Urology Annals
About UA | Search | Ahead of print | Current Issue | Archives | Instructions | Online submissionLogin 
Urology Annals
  Editorial Board | Subscribe | Advertise | Contact
Users Online: 1195   Home Print this page  Email this page Small font size Default font size Increase font size


 
Table of Contents
ABSTRACT
Year : 2015  |  Volume : 7  |  Issue : 6  |  Page : 89-106  

Infertility


Date of Web Publication10-Jul-2015

Correspondence Address:
Login to access the Email id


Rights and Permissions

How to cite this article:
. Infertility. Urol Ann 2015;7, Suppl S2:89-106

How to cite this URL:
. Infertility. Urol Ann [serial online] 2015 [cited 2020 Sep 22];7, Suppl S2:89-106. Available from: http://www.urologyannals.com/text.asp?2015/7/6/89/160673

Male infertility in bahrain - the bdf experience

Mazin A. Ismail


Bahrain Defence Force Hospital, Bahrain

This is a study of 166 male patients investigated for infertility at the BDF Hospital during the last two years. Their ages ranged between 18-51 years.

Primary infertility was seen in 121 (72.9%) cases and secondary infertility in 45 (27.1%) cases. Azoospermia was noted in 61 (36.7%) cases of which 46 (75.4%) were primary and 15 (24.6%) were secondary. The causes for infertility included hyperprolactinaemia (27 cases - 45.9%), idiopathic testicular atrophy (13 cases - 21.3%), seminal pathway obstruction (3 cases - 5%) & presence of Serum Anti-sperm Antibodies (7 cases - 4%).

Hyperprolactinaemia was noted in 51 patients (30.7%), of whom 27 (52.9%) had azoospermia, 13 (25.5%) had oligospermia, while 11 patients (21.6%) had a normal sperm count exceeding 60 million/ml. Parloydyl (Bromocriptine) was used in treating 18 cases (35.3%) and resulted in the return of serum Prolactin levels to normal values in 10 patients within four months.

Serum Anti-sperm Antibodies were detected in 7 cases (42.2%) out of 78 patients submitted to the test. Five positive cases were treated with Prednisolone, two of them showing complete disappearance of the antibodies from the serum within one year.

32 patients (19.3%) with normal wives have been referred to or are being considered for referral to the GIFT (Gamete Intra-Fallopian Transfer) programme due to commence shortly at our hospital. Reasons for referral are discussed.

Clomide (Clomiphene Citrate) and Proverone (Androgen) were used in 118 cases (indications discussed) and resulted in 12 pregnancies.

Presented at the: 5 th Saudi Urological Conference

King Fahd Military Medical Complex

22-23 March 1989

"Kartagener's syndrome with male infertility a urologist's unsolved puzzle - regarding the management

A. Jar, J.T. Flynn, C. McCreadie, J.R. MacFarlane, W.S. Stockwell, A. Busuttil


Department of Urology, King Fahad Central Hospital, Gizan, Saudi Arabia

The triad of situs inversus, Bronchiectasis and sinusitis, known as Kartagener's syndrome was first reported by Siewert (1904), Kartagener (1933), (1935), described the congenital nature of the condition.

The extreme rarity of this condition, associated with male infertility (Greeal, et al. 1965), may elude many experienced urologists who may never see a single case in their clinical experience.

Four interesting cases including two brothers of this syndrome with infertility over a period of 10 years, in the various institutions in U.K. and Saudi Arabia (one case), in the author's experience is presented and relevant literature discussed.

Detailed electron microscopic study of the sperm and cilia of one case is illustrated, emphasizing the variance noted, from the available literature showing usual absence of dyneim arm of outer microtubular doublet or filaments under electron microscopy of sperm tails and cilia, leading to immotility of sperms (Imotile cilia syndrome), Eliason, et al. 1977, Afzelius, 1981.

The management of prospect of infertility is associated with the future, further development of Genetics and invitro fertilization techniques, and will be a frontier of scientific developmental landmark.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

The relationship between genital infection and type of male infertility

Hisham Ahmed Mosli, H.M.A. Farsi, H.S. Abdul Jabar, F.S. Gazzas


King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Are patients with secondary infertility at more risk to have genital infection than patients with primary infertility?

To answer this question, we studied 63 infertile male patients; 48 of whom were with primary infertility and 15 were with secondary infertility. 14 age matched control volunteers with recent fertility were also studied for the same types of infection.

The genital infections studied were Bacterial non-gonococcal infections, infections with Chlamydia trachomitis (2 methods used), Mycoplasma Homonis and Uroplasma Urealyticum.

The infection was looked for in Urine, Seminal fluid and in male Urethral Swabs.

The method's used in the study, results as well as conclusions will be presented in this paper.

Presented at the: 8 th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Advances in the treatment of infertile men with congenital absence of the vas deferens

Talal Merdad, K. Jaroudi, J.A. Carver-Ward


King Faisal Specialist Hospital, Riyadh, Saudi Arabia

For many years, there was little that fertility specialists could do to assist couples whose prime cause of infertility lay in disorders with the male partner, other than to suggest donor fertilization insemination. However, recently there have been great advances in the microsurgical and microassisted techniques suggesting that most types of male infertility can now be treated. Fertilization rates with routine IVF techniques regularly exceed 70% per oocyte. However, sperm obtained by the newer, more invasive microsurgical epididymal sperm aspiration techniques, fertilization rates of around 20% are more common. Subsequently, this means that pregnancy rates are well below those obtained by more conventional IVF procedures, including ICSI. We present our first series of 11 patients who underwent microsurgical epididymal sperm aspiration for congenital bilateral absence of vas deferens. Of these 11, 10 received general anaesthesia, while one patient received local anaesthesia. A total of 196 oocytes were injected with sperm obtained from the microsurgical epididymal sperm aspiration procedure. The damage rate was 15%. Overall fertilization was 32% with a subsequent 94% of those fertilized undergoing cleavage. A total of 34 embryos were transferred and 7 embryos were cryopreserved.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Scrotal exploration in 123 azoospermia patients

Mostafa K. Mansi


King Fahad National Guard Hospital, Riyadh, Saudi Arabia

During the last 8 years, scrotal exploration for attempted vaso-epididymostomy was performed in 123 azoospermia patients. All patients had normal or slightly elevated serum FSH, and normal size testes (at least on one side). Testicular biopsy was not recommended but had already been done before referral in 73 patients and was reported to show normal spermatogenesis or mild hypo-spermatogenesis.

Vaso-epididymostomy could be performed in only 83 (67.5%) of patients using conventional fistula technique in 34 patients and microsurgical single tubule anastomosis in 49 patients. Sixty-seven patients were followed between 6 and 30 months (mean 17.8 months). Among these patients, 25 produced sperm in the ejaculate with a potency rate of 37.3 percent, and seven patients impregnated their wives for a pregnancy rate of 10.4%. These pregnancies resulted in 4 living children.

Micro surgical single tubule vaso-epididymostomy is strongly recommended for the treatment of obstructive azoospermia.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Early experience with transrectal seminal vesiculography - TSV

S. Memon, S. Mahmoud, A.K. Kakaria, G. Attassi


King Fahd Specialist Hospital, Buraidah, Saudi Arabia

The standard method for the diagnosis of vasal obstruction is vasography which involves open vasotomy, injection of contrast under anaesthesia. We report our experience with TSV technique to detect obstruction of vas deferens in patients with azoospermia. TSV was performed in the Radiology Department on 20 adult patient with suspected obstruction.

With transrectal ultrasound transducer of 5MHZ and biopsy needle assembly 10 ml of non-ionic contrast was injected into the seminal vesicle on each side using chiba 22 gauge needle.

All the patient received prophylactic antibiotics and none experienced a serious complication. TSV showed filling of vas deferens on both sides in 2 patients, unilateral filling in 7 patients, non filling of both vas deferens in 7 patients. There was failure of filling of VD, but visualisation of seminal vesicles & ejaculatory ducts in 3 patients. Two of these patients had agenesis of seminal vesicles and in one patient contrast was injected outside seminal vesicle. Two of those with unilateral obstruction subsequently had scrotal explorations during which the obstructions were confirmed.

Compared with open vasography, TSV is a simple out patient procedure performed without anaesthesia. Visualisation of the entire vas deferens rules out obstruction. While failure to visualise the vas requires confirmation of obstruction with vasography.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Hormonal profile and testicular histology in oligospermic or azoospermic men

S.A. Egail, A. Al Dayel, M.Y. Ezzibdeh, I. Al Oraifi, E. El Sayed, A. Abo Zallat


King Fahd Military Medical Complex, Dhahran, Saudi Arabia

A group of 107 patients attending male infertility clinics with abnormal sperm count were examined; 69 patients (64.5%) were azoospermic and 38 (35.5%) were oligospermic. Luteinising hormone (LH), follicle stimulating hormone (FSH), testosterone and prolactin serum concentration were estimated in all patients. Serum FSH was raised in 28 (40.6%) of all azoospermic men but in only 6 (15.8%) oligospermic men. Testicular biopsies were obtained from 70 oligo or azoospermic patients and evaluated in paraffin sections. Those patients were divided into four groups on the basis of histological criteria. The mean serum FSH value of patients with or without obstructive oligo/azoospermia and normal histology (group 1, n=31) was (5.2 ΁ 3.6 iu/l) (mean ΁ SD). Serum FSH in group 2: maturation arrest (n=8) (5.2 ΁ 2.9 iu/l), group 3: partial tubular atrophy (n=11) (12.7 ΁ 7.5 iu/l) and group 4: total absence of spermatogenesis (n=20) (19.8 ΁ 10.2 iu/l). Mean serum FSH level was significantly higher in group 4 than other groups (P0 < 0.05). There was no significant difference in serum LH, testosterone and prolactin concentration between the different groups.

