[Analysis of 10 years' data of systematic male reproductive system ultrasonography in diagnosis of azoospermia etiology].

OBJECTIVE: To explore the value of systematic male reproductive system ultrasonography in the diagnosis of azoospermia etiology. METHODS: Retrospective analysis and classification statistics were conducted on the data of azoospermia cases who underwent systematic male reproductive system ultrasound examination at the First Affiliated Hospital of Ningbo University from January 2013 to January 2023. RESULTS: A total of 375 cases were included in the group, of which 303 cases could be diagnosed by ultrasound, including 161 cases of obstructive causes, 110 cases of non obstructive causes, and 32 cases of mixed causes. Obstructive causes mainly include bilateral absence or underdevelopment of the seminal vesicles and vas deferens, non obstructive causes mainly include bilateral simple testicular dysplasia, and the most common combined causes are bilateral absence or underdevelopment of the seminal vesicles and vas deferens combined with bilateral testicular dysplasia. The main causes involved a single organ in 174 cases, with 82 cases, 43 cases, and 4 cases involving 2-4 organs, respectively. In addition, there are multiple accompanying ultrasound manifestations of non primary causes. CONCLUSION: Systematic ultrasound examination can comprehensively evaluate the male reproductive system, effectively diagnose the causes of most azoospermia, and provide valuable imaging evidence for clinical treatment.

[The new progress and significance of new ultrasound technology in the diagnosis of azoospermia].

The diagnosis and treatment of azoospermia rely heavily on auxiliary ex-amination technology. Compared with CT and MRI, ultrasound has more practical value in the diagnosis of azoospermia.Currently, the main ultrasonic technologies are contrast-enhanced ultrasound, real-time ultrasound elastography and ultrasound tar-geted puncture. This article aims to summarize and prospect the application of new ultrasound technology in azoospermia.Real-time ultrasound elastography is widely used in breast diseases and is expected to play a greater role in azoospermia. Ultra-sound targeted puncture can greatly reduce the damage of testicular spermatogenic function, but its application is still not widely used.The combined application of new technologies can make up for their respective shortcomings and improve the accuracy of azoospermia diagnosis.Therefore, further research on new ultrasound technology in the diagnosis of azoospermia will play a greater role.

Volumetric apparent diffusion coefficient histogram analysis of the testes in nonobstructive azoospermia: a noninvasive fingerprint of impaired spermatogenesis?

OBJECTIVES: To explore the association between testicular volumetric apparent diffusion coefficient (ADC) histogram analysis metrics and histologic categories in nonobstructive azoospermia (NOA). The role of ADC histogram analysis in predicting the presence of spermatozoa, prior to testicular sperm extraction (TESE), was also investigated. METHODS: Forty-one NOA men and 17 age-matched controls underwent scrotal MRI with diffusion-weighted imaging. Histogram analysis of ADC data of the whole testis was performed. Metrics including mean, standard deviation, median, mode, 25th percentile, 75th percentile, skewness, kurtosis, and entropy of volumetric ADC histograms were calculated. Nonparametric statistical tests were used to assess differences in ADC histogram parameters between NOA histologic categories (hypospermatogenesis, severe hypospermatogenesis, early maturation arrest, and Sertoli cell-only syndrome) and normal testes and, between NOA with positive and negative sperm retrieval. RESULTS: Normal testes had a lower mean, median, mode, 25th percentile (p < 0.001), and 75th percentile of ADC (p = 0.001), compared to NOA histologic phenotypes. NOA with hypospermatogenesis had a lower 25th percentile of ADC compared to NOA with severe hypospermatogenesis. Regression analysis revealed that the 25th percentile of ADC had a moderately negative correlation with NOA histologic phenotype. The median ADC proved the most significant metric (p = 0.007) to predict the presence of sperm. CONCLUSIONS: Testicular volumetric ADC histogram parameters may contribute in the identification of the subpopulation of NOA men with a specific type of spermatogenic arrest. KEY POINTS: • Volumetric ADC histogram analysis metrics may be used as noninvasive markers of impaired spermatogenesis in nonobstructive azoospermia. • The 25th percentile of ADC proved useful in discriminating between NOA testes with hypospermatogenesis and severe hypospermatogenesis. • The median ADC proved the most significant parameter to predict the presence of viable spermatozoa prior to TESE.

