De Berardis et al., 2007, Demir et al., 2009). On the other side, ED is a marker of significantly increased risk of cardiovascular disease, stroke, and all-cause mortality (Dong et al., 2011).

Materials and Methods: The present cross-sectional study lasted 6 months (from 1 April to 30 September) and reviewed Saudi married men with DM (n = 524; 20-60 years old; On oral hypoglycemic and/or insulin). Patient attended diabetes clinics at the primary health care centers (21 PHC) of the northern Al-Jouf Region of Saudi Arabia. The study enrolled all patients voluntarily agreed to participate and did not have an exclusion criterion. A structured questionnaire based on IIEF-5, which consists of items 5, 15, 4, 2, and 7 from the full-scale IIEF-15 was devised to assess prevalence of ED (Rosen et al., 2002). Each item is graded 1-5 and a sum score of ≤21 indicates the presence of ED. Grade-1 indicates almost never/never, grade-2 indicates a few times, grade-3 indicates sometimes, grade-4 indicates most times and grade-5 indicates almost always/always that an event happens. The 5 items included erectile strength and duration, orgasm achievement, sexual desire, intercourse satisfaction and over-all satisfaction with sexual life. The questionnaire was administered to patients in the local Arabic language by the attending physician at spot. Data collected also included patients age, duration of diabetes, remarkable medical history particularly hypertension and its medication, smoking status, erection medication and concomitant medications for diabetes. Exclusion criteria included: History of current inflammatory disease or infection, prostate enlargement, prostate cancer, prostatectomy, increased level of prostate-specific antigen, current hormone replacement therapy or current suffering of neoplastic diseases. A written informed consent from participants was obtained and the local ethical committee of the College of Medicine, Aljouf University approved the study. Data were presented as frequency (number and percentage) and mean ΁ SDM. Chi-square test P value was used for categorical data comparison (SPSS software version 18; SPSS Inc., Chicago, IL, USA). P < 0.05 was considered statistical significance.

Results: The prevalence of the ED related sexual satisfaction items 5, 15, 4, 2, and 7 of IIEF-5 questionnaire among the enrolled Saudi diabetic patients. The summative questionnaire results showed that among the reviewed 524 married Saudi diabetic men, 319 (60.88%) patients had ED. Among the whole group, 470 (89.69%) had sexual desire, 313 (59.73%) achieved proper erection, 195 (37.21%) felt having adequate erection time, 299 (57.06%) had satisfactory intercourse, and 355 (67.74%) had overall sexual satisfactory life.

Discussion: Diabetes-induced ED has multifactorial pathogenesis depending on both psychological and organic changes. The latter include vasculopathy (macro- and micro-angiopathy and endothelial dysfunction with consequent penile arterial insufficiency), neuropathy, visceral adiposity, insulin resistance, and hypogonadism (Giuliano et al., 2004). Accumulation of advanced glycation end products, impaired endothelial and neuronal nitric oxide (synthesis, enzyme expression, and activity), proinflammatory state and oxidative stress (that also reduce the bioavailability of nitric oxide), and imbalance between the vasoconstrictive and vasorelaxant intracellular pathways - all are involved in endothelial dysfunction (Esposito et al., 2007, Malavige et al., 2009, Esposito et al., 2011). Microvascular disease determines ischemic damage in the distal circulation and autonomic and somatic peripheral neu­ropathy that contribute to diabetes-induced ED due to the impairment of sensory impulses from the penis to the reflexogenic erectile center, and reduced or absent parasympathetic activity necessary for relaxation of the smooth muscle of the corpus cavernosum (Sαenz de Tejada et al. 2005).

The present study found that prevalence of ED was 60.88%, which is very close to results of other Saudi and Jordanian studies (El-sakka, 2004, Faisal et al., 2006, Al-Turki, 2007). This study revealed that prevalence of ED is significantly higher in the advanced DM of more than 5 years duration that could be due to organic causes particularly the microvascular changes as compared to early DM of ≤5 years duration - where ED could be related to anxiety and psychological causes. Reportedly, the prevalence of ED was 86.7% in type-2 diabetic Saudi patients recruited from the capital city of Riyadh with low testosterone level of 8-12 nM/L. BMI and waist circumference were both significantly negatively correlated with testosterone levels in these patients. 71.6% of these patients with free testosterone <0.255 nM/L had hypogonadism. ED and hypogonadism correlated positively with each of advancement of age, diabetes disease duration, obesity, hypertension, poor glycemic control and increased triglycerides (Hassan et al., 2014).