These data seem to indicate that elevation of serum FSH correlates with the histological appearance but normal FSH does not exclude severe derangement of spermatogenesis in individual cases.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Percutaneous epididymal sperm aspiration - a simple method of sperm retrieval

A.H. Kardar, K. Jaroudi, S. Coskun


Departments of Urology, Obstetrics & Gynecology, Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Aim of Study: 1. To assess the success rate of Percutaneous Epididymal Sperm Aspiration (PESA), in retrieving sperms. 2. To evaluate the fertilization rate and pregnancy rate following intracytoplasmic sperm (ICSI) of sperm retrieved.

Material and Methods: Between April 1996 and September 1996, 20 patients underwent PESA to recover sperms for ICSI. Patient age ranges were 27-57 years (mean = 33.3). 27 patients had primary infertility and 2 had secondary infertility. Nine patients had congenital absence of vas deferens (CAV). 13 patients had undergone multiple vasoepididymostomies previously.

Results: Sperm retrieval was successful in 25 patients. One puncture was sufficient in 19 patients. The sperm extraction for ICSI was much faster and easier from PESA than testicular biopsy and the quality of sperm was also better. Reviewing the results of the first 21 couples, 280 oocytes were obtained, 223 of which were available for ICSI. 116 oocytes fertilized, a fertilization rate of 52%. A total of 63 embryos were transferred and achieved 8 pregnancies, a pregnancy rate of 38%.

Conclusions: 1. In obstructive azoospermia, simpler technique of PESA can be successfully used to retrieve sperm for ICSI. 2. PESA would obviate the need of construction of spermatocele in CAV cases. 3. Sperms retrieved by PESA can be successfully used for ICSI.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Fertility outcome after assisted stimulatory ejaculation

A.H. Kardar, S. Coskun, K. Jaroudi, K. Hanash


King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction: Several patient groups are suitable for treatment by assisted ejaculation, i.e., psychogenic, idiopathic and other medical and surgical causes of anejaculation. Spinal cord injury patients with anejaculation is another group which may also be suitable.

Aim of Study: This clinical prospective study is to assist the fertility outcome of all types of anejaculation patients in combination with assisted reproductive techniques, i.e. IVF, ICSI, or vaginal insemination.

Materials and Method: Patients referred to our tertiary care hospital for assisted reproductive techniques due to anejaculation, when retrograde ejaculation and ejaculatory duct obstruction were ruled out and when medical treatment failed to restore ejaculation. All the wives were less than 39 years old, with normal FSH and normal uterine cavity. Spousal preparation and timing was planned according to IVF protocol.

Results: A total of nine patients were electroejaculated to obtain spermatozoa to be used for assisted reproduction (ICSI). All patients yielded sperm, however, quality of sperm was not good enough for injection in two patients, thus testicular biopsy was performed (by biopsy gun) and the testicular sperm was used for injection. Total of 91 oocytes were recovered from seven patients, 74 oocytes were injected with electroejaculated sperm and 65% of them fertilized. Four of the patients got pregnant after embryo transfer (57% pregnancy rate).

Conclusion: Many retrospective reports indicate that rectal probe electrostimulation is an effective procedure to assist paraplegic patients, secondary to spinal cord injury, to the point where children can be sired. We collected semen from nine patients via this method resulting in 4 successful pregnancies. We feel that it may be more conclusive to carry out this study on a large scale.

Presented at the: 11 th Saudi Urological Conference

24-26 February 1998 (27-29 Shawwal 1418)



King Fahd Military Medical Complex - Dhahran

Application of ICSI in testicular failure azoospermia patients

T. Merdad, S. Kattan, A.H. Kardar, K. Jaroudi,

S. Coskun, K. Hanash


King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction: It is evident that in Sertoli cell only syndrome and maturation arrest the defects are not always total: Silber [1] found foci of spermatogenesis in 50% of cases. Tournaye [2] could recover sperms in 76% of 124 cases, with ICSI possible in 91.9%. All reports in the literature were obtained from retrospective analysis. The aim of this clinical prospective study was to assess the feasibility of combined multiple testicular sperm extraction (MTSE) to be utilized in intracytoplasmic sperm injection for infertile couples with non-obstructive azoospermia with a histopathological diagnosis of maturation arrest, Sertoli cell only syndrome, and other histoipathological causes of testicular failure.

Materials and Method: 8 infertile couples, due to non-obstructive secretory azoospermia (testicular failure), were enrolled in the study initially. Ovarian stimulation was carried out according to the IVF protocol and on the target day for oocyte retrieval, the husband was admitted for MTSE. Detailed counseling was done for all couples before starting the cycle.

Results: A total of 8 patients underwent MTSE for possible sperm recovery to be used for ICSI. All patients had either Sertoli cell only or maturation arrest on diagnostic testicular biopsy. MTSE from 2 patients yielded sperm for injection (25% recovery), while no sperm was found in others after long search. 27 oocytes were obtained from the wives of the two patients with sperm and 19 of them were injected. The fertilization rate was 74% (14/19) and all the fertilized oocytes cleaved in culture, 6 embryos transferred to the wives. Unfortunately, none of them became pregnant.

Conclusion: The chances of retrieving sperm from patients with severe male factor infertility are considered debatable. From the results of our early experience in treating these patients, we feel it may be more conclusive and statistically significant to conduct this study on a large group of patients.

References

1. Silber S. Sertoli cell only revised. Hum Reprod 1995;10:1031-2.

2. Tournaye H, Liu J, Nagy PZ, Camus M, Goossens A, Silber S, et al. Correlation between testicular histology and outcome after intracytoplasmic sperm injection using testicular spermatozoa. Hum Reprod 1996;11:127-32.

Presented at the: 11 th Saudi Urological Conference

24-26 February 1998 (27-29 Shawwal 1418)



King Fahd Military Medical

Complex - Dhahran

Early surgical sperm retrieval for assisted reproductive technique in azoospermic patients

T. Merdad, K. Jaroudi, H. Al Zahrani, S. Kattan,

H. Al Faraj, A.H. Kardar, A. Peracha, M. Aslam,

K. Hanash


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

Introduction : Surgical sperm retrieval is routinely performed on the day of oocyte pick up, sperms are then processed and intracytoplasmic sperm injection (ICSI) is performed utilizing the freshly recovered spermatozoa. Fertilization rate of 60% and pregnancy rates of 35% have been reported. Failure to recover sperm occurs in approximately 10% of cycles.

Objective : To compare fertilization and pregnancy rates of freshly retrieved sperms, those retrieved are processed one or two days earlier.

Materials and Methods: Surgical sperm retrieval was done on an outpatient set up, under local analgesia. After processing the sperms, they were kept at room temperature until the time for ICSI, which was performed either after 24 or 48 hours.

Results: Advanced and fresh surgical sperm recovery was performed in 20 and 53 cycles respectively. One hundred and thirteen eggs fertilized out of 180 injected (63%) in the delayed group as compared to 262 out of 454 (58%) p=0.28 on the same day ICSI. Pregnancy rate was similar between both groups 30% (6/20) in advanced versus 36% (19/53) in fresh sperm recovery p=0.84.

Conclusions: Surgical sperm recovery performed 24 to 48 hours earlier may be safe for ICSI procedure. This results in better planning of the assisted reproductive technique and in cases of failure to retrieve sperm, ovum pick up may be cancelled reducing the cost and preventing the potential risk for ovarian hyperstimulation.

Presented at the: 12 th Saudi Urology Conference

23-25 February 1999 (7-9 Dhu Al Qa'dah 1419)



Al Hada and Taif Armed Forces

Hospitals Program

Comparative study of testicular sperm maturation in vitro using ham's F-10 earle's and ferticult culture media

B. Abdel-Naser, M.A. Farid, M. El Bahrawy


Department of Urology, Al Obaid General Hospital, Al Hasa, Saudi Arabia

Objective: Testicular sperm extraction (TESE) from azoospermic males followed by subzonal or intracytoplasmic sperm injection (SUZI, ICSI) is a recent advance in treatment of male infertility. This study describes the total number and motility changes in vitro of freshly extracted testicular sperm and compares between Ham's F-10, Earle's and Ferticult culture media.

Methods: Testicular biopsies were obtained from azoospermic patients (n=9) and processed to obtain a cell suspension that was incubated in equal portions in each culture medium supplemented with 10% human albumin for 5 days. The number of total and motile spermatozoa was evaluated on day 0 and daily afterwards for 5 days.