Sonography in male infertility: a useful yet underutilized diagnostic tool.

PURPOSE: To assess the utility of comprehensive sonographic examination including scrotal sonography, Testicular Doppler and Transrectal Ultrasound (TRUS) to evaluate the male reproductive system and differentiate between obstructive (OG) and non-obstructive (NOG) causes of azoospermia. METHODS: 30 infertile men with azoospermia and 30 control subjects with normospermia underwent sonographic evaluation. FNAC/biopsy findings were used for assigning a final diagnosis of obstructive or non-obstructive azoospermia. Qualitative and quantitative imaging parameters were retrospectively compared between the groups using Chi-square/Fisher's exact test and unpaired t-test, respectively. P < 0.05 was considered significant. RESULTS: Ectasia of rete testis/epididymal tubules, altered epididymal echogenicity, dilated terminal vas deferens were significantly more common in OG while inhomogeneous testicular echo-texture and reduced testicular vascularity were more common in NOG (P < 0.05). Testicular volume and epididymal head size were significantly higher in OG than in NOG and controls (18.2 ml/10 mm Vs 8.2 ml/7.2 mm and 13.4 ml/8.8 mm respectively; P < 0.05); while Resistive Index (RI) of intra-testicular vessels was higher in NOG as compared to OG and controls (0.65 vs 0.54 and 0.52 respectively; P < 0.05). On ROC curve analysis, cut-off values of testicular volume (AUC: 0.939; P < 0.001), epididymal head size (AUC: 0.772; P = 0.001) and testicular RI (AUC: 0.761; P = 0.001) to differentiate between the groups were 12.1 ml (sensitivity-94.4%; specificity-83.3%), 9 mm (sensitivity-66.7%; specificity-71%) and 0.62 (sensitivity-62%; specificity-100%) respectively. CONCLUSION: Comprehensive sonographic evaluation can be used to differentiate obstructive from non-obstructive infertility and should be routinely incorporated in the diagnostic workup of infertile men with azoospermia.

Diagnostic value of transrectal combined scrotal ultrasonography in acquired obstructive azoospermia.

OBJECTIVE: To investigate the transrectal and scrotal ultrasonographic features of acquired obstructive azoospermia and evaluate the role of ultrasonography in the location diagnosis of acquired obstructive azoospermia patients. METHODS: Retrospectively analysis of 92 cases of acquired obstructive azoospermia in recent years. All the patients underwent transrectal and scrotal ultrasonography. The ultrasonographic features were observed of testis, epididymis, scrotal segment of vas deferens, seminal vesicle, ejaculatory duct and prostate. Eighty cases with normal semen were taken as control group. RESULTS: Among the 92 cases of acquired obstructive azoospermia, 28 cases were prostate midline cyst, 32 cases were stone or calcification of the ejaculation duct and 21 cases were chronic seminal vesicle inflammation, which were found through transrectal ultrasonography; 27 cases were vas deferens dilation, 30 cases had abnormal mass of epididymis tail, 31 cases were epididymis thickness with reticular change, 8 cases were cystic dilatation of rete testis, which were found through scrotal ultrasonography. Compared with the control group, ultrasound examination increased the detection rate of distal seminal duct lesions and epididymal lesions in acquired obstructive azoospermia patients (p<.01). Comparison of testicular volume between case group and control group did not reveal significant difference (p>.05). The thickness of the head, body and tail of epididymis in case group was significantly bigger than that in control group (p<.01). CONCLUSION: Transrectal and scrotal ultrasonography can find lesions in different parts of the seminal passage. Acquired obstructive azoospermia patients have increased rate of distal seminal duct lesions, epididymal lesions and epididymis volume. Transrectal and scrotum ultrasonography can provide reliable imaging evidence for the location diagnosis of acquired obstructive azoospermia.

Testicular microlithiasis defines a subgroup of azoospermic men with low rates of sperm retrieval.