The present study revealed higher prevalence of ED among DM smoker patients and lower ED prevalence among hypertensive DM patients on treatment. While smoking is consistently reported as additional risk factor for DM-induced ED, variable effects for the different hypotensive drugs on DM-induced ED were reported although hypertension per se is an additional risk factor for ED (Selvin et al., 2007, Al-Turki, 2007, Foresta et al., 2009, Sharifi et al., 2012, Corona et al., 2013). Nebivolol - a hypotensive β1-adrenoceptor antagonist that promotes vasodilation through a nitric oxide (NO)-dependent mechanism - in vivo activated the NO/cGMP pathway, enhanced erectile response and reversed diabetes-induced ED. These effects may account for the low incidence of ED in nebivolol-treated hypertensive patients (Angulo et al., 2010). Among Saudi Arabians with metabolic syndrome, a significant association of 894G>T, 4a/b, and −786T>C polymorphisms in endothelial nitric oxide synthetase is evident (Csaba, 2011). Diabetic patients with hypertension and high risk of vascular damage showed significantly higher levels of plasma fibulin-1 - an indicator of vascular damage - particularly in diabetic patients reporting ED. Low-dose of the antihypertensive spironolactone (a mineralocorticoid receptor blocker) reduced plasma fibulin-1 levels in patients with type-2 diabetes and resistant hypertension (Oxlund et al., 2014).

In the present study a majority of the patients were administrating erection medication. However, such medications did not cause significant improvement in patients' erectile efficiency. Because of its multifactorial etiology, the treatment of ED in diabetic men requires a comprehensive approach through correcting modifiable risk factors and promoting lifestyle changes, and then treatment modalities. Lifestyle changes (such as weight loss, low intake of saturated fat and caloric intake, high consumption of Mediterranean diet with monounsaturated fat and fiber, and moderate physical activity) ameliorate ED in the general male population - through amelioration of endothelial dysfunction, insulin-resistance, and low-grade inflammatory state. Oral type 5 phosphodiesterase inhibitors (PDE5Is; contraindicated in nitrate users) represent first-line pharmacologic therapy for ED (Esposito et al., 2009). Although the overwhelming percentage of the present study patients used drug aids for erection (86.3%), only 67.74% were sexually satisfied, 59.73% achieved proper erection and 37.21% maintained enough erection duration. This may reflect drug resistance due to diabetic vascular complications (with diminished nitric oxide generation in the penile nerves and/or endothelium), concurrent hypogonadism and/or other DM complication-induced organic changes (Kalinchenko et al., 2003, Kapoor et al., 2006, Shabsigh et al., 2008, Francis and Corbin, 2011, Giuliano and Droupy, 2013, Hassan et al., 2014). The efficacy of PDE5Is pharmacotherapy for ED is significantly reduced in diabetic patients (Hamidi-Madani et al., 2013, Martνnez-Salamanca et al., 2014). There is a low clinical response to PDE5Is for treatment of ED in the patients with high cardiovascular risk profile, such as diabetics, as an expression of higher endothelial damage in such patients (Condorelli et al., 2013). Alternatively, the implantable penile prosthesis, intra-cavernosal injections and vacuum constriction devices remain safe, and are highly effective treatment options for those DM patients with PDE5Is refractory ED (Redrow et al., 2014). DM patients with ED not responding to sildenafil alone were successfully treated with either a vacuum erection device or combination therapy of sildenafil and the vacuum erection device (Sun et al., 2014). Intra-cavernosal injection of papaverine, phentolamine, and prostaglandin E1 (PGE1), and intra-urethral administration of PGE1, are good alternatives for non-responsives (Williams et al., 1998). Testosterone replacement therapy is recommended in men with ED who show low levels of testosterone (Wang et al., 2008, Hackett et al., 2013).

