PATHOLOGY OF THE TESTES.

In this class we will begin to study the testicular pathology (of the scrotal co
ntents and funicular). We can say in my favor that the class was "very quickly",
so that left over 25 minutes to the teacher, who used to talk about male infert
ility (since according to him will not give us time to further below). As separa
te issues separate them as two different classes but with the same date, to faci
litate the management of the notes. Abenza Jesús Campuzano. 1. Cryptorchidism. I
ntroduction. The term cryptorchidism refers to "no testicular descent." Cryptorc
hidism, testicular etymologically hidden [from the Greek Kripta (hidden) and orq
uis (testicle)], is the lack of complete testicular descent (to the scrotum, whe
re it is withheld), either unilateral or bilateral, so that the gonad is outside
the scrotum. The term includes any location of the testis along its normal rout
e, both abdominal and groin, and abnormal or ectopias1 locations. From a practic
al standpoint, cryptorchidism include: 1) the absence of palpable testis, 2) the
inability to make it descend into the scrotum manually, and 3) the situation in
which, once dropped by appropriate maneuvers, the testicle becomes immediately
to its former position, outside the scrotum. Embryology. In humans, gonadal morp
hological characters only become male or female in the seventh week of gestation
. From the proliferation of coelomic epithelium and condensation of mesenchyme u
nderlying form folds or genitals, or gonadal ridges. Germ cells or germ line, on
ly appear in the genital folds at week 6, and appear between the yolk sac endode
rmal cells and migrate along the dorsal mesentery, reaching the primitive gonads
, medial to the mesonephros (origin of the urinary tract). At the beginning of t
he 5th week and in the 6th, invade the genital folds. It is thus indifferent or
bipotential gonad, in which the coelomic epithelium of the genital fold epitheli
al cells proliferate and penetrate the underlying mesenchyme, forming the primar
y sex cords.
1
Because of its pathophysiology and for its prognostic implications, the testicul
ar ectopia is a
considered by many experts as a clinical entity different from cryptorchidism an
d should not be included in the definition of it. The ectopic testis is a normal
testicle has been "misled" by the gobernaculum testis, while the testes cryptor
chidic all possess some degree of dysgenesis, the greater the higher location.
In the week 6-7 gonadal differentiation occurs from the effects of HI antigen, w
hich together with other factors conducive to synthesis of testosterone. From th
e 2nd month, the testicle descends on the growth of the embryo, because the test
icle is attached to the inguinal region, which is more caudal. Later forms testi
gubernaculum ligament, a fibrous ligament that is attached to the scrotum, pull
ing it down to the testicle. By the 5-7th month, the testicle passes through the
inguinal ring, by shortening of the gubernaculum tes, so that the 9th month, bo
th testicles should be within the scrotum. Epidemiology. Cryptorchidism is the m
ost common congenital malformation affecting the external genitalia in the male.
At the time of birth is found in the 3 to 4% of men born at term and in more th
an 30% of the infants, depending on the age gestacional2 directly. That is why m
any premature (born in the 7th month) the present, but in 90% of them the testis
descends into the scrotum during the first year of age. Anyway, may fall furthe
r ahead. In more than 80% of cases, the undescended testicle is in the inguinal
canal, and only 5% are real absence of the gonad. After the first year, the prop
ortion of children with cryptorchidism ranges between 0.8 and 2%. Also appears t
o be a component of familial aggregation. Approximately two thirds of the crypto
rchid testis are cases of unilateral presentation and for the most part, the aff
ected testicle is the right (70%), since it is the last drop. The bilateral cryp
torchidism is associated with more general problems often genetic, endocrinologi
cal, etc. Classification. We distinguish different types of cryptorchid testis,
although there is no accepted system of classification, and that the most useful
is to specify its location.€- Retractable Test (lift) is considered that the re
tractable testicle rises from the scrotum by a hyperactive cremaster muscle and
because it fails to complete fixation of the lower pole testicular gubernaculum
into the scrotum through the testi. Usually descends into the scrotum to numb th
e patient and are usually bilateral, and usually end up staying in the scrotum a
t puberty.
2
In term infants, the descent of the testis is usually completed in the first six
months of life,
so if you have not fallen into the scrotum at the time, in most cases will not f
all. In premature infants, may cover more than the first half of life.
