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Dr. Anand K ShindeMD (Gyn)
• Director Andrology @ ‘IVF-Pune’
Deenanath Mangeshkar Hospital Pune
• President Elect POGS (PUNE OBGYN SOCIETY )
• Founder Member Indian Menopause Society
• Member Safe Motherhood Committe FOGSI
• Consultant & P.G. Teacher Dept OBGYN D.M.H
Welcome to S I G A
SIGA - ANDROMEDAGreetings for 2010 !
Dr. Anand K ShindeMD (Gyn)
Director Andrology
‘IVF-Pune’
Deenanath Mangeshkar Hospital
Pune - 411 004
Cell - 09822012166, Tel. 020-40151777
Waist to Hip Ratio
The Soil, the Tree & the seeds !
Diagnostic TESA
What Do We Diagnose ?
1. Presence of Sperm in Testis
2. Histopathological picture to explain the
Azoospermia
3. Carcinoma In Situ (C.I.S.)
Dr. Anand K Shinde
TESA
TESA as a method to retrieve sperms in Azoospermia
( For ICSI = Yes ! ) but...TESA as a method of
Testicular Biopsy ?
Yes it is possible to get Testicular Biopsy by TESA ! (Diagnostic use ? )
Dr. Anand K Shinde
HPE Seminiferous Tubule (N)
Dr. Anand K Shinde
HPE Spermatogenic arrest
Dr. Anand K Shinde
Mixed Phenotypes
SCO + Normal Heterogenous Tubules High chance of success at TESE ShowingTesticularDamage
Sertoli Cell Only Syndrome
SCOS as in Idiopathic infertility, Y Microdeletions, Orchitis, Chemo/ Radiotherapy, Embryonal failure of Germ Cell migration to the Gonadal
Ridge….TESE -25% successful..due to mixed variants…
Klinefelter’s Syndrome can have Sperms !
(E) The typical appearance of a biopsy from a man with Klinefelter’s syndrome is shown composed of seminiferous tubule hyalinization (arrows), aggregations of LC and occasional tubules with Sertoli cells only. This pattern is not diagnostic of Klinefelter’s syndrome and can result from a range of pathological processes (×10). (F) A biopsy from a man with Klinefelter’s syndrome illustrating a tubule showing full spermatogenesis surrounded by aggregations of LC (×25). All tissues are fixed in GR fixative, except F, which is fixed in Cleland’s fixative, and all are haematoxylin–eosin (HE) stained. R.I.McLachlan et al.
CIS
Positive Negative
Positive Semen
PositiveCIS Tubule
Immunocytological semen analysis for CIS
Indications of Tesicular Biopsy(in general are as follows…)
1. Detection of severity & type of
Spermatogenic falilure
A. Prognostic factor for subsequent ICSI
B. Phenotyping in clinical research.
Dr. Anand K Shinde
Indications of Tesicular Biopsy(in general are as follows…)
2. Differentiating Obstructive Azoospermia (OA) from
Non-obstructive Azzospermia (NOA)
A. Equivocal Endocrine (FSH, inhibin B)
B. Equivocal Clinial findings (Testicular Vol.)
C. Prior to reconstructive surgery for OA
Dr. Anand K Shinde
Indications of Tesicular Biopsy(in general are as follows…)
3. Evaluation for Testicular Neoplasia / CIS
A. At Pubertal / Adult Orchiopexy
B. For at Risk Population
- NOA
- H/O Cryptorchidism
- Scrotal USG - Microlithiasis
- In Ca Testis case for other sideDr. Anand K Shinde
Indications of Tesicular Biopsy(in general are as follows…)
4. Failure of prolonged Gonadotrophin therapy in Hypogonadotrophic Hypogonadism
If Testicular Biopsy for diagnosis
(and subsequent Rx) is so important…..
Is TESA the best way to do it ?
Let us see …..
Dr. Anand K Shinde
TESA Efficacy & Ease
100%
Let us see !
100%
Let us see !