Conclusion: There is a high prevalence of ED among Saudi diabetic patients in Al-Jouf Region. They were also unresponsive to erection medication. Smoking worsened their ED status. Surprisingly, hypertension seamed to reduce ED in such diabetic patients. The latter effect could not be reasoned to hypertension per se but rather to specific antihypertensive medication. These results highlight the importance of early screening for ED among such patients. Moreover, because almost 50% of early DM suffered ED without remarkable neuro- and/or vasculo-pathies, psychiatric consultation and follow up should be initiated early in the disease to rule out public misconceptions about intimacy of DM and ED. The usage of prosthetic devices or intra-cavernous injectable medication for erectile dysfunction could be more suitable since oral systemic medication are ineffective. Interventions aimed at prevention, early diagnosis and detection of DM and its complications, and adherence to treatment to prevent complications should be implemented. Further longitudinal studies should emphasize on temporal variation to show true causality of DM and/or its complications on ED through dissecting biochemical gonadal and diabetic changes.

Abstract: Micro-dissection testicular sperm extraction: Overall results and experience at KFSH and RC

Shahbaz Mehmood, Ali Al-Sulihem, Nor Nabi Junejo, Hamad Al-Akrash, Naif Alhathal


Introduction: Non-obstructive azoospermic patients was once considered to be infertile due to non availability of sperms in ejaculate because of impaired testicular spermatogenesis. Various testicular sperm retrieval techniques have been introduced recently after the discovery of intracytoplasmic sperm injection (ICSI), microdissection testicular sperm extraction is one of the most successful technique in sperm retrieval.

Aims: To review the overall results of sperms retrieval rate in non-obstructive azoospermic patients with Micro TESE in KFSH and RC from August 2013 to December 2014.

Materials and Methods : We retrospectively reviewed the data of 195 patients with non-obstructive azoospermia, underwent microdissection testicular sperm extraction followed by intracytoplasmic sperm injection. We noted all preoperative investigation like hormonal analysis i.e. FSH, LH, E2, prolactin and level of testosterone. We also documented the age of patients, Klinefelter syndrome, and history of cryptorchidism, chemotherapy, testicular volume and presence or absence of varicocele on scrotal ultrasonography. Chromosomal analysis was also performed in suspected cases. All the patients underwent Micro TESE under G/A. Sperm retrieval rate, Histopathology, clinical pregnancy and postoperative complications were also documented.

Results: Testicular sperms were successfully retrieved in 55% of the cases. Mean age of patients was 34.2 (range: 22-56 years). The mean serum FSH levels was 17.4 IU/L (1.5-71). Sperm Retrieval (SR) rates in the respective groups were 20% in sartoli cell only patients, 36% in maturation arrest and 78.25%in hypo spermatogenesis patients (P = 0.023). There were no post-operative complications. In the 25 men who had previously undergone unsuccessful procedures elsewhere, the SR rates were 49%in these patients.

Conclusion: Micro TESE is a safe and successful technique of sperm retrieval in our centre. It allows extraction of large opaque high probability of sperms containing seminiferrous tubules with minimum tissues excision. Small testicular volume and klinefelter syndrome is not a contraindication for micro TESE.

Pattern of erectile dysfunction medication prescription by community pharmacist in Al-Khobar and Dammam cities of Saudi Arabia

Majid Alhumaidi Aldossary, Abdulaziz Mohammed Al Sharydah. Naif Salim Alotaibi,

Ahmed Abdulrahman Al-Rahim, Nasser Hassan Bukhamseen, Motazz Abdillatif Alarfaj,

Ibrahim Mohammed Albawardi,

Waleed Mahfooth Alamrai, Mosab Salah Al-Majed, Abdulrahman Khalid Alahmar, Ali Al-Zahrani


Department of Urology, University of Dammam, Saudi Arabia

Introduction and Objectives: Erectile dysfunction (ED) is a prevalent sexual problem among men, affecting more than half of those over 40 years of age. Because of the wide availability of medical therapy, community pharmacists play an important role in evaluation of patients with erectile dysfunction. The aim of study is to assess the pattern of referral of patients with ED without prescription by the community pharmacist.

Method : A cross sectional study was conducted to include most of pharmacies in Al Khobar and Dammam cities, Saudi Arabia. A total number of 157 pharmacies were randomly selected and visited over one day only. All pharmacists were examined by trained investigators and four scenarios were discussed with them. The first scenario was aiming to know if the pharmacist would get proper medical evaluation for patient complaining of ED without being seen by medical doctor before. The second scenario was aiming to know if the pharmacist would incest on medical prescription. The third scenario was aiming to see the response of the pharmacist would change if the condition belongs to investigator father. The fourth was aiming to see if there was any change in response when he knew about the related cardiac problems with investigator father. The data collected were entered and analyzed using the Statistical Package for Social Science (SPSS).