OBJECTIVE: To investigate the prevalence of testicular microlithiasis and its association with sperm retrieval rates and histopathology in men with non-obstructive azoospermia. METHODS: A total of 120 men underwent scrotal ultrasonography prior to microsurgical testicular sperm extraction. Sperm retrieval rate, testicular histopathology, testicular size, reproductive hormones, karyotyping, Y chromosome microdeletion analyses, and presence of varicoceles and hydroceles were compared between men with and without testicular microlithiasis. RESULTS: The total sperm retrieval rate was 40%. Ten men with normal spermatogenesis were excluded. The remaining 110 men with non-obstructive azoospermia were analyzed and testicular microlithiasis was detected in 16 of them (14.5%). The sperm retrieval rate in that subgroup was only 6.2% (1/16) as opposed to 39.4% (37/94) in men with non-obstructive azoospermia and no evidence of microlithiasis (P = 0.009). The mean right and left testicular diameters were significantly lower in the microlithiasis group (P = 0.04). On multivariate logistic regression analysis, the presence of mictolithiasis (odds ratio 7.4, 95% confidence interval 2.3, 12.2; P = 0.01) was the only independent predictor of unsuccessful sperm retrieval. The 15 patients with microlithiasis and without successful sperm extraction were diagnosed by histopathology as having Sertoli cells only. The 16th patient with successful sperm retrieval had a histopathology of mixed atrophy and was diagnosed with Klinefelter syndrome. CONCLUSION: The presence of testicular microlithiasis is associated with low sperm retrieval rates among our cohort of men with non-obstructive azoospermia undergoing scrotal ultrasonography prior to microsurgical testicular sperm extraction. Larger, prospective studies should be conducted to confirm these findings.

A magnetic resonance imaging study in etiology of nonobstructive azoospermia.

BACKGROUND: Testicular magnetic resonance imaging parameters, including apparent diffusion coefficient, fractional anisotropy, magnetization transfer ratio, and normalized metabolite concentrations represent useful noninvasive fingerprints of nonobstructive azoospermia. Nonobstructive azoospermia etiology might correlate with the spermatogenesis status. OBJECTIVES: To assess the possible association between apparent diffusion coefficient, fractional anisotropy, magnetization transfer ratio, and normalised metabolite concentrations with nonobstructive azoospermia etiology. MATERIALS AND METHODS: This retrospective study included 48 consecutive men with nonobstructive azoospermia and 18 age-matched controls. All participants underwent scrotal magnetic resonance imaging. The testicular apparent diffusion coefficient, fractional anisotropy, magnetization transfer ratio, and normalized metabolite concentrations were calculated. nonobstructive azoospermia men were classified into three groups, based on etiology: group 1, idiopathic; group 2, genetic causes; and group 3, non-genetic causes. Parametric and nonparametric statistical tests were used to evaluate differences in magnetic resonance imaging parameters between nonobstructive azoospermia groups and normal testes (group 4). Regression analysis was performed to assess the most predictive magnetic resonance imaging factor of nonobstructive azoospermia etiology. RESULTS: Differences in mean apparent diffusion coefficient (p < .001), fractional anisotropy (p < .001), magnetization transfer ratio (p < .001), and normalized concentrations of total choline (p = .005), glucose (p = .012), myo-inositol (p = .024), and lipids (p = .010) were observed among groups. Regression analysis failed to identify the most discriminating magnetic resonance imaging feature for nonobstructive azoospermia etiology. DISCUSSION AND CONCLUSION: Apparent diffusion coefficient, fractional anisotropy, magnetization transfer ratio, and normalized concentrations of total choline, glucose, myo-inositol, and lipids are helpful in discriminating nonobstructive azoospermia etiology. Magnetic resonance imaging may provide useful, noninvasive information on the microstructural and biochemical milieu of nonobstructive azoospermia testes.

[Real-time transrectal ultrasound-guided seminal vesiculoscopy for the treatment of azoospermia secondary to ejaculatory duct obstruction].

OBJECTIVE: To evaluate the effect of real-time transrectal ultrasound-guided seminal vesiculoscopy (TRUS-SVS) in the treatment of azoospermia secondary to ejaculatory duct obstruction. METHODS: This retrospective study included 40 cases of azoospermia secondary to bilateral ejaculatory ducts obstruction treated by TRUS-SVS from June 2016 to June 2018 after failure to enter the vesiculoscope through the ejaculatory duct or prostatic utricle. We analyzed the success rate of surgery, operation time, postoperative complications, treatment results, and application value of TRUS-SVS. RESULTS: Real-time TRUS-SVS was successfully performed in 36 (90.0%) of the cases, 33 through bilateral and the other 3 through unilateral seminal vesicle, with a mean operation time of (32.8 ± 16.6) min. Thirty-seven of the cases were followed up for 6－15 (mean 9.3) months, of which sperm were found in 31 at 1－3 months and in 25 at 3－12 months, and pregnancies achieved in 9 cases within 12 months after surgery. No serious complications as retrograde ejaculation, urinary incontinence and rectal injury were observed postoperatively, except 2 cases of epididymitis and 2 cases of hematuria, which were all cured. CONCLUSIONS: For the patients who failed in seminal vesiculoscopy through the ejaculatory duct or prostatic utricle, real-time TRUS-SVS is a recommended procedure with the advantages of a high success rate, less damage to the prostate and rectum, and benefit to the improvement of semen quality.