Results: Our results revealed that all patients were suffering from obstructive azoospermia with mean age of 39+3.36 and duration of infertility of 9.25+2.98 years. The total number of spermatozoa showed no significant changes in all days of incubation and between all used media (P>0.05). However, the number of motile spermatozoa was significantly higher in Ferticult medium when compared with Ham's F-10 and Earle's media in day 1 through day 5 (P<0.05). Similarly, number of motile sperm was significantly higher in Earle's medium when compared with Ham's F-10 but only on day 3 and 4 of incubation (P<0.05). In all used media, spermatozoa become motile within 24 hours of culture and the motility was maintained for the 4 th day before a decline to the near 0 level is observed on the 5 th day of incubation. Furthermore, the number of progressively motile sperm significantly peaked on day 3 of incubation in all media but the best significant yield was observed in Ferticult medium (P<0.05). No significant correlation was found with age of patients or duration of infertility (P>0.05).

Conclusion: From our study we recommend that TESE is carried out approximately 3 days before oocyte retrieval and that Ferticult medium is the medium of choice to use in vitro cultivation for obtaining the best yield of mature testicular tissue sperm to be used for IVF related procedures, such as SUZI and ICSI.

Presented at the: 12 th Saudi Urology Conference

23-25 February 1999 (7-9 Dhu Al Qa'dah 1419)



Al Hada and Taif Armed Forces

Hospitals Program

Sertoli cell only syndrome, sperm retrieval: A clinical dilemma

T. Merdad, S. Coskun 1 , H. Al Zahrani, S. Kattan,

K. Jaroudi 2 , K. Hanash

Departments of Urology, 1 Pathology and Laboratory Medicine and 2 Center for Reproductive Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: To investigate the effects of micro dissection of testicular tissue for sperm retrieval in patients with previously diagnosed Sertoli Cell Only Syndrome.

Design: Prospective clinical study.

Setting: Tertiary care referral hospital.

Materials and Methods: From April 1999 to September 1999, 12 patients with previously diagnosed Sertoli Cell Only Syndrome on fine needle aspiration underwent diagnostic microdissection of testicular tissue (Schlegel Technique), from the right testis and a diagnostic wet preparation from the left testis, at the same time, bilateral testicular biopsies' histopathology were obtained simultaneously from both sides. All patients had testicular volume > 8 ml and FSH . double the normal.

Results: Five patients had positive sperm on wet preparation, microdissection and the histology of both sides. One patient had positive sperm on wet preparation and the histology, while the microdissection was negative for all patients (6) with their histology confirming Sertoli Cell Only Syndrome. No sperm was retrieved with microdissection.

Conclusions: The retrieval of spermatozoa from men with non-obstructive azoospermia is possible for some patients using TESE procedure. However, sperm recovery with Sertoli Cell Only Syndrome is very low, which we concluded from our last year's study with multiple testicular biopsies presented at the November 1998 Saudi Fertility Society meeting in Jeddah. One out of 16 patients. It was therefore postulated and microdissection technique for sperm retrieval is not a promising procedure for patients with Sertoli Cell Only Syndrome and perhaps, for patients with hypospermatogenesis.

Presented at the: 13 th Saudi Urological Conference



14-17 February 2000

(09-12 Dhu Al Qa'dah 1420)

Riyadh Armed Forces Hospital

Multiple testicular biopsies for sperm retrieval. Is it safe?

Kardar AH, Merdad T, Aslam M, Peracha A, Kattan S, Zahrani H, Hanash K.


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

Introduction and Objectives: With the recent advance in management of male infertility, repeated testicular biopsies using fine needle and bioptygun are used to retrieve sperms for assisted reproductive techniques. The immediate and delayed effects of needle biopsies were studied on the testes of Sprague-Dawley rats.

Methods: Fine needle gauge 25 and true cut needle gauge 18 were used to aspirate sperms from the testes of age and weight matched Sprague-Dawley rats. These animals were grouped into A where testes were removed immediately and B where testes were removed 6 weeks later. These were further sub-grouped according to the needle used. A1, B1 (fine needle) and A2, B2 (Bioptygun). Formaline fixed sections from the affected parts of the testes were examined histologically to assess the early and delayed effects of the procedures.

Results: Three animals of group B2 had died due to bleeding. There were 3 specimens in group A1, 4 in A2, 13 specimens in group B1 and 6 in group B2. There was evidence of hemorrhage at the surface and in between the tubules in 2 out of 3 specimens in A1. All 4 specimens in A2 showed hemorrhage at the surface and in between the tubules.

Histological changes of calcification, scarring focal intratubular and interstitial oedema and focal tubular atrophy of varying degree were noticed in 9 (70%) of specimens in group B1. All specimens in B2 showed evidence of moderate to severe damage including extensive tubular atrophy, calcification, infarction and intratubular oedema.

Conclusions: Fine needle as well as bioptygun when used to retrieve sperm from the testes lead to damage to the testicular parenchyma. This damage is more extensive with bioptygun.

Presented at the: 13 th Saudi Urological Conference



14-17 February 2000

(09-12 Dhu Al Qa'dah 1420)

Riyadh Armed Forces Hospital

Surgical sperm retrieval technique and methodology

T. Merdad, H. Al Zahrani, S. Kattan, K. Jaroudi 1 ,

K. Hanash

Departments of Urology and 1 Center for Reproductive Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh,

Saudi Arabia

Objective: To demonstrate the methodology and technique of surgical sperm retrieval for obstructive, non-obstructive and anejaculation infertile men.

Design: Demonstration.

Setting: Tertiary care referral hospital.

Materials and Methods: Close up video demonstration and description of the methodology of surgical sperm retrieval for obstructive azoospermia and non-obstructive azoospermia and a patient with organic anejaculation. Seven patients with various infertility causes underwent the following procedures: open testicular biopsy, testicular fine needle aspiration, bioptygun biopsy, percutaneous epididymal sperm aspiration, vibratory ejaculation and electroejaculation.

Results: This video underlines the importance of selecting the type of technique to be used on a patient. Also, it demonstrates the patient preparation required for surgical sperm retrieval.

Conclusions: These techniques are cost effective, rapid, safe and relatively harmless.

Presented at the: 13 th Saudi Urological Conference



14-17 February 2000

(09-12 Dhu Al Qa'dah 1420)

Riyadh Armed Forces Hospital

Sertoli cell only syndrome: The value of diagnostic fine needle aspiration biopsy

T. Merdad, W.A. Mourad, S. Kattan, H. Zahrani,

A. Kardar, M. Aslam, M. Mandil, K. Ghamdi, K. Hanash


Departments of Urology and Pathology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction and Aim of Work: Diagnostic testicular biopsy is often necessary; especially before planned assisted fertilization using intra-cytoplasmic sperm injection (ICSI). In cases of Sertoli cell only syndrome it is sometimes difficult to decide on whether pre-biopsy fine needle aspiration biopsy (FNAB) is helpful or not.

Materials and Methods: We retrospectively reviewed cases of FNAB of the testis and correlated our findings with the results of open biopsy and wet preparation results. We also correlated these findings with testicular size and Follicle stimulating hormone (FSH) levels.

Results: There were 365 infertile males examined with 785 FNAB (right and left). Open biopsy was performed in 205 patients (410 biopsies). Sperms were identified in 375 FNABs (47.7%). No sperms were identified in 410 FNABs (52.2%). Of the 410 negative FNABs sperms were identified in 176 (42.9%) subsequent open biopsies. Patients with no sperms identified on either FNAB or open biopsy had significantly smaller testicular sizes and higher FSH levels (results to be discussed).

Conclusion: Our study indicates that, in infertile males, FNAB is a helpful procedure in detecting sperms; especially in males requiring ICSI. Our study also indicates that testicular biopsy with histological examination and/or wet preparation is more sensitive in detecting sperms.

Presented at the: 14 th Saudi Urological Conference



13-15 February 2001

(19-21 Dhu Al Qa'dah 1421)



King Fahd Military Medical

Complex - Dhahran

Experience with testis FNA mapping and microdissection - tese (M & M)

Amr M Jad, Paul J Turek


Riyadh Armed Forces Hospital, Saudi Arabia/University of California, San Francisco, California, USA

Several approaches are used for sperm retrieval for ICSI in non-obstructive azoospermia (NOA). To obtain maximal retrieval success and also preserve organ function, we perform diagnostic FNA mapping followed by directed TESA/TESE (testis sperm aspiration/extraction) at the time of ICSI. When FNA mapping reveals fewer than 2 sites of sperm, TESE can be difficult. We report our experience with microdissection-TESE after mapping these difficult cases and compare retrieval success in microdissection and routine TESE cases. A full demonstration of FNA mapping technique as well as the microdissection TESE will be presented.