Results: Out of 157 reports which were collected from the pharmacies, 34 pharmacist (21.8%) asked about the problem in details. Most of the pharmacist (85.3%) would sell medication to treat proposed ED without prescription. Sildenaϐil (Viagra 50 mg) was the most common medication prescribed by the pharmacists (53.2%) for ED. Regarding the side effects of the medication given; 103 pharmacists (66%) did not discuss the side effect of ED medication. When the pharmacist have been told that the medication will be given for the investigators' fathers most of them (79.5%) did not change the medication or asked for further medical assessment. Signiϐicant number of the pharmacists (49.4) agreed to prescribe initially prescribed medication even when with positive medical history of possible cardiac disease.

Conclusion: Most of the pharmacist in Al-Khobar and Dammam cities would prescribe a medication for treatment of ED without proper medical evaluation. Active referral should be implemented by the community pharmacist for patients complaining of ED without valid prescription.

Percutaneous epididymal sperm aspiration in the treatment of obstructive azoospermia; analysis of factors predicting treatment outcome

T. Yap, F. A. Almashat, M. Y. Thum 1 , S. Abumelha, D. Ralph, H. Abdalla 1 , S. Minhas


Dpartment of Andrology, University College London Hospital, 1 Department of Assisted Reproduction, Lister Fertility Clinic, London, UK

Introduction and Objectives: In patients with congenital or acquired obstructive azoospermia (OA) sperm retrieval and ICSI can be used as a treatment modality for couples. Variable success rates have been reported from percutaneous epididymal sperm aspiration (PESA) combined with ICSI, in men with OA. The aim of this study was to determine the role of PESA in the treatment of men with obstructive azoospermia, determine factors predicting outcome and to assess if fresh or frozen epididymal sperm has an impact on live birth rates.

Materials and Methods: The medical records of consecutive couples undergoing ICSI treatment for obstructive azoospermia using PESA were analysed. Men were subdivided into those with vasal aplasia, idiopathic obstruction, postvasectomy and failed vasectomy reversal. PESA was performed by a standard technique as an outpatient procedure under local anaesthetic. Fertilisation rates, age of male/female partner, pregnancy rates and live births were determined in each group. All men in the bilateral vassal aplasia and primary idiopathic groups underwent genetic analysis. We also compared the ICSI outcome from using fresh versus frozen sperm.

Results: 76 men underwent a total of 118 cycles of ICSI. The mean age of male and female patients was 45 (range: 29-66) and 36 (range: 26-49) respectively. In the bilateral vasal aplasia group (n = 11), 7 (63%) were CFTRgene positive. Viable sperm for ICSI was retrieved in all men with the mean egg fertilisation rate per cycle of 5.0 (range: 0-22).

Conclusions: Percutaneous epididymal sperm aspiration is an effective simple outpatient method of obtaining sperm for ICSI, with the opportunity for sperm cryopreservation. There was no difference in outcome using fresh or frozen epididymal sperm. In this small series live birth rates are not related to the timing of vasectomy or if reversal was performed but are lower in patients with vassal aplasia compared to other aetiologies and may indicate an intrinsic abnormality sperm function in this group.

Pre-ejaculatory illness syndrome: Two cases of a rare psychosomatic disorder

Mohammed Elawdy


Ministy of Health, Oman

Introduction:
Human ejaculation is a coordinated mechanism of male sexual organs and the pelvic floor muscle. Psychosomatic ejaculatory disorders may happen before, during, or after ejaculation. No reported cases of pre-ejaculation illness have been found in the literature. We present two cases of such rare syndrome.

Case One: A 30-year-old Omani patient presented with episodes of palpitation, sweating, fainting, loss of muscle tone and sense of impending death. This would occur just before ejaculation during sexual intercourse resulting in his inability to ejaculate. His history included reactive depression and an anxiety disorder. Clonazepam 0.5 mg was prescribed empirically for a couple of months with no improvement that was substituted by Fluoxetine 20 mg OD and propranolol 10 mg HS. After 2 weeks, the patient reported significant improvement.