- Cryptorchidism true: it is usually unilateral (bilateral forms are usually ass
ociated with malformation syndromes and genetic abnormalities). 20% are not palp
able (eg, because they are intra-abdominal), and 80% are at high scrotal cable c
ar, so it is palpable. All have some degree of dysgenesis, the more higher your
location. - Testicular Ectopic descends through the internal inguinal ring, but
away from the scrotum to his thigh, at the suprapubic or to the perineum. The ec
topic testis is a normal testicle has been "misled" by the gubernaculum tes, whi
le the testes cryptorchidic all possess some degree of dysgenesis, the greater t
he higher location. For all the testes is common the need to achieve the best th
ermal conditions encountered in the scrotum. Therefore favors cryptorchidism ste
rility, the thermal dysregulation and because the cryptorchid testis dysgenesis
have a certain degree of (which is also associated with a higher rate of testicu
lar tumors.) Exploration. When young children bear the brunt of this disease, th
ere is no exploratory measures appropriate to assess the existence of cryptorchi
d testis, or testicular absence. If we can explore unit laparoscopy and abdomina
l peritoneal cavity to assess the presence of the gonads. If you do not see the
testicle (because it is formed) we can see remnants of embryological hypoplastic
type of vas deferens, etc (monorquidia a missing testicle, anorquidia missing b
oth). We can find an ectopic testis intraabdominopélvica virtually any location,
so I look good in these cavities. Diagnosis. This is done by physical examinati
on and laboratory investigations may be needed, especially in cases in which the
testes are not palpable. Investigations: ECO pelvic, pelvic laparoscopy (there
are different paths), CT and radiological tests (not as often in young children
but in older). ECO-Doppler and Angio-MRI are still weak, new techniques. Medical
treatment. In prepubertal patients in which we did not find the testicle in the
scrotum, can do a study hormone HCG (human chorionic gonadotropin), FSH and LH.
This study serves hormone to stimulate the pituitary gland (pituitary-hipotálam
ogonadal axis), so that if / n testicle / s showed a rise in testosterone levels
, and if no testicle / s, hormone levels will not increase. This hormonal study
has a threefold purpose: 1) assess the proper functioning of the hypothalamic-pi
tuitary-axis gonadal, 2) determining the existence of hidden testis, and also 3)
as
medical and / or preoperative management. In fact, medical treatment of cryptorc
hidism is based on the administration of hormones, but is rarely effective, but
useful in the preoperative management of orchidopexy. The main problem is that m
edical treatment in cases of monorquidia virilization occurs early (the penis is
developed at odds with the biological age, projected images in the classroom: c
hildren 4-5 years with a penis and pubic hair of 15 cm .) There are usually no s
uch medical treatment should be administered (HCG) in children under 1 year of a
ge. Surgical treatment: orchidopexy. The testes are usually dysgenetic cryptorch
idic (abnormal) and an increased incidence of testicular tumors (25% more freque
nt, the risk is higher when intra-abdominal and in those diagnosed late.) Thus i
t is said to be operating all cryptorchidism for proper testicular development,
intra-scrotal. Early diagnosis of cryptorchidism is important to prevent irrever
sible testicular damage, especially if bilateral, the greater likelihood of ster
ility and the probable association with malformations.€Surgical treatment is cal
led orchidopexy and consists in fixing the testicle to the scrotum (intra-dartos
): we must practice a release of the inguinal ring to the testicle may descend t
o re-locate and keep him confined and fixed to the scrotum (without any up). No
need to operate early, but the 2-4 years of age. The lower the testicle is locat
ed, the easier it will be re-located in the scrotum (which are located higher, t
end to atrophy).
2. Germ cell tumor. Testicular tumors are rare, especially in children older tha
n 50 years. The vast majority are malignant, but the degree of malignancy is ver
y different depending upon the histological type. 95% are germ cell tumors: they
are derived from primordial germ cells (gonocytes fundamental). Although later
we see the histological classification of testicular tumors of WHO, we can say f
rom a practical point of view that germ cell tumors are classified as: germinal
epithelium derived tumors (seminoma, embryonal carcinoma and yolk sac tumor) and
tumors derived from the stroma (choriocarcinoma and teratocarcinoma).