In a series of consecutive NOA patients who underwent a diagnostic procedure (FNA mapping or testis biopsy) to determine candidacy (sperm presence) for ICSI, we identified 2 cohorts: a) The "easier" patients with at least 2/22 mapped sites or a single biopsy showing sperm who proceeded with simple, directed TESE, and b) The "harder" patients with testis sperm in only 1 of 22 mapped sites who either could (or did) fail simple TESE in whom microdissection TESE was performed. Sperm retrieval procedures from these two cohorts were compared to gain information on the value of microdissection after FNA mapping in difficult NOA patients. Of 150 NOA men, 132 men underwent diagnostic FNA mapping and 18 had a prior testis biopsy that suggested sperm presence. Among these patients, 59 proceeded to sperm retrieval and ICSI with testicular sperm: 45 patients with directed TESA/TESE and 14 with microdissection TESE. Sufficient sperm, defined as enough sperm for all eggs retrieved at IVF, was obtained in 44/45 (98%) of TESA/TESE cases and in 12/14 (86%) of microdissection cases. Oocyte fertilization and clinical pregnancy rates were statistically similar between the 2 cohorts.

Conclusions: The addition of microdissection to FNA mapping maintains the high sperm retrieval rates in NOA patients that mapping has allowed, even in very difficult cases.

Presented at the: 16 th Saudi Urological Conference

2 - 4 March 2004 (11-13 Muharram 1425)



King Faisal Specialist Hospital &

Research Centre

Prognostic significance of seminal plasma transferrin in varicocele associated male infertility. Its correlation with semen parameters and pregnancy rates following different treatment modalities. Prospective randomized controlled study

Hisham El-Shawaf, Naeim Dawood 1 , Tarek El-Zayat, Yasser Galal Moustafa 2


Lecturer of Urology, Ain Shams University, Cairo, Egypt, 1 Lecturer of Dermatology, Andrology and STDs, Tanta University, Egypt, 2 Assist. Prof. of Obs. and Gyn, Ain Shams University, Cairo, Egypt

Objective: One of the old romances between Urology, Gynecology and Venereology is varicocele associated male infertility. Interventional treatment has been the routine therapy for varicocele associated male infertility. However, empirical treatment regimens should be reconsidered and the pathophysiology of the varicocele should be elucidated to provide a basis for rational treatment. Our aim is to assess whether seminal plasma transferrin (SPT) can be considered as a significant prognostic indicator for the recovery of both semen parameters and Sertoli cell function in relation to pregnancy rates as an index for overall success of treatment options. Consequently, our study is designed to compare the effects of sequential therapy (loupe magnified subinguinal varicocelectomy & empirical medical therapy with clomiphene citrate) versus each of them separately on global testicular functions (seminiferous tubular and Sertoli cell functions).

Methods: Seventy two patients with primary varicocele and oligosasthenoteratozoospermia were included in the study and allocated randomly into 3 groups (G1, G2, and G3) who underwent estimation of seminal plasma transferrin (SPT) and semen analysis before, 3 and 6 months after treatment. G1 (n=24) patients underwent sequential therapy (loupe magnified subinguinal varicocelectomy plus clomiphene citrate 25mg daily for 6 months), G2 (n=25) patients allocated for loupe magnified subinguinal varicocelectomy alone and G3 (n=23) for clomiphene citrate monotherapy in a daily dose of 25 mg for 6 months. All patients were followed up to 12 months from the start of treatment in particular attention to pregnancy rates.

Results: There is no significant difference between the mean pretreatment transferrin concentration in seminal plasma among the three treatment groups (p>0.05). The mean transferrin level in seminal plasma of the first group (G1) before the operation is 44.54 ΅g/ml + 12.3, in G2 is 43.68 ΅g/ml +15.4 and in the G3 patients is 42.1 ΅g/ml + 13.2. Transferrin level in seminal plasma increased significantly (P<0.05) in G1 patients 3 & 6 months after the operation to 87.8 ΅g/ml + 22.2 & 106.5 ΅g/ml + 28.6 respectively and in G2 patients, it increased significantly to 79.6 ΅g/ml + 25.6 & 104.2 ΅g/ml + 29.9 respectively. In G3 patients, 3 months after treatment, SPT increased insignificantly to 52.3 ΅g/ml + 10.8 but increased significantly to 61.5 ΅g/ml + 12.3 6 months after treatment. All semen parameters had been improved in G1 & G2 patients. In the G3 patients only sperm density had improved. The mean sperm density had improved significantly (p<0.05) 6 months after the operation in 83.3% & 72% of patients in G1 & G2 respectively (by showing increased sperm concentration >15 million/ml from the pretreatment level) compared to 34.7% in G3. Other semen parameters (motility and morphology) that had improved significantly in G1 & G2 showed subtle changes in the G3 which is insignificant. The 12 months pregnancy rate is significantly higher among G1 and G2 (58.3%, 28% respectively) in comparison to 4.3% among the G3 patients (P<0.01). G1 patients had a highly statistically significant higher pregnancy rate (P<0.01) in comparison to either G2 or G3 (Z test results was 2.4 & 4.9 respectively) confirming the superiority of sequential therapy in comparison to either surgical or medical therapy alone.

Conclusion: Seminal plasma transferrin (SPT) can be considered as a useful marker for Sertoli cell function and predictor of improvement of semen parameters. The highly significant improvement of all semen parameters which is strongly correlated with changes of the transferrin levels 3 and 6 months after the operation in the (G1) patients reflects the superiority of sequential therapy compared with varicocelectomy alone in (G2). G3 patients who received pharmacologic therapy alone are the least responders. The pregnancy rate is significantly higher among the sequential group when compared with either treatment groups.

Presented at the: 16 th Saudi Urological Conference

2 - 4 March 2004 (11-13 Muharram 1425)



King Faisal Specialist Hospital &

Research Centre

The changing management of male infertility in the era of assisted reproductive techniques

Salah El Faqih


Chief, Division of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Since the birth of the first tube baby in 1978 by in-vitro fertilization (IVF) for female factor infertility, IVF was successfully applied in treatment of couples with unexplained infertility including male infertility. The subsequent introduction of Intracytoplasmic Sperm Injection (ICSI) in 1992 has widened the scope of treatment and since then IVF with ICSI has been widely used for treatment of infertile couples. Urologists are very fortunate because the most exciting advances of these assisted reproductive techniques (SRT) have been in the area of male factor infertility. Couples who have been previously hopeless are now achieving pregnancy despite severe impairments in semen quality or the presence of single numbers of sperms in the ejaculate. Sperm extraction directly from the testicular parachyma (TESE) has made it possible to add even non-obstructive azoospermia resulting from maturation arrest or germ cell development problems to the list of treatable conditions in male infertility.

Semen analysis remains one of the important cornerstones of fertility work up but its value and the way we look at it has changed. The normality of semen parameters may need to be redefined and we have to be cautious in utilizing those parameters to predict ICSI success. The only parameter proved important for prediction of ICSI success is sperm vitality. It is becoming increasingly clear that spermatozoa contain prognostic information for the fate of the early embryo and testing for these factors will become of increasing importance in the future. Testicular biopsy was used before for diagnostic purposes but now is increasingly used for prognostic as well as therapeutic purposes. Testicular histopathology has proved to be the only reliable predictor of sperm retrieval and is been increasingly used to retrieve sperms from obstructive and non-obstructive azoopermic patients. Preliminary diagnostic biopsy retrieval combined with cryopreservation of the tissue for future use made it much less stressful and more convenient for the couples. Electroejaculation and the systematic application of ART is an effective treatment for anejaculation infertility due to spinal cord injury and other anejaculation disorders. Varicocele and male infertility remains a dilemma; despite the long history of association, there remains much controversy regarding the diagnosis and management. The imaging diagnostic criteria are changing and the value of varicocele treatment has been challenged by evidence based andrology.

To date, the data available indicates that ICSI is a safe procedure but the possibility of adverse effects still exists regarding the potential risk of congenital malformation and genetic defects. The unique accessibility of the embryo in the IVF procedures gives unique opportunities to biopsy these embryos for pre-implantation diagnosis of both genetic disease and aneuploidy, a major cause of early embryo demise and miscarriage. The door is kept widely opened for future developments in assisted reproduction to improve the success rates and reduce multiple pregnancies.

Presented at the: 17 th Saudi Urological Conference

8 - 10 March 2005

King Fahd Military Medical Complex

Transrectal electroejaculation combined with intracytoplasmic sperm injection: An effective treatment of male infertility in anejaculatory men

K. Al Mitwalli 1 , S.R. El Faqih, L. Khalil, S. Khalil,

O. Abdulrazak

1 Dallah Hospital and King Khalid University Hospital, Riyadh,

Saudi Arabia

Introduction: Infertility due to anaectroejaculation is a relatively uncommon cause of male infertility. Eletroejaculation (EE) has been successfully used for sperm procurement in anejaculatory men. The development of assisted reproductive techniques has changed the management of male infertility and the development of intracytoplasmic sperm injection (ICSI) has made it possible to achieve pregnancies with ejaculates containing minimal number of sperms. In this study, we report our experience in treatment of anejaculatory infertile men using combined EE and ICSI.

Patients and Methods: Between May 1998 and March 2004, 30 anejaculatory men were treated at Dallah Hospital Fertility Unit with combined transrectal probe EE & ICSI. The etiologies of anejaculation in those men included spinal cord injuries (SCI) (n=11) age range 24-33 years, psychogenic (n=10) age range 27-45 years, and anejaculation due to medical conditions (n=9) age range 20-60. Electroejaculation was performed by using the transrectal probe, Seager model 14, electroejaculator and the retrieved fresh sperms were used for ICSI in the 24 patients interested to achieve pregnancy, the remaining other 6 patients were interested to determine their fertility potential.