Case Two: A 30-year-old who presented with similar symptoms during sexual intercourse. A recent head injury resulted in multiple disabilities including depression from the breakdown of his finances. Due to the previous diagnosis, we started the patient on a treatment of fluoxetine 20 mg OD with significant improvement after 2 weeks. The patient stopped the medication for a couple of weeks. He reported the recurrence of the symptoms. Fluoxetine was prescribed for a second time.

Conclusion: Pre-ejaculatory illness syndrome is a rare psychosomatic disorder. Patients may have symptoms of sympathetic over-activity, muscle atonia and the sensation of impending death. Although this condition is embarrassing, both patients were prescribed Fluoxetine resulting in the successful restoration of their sexual activity.

Recurrent acute scrotal pain among young male students: Cross-sectional study

A. L. Alzahrani, A. Alsharydah, I. Bawardi,

A. Alahmer, M. Almajed, A. A. Al-Zahrani


Department of Urology, University of Dammam, Dammam, Saudi Arabia

Objectives: To assess the prevalence of recurrent acute scrotal pain at young adult males that might suggest intermittent spermatic cord torsion.

Methods: A cross-sectional study was conducted through a survey distributed to randomly selected sample of 600 medical students at Dammam University. The study conducted between October and December 2014. The questionnaire consisted of direct question about occurrence of scrotal pain and the characteristic of the pain. Data was entered and analyzed using SPSS version 20.

Result : A response rate of 58.67% was obtained (352 out of 600). Participant age ranged from 17 to 26 (mean: 19.68, SD: 1.87). Around 30% of the participant had episodes of recurrent acute, sudden scrotal pain. Most of the participant described the pain as of short duration. However, 49% of the participant with recurrent scrotal pain described the pain to occur at least once per month. Most of the participant with scrotal pain (54.45%) did not describe any specific position or activity to provoke the pain. The scrotal pain gets resolved spontaneously in 95.28%, while 3.77% usually take analgesics. Almost all participants (90.70%) were not aware about self-testicular examination or management of testicular torsion.

Conclusion: Recurrent acute scrotal pain is not uncommon among adolescence. Young male student should be aware about the dangerous of testicular torsion.

Semen analysis in men with testicular cancer: Effects of orchidectomy and fertility preservation

S. Abumelha, T. L. Yap, F. Spitaleri, F. A. Al-Mashat, A. Raheema, F. De Luca, N.Christopher, G. Garraffa, E. Williamson, D. Ralph, S. Minhas


Department of Assisted Reproduction, Lister Fertility Clinic, London, UK

Aims and Objectives: There is controversy as to when sperm should be cryopreserved at the time of treatment for testis cancer. Conventionally sperm freezing is performed after orchidectomy and prior to chemotherapy. The aim of this study was todetermine the effects of orchidectomy in patients with testicular cancer and compare patients' sperm quality according to pathological and biochemical variables and the timing of cancer management.

Material and Methods: We retrospectively evaluated data from 198 semen analysis of patients with testicular cancer whose sperm samples were banked at a Fertility Laboratory from 2010 and 2014. Age at banking, sperm parameters, timing of orchidectomy, histology type and relationship to tumour markers were analysed. Group I (n = 69) included patients who had undergone sperm cryopreservation prior to orchidectomy, whilst group II (n = 117) were patients who underwent CP prior to adjuvant treatment and after orchidectomy. A third subset of patients (n = 12) had pre and post orchidectomy semen analysis (group III). Semen analysis were reported according to the 2010 WHO standards.

Results: Table 1 summarizes the patient characteristics in each group. There was a significantly higher rate of oligospermia but similar azoospermic rates in post-orchidectomy patients compared to the pre-orchidectomy cohort [Table 1, P < 0.05], with no significant difference in mean sperm density between Group I and II (23 million (M)/mL pre orchidectomy vs. 19 M/ml post orchidectomy, P < 0.22). The other semen parameters were comparable between the two groups (P > 0.05).There was no significant difference in mean sperm density between pre and post orchidectomy patients (Group III) (P = 0.40). There was an association of semen parameters pre and post orchidectomy (Group I, II and III) with age (P = 0.001) but not with tumour stage, tumour markers or type of tumour (P all > 0.05). In all, 9 patients underwent sperm retrieval, of which 4(44%) were successful. Sperm was successfully retrieved on the diseased side in 50% and in the contralateral, unaffected side in 100%.