OA
NOA
TESE : Sperms RecoveryTESA : Sperms Recovery
Dr. Anand K Shinde
TESA Efficacy
NS39.5% (30)40.8%(31)38 (76)Aridogan et al(2003)
<0.001 †24.1% (21)62.1% (54)87 (167)Hauser (2006)
NS30% (8)33% (9)27Qublan et al (2002)
…7.1% (1)64.3% (9)14Tournaye (1999)
.02‡11% (4)43% (16)37Freodler et al (1997)
<.0001†14% (5)63% (22)35Ezeh et al (1998)
…60% (6)70% (7)10 (16)19 gauge*
…16.7% (2)50% (6)12 (17)21 gauge*
Rosenlund et al(1998)
PSperm Recovery by
TESA
Sperm Recovery by
TESE
No of Men
Study
Efficacy of TESAHow much tissue is obtained ?
How many sperms are recovered ?
<.001† 0.6 ± 1.14.4 ± 5.4No. of frozen straws per subject
<.001†0.3 ± 0.80.9 ± 1.1No. of locations with motile sperm cells per testis
<.001†0.7 ± 1.01.3 ± 1.3No. of locations with spermatogenesis per testis
<.001†0.5 ± 0.51.1 ± 1.1Quantity of sperm cells (Scale of 1-3)*
PTESATESEParameters Compared
RON HAUSER, et al (2006) J of Andrology Vol. 27 No. 1 2006
Efficacy of TESA
Do we get sufficient material for
Histopath Exam by TESA ?
Yes, if multifocal TESA is
performed, on both testes.
Dr. Anand K Shinde
How can CIS be picked up by blind TESA ?
Testicular Biopsy is important in the evaluation of men at risk of CIS or Testicular cancer.
TESA is not the ideal way.
Open procedures with magnification to look for micronodules are better suited
Towards a non –invasive method for early detection
C.E. Hoei-Hansen, N.E.Skakkebaek ,
Human Reproduction Vol 22 No.1 (2007)
Dr. Anand K Shinde
Can Needle biopsy give Histology Specimen ?
Open Versus Percutaneous
Dr. Anand K Shinde
TESA DROPLET UNDER INVERTED MICROSCOPE
Open biopsy
Needle biopsy
If in azoospermic man percutaneous TESA, HPE shows Sertoli Cell only (SCO) pattern & if Clinical exam & / or USG Scrotum shows micronodule, you must go for open TESE
2Maligmant neoplasm
2In - situ carcinoma
4Leydig cell hyperplasia
3Leydig cell tumour
09Nodule removed
110Ultrasound nodule
5938Patients
No Sertoli cell-only syndrome (Group B)
Sertoli cell-only syndrome (Group A)
97 Azoospermic biopsies
M.Mancini et al , Human Reproudction Vol.22 (2007)
Take Home messages
1) Diagnostic TESA is important as it gives
Sperms for freezing, tissue for
Histopathology which helps in
Prognostication for ICSI
Dr. Anand K Shinde
Take Home messages
1) In Azoospermic men think of CIS testis & do
not forget Clinical exam for nodules &
ultrasound for testicular microlithiasis
(Prevalence 1:250).
Addition of Immunohistochemistry helps the
pickup rate
Dr. Anand K Shinde
M.Mancini et al , Human Reproudction Vol.22 (2007)
Take Home messages
Percutaneous TESA needs to be multifocal &
bilateral before you resort to TESE.
Andrologists prefer GA while Uro-Surgeons
may manage with Local Anaesthesia !.
Take Home messages
Lower FSH (< 10 mIu / ml)
Larger Testis Vol ( > 10 ml)
means TESA will be
satisfactory
otherwise TESE is better.
Take Home messages
TESA may be less disruptive for testis
- Hematoma,
- infarcts,
- raised LH, FSH &
- lowered Testosterone
than open Biopsies.
Stem cells research !!!
Dr. Anand K. ShindeM.D (Gyn)• IVF - Consultant at IVF Pune,
DMH Pune - 4 • Director Andrology IVF Pune,
Deenanath Mangeshkar Hospital
Pune - 411 004
Thank you !
A.I.C.O.G.- 2010GUWAHATI
Dr. Anand K. ShindeM.D (Gyn)M.D (Gyn)