Results: Semen was obtained in all the 30 patients (100%), 28 antegradely and 2 retrogradely, sperms were retrieved in 29 out of 30 patients (96.6%). No complications were noted during or after the procedure. In the SCI group ICSI was performed on 6 patients with 3 pregnancies resulting in live birth (50%), in the psychogenic group 10 patients underwent ICSI with pregnancy resulting in live birth in 2 patients (20%), and in the anejaculation due to medical condition group 7 patients underwent ICSI with only one pregnancy resulting in live birth (14%). So the overall pregnancy resulting in live birth is 6 out of 24 (24%).

Conclusion: Electroejaculation is a very reliable method of obtaining sperms from anejaculatory men, it is safe with reproducible results and it is non-invasive in comparison to testicular aspiration and open biopsies, furthermore large amount of semen can be obtained and kept frozen for future use. With the good ICSI results of 25% live birth rate in this population, electroejaculation combined with ICSI provides anejaculatory men the best possible chance to have children.

Presented at the: 17 th Saudi Urological Conference

8 - 10 March 2005

King Fahd Military Medical Complex

Testicular sperm aspiration: Experience using a modified technique

Ahmed Al Asker, Khaled Madbouly and Hamoud Al Matrafi


King Fahad National Guard Hospital, Riyadh, Saudi Arabia

Objective: To preset our experience in testicular sperm aspiration to retrieve sperms for intracytoplasmic sperm injection (ICSI) in men with infertility using a modified technique.

Patients and Methods: Since total of 90 adult infertile male patients were subjected to testicular sperm aspiration (fine needle aspiration, FNA) for ICSI using a modified technique. Mean age (+ SD) was 41.47 (+ 9.33) years, range: 25-74 years. Out of these, 79 (87.8%) had primary infertility, 11 (12.2%) had secondary infertility, 64 (71.1%) azoospermic, 14 (15.6%) with severe oligospermia and 12 (13.3%) with failed or no ejaculation. The technique involved the use of a 23 gauge butterfly needle. Multiple punctures and aspirations (up to 8 per testis) were performed systematically throughout the whole testis on both sides while squeezing and holding the testis gently. Every testicular puncture was composed of multiple in and out movements in the same direction with clockwise and anticlockwise rotatory movements.

Results: FNA resulted in the recovery of mature spermatozoa in 133 of 296 (44.9%) of the pricks in 75 of the 90 (83.3%) patients. Ten of the remaining 15 patients underwent testicular sperm extraction (TESE) while 5 refused further management. The relation among FNA success rate and size of both testes, cause of azoospermia (obstructive or not), testicular histopathology (when available) and serum FSH & Testosterone was assessed using chi-square, Fisher's Exact and Mann-Whitney tests and all showed no significance. None of the patients developed scrotal hematoma infection or procedure-related testicular atrophy.

Conclusions: Testicular sperm aspiration is a successful approach for sperm retrieval. It is quick, safe and minimally invasive modality. It allows screening of multiple intratesticular sites increasing the chances of sperm retrieving almost without reduction of testicular volume. The modified technique is highly effective and well tolerated by all patients.

Presented at the: 17 th Saudi Urological Conference

8 - 10 March 2005

King Fahd Military Medical Complex

Microsurgical subinguinal varicocelectomy under local anesthesia: Outcome assessment

Taha Abo-Almagd Abdel-Meguid


Department of Urology, Faculty of Medicine, El-Minia University - Egypt, Consultant of Urology, Baksh Hospital - Jeddah

Purpose: Varicocele has been related to infertility and several impairments of semen parameters. Many suggest that varicocelectomy improves semen quality and pregnancy rates. However, others argue against its role. We, hereby, prospectively evaluate the outcome of microsurgical subinguinal varicocelectomy under local anesthesia.

Patients and Methods: Out of 82 varicocele patients, a total of 58 patients (age range 18-46 years) underwent 99 procedures (study group). Fifteen of the non operated married patients served as control group. The selection criteria were: evident varicocele; with varicocele related infertility and/or impairment of one or more of semen parameters (sperm count > 20 million/ml, sperm motility > 50% and/or normal sperm morphology > 50%). Patients with azoospermia, hormonal disturbance, or female factor infertility were excluded. Microsurgical subinguinal varicocelectomy under local anesthesia was performed. Study patients were followed up for a maximum of 2 years post surgery for varicocele recurrence, hydrocele formation, testicular size, semen quality and pregnancy rates.

Results: Fifty eight study patients underwent 99 varicocelectomies on an outpatient basis under local anesthesia. The operative time ranged from 20-55 minutes per side. No intraoperative complications were encountered. Postoperative hospital stay ranged from 2-6 hours, return to work 1-3 days and analgesic pills use was 0-9 pills. Fifty eight patients (94 varicocelectomies) were followed for > 3 months, 48 patients were followed for > 3-6 months, while 27 patients with stable marriage were followed for 2 years. Recurrence of varicocele occurred in 3.2%, mild hydrocele formation occurred in 1.06%, while no testicular atrophy was encountered. Sperm concentration, motility, morphology, and multiple parameters improvements were seen in 25 (52.1%), 31 (64.6%), 20 (41.7%), and 34 (70.8%) patients respectively. Pregnancy rates were 29.6% during the first year after surgery and 11.1% during the second year with a total of 40.7% over 2 years. The pregnancy rate in the control non-operated group was only 13.3% during 1 year follow up.

Conclusions: Microsurgical subinguinal varicocelectomy under local anesthesia is a safe, simple, and effective treatment for varicocele and its related infertility. It can be performed on an outpatient basis with rapid recovery and minimal risk. Significant improvements of semen quality and pregnancy rates are obvious with this procedure.

Presented at the: 17 th Saudi Urological Conference

8 - 10 March 2005

King Fahd Military Medical Complex

Microdissection testicular sperm extraction in non-obstructive azoospermia: Early experience

Hamoud Al Matrafi, Ahmed Al Asker,

Khaled Madbouly


King Fahad National Guard Hospital, Riyadh, Saudi Arabia

Objective: Microsurgical techniques in testicular sperm extraction can improve sperm retrieval in patients with non-obstructive azoospermia (NOA). We present our early experience and establish a practical and safe strategy for testicular sperm retrieval in such patients.

Patients and Methods: From January 2003, 54 adult infertile male patients with NOA were subjected to microdissection testicular sperm extraction for ICSI. Mean age (+ SD) was 34 (+ 6.45) years, range: 25-52 years. Most of the patients had primary infertility and had at least failed once conventional TESE before. The majority of the testes were small in size. Patients were managed under general anesthesia. Scrotal contents were extruded and the tunica albuginea was opened for 1 to 3cm at its mid portion under an operating microscope. Direct examination of testicular parenchyma was then carried out at high magnification to identify dilated opaque or whitish tubules which were considered to contain spermatozoa.

Results: All the procedures were performed by one surgeon (HAM). Most of the patients were subjected to bilateral microdissection TESE. Sertoli-cell-only histopathology was diagnosed in the majority of the patients. Microdissection TESE: retrieved mature spermatozoa in 16 (29.6%) patients. The relation among microdissection TESE success rate and size of both testes, testicular histopathology and serum FSH and Testosterone was assessed using chi-square, Fisher's Exact and Mann-Whitney tests and all showed no significance. None of the patients developed clinically detected scrotal hematomas, infection of procedure-related testicular atrophy.

Conclusion: Microdissection TESE is safe. Meticulous hemostasis could be easily achieved under clear magnified vision. It improves the frequency of sperm retrieval for men with non-obstructive azoospermia.

Presented at the: 17 th Saudi Urological Conference

8 - 10 March 2005

King Fahd Military Medical Complex

The role of the primary health physician in the management of male factor infertility

Eyad Z. Al Aqqad


Specialist Urologist, Nablus, Palestine

Male factor abnormalities contribute to reproductive failure in over 50% of infertile marriages. A systemic work up may be initiated by the primary health physician before further medical care is needed.

Many drugs have been used empirically over the years to overcome male factor contribution to the devastating problem of infertility, but mostly without sound evidence of effectiveness.

This presentation will concentrate on important points to consider in the medical history, clinical examination and laboratory investigations of males presenting to primary health physician with infertility problems.

We will also illustrate the evidence-based medicines that can be used in the appropriate clinical circumstances in the management of these males.