Central role of ultrasound in the evaluation of testicular function and genital tract obstruction in infertile males.

BACKGROUND: Scrotal color Doppler ultrasonography and transrectal ultrasonography provide crucial information about the clinical status of testes and male accessory glands. OBJECTIVE: To analyze the impact of ultrasound in the evaluation of infertile males. MATERIALS AND METHODS: A total of 1120 records from infertile men were retrospectively evaluated (from January 2016 up to June 2020). Data on physical examination, semen analysis, sperm culture, scrotal color Doppler ultrasonography and transrectal ultrasonography, as well as sex hormones were analyzed. Among them, 238 reports from oligozoospermic/azoospermic infertile patients (P) fulfilling the inclusion criteria were considered for data analysis. Patients were subdivided into two groups according to follicle-stimulating hormone (FSH) values (Pa with FSH < 8 U/L and Pb with FSH ≥ 8 U/L). Sixty-three fertile volunteers (mean ± SD years) were enrolled as controls (C). RESULTS: A higher prevalence of ultrasound abnormalities was recorded in P compared to C. Pb group had significantly lower bitesticular volume compared to Pa and C. Pa had a higher prevalence of transrectal ultrasonography abnormalities than Pb (69.9% vs. 38.4%), whereas Pb had a higher prevalence of abnormalities at scrotal color Doppler ultrasonography (60.0% vs. 28.3%, both p < 0.01). Bitesticular volume was inversely proportional to the number of altered seminal parameters and able to predict gonadotropin levels. A bitesticular volume <17 cc was associated with a higher risk of azoospermia (odds ratio = 1.799). Intratesticular vascularization was inversely correlated with gonadotropin levels and directly correlated with sperm count. A higher prevalence of prostate and seminal vesicle alterations was detected in patients and in Pa group, when compared with Pb group. DISCUSSION AND CONCLUSION: Ultrasound abnormalities are correlated with seminal parameters and may guide the clinician in the diagnostic workflow of male infertility, suggesting spermatogenesis impairment or genital tract obstructions.

Evaluation of the potential role of shear wave elastography as a promising predictor of sperm retrieval in non-obstructive azoospermic patients: A prospective study.

BACKGROUND AND OBJECTIVES: Testicular sperm extraction (TESE) has been a useful diagnostic and therapeutic tool with sperm retrieval opportunity varying according to the pathological finding in azoospermic patients. Sonoelastography (SE) is an exciting radiologic method that can measure relative elasticity of different tissues in a selected region of interest (ROI) by depending on fast cross-correlation technique and a combined autocorrelation method. Real-time elastography (RTE) can be used for structural analysis of testicular tissue to detect pathological tissue alterations. We aimed in the current study to evaluate the efficacy of shear wave elastography (SWE) in predicting sperm retrieval in non-obstructive azoospermic (NOA) patients undergoing TESE. PATIENTS AND METHODS: This prospective study included 50 NOA patients who did two successive semen analyses with normal or elevated gonadotrophic hormones. All participants were subjected to SWE imaging on the testes by a radiologist. The measurements were recorded in terms of kPa using the SWE mode. They were done on each testis in the longest longitudinal plane. SWE images were viewed using dual mode: elasticity mode (kPa) and propagation (arrival time contour) mode then patients underwent TESE. RESULTS: A significant difference in SWE values was observed between patients with successful sperm retrieval and those with negative sperm retrieval providing 94.7% negative predictive value and 50.0% positive predictive value for sperm retrieval in NOA patients undergoing TESE with 75.0% sensitivity and 85.71% specificity (p  =  0.0001). Mean stiffness index measured by SWE correlated significantly with the histopathological types as 8 patients only were diagnosed as having severe hypospermatogenesis. DISCUSSION AND CONCLUSION: These prime data suggest that SWE as a non-invasive, easily applicable, and repeatable imaging method has a promising potential to be one of the reliable sonographic modalities that can be used as one of the predictors for sperm retrieval in NOA patients.