Seminoma germ cell tumor is the most common and least malignant. Each of the fou
r basic types, seminoma, embryonal carcinoma, teratoma and choriocarcinoma, may
have given varieties and in various combinations with other types. Tumor staging
. Describes four stages: - Stage I: limited / confined to the testicle. - Stage
II: infradiaphragmatic lymph node; II-a, node <2cm; II-b ganglia 2-5cm and stage
II-c, node> 5cm. - Stage III: beyond the diaphragm lymphatic involvement is abo
ve and infradiaphragmatic. - Stage IV: distant metastases. Let's talk a bit abou
t these tumors, you do not know everything, the end will highlight the most impo
rtant in a section I have called "Summary." (Explained in class is not much, but
I do not trust a lot because they spent all the slides very fast and you could
not tell what was most important and what was not). Seminoma. The name of this t
umor derives from the word semen. Is half of germ cell tumors of the testis, ger
m cell tumor is the most common and least malignant. There are three degrees of
differentiation: well differentiated (type I, 10%), moderately differentiated (t
ype II, is the most frequent, 60%) and poorly differentiated (type III or atypic
al seminoma, 28%). There is another variety, very rare, Spermatocytic seminoma (
2%). This tumor is highly radiosensitive. The 5-year survival for stage I is 100
% for stage II, 95% and for stage III, 90%. According to experiences in previous
decades, up to 40% of pure seminomas may have regional lymph node metastases at
the time of consultation. Recent studies in just over 20% of patients with semi
noma is elevated blood levels of human chorionic gonadotropin, beta subunit, whi
ch may be useful for monitoring patients and to evaluate the therapeutic outcome
. Embryonal carcinoma. Corresponding to 25% of testicular germ cell tumors. The
tumor is composed of epithelial and mesenchymal elements immature embryo. Any of
these components may predominate in a given tumor. 75% of embryonal carcinomas
produce a-feto-protein. This substance is normally produced in the fetal liver a
nd gastrointestinal tract and is found not in choriocarcinoma or pure seminoma.
80% of embryonal carcinomas occur betaHCG. Overall, 60% of embryonal carcinomas
with regional lymph node metastases at diagnosis.
Teratoma. Corresponds to 8% of the tumors derived from germ cells. It consists o
f components derived from three embryonic layers: endoderm, mesoderm and ectoder
m. Tissues may be composed of mature, well differentiated (mature teratomas) or
in a more embionario or less differentiated (immature teratoma). The mature pred
ominate in infants and children and immature adults. AlfaFP producers are at abo
ut 40% of cases and betaHCG in 25% of cases. The prognosis is good if it is a ma
ture teratoma. The malignant variety, the teratocarcinoma, is highly malignant,
as choriocarcinoma. Choriocarcinoma. It is rare, it is for only 2% of the tumors
derived from germ cells. The tumor is small and bleeding, consisting of two com
ponents of the trophoblast, both are together forming the tumor tissue. This tum
or is very active producing betaHCG. Metastases occur early and through the bloo
d to the lungs, then spreading to the rest of the body.€This is the worst progno
sis testicular tumor: it has a mortality of 100% at 5 years. In contrast, other
nonseminomatous have a survival of 90% in stage I, 80% in stage II and 70% in st
age III. Combined forms. Among these forms teratoma with embryonal carcinoma is
relatively frequent, which corresponds to 15% of germ cell tumors. Summary of
germ cell tumors. Germinal epithelial tumors are often mixed tumors, occurring i
n young males (20-30 years). Today 95-99% cure because they respond very well to
radio / chemotherapy. Seminoma is half of germ cell tumors of the testis, germ
cell tumor is the most common and least malignant. In the mixed, the predominanc
e of one form or another give us histological tumor markers. In turn, markers al
low us to assess the existence of residual tumors after surgery and / or tumor m
etastases. It is highly metastatic tumors, especially through the blood, except
for seminoma, which mainly metastasizes via the lymphatic system. We must explor
e the supraclavicular lymph node, which to be affected is a criterion of maligna
ncy (because translated supradiaphragmatic involvement). Elevation of tumor mark
ers: alpha-FP and beta-HCG. alpha beta-HCG-FP pure Seminoma Embryonal carcinoma
+ + + yolk sac tumor Choriocarcinoma Teratoma + Then, classification of testicul
ar tumors, WHO, 1977. (It is only indicative, to enhance, not given in class and
not have to study.).
CLASSIFICATION of testicular tumors (World Health Organization, 1977) 1. Seminom
a Germ Cell Tumors Seminoma Embryonal carcinoma Spermatocytic Histologic Type SI
NGLE yolk sac tumor Choriocarcinoma Teratoma Polyembryoma embryonal carcinoma an
d teratoma OF MORE THAN ONE TYPE OF GERM HISTOLOGICAL intratubular neoplasia (ca
rcinoma in situ) 2. 3. CELL Choriocarcinoma and Other combinations
SEXUAL cord tumors and tumor cells of Leydig, Sertoli, granulosa STROMA, mixed,
and GERM CELL TUMOR AND Gonadoblastoma other sex cord STROMA Lymphoma Carcinoid,
plasmacytomas Metastatic lung cancer, kidney, pancreas, etc. . prostate,
4. MISCELLANEOUS 5. Lymphoid tumors and Hematopoietic 6. SECONDARY TUMORS
Adenomatoid tumor, mesothelioma, MISCELLANEOUS TUMORS AND THE ANNEXED tumor of t
he testis, tumor, 7. Brenner testicular tumor, rhabdomyosarcoma soft tissue) 8.