Presented at the: 18 th Saudi Urological Conference



20 - 23 February 2006

(21-24 Muharram 1427)

King Abdulaziz University Hospital

The impact of high dose gonadotrophine releasing hormone agonist on spermatogenesis in rat cryptorchid testis after orchiopexy

Osama Kamhawy, Salah Mostafa


Department of Urology, Faculty of Medicine, Zagazig University, Egypt

Cryptorchidism is a condition that negatively affects spermatogenesis that can not be completely recovered even after orchiopexy. To evaluate the efficacy of high dose gonadotropine releasing hormone agonist leuproline acetate on damaged spermatogenesis in cryptorchid rat testis, 20 male rats were used and divided into two groups and bilateral cryptorchidism was artificially induced. Five weeks later, all rats underwent bilateral orchiopexy. One group received Gn-RH agonist injection at the time of orchiopexy and 4 weeks later, while the other group served as control. The animals were sacrificed 15 weeks after orchiopexy. The weight of the body, testis and epididymis were measured and histopathological examination was done. Student T test was applied for statistical analysis. Testes in Gn-RH rats showed significant recovery of spermatogenesis, while those in the control group remained almost degenerated. From this study we conclude that administering high dose Gn-RH agonist after orchiopexy enhanced the recovery of spermatogenesis in rats. This finding comes in accordance with recent reports that treatment with Gn-RH agonist promotes regeneration of damaged spermatogenesis of different aetiologies.

Presented at the: 18 th Saudi Urological Conference



20 - 23 February 2006

(21-24 Muharram 1427)

King Abdulaziz University Hospital

Microdissection testicular sperm extraction: Sensitivity and specificity of intraoperative findings

A Al Asker, K Madbouly and Hamoud Al Matrafi


King Fahad National Guard Hospital, Riyadh, Saudi Arabia

Objective: Identification of healthy looking testicular tissue is the rationale behind and corner stone of successful Microdissection testicular sperm extraction (TESE). Our aim is to determine the sensitivity and specificity of intraoperative microscopic findings as correlated to successful sperm retrieval.

Patients and Methods: Forty five adult infertile male patients with non obstructive azoospermia were subjected to Microdissection TESE for ICSI. Mean age (SD) was 36 (9) years, range 25-67 years. All the patients had primary infertility. Patients were managed under general anesthesia. Direct examination of testicular parenchyma was carried out at high magnification using an operating microscope to identify dilated opaque or whitish tubules which are considered to contain spermatozoa.

Results: All the procedures were performed by a single surgeon (1-JAM). Two patients had solitary left testes. Both testes were examined in 33 patients, the right testis was examined in 4 and the left testis in 8. Microdissection TESE retrieved mature spermatozoa in 16 patients (35.6%). A total of 78 testes were examined and foci of healthy looking testicular tissue were identified in 28 testes (23.1%). A false positive result (healthy testicular tissue was identified with no sperms retrieved) was encountered in 2 testes. A false negative result (no healthy tissue was identified in spite of retrieval of mature sperms) was found in 2 testes. The over all sensitivity and specificity were 90% and 96.8% respectively.

Conclusions: Identification of healthy looking testicular tissue at high magnification during Microdissection TESE is highly sensitive and specific when correlated with sperm retrieval. Our results prove the rationale behind the procedure.

Presented at the: 18 th Saudi Urological Conference



20 - 23 February 2006

(21-24 Muharram 1427)

King Abdulaziz University Hospital

Microdissection testicular sperm extraction: Our further experience with a modified surgical technique

H. Al Matrafi, S. Al Khateeb, A. Al Asker,

K. Madbouly


Department of Surgery, Division of Urology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia

Objectives: Microdissection testicular sperm extraction is shown to improve the yield of sperm retrieval in patients with infertility due to non-obstructive azoospermia; we present our further experience with a modified surgical technique.

Materials and Methods: 112 patients with non-obstructive azoospermia underwent microdissection testicular sperm extraction at our institute between August 2004 to December 2005. After the first 50 patients we developed a modification in the original surgical technique, which we call "Flower technique", where scrotal contents were extruded, then using the operating microscope at X 20-25 magnification, the tunica albuginea was opened longitudinally avoiding subtunical vessels, then without separating the testicular tissue from the tunica, gentle dissection of the septa was carried out looking for dilated opaque tubules which if identified they were processed and examined for the presence of sperms which can be used for intracytoplasmic sperm injection (ICSI). All patients are being followed up with scrotal ultrasound and serum testosterone six months later. Relevant patient data were recorded and analyzed in correlation with the outcome of the procedure.

Results: The mean age of patient was 36.3 years (range 25-67), all were having non-obstructive azoospermia, 110 patients (98.2%) had primary infertility and 2 (8%) were secondary. Histopathology constituted of Sertoli-cell only syndrome in 64.3%, maturation arrest in 16.9%, testicular atrophy in 11.6% and hypospermatogenesis in 7.2%. We were able to retrieve sperms in 36 patients (32%). Relation between the outcome of the procedure and testicular size, serum FSH and testosterone and testicular histopathology was evaluated using chi-square, Fischer's exact and Mann-Whitney tests and all showed no significant relationship. None of the patients developed early procedure-related complications, while the effect on testicular size and serum testosterone is still being evaluated.

Conclusion: We believe that our modified technique of microdissection testicular sperm extraction is a safe, simple and effective procedure with improved yield of sperm retrieval in non-obstructive azoospermia.

Presented at the: 18 th Saudi Urological Conference



20 - 23 February 2006

(21-24 Muharram 1427)

King Abdulaziz University Hospital

Etiology of azoospermia: Experience of a tertiary referral center

Tariq Al Omair, Saad Abu-Melha, M. Mahzari,

K. Madbouly, H. Al Matrafi


Department of Urology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia

Objectives: To evaluate the etiology of azoospermia in Saudi Arabia patients referred for tertiary care.

Patients and Methods: Azoospermic, nonvassectomized men referred to us during 3-year period thoroughly evaluated and the etiology was recorded. In each subject, the diagnosis of azoospermia was verified in at least two ejaculates examined untreated and after centrifiguration. The history included as detailed information as possible regarding cryptorchidism, genital infections, trauma, scrotal and pelvic surgeries. The external genitalia were examined for number, size, consistency and location of the testes. The epididymides and the scrotal part of the vasa deferentia were palpated bilaterally throughout its length. FSH and Testosterone were assessed using routine techniques. Karyotypes were determined whenever possible. Histopathology of patient referred with biopsy slides was revised, otherwise, testicular biopsies were obtained as required or during process of conventional or microscopic sperm extraction.

Results: One hundred seventy two patients were recruited. The mean (SD) age was 38 (9.47) years. Presentation was primary infertility in 149 (86.6%) patients and secondary infertility in 23 (13.4%) with a mean (SD) duration 9.1 (7.28) years. Spinal cord injury-associated anejaculation was encountered in 5 (2.9%) patients, history of mumps orchitis in 5 (2.9%), cryptorchidism in 8 (4.7%), vasovasostomy or vasoepididymostomy in 8 (4.7%), and ejaculatory duct resection in 4 (2.3%). A small right and left testes were detected in 43.6 and 42.4% of the patients respectively. Testosterone and FSH mean (SD) values were 15 (11.6) nmll/L and 11.7 (9.2) IU/L respectively. Eighty patients of 38 (21.1%) were diagnosed to have 47xxy (lkinefelter) syndrome. A histopathology results was available for 80 (46.5%) patients, most commonly Sertoli cell only and maturation arrest in 26 (32.5%) and 18 (22.5%) respectively.

Conclusions: Many etiologies were identified as a cause of azoospermia. Klinefelter's syndrome and cryptorchidism are of the common etiologies. Sertoli cell only syndrome is the most common histopathological finding in azoospermic patients. Azoospermic condition remains unexplained in a considerable portion of the patients.

Presented at the: 19 th Saudi Urological Conference

King Khalid University Hospital - Riyadh

26 February - 01 March 2007

Azoospermic patient: Mosaic pattern in tese

Mai A. Banakhar, Farsi Hassan


Department of Urology, King Abdulaziz University, Jeddah, Saudi Arabia

Objective: To study the mosaic pattern of spermatogenesis in azoospermic patients.

Materials and Methods: We reviewed 81 azoospermic patients according to their sperm analysis who had TESE. We include those who had histopathology sample sent at the same time with TESE and excluded those who did not. We compared the TESE result to the histopathology with fixing a criteria for considering the presence or absents of mosaic pattern in our study.

Results: Mosaic pattern is identified in 25% in our study sample. There was no difference in mosaic pattern between the right and the left testicle. The histopathology showed difference in the mosaic distribution. 50% mosaic pattern was identified in maturation arrest, 15% in testicular atrophy, 15% in Sertoli cell only, 10% in hypospermatogenesis, 5% in the mixed histopathology at which testicular atrophy, maturation arrest and hypospermatogenesis all were identified at the same histopathology sample.

Conclusion: Mosaic pattern is identified in azoospermic patients with 25%, which can give them a chance for fertility with ICSI. We suggest to take more samples during testicular mapping for TESE. The patients with maturation arrest in their histopathology are having a higher chance for mosaic pattern compared to others.

Presented at the: 19 th Saudi Urological Conference

King Khalid University Hospital - Riyadh

26 February - 01 March 2007

Male infertility after kidney transplantation

M. El-Bahnasawy, E. Elsawy, M. Abol-Ghar,

O. Gheith, N. Hassan


Urology and Nephrology Center, Mansoura, Egypt

Aim of the Work: Multiple risk factors can contribute to male infertility after kidney transplantation including hormonal disturbances, graft function, immunosuppressive drugs and other comorbidity factors. Our aim is to investigate the impact of the previous factors on male infertility in our infertile male transplant recipients.