Preliminary investigation of the diagnostic value of shear wave elastography in evaluating the testicular spermatogenic function in patients with azoospermia.

To assess the diagnostic value of shear wave elastography (SWE) for evaluating the histological spermatogenic function of azoospermic males, 91 patients with azoospermia who underwent standardised greyscale ultrasound and SWE examinations followed by testicular biopsy were retrospectively recruited. Spermatogenic function was classified by biopsy as normal testicular spermatogenesis (n = 61), hypospermatogenesis (n = 18), spermatogenesis arrest (n = 6) and Sertoli cell-only syndrome (n = 6). Significant differences in testicular size and SWE values were observed between these 4 groups (p < .01). The mean SWE value had good discrimination power (AUC = 0.79) with a cut-off value of 1.55 KPa, a sensitivity of 0.58, specificity of 0.85, positive predictive value (PPV) of 0.36 and negative predictive value (NPV) of 0.93. Testicular volume had an AUC of 0.75. With a cut-off value of 8.41 ml, the testicular volume had a sensitivity of 0.58, specificity of 0.92, PPV of 0.54 and NPV of 0.93. The mean SWE value and testicular volume efficiently discriminated patients with normal spermatogenesis and hypospermatogenesis from patients with Sertoli cell-only syndrome and spermatogenesis arrest.

Testicular quantitative ultrasound: A noninvasive monitoring method for evaluating spermatogenic function in busulfan-induced testicular injury mouse models.

Busulfan-induced testicular injury mouse models are commonly used for experiments on spermatogonial stem cell transplantation, treatments for azoospermia due to spermatogenic failure and preserving male fertility after chemotherapy. Here, we investigated the value of testicular quantitative ultrasound for evaluating spermatogenic function in this model. In this study, testicular ultrasound was performed on mice from day 0 to 126 after busulfan treatment (n = 48), and quantitative data, including the testicular volume, mean pixel intensity and pixel uniformity, were analysed. The results revealed that from day 0 to 36, the testicular volume was positively associated with the testicle-to-body weight ratio (r = .92). On day 63, the pixel uniformity, which remained stable from day 0 to 36, declined significantly compared with that on day 36 (p < .01). On day 126, when the whole progression of spermatogenesis could be observed in most tubules, the mean pixel intensity also returned to normal (p > .05). In conclusion, testicular quantitative ultrasound could be used as a noninvasive and accurate monitoring method for evaluating spermatogenic function in busulfan-induced testicular injury mouse models.

Noninvasive Differentiation of Obstructive Azoospermia and Nonobstructive Azoospermia Using Multimodel Diffusion Weighted Imaging.

RATIONALE AND OBJECTIVES: To evaluate the diagnostic performance of parameters derived from multimodel diffusion weighted imaging (monoexponential, stretched-exponential diffusion weighted imaging and diffusion kurtosis imaging [DKI]) from noninvasive magnetic resonance imaging in distinguishing obstructive azoospermia (OA) from nonobstructive azoospermia (NOA). MATERIALS AND METHODS: Forty-six patients with azoospermia were prospectively enrolled and classified into two groups (21 OA patients and 25 NOA patients). The multimodel parameters of diffusion-weighted imaging (DWI; apparent diffusion coefficient [ADC], distributed diffusion coefficient [DDC], diffusion heterogeneity [α], diffusion kurtosis diffusivity [Dapp], and diffusion kurtosis coefficient [Kapp]) were derived. The diagnostic performance of these parameters for the differentiation of OA and NOA patients were evaluated using receiver operating characteristic analysis. The area under the curve (AUC) was calculated to evaluate the diagnostic accuracy of each parameter. RESULTS: All the parameters (ADC, α, DDC, Dapp, and Kapp) values were significantly different between OA and NOA (P < 0.001 for all). For the differentiation of OA from NOA, Kapp showed the highest AUC value (0.965), followed by DDC (0.946), Dapp (0.933), ADC (0.922), and α (0.887). Kapp had a significantly higher AUC than the conventional ADC (P < 0.05). CONCLUSION: Parameters derived from multimodels of DWI have the potential for the noninvasive differentiation of OA and NOA. The Kapp value derived from the DKI model might serve as a useful imaging marker for the differentiation of azoospermia.

