Approach to Testicular Biopsy.........pptx

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1. Approach to Testicular Biopsy Prof. Dr. Nafissa El Badawy

2. Purpose: Testicular biopsy is used in cases of infertility in males with azoospermia; to define the cause of azoospermia; obstructive or non-obstructive When the hormonal profile is inconclusive, a biopsy can provide definitive evidence of spermatogenic activity Testicular biopsy can also be used for sperm retrieval in azoospermic pts for ICSI (Intra Cytoplasmic Sperm Injection)

3. The testis

4. Methods Open incisional biopsy or Wedge biopsy : 2-3 cm incision to obtain a piece of testicular tissue Percutaneous biopsy: Obtained by a syringe & needle through the scrotum into the testicular parenchyma

5. Adequacy of the biopsy: Grossly: At least 3 mm Microscopically: 3-5 lobules with septa Fixation of the biopsy is very important and best done using Bouin’s solution

6. Evaluation of testicular biopsy Should be done for: 1.Overall morphology 2.Size & structure of seminiferous tubule 3.Interstitial tissue 4.Spermatogenesis 5: Quantitative assessment

7. The normal testis The S.Ts contain two types of cells contain 2 types of cells: Germ cells & Sertoli cells Spermatogenesis is a continuous process All tubules show active spermatogenesis and germ cells are present in various stages The number late spermatids correlates with the number of sperm count

8. Spermatogenesis

9. Patterns of testicular damage 1. Hypospermatogenesis 2. Germ cell matration arrest 3. Sertoli cell only syndrome 4. Seminiferous tubular hyalinization 5. Intratubular germ cell neoplasia 6. Immature testis

10. Hypospermatogenesis All stages of spermatogenesis are present but reduced May be due to hormonal dysregulation, androgen insensitivity, exposure to heat, radiation or chemicals With prolonged exposure, there maybe some tubules containing Sertoli cells only or hyalinized tubules mixed with other tubules showing complete spermatogenesis The reduction may be mild moderate or severe

11. Germ cell maturation Arrest This is interruption of development and differentiation of germ cells at a certain stage It is of two types; complete and incomplete Complete: Germ cell maturation arrest at a specific point , commonly at the primary spermatocyte level in all tubules, the sperm count usually zero Incomplete: The arrest is present in many tubules but some tubules still show maturation and late spermatids are seen

12. Sertoli cell only Syndrome Also known as Germ cell aplasia Seminiferous tubules contain only one type of cells, Sertoli cells In some pts, there may be some tubules exhibiting reduced spermatogenesis where we see very low sperm count Four types of Sertoli cells are identified: 1. Normal cells 2. Immature cells 3. Dysgenetic cells 4. Involuting cells

13. Tubular hyalinization The tubules are fibrosed and hyalinized with peritubular fibrosis Commonly seen in klinfelter syndrome, hypoprolactinemia and postpubertal androgen/estrogen excess Usually, the number of Leydig cells is increased but the function is impaired

14. Intratubular germ cell neoplasia It is an in situ stage of germ cells neoplasia The tubules are lined by large atypical cells with clear cytoplasm The basement membrane is thickened The spermatogenesis is absent It is subdivided into intratubular seminoma, intratubular non-seminoma. Intratubular yolk sac tumor and intratubular teratoma Immuno-stains can be used for diagnosis and further typing e.g. PLAP, oct 3/4, CD117, D2-40, SALL4…

15. Quantitative assessment Johnsen’s scoring system A 10-tire scoring system was developed to evaluate the examined seminiferous tubules:

16. Role of testicular biopsy in assisted reproductive techniques In pts with azoospermia, spermatozoa can be retrieved from the testis using different methods such as: TESE: Testicular sperm extraction TESA: Testicular sperm aspiration MicroTESE : Microdissection sperm extraction Testicular mapping: can be done to define sperm spots to increase the chances of success

17. Take home message Testicular biopsy is a definitive diagnostic tool, can guide treatment dissension and assist in sperm retrieval It is rather safe with minimal risk of bleeding or infection Advances in biopsy techniques and molecular diagnostics can improve the accuracy and safety of the procedure