Patients and Methods: The study included 43 patients referred from the kidney transplantation follow up clinic with the complaint of primary or secondary infertility. Patients were investigated after thorough history taking and clinical examination by semen analysis, hormonal profile (FSH, LH, prolactin and total testosterone) and scrotal duplex ultrasonography. TRUS ΁ endorectal MRI were requested in patients with low semen volume.

Results: Very poor semen parameters were seen in this cohort of patients. Azoospermia was detected in 17 patients (39.5%) while severe oligo-asthenospermia was seen in other 10 patients (23.3%). There was no significant impact of either transplant duration or pre-transplant hemodialysis duration on testicular size or sperm concentration. However longer transplant duration (more than one year) was found necessary to significantly improve FSH and prolactin abnormalities. Graft function was significantly correlated with infertility duration, FSH and LH but not with prolactin, testicular size or sperm concentration. FSH was shown to significantly correlate with testicular size and sperm concentration. There was also good correlation between testosterone level and sperm concentration. Cyclosporine-based immunosuppressive protocols were associated with significantly better sperm concentration than other protocols (p=0.02). In 16 cases there were positive TRUS findings mainly prostatic cysts; 8 of them were further confirmed by endorectal MRI. Moreover, varicocele was detected in 17 cases (6 unilateral and 9 bilateral).

Conclusions: Infertile male kidney transplant recipients have mostly very poor semen parameters. Cyclosporine based immunosuppression have less deleterious effect on sperm density. Graft function is fairly correlated with FSH and LH levels and with infertility duration. Varicocele and/or prostatic cysts are present in a significant number of these patients. Prospective study on a larger number of patients to assess accurately the impact of kidney transplantation-related comorbidities on male fertility is warranted.

Presented at the: 20 th Saudi Urological Conference



King Fahad Hospital of the

University - Tabuk

18 - 20 March 2008

Impact of varicocelectomy on seminal fluid parameters in subfertile men in a military population

B. Saleh, M. El-Bahnasawy, A. Albalawi, M. Howaiti, M. Zakaria


North West Armed Forces Hospital, Tabuk, Saudi Arabia

Objectives: There is continuous debate about the necessity of varicocelectomy in subfertile men and its beneficial effect on seminal fluid parameters and consequently pregnancy outcome. Our aim is to test for the impact of this procedure on the spermogram by conducting this retrospective study.

Patients and Methods: 79 subfertile men with mean age of 24.5 years who underwent high ligation (Baloomo approach), inguinal or laparoscopic varicocelectomy for fertility problems in a period of 5 years (2003 - 2008) were included. Preoperative seminal fluid parameters were compared to those done not less than 3 months after surgery. A univariate statistical analysis showed a significant overall increase in the sperm density after surgery by 6.1 million/ml (92.5%) (p , 0.001). Patients having counts less than 5.0 million/ml showed an increase of about 8 million/ml (380%) (p < 0.001) compared to those with preoperative counts of > 5 M/ml who showed an increase of 4.7 M/ml (41%) (p < 0.001). No significant improvement was noted in the rapid motility parameter (W.H.0. System). The abnormal morphology decreased after surgery by 33% ( < 0.001).

Conclusion: Varicocelectomy significantly improved the sperm density and morphology in our patients particularly in those with worse pre-operative semen parameters. These findings closely match with the current evidence-based body of literature, but the study failed to demonstrate a significant improvement in motility contrary to the conclusion of most of the recent similar studies.

Presented at the: 21 st Saudi Urological Conference

North West Armed Forces Hospital - Tabuk

14 - 16 April 2009

Seminal parameters in patients with varicoceles: Impact of clinical presentation

M. El-Bahnasawy, A. Fahd, F. Fadl, A. Balaha


Almoosa General Hospital, Al-Hasa, Saudi Arabia

Objective: Controversy continues regarding impact of varicocele on the different seminal parameters and the possible bias in case of patients attending infertility clinics. Our aim is to compare different seminal parameters in patients presented for infertility versus those presented for testicular pain.

Materials and Methods: This study included 117 varicocele patients presented by infertility problems and 107 varicocele patients presented with testicular pain. All of them were assessed clinically, radiologically and laboratory by single observer each. Statistical analysis was done using Wilcoxon matched-pairs signed-ranks test and correlations were made using Spearman correlation coefficients.

Presented at the: 21 st Saudi Urological Conference

North West Armed Forces Hospital - Tabuk

14 - 16 April 2009

Varicocele diagnosis: Clinical experience is not enough

M. El-Bahnasawy, M. Mohamed Kandeel, F. Fadl


Almoosa General Hospital, Al Hasa, Saudi Arabia

Objectives: To assess the inter-individual variation of varicocele diagnosis compared to the Doppler findings.

Patients and Methods: In this prospective blinded study, two hundred cases of suspected varicocele were examined by one urologist and a general surgeon separately then by color Doppler Ultrasonography for diagnosis and staging. Kappa measurements were used to assess degree of agreement.

Results: The degree of agreement regarding the presence or absence of varicocele was high between the urologist and general surgeon (Kappa=0.688, P<0.001), weak between urologist and radiologist (Kappa=0.396, P<0.001) while it was least between general surgeon and radiologist (Kappa=0.324, P<0.001). The two surgeons (urologist and general surgeon) had good agreement for the grade of varicocele (Kappa=0.68, P
<0.001). The urologist had fair agreement with the Duplex Doppler findings regarding the grade of varicocele (Kappa=0.4728, P<0.001). Total agreement was achieved in all cases with grade 3 varicoceles and was higher among left sided varicoceles. Both the urologist and general surgeon missed diagnosis of varicocele completely in 19% of Doppler-diagnosed varicoceles respectively. On the other hand in 16 cases (8%), Doppler denied the presence of surgeons-diagnosed varicoceles.

Conclusion: In spite of high clinical experience, still there is misdiagnosis of varicocele in more than one third of the cases. It is advised for clinically diagnosed varicoceles (less than grade 3) to have Doppler study before decision for varicocelectomy.

Presented at the: 21 st Saudi Urological Conference

North West Armed Forces Hospital - Tabuk

14 - 16 April 2009

Oncologist's knowledge and practice towards sperm cryopreservation in Saudi Arabia

Abdulmalik Husain Al Mardawi, Danny M. Rabah, Eman H. Wahdan, Bassem Abourafe, Mostafa A. Arafa


Princess Al Johara Al Ibrahim for Cancer Research, King Saud University, Prostate Cancer Unit, Riyadh, Saudi Arabia

Introduction: A debate has flourished over the need for oncologists to recommend cryopreservation of sperm, if time permits, before the initiation of cancer therapy. Today, cryopreservation of sperm with subsequent assisted reproductive technology (ART) can provide most post therapy infertile cancer patients an opportunity to father children.

Methods: The authors surveyed the current knowledge, opinions, and clinical practices of oncologists regarding pre-therapy cryopreservation of semen from male cancer patients since the introduction of intracytoplasmic sperms injection (ICSI). A survey questionnaire was sent to all registered oncologist in the Kingdom of Saudi Arabia.

Results: The response rate was 70%. Half of the oncologists were unaware about ICSI. Only 20% refer their young patients to the fertility specialist prior to therapy. Thirty percent don't know where they can send their patients for sperm cryopreservation. Nearly most of them (94%) thought sperm freezing will help patients and their family psychologically. The most important factors which make the physicians consider discussing cryopreservation with patients were marital status, type of cancer, age of the patients, and the cost, respectively.

Summary and Conclusion: Half of the oncologists surveyed were unaware of the advances in reproductive technology and this may be contributing to underutilization of sperm cryopreservation by male cancer patients. Increase physicians' awareness would have a beneficial effect on their patients' future fertility potential.

Presented at the: 22 nd Saudi Urological Conference



King Faisal Specialist Hospital &

Research Centre

15 - 18 March 2010

Varicocelectomy for male infertility: A comparative study of open, laparoscopic and microsurgical approaches

S. Al-Said, A. Al-Naimi, A. Al-Ansari, N. Younis,

A. Shamsodini, K. Al-Sadiq, A. Shokeir


Hamad Medical Corporation, Qatar

Introduction: Varicocele is present in 12% in normal male population and in approximately in 25% of men with infertility. We compared the outcomes of 3 techniques of varicocelectomy in infertile patients with varicocele.

Methods: The study included 298 infertile patients (446 varicoceles) who were randomized to varicocelectomy by an open inguinal technique in 92, laparoscopy in 94 and subinguinal microsurgery in 112. The 3 techniques were compared regarding intraoperative, and early and late postoperative parameters, changes in semen parameters and the pregnancy rate. Patients were followed a ΁ mean ΁ SD of 21 ΁ 9 months (range 4 to 35).