In vivo biochemical investigation of spermatogenic status: 1H-MR spectroscopy of testes with nonobstructive azoospermia.

OBJECTIVES: To evaluate the biochemical milieu in testes with nonobstructive azoospermia (NOA) by using proton MR spectroscopy (1H-MRS) in detecting differences in testicular metabolites between histological stages of NOA and in assessing the possible presence of spermatozoa before microdissection testicular sperm extraction (mTESE). METHODS: Forty-nine NOA men and fifty age-matched controls were included in this prospective study. A single-voxel point-resolved spectroscopy sequence with TR/TE (2000/25 ms) was used. NOA testes were classified using the higher Johnsen score (hJS) (group 1, hJS ≥ 8; and group 2, hJS < 8). Nonparametric statistical tests were used to assess differences in normalized metabolite concentrations, defined as ratios of the metabolite concentrations versus creatine concentration between (a) NOA and controls, (b) NOA groups, and (c) NOA with positive and negative sperm retrieval. RESULTS: Normalized concentrations of total choline (median 0.396 vs 1.09 mmol/kg, p = 0.002), myo-inositol (median 1.985 vs 3.19 mmol/kg, p = 0.002), and total lipids and macromolecules (TLM) resonating at 0.9 ppm (median 0.962 vs 2.43 mmol/kg, p = 0.024), 1.3 ppm (median 4.88 vs 10.7 mmol/kg, p = 0.043), and 2.0 ppm (median 2.33 vs 5.96 mmol/kg, p = 0.007) were reduced in NOA testes compared with controls. Decreased concentrations of TLM 2.0 (median 3.755 vs 0.436 mmol/kg, p = 0.043) were found in group 2 compared with group 1. Increased normalized concentrations of glutamate were observed in NOA testes with failed sperm retrieval (median 0.321 vs 0.000 mmol/kg, p = 0.028). CONCLUSIONS: 1H-MRS provides metabolic information about the testis in NOA patients and assesses spermatogenic status before mTESE. KEY POINTS: • NOA testes differed from age-matched controls, in terms of reduced normalized concentrations of tChol, mI, and lipids. • TLM 2.0 peaks were found useful in the identification of NOA testes with the presence of foci of advanced spermatogenesis up to the haploid gamete stage. • Glu proved a reliable metabolic signature of spermatogenesis in NOA population by assessing the possible presence of sperm after mTESE.

Ultrasonographically determined size of seminiferous tubules predicts sperm retrieval by microdissection testicular sperm extraction in men with nonobstructive azoospermia.

OBJECTIVE: To investigate the value of the ultrasonographically determined size of seminiferous tubules and other conventional parameters for predicting sperm retrieval by microdissection testicular sperm extraction (micro-TESE). DESIGN: Clinical retrospective study. SETTING: Two urological clinics. PATIENT(S): Eight hundred six men with nonobstructive azoospermia. INTERVENTION(S): Micro-TESE. MAIN OUTCOME MEASURE(S): Sperm retrieval. RESULT(S): Sperm retrieval was successful in 240 (29.8%) of the 806 men. In a receiver operating characteristic analysis of sperm retrieval, the area under the curve (AUC) for seminiferous tubules, assessed as 0, 100, 200, 250, or 300 µm, was no less than 0.82 (95% confidence interval [CI] 0.79-0.85). Sensitivity and specificity at a cutoff point of 250 µm were 76.7% and 80.7%, respectively. An AUC of 0.85 (95% CI, 0.81-0.88) was attained in a parsimonious multiple logistic regression model that included age (<30, 30-39, and 40-59 years), low follicle-stimulating hormone (<14 IU/L), history of cryptorchidism, and sex chromosome abnormality in addition to the diameter of seminiferous tubules. CONCLUSION(S): The gray-scale image in testicular ultrasound was shown to be highly predictive of sperm retrieval in micro-TESE in a large series of men with nonobstructive azoospermia.

MRI findings of obstructive azoospermia: lesions in and out of pelvic cavity.