Conclusion: This study suggests that orchidectomy itself does not have a significant negative impact on sperm parameters, although a significant proportion of men with testis cancer pre-orchidectomy have impairment of sperm concentration, with up to 42% presenting with oligozoospermia/azoospermia. We propose that all patients undergoing radical orchidectomy should consider preoperative sperm cryopreservation.

Semen parameters, intraindividual variation at the day of OPU, success of IVF abstract

Hamad Alakrash


Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Purpose: To investigate influence of semen parameters intraindividual variations at the day of egg collection.

Materials and Methods: Charts from year 2010 to 2014 were reviewed. I.V.F cycles identified, were semen quality parameters were recorded.

Results: A total 300 IVF cycles were reviewed. 150 cycles with an increase in the percentage of motile sperms at the day of OPU. 150 cycles with a decrease in the percentage of motile sperms at the day of OPU.

Conclusion: Semen analysis can't predicate the IVF outcomes.

Sperm retrieval in patient with non-obstructive azoospermia and 5-alpha reductase deficiency through micro-surgical testicular sperm extraction

Hamad Al-Akrash, Mohamed Kattan,

Mohammed Alshayie, Naif Al-Hathal


Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

Objective: Sperm retrieval through micro-surgical testicular sperm extraction in a patient with 5-alpha-reductase deficiency.

Design: Clinical article.

Setting: Healthy volunteer in a hospital environment.

Patient: 5-alpha-reductase deficiency.

Interventions: Micro-surgical testicular sperm extraction, sperm retrieval.

Main Outcome Measure: Micro TESE.

Results: Sperms were retrieved through micro-TESE.

Conclusion: Sperm retrieval through micro-TESE in infertile men with 5 alpha reductase deficiency and azoospermia is possible and encouraging.

Testicular pain: Warning sign for post-operative ischemia following inguino-scrotal surgery

Magdy Elbahnasawy


NWAFH, Prince Salman Military Hospital, Tabuk, Saudi Arabia

Purpose: Post-operative pain after inguino-scrotal surgeries is a common finding among our patients. However severe testicular pain is not a common one and may indicate serious complication.

Methods: Herein we will present 2 cases of post-operative testicular pain which were associated with testicular ischemia.

Results: The first case was complicating left inguinal hernia repair who experienced persistent testicular pain since early post-operative period which was managed by pain killers and NSAID for several months until he was referred to urologist with testicular atrophy 6 months later. Scrotal US showed diminished blood supply with small atrophic testis. The second case was following bilateral subinguinal varicocelectomy. Patient complaind of persistent left testicular pain which was managed by pain killers up to Pethidine injections. Scrotal Doppler US was requested on the 3 rd day and showed diminished blood supply which progressed to absent blood supply to the testis with intra testicular hemorrhages next day. Exploration showed black infarcted testis which necessitated orchidectomy.

Conclusion: Early post-operative testicular pain may indicate aute testicular ischemia and warrants immediate investigation by Doppler scrotal US for diagnosis and possible urgent intervention to salvage the insulted testis.

Thyroid function, serum testesterone and prolactin don't seem to be risk factors in men complaining of premature ejaculation

Mohamad Habous, Osama Abdelwahab 1 ,

Saad Mahmoud, Alaa Tealab 2 , Ziad Abdelrahman, Chris Nelson 3 , John Mulhall 3


Elaj Medical Centers, KSA, 1 Benha University, Benha, 2 Zagazig University, Egypt, 3 Memorial Sloan Ketring Cancer Center, NY, USA

Introduction: Most epidemiological studies suggest that premature ejaculation (PE), also referred to as early ejaculation and rapid ejaculation, may be the most common male sexual disorder. The exact etiology of PE is unknown. Psychological/behavioristic and biogenic etiologies have been proposed.Previous reports in the literature advocated thyroid dysfunction and hypogonadism as risk factors for PE especially for secondary (acquired) type.

Objectives: We investigated the thyroid stimulating hormone (TSH), testosterone (T), and prolactin (P) in patienta with PE.

Patients and Methods: A total of (xx) patients who presented to our outpatient clinics complaining of PE were enrolled in this study, and another group of patients of age matched who presented to our urology clinics for other reasons PE not one of them were investigated as control group. Full medical history, complete physical examination, and blood samples were taken for TSH, T, and P and were all taken as morning sample.