Results: Operative time was significantly longer in the microscopic group. Early postoperative complications were comparable in the 3 groups. At follow up, none of the patients in the microsurgical group had hydrocele, while it was observed in 4 of 143 (2.8%) in the open group and in 8 of 148 (5.4%) in the laparoscopy group, representing a significance difference in favor of microsurgery. The incidence of recurrent varicocele was significantly lower in the microsurgical group than in the open and laparoscopy groups (4 of 155 patients or 2.6% vs. 16 of 143 or 11% and 25 of 148 or 17%, respectively). Compared to preoperative values in the 3 groups, postoperative semen parameters showed significant improvement in sperm concentration, motility and morphology. The incidence of patients with improved sperm count and motility was significantly higher in the microsurgical group. The pregnancy rate at 1 year was not significantly different among the 3 groups.

Summary and Conclusion: Compared with open and laparoscopic varicocele treatment microsurgical varicocelectomy has the advantages of no hydrocele formation, a lower incidence of recurrent varicocele, and better improvement in sperm count and motility.

Presented at the: 22 nd Saudi Urological Conference



King Faisal Specialist Hospital &

Research Centre

15 - 18 March 2010

Outcome of testicular biopsies: Experience of a single center

Qais Mohammed Al-Hooti, Khaled Madbouly, Abdullah Albkri, Samir Ragheb, Khaled Alghamdi, Abdullah Al-Jasser


Security Forces Hospital, Riyadh, Saudi Arabia

Introduction: To evaluate the outcome of testicular biopsies as well as the etiology of azoospermia and severe oligospermia in Saudi patients referred for tertiary care.

Methods: Charts of men subjected for testicular biopsies in the last 10-year period were retrospectively reviewed. History of cryptorchidism, genital infections, trauma, scrotal and pelvic surgeries were reported. Findings of external genitalia examination for number, size, consistency and location of the testes as well as the epididymides and the scrotal part of the vasa deferentia were recorded. Results of male fertility profile tests and semen analysis of at least two (2) ejaculates were collected. Reported histopathology was obtained.

Results: Reports of the 229 patients were included. The mean (SD) age was 30.6 (6.4) years. Presentations were primary infertility in 184 (80.3%) patients and secondary infertility in 32 (14%). Thirteen patients (5.7%) showed other presentations. History of mumps orchitis was encountered in 5, cryptorchidism in 5, vasoepididymostomy in 2, left orchidectomy in 3 and left testicular torsion in one. A small right and left testis were detected in 38.4 and 38% of the patients respectively. The mean (SD) Testosterone and FSH values were 17.2 (7.2) nmol/L and 13.1 (10.9) IU/L respectively. Hyperprolactinaemia more than 2 folds was encountered in 5 patients (2.2%). Primary testicular failure was evident in 45 patients (19.7%). Sertoli cell only or associated with hypospermatogenesis was the commonest histology and was diagnosed in 37.1% of the specimens. Both testes showed a histology discordance rate of 4.8%.

Summary and Conclusion: Primary testicular failure is a common etiology of azoospermia. Sertoli cell histology is the commonest outcome of testicular biopsy(ies). Histology discordance rate is 4.8%.

Presented at the: 22 nd Saudi Urological Conference



King Faisal Specialist Hospital &

Research Centre

15 - 18 March 2010

Testicular biopsy in the era of micro dissection tese

Naif Al Hathal, Said Kattan


King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: To assess the yield of therapeutic testicular biopsy in sperm retrieval for ICSI and what percentage of patients will be spared a Micro dissection TESE.

Materials and Methods: A retrospective chart review study for azoospermia patients who had a therapeutic TESE for sperm retrieval in IVF center at King Faisal Specialist Hospital and Research Centre from August 2003 through November 2009. Inclusion criteria were confirmed azoospermic patients on two subsequent semen analysis regardless of testicular size or FSH reading. An exclusion criterion was obstructive azoospermia patients. The primary end-point result was the percentage of positive TESE (sperm retrieved) that is suitable for ICSI among all azoospermic patients and different histology of testicular tissues.

Results: Total of 200 therapeutic TESE were done among 165 patients under local anesthesia from 2003 to 2009. Seven patients were excluded for a normal spermatogenesis (obstructive azoospermia). Sperms were retrieved successfully in as many as 105 TESE (52.5%), in contrast to 95 negative TESE (47.5%). Histopathology was available in 159 testes where the most predominant pattern was Sertoli cell only syndrome (Germ cell aplasia) in 79 cases (49.6%). Second most common morphologic pattern was Hypospermatogenesis in 40 cases (25.1%). Maturation arrest diagnosed in 38 patients (23.8%). Another 2 patients had testicular infarction and hyalinization histology.

Conclusion: We recommend therapeutic TESE as the initial procedure of choice for azoospermic patients intended for ICSI because as many as half of patients will have positive results regardless of their FSH, testicular size or morphologic pattern. This in turn will spare patients the long waiting list and general anesthesia associated with Micro-dissection TESE which will be reserved only for patients with negative results.

Presented at the: 22 nd Saudi Urological Conference



King Faisal Specialist Hospital &

Research Centre

15 - 18 March 2010

Kruger's strict criteria effect on intrauterine insemination reproductive outcomes

Mussa Al Numi, Mohammed Al Brikeet, Abdulrahman Al Ruwaily, Abdulrahman Al Elaiwai


Department of Urology, Riyadh Military Hospital, Saudi Arabia

Introduction: It is well known that sperm morphology and motility are the best criteria for demonstrating the fertilization capacity of the male. In-vitro studies in humans have indicated that abnormal spermatozoa can drastically affect fertilization, embryo cleavage, implantation, and fetal development. Currently, the rigid Kruger's 4% criteria is used for the definition of abnormal sperm.

Objective: Intra-uterine insemination (I.U.I.) is a widely used treatment option for many couples with infertility. The aim of the study is to determine the effect of low morphology of semen parameters on the reproductive outcomes following I.U.I. in our I.V.F. center.

Materials and Methods: It is a retrospective study including 296 couples with unexplained infertility, between January 2007 and December 2009, with female age ranging 20-40 years. All female patients were stimulated with r-FSH starting cycle day 3. Then final maturation was triggered with r-HCG after ultrasound confirmation of the ovary follicles. One I.U.I. was carried out. Sperm samples were collected after 3 days of abstinence. Males with sperm density > 15 million/ml and motility of > 40% were categorized into two groups: Group I (<4%) and Group II (4-15%). Pregnancy rate and abortion, take home birth were analyzed in both groups.

Results: 203 patients in the 4-15% category had a mean count of 58 million/ml and a motility of 42% with mean female age of 30 years. The <4% group had a patient number 93 and sperm mean count of 60 million/ml and motility of 40%. The mean female age was 29 years. The <4% group 81 out of 93 had negative pregnancy and 6 out of the remaining 12 positive pregnancy had take home birth. The 4-15% group out of 203 patients only 48 had positive pregnancy and 34 of them had their births taken home.

Conclusions: Morphologically abnormal sperm may have a significant role in having numerical and/or structural chromosomal aberrations; this could explain the low pregnancy rate among the two groups along with higher abortion rate among those with the low morphology. It is suggested that I.U.I. is a reasonable first line therapy because of low cost for patients with sperm morphology of > 4% normal forms. Failing couples, along with those with < 4% normal forms should be advised to use I.V.F. with I.C.S.I. instead of repeated I.U.I.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital - Dammam

21 - 24 February 2011

Pattern of semen fluid abnormalities in male partners of infertile couples in riyadh, saudi arabia

Husain Al-Enezi, Basim AbuRafea, Saleh Binsaleh


King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia

Introduction: Recent worldwide reports suggest a decline in semen quality in men with increasing percentage of male factor abnormalities in infertile couples. The pattern of abnormalities may be different from one part of the world to another, and this is probably multifactorial.

Objectives: To review the pattern of semen fluid abnormalities in men screened for infertility in Saudi Arabia in order to help future identification of responsible etiologic factors and possible treatments.

Materials and Methods: A retrospective study of semen analysis results of men screened for infertility in dedicated infertility clinic, King Khalid University Hospital, Riyadh, Saudi Arabia between 1 st of January 2009 to end of December 2009.

Results: A total of 485 semen analysis reports for different patients were reviewed. According to WHO reference values for normal semen analysis in 1992, only 20 (4.1%) patients had normal semen parameters. 245 (50.5%) had single factor abnormality with almost all of the results being Teratospermia, except for one case of isolated Oligospermia. Oligo-Teratospermia was evident in 68 (14%) of the patients and it constituted nearly two thirds of those who had 2 factors abnormality. 63 (12.9%) patients had combined Oligo-Astheno-Teratospermia. 3 patients had only low volume ejaculate with no associated other abnormalities. Oligospermia was evident in 132 (27.2%) of patients and 41% of that group had sperm concentrations of 5 - 10 million/ml. 51 subjects (10.5%) had azoospermia.

Conclusion: The study showed a very high percentage of semen fluid abnormalities in our environment together with significant abnormal sperm morphology. Thus, more studies are needed to address possible etiologies and treatments for Teratospermia in our region in order to improve fertility rates.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital - Dammam

21 - 24 February 2011




 

Top
 
  Search
 
    Similar in PUBMED
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article

 Article Access Statistics
    Viewed1612    
    Printed23    
    Emailed0    
    PDF Downloaded204    
    Comments [Add]    

Recommend this journal