Obstructive azoospermia (OA) is caused by excurrent duct obstruction, which can occur anywhere along the course of the male reproductive tract and is classically characterized by normal spermatogenesis. To be familiar with the imaging anatomy of normal and abnormal male genital ducts is essential to the diagnosis of OA. In some circumstances, OA can also be related to some specific syndromes; thus, making an accurate diagnosis may require an integral view of the whole abdomen and pelvis. MR is a great complementary imaging modality either for the detection of obstructive factors, especially for characterization of those indeterminate features on ultrasound, or for the identification of specific syndromes related to OA. In this article, a series of patients with OA caused by different kinds of lesions in and out of the pelvic cavity (abdomen) shown on MR imaging were included, and some cases of specific syndromes related to OA were also reviewed.

MRI findings of nonobstructive azoospermia: lesions in and out of pelvic cavity.

Nonobstructive azoospermia (NOA) can be caused by various diseases, including congenital disorders, endocrine disorders, infections, tumor or tumor-like diseases, vascular diseases, etc. Diagnosis of the underlying cause of NOA is complicated and challenging. In this study, we introduce an MR examination protocol for the etiological diagnosis of NOA, and demonstrate a series of NOA patients with different causes and imaging findings. Except for lesions of testes, the patients may also combine abnormalities of adrenal glands and central nervous system. In such cases, the patients could benefit from additional abdominal and intracranial scans.

Testicular ultrasound inhomogeneity is an informative parameter for fertility evaluation.

Testicular volume (TV) is proposed to be a positive predictor of male fertility status, because of the relation known between the TV and the seminiferous tubule content. Independently of the measurement methodology, the role of TV and testicular ultrasound (US) assessments is still debated in andrological clinical practice. In this retrospective cohort study, we evaluated TV and testis US role in the diagnostic workup of andrological patients. All consecutive outpatients undergoing single-operator testis US (Modena, Italy) from March 2012 to March 2018 were enrolled, matching sonographic, hormonal, and seminal data. A total of 302 men were referred and evaluated for gynecomastia, suspected hypogonadism, couple infertility (CI), or sexual dysfunction. In the hypogonadal group, TV was lower compared to that in other groups (P < 0.001), and a significant, direct correlation between TV and testosterone level was observed in nonandrogen-treated patients (R = 0.911, P < 0.001), suggesting that testicular size could be related to the testosterone-secreting compartment. In the CI group, normozoospermic patients showed higher TV compared to men with impaired semen quality (P = 0.003) and azoospermia (P = 0.003). However, TV was not able to discriminate between patients presenting normal and altered semen quality. On the contrary, testis US inhomogeneity was more frequent in patients with impaired sperm quality (55.0%; P = 0.007) and azoospermia (40.0%; P = 0.012), compared to patients with normozoospermia (5%), identifying thereby the sonographic pattern as an informative parameter of the fertility status. Therefore, in the CI workup, US evaluation seems to be more informative than the TV assessment alone.

Infertility case presentation in Zinner syndrome: Can a long-lasting seminal tract obstruction cause secretory testicular injury?

Zinner syndrome (ZS) could represent an uncommon cause of male infertility, as result of the ejaculatory duct block, which typically leads to low seminal volume and azoospermia. A 27-year-old Caucasian man reported persistent events of scrotal-perineal pain and dysuria during the past 6 months. The andrological examination showed testicular volume of 10 ml bilaterally. Follicle-stimulating hormone was 32.0 IU/L, luteinising hormone was 16.3 IU/L, total testosterone was 9.0 nmol/L, and 17-beta-oestradiol was 0.12 nmol/L. The semen analysis revealed absolute azoospermia, semen volume of 0.6 ml and semen pH of 7.6. The abdominal contrast-enhanced computed tomography showed (a) left kidney agenesis; (b) an ovaliform hypodense mass of 65 × 46 millimetres with fluid content, which was shaping the bladder and the left paramedian prostatic region, compatible with a left seminal vesicle pseudocyst; and (c) an enlargement of the right seminal vesicle. The patient was diagnosed with ZS, and he was scheduled for robot-assisted laparoscopic left vesiculectomy. Subsequently, testis biopsy was characterised by complete germ cell aplasia. The onset symptomatology is often blurred and difficult to detect. It is important to diagnose and manage early this condition, because a long-lasting seminal tract obstruction could determine an irreversible secretory testicular injury.