Results: 642 men with an average age of 44 ΁ 13 years old were included in this analysis. The mean levels of testosterone, TSH, and prolactin for the entire sample was 4.38 ΁ 1.69, 2.31 ΁ 3.56, and 10.56 ΁ 11.04, respectively. There was no differences between the primary PE and secondary PE groups in testosterone (4.39 ΁ 1.66 vs. 4.38 ΁ 1.84, P = 0.94), TSH (2.31 ΁ 4.89 vs. 2.20 ΁ 2.07, P = 0.76), and prolactin (10.65 ΁ 8.13 vs. 10.46 ΁ 13.46, P = 0.86). We also looked at hormone profiles of men with primary vs. secondary PE in the PE group and there were no differences between the two groups.

Conclusion: In contrast to some previous reports which showed a correlation between thyroid dysfunction, T and P levels, we didn't find such a correlation.

Ultrasound scanning in the screening of men with subfertility for testicular malignancy - Incidence of abnormalities detected and management

T. L. Yap, S. Abumelha, F. A. Al Mashat, A. Raheema, N. Christopher, G. Garraffa, M. Walkden, D. Ralph, S. Minhas


Department of Andrology University College London Hospitals, London, UK

Introduction and Objectives: There are a number of reports in the literature suggesting that men with subfertility have a higher risk of testicular tumours, although there is no consensus opinion on the value of testicular imaging in the routine screening for malignancy in men with subfertility. The aim of this study was to evaluate the incidence of testicular tumours in infertile men presenting with subfertility and offer guidance on the management of these lesions.

Materials and Methods: 795 men underwent routine testicular ultrasound scanning for the evaluation of subfertility. None of the men had a previous history of testicular cancer or ITGCN. FSH, LH and semen analysis were correlated to abnormal findings. Multiple regression analysis was used to predict the likelihood of testicular neoplasia based upon USS and biochemical parameters.

Results: 76 (9.6%) men were found to have impalpable indeterminate lesions on USS. Of these, 41 patients had hypoechoic lesions (8 bilateral) and 38 patients had hyperechoic lesions (12 bilateral). In total 99 testicular units were found to have indeterminate lesions [Table 1]. 43 (5.4%) patients were found to have testicular microlithiasis (TML) and 6 of these had concurrent indeterminate lesions.

Of the testicular units with hypo- and hyperechoic lesions 31 (31%) underwent exploration and an intra-operative frozen section, either as a primary procedure or as a concurrent procedure with micro TESE. The results are shown in Table 2. The remaining 68 units (69%) were placed on a strict imaging surveillance programme with no malignancies detected at an average of 3.8 years follow up (range: 1-7 years). All patients with TML (including the 6 with concurrent lesions) were not found to have germ cell tumours at an average of 2.3 years (range: 1-6 years).

Hypoechoic and vascular indeterminate lesions were significantly associated with pathologically significant testicular tumours (ITGCN, seminoma, Leydig cell tumours) (P = 0.01) but not testicular size, lesion size, presence of TML, sperm concentration or FSH/LH levels.

Conclusions: In this series of patients, significant testicular tumours (ITGCN, seminoma, Leydig cell tumours) were found in 1% of subfertile men, which is far higher than the 3 in 100,000 incidence of testicular tumours in the general population. Therefore screening for testicular malignancy appears justified in men with subfertility. Hypoechoic and vascular lesions were significantly associated with finding significant tumours at biopsy. Surveillance can be offered in men with TML and hyperechoic lesions.

Testicular FNA mapping

Amr Jad


Department of Urology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Azoospermia, the absence of sperm in ejaculated semen, is the most severe form of male factor infertility and is present in approximately 5% of all investigated infertile couples. The testicular sperm retrieval and intra - cytoplasmic sperm injection (ICSI) give an alternative treatment for this type of severe male factor infertility. FNA testicular sperm aspiration (TESA) is considered one of the low risk complication techniques for sperm retrieval and mapping technique increase the accuracy of the sperm retrieval to be comparable to micro dissection TESE 47% of non-obstructive azospermic patients by using FNA mapping technique. [1] A new modification of this technique increases its efficacy and gives better biopsy. In this video we will show the classic mapping technique and the modification on it.




 

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