Untested tumors 9. Epidermal Cyst pseudotumoral lesions, orchitis, malakoplakia,
lipogranuloma, adrenogenital, etc.
Stromal tumors. Occur infrequently. Clinical manifestations and diagnosis of ger
m cell tumors. These testicular tumors are often clinically silent, asymptomatic
. Discover what is normal by palpation: hard testicular area, initially painless
. Later it may cause discomfort. It is usually diagnosed when consulting for ano
ther reason. ECO confirms the existence of the tumor and, according to operator
experience, ultrasound findings may indicate more or less the type of tumor invo
lved. The TAC is essential when determining the existence of metastasis. Surgica
l treatment. Orchiectomy. Orchiectomy is the partial or total removal of the tes
ticle. If the total orchiectomy is also removed and part of the epididymis
testicular cord, other times only partial orchiectomy, removing only the functio
nal part of the testicle, leaving the remaining structures (subcapsular orchiect
omy). The total orchiectomy is indicated for tumors, infections that destroyed t
he testis, and in cases of testicular atrophy (you can then place a prosthesis).
Subcapsular orchiectomy is indicated for those interested in processes in which
cause a decrease in levels of blood testosterone (male hormone), as in carcinom
a of the prostate for a better control over it. In this case the operation is pe
rformed in both testes. These interventions are performed under regional anesthe
sia, general or local. The incision is made in the scrotal skin (case of subcaps
ular orchiectomy) or in the groin area (if total or radical orchiectomy) on the
side to remove. If partial orchiectomy is the incision will be at the level of t
he scrotal skin. In our case, for germ cell tumors make the incision in the groi
n area for a radical orchiectomy. Binds the spermatic cord and testicular conten
ts emptied. The postoperative period is usually short (1-3 days) may then follow
an outpatient. Then one is usually placed testicular prosthesis. Secondary test
icular tumors.€Testicular lymphoma, lymphoblastic leukemia, melanoma, etc.. The
treatment will be according to age. They usually do well if it is the primary tu
mor.
3. Varicocele. Introduction. A varicocele is a dilation of the plexus pampinifor
m above testicle more common in the left side, and secondary valvular incompeten
ce of the spermatic vein in question. It is a disorder that occurs in approximat
ely 10% of young men, 2-5% of the population and up to 10-20% of patients consul
ting for infertility. A varicocele occurs when the valves of the veins along the
spermatic cord do not function properly, preventing normal blood flow and cause
blood to be retained, resulting in an enlarged or dilated veins. (This is essen
tially the same process that occurs with varicose veins common in the legs). It
is usually congenital. Varicoceles usually develop slowly and may be asymptomati
c, their occurrence is more common in men between 15 and 25 years old and are mo
re on the left side. Varicoceles are often the cause of infertility in men. The
sudden appearance of varicocele in an older person may be the result of a renal
tumor that has affected the renal vein and altered blood flow through the vein e
spermática3.
3
Formerly one of the signs of renal tumor was secondary varicocele was produced b
y venous outflow obstruction of the renal vein.
Spermatic veins draining ...
Left- Vena renal vein (99% of varicoceles). Right- Vena vena cava;
Cava flow is greater than the renal vein flow, so it is more difficult to occur
on this side varicocele. Clinic. The symptoms are predictable: visible veins, en
larged and twisted in the scrotum (varicose veins in the scrotum); Infertility p
ainless testicle lump, scrotal swelling or lump in the scrotum, most common on t
he left side. It can be a source of pain inguinoscrotal Signs: If a person has v
aricocele, your doctor may feel tender, twisted mass along the spermatic cord (f
eels like a bag of worms.) However, the mass may not be felt or it is not obviou
s if the patient is lying down. The diagnosis can be made to the naked eye with
the patient standing if the varicocele is large, otherwise you can press above t
he inguinal ligament and forced Valsalva maneuver to see if it gets bigger (whol
esale outflow obstruction). The testicle on the side of the varicocele may be sm
aller or not when compared to the other side. Clinical grades. There are four cl
inical grades (0-3): - grade 0: subclinical, asymptomatic. Not in the examinatio
n. - Grade 1: Valsalva maneuver appears. - Grade 2: is clear, without deception
or efforts - Grade 3: is standing. ((Note: In an article of the European Society
of Urology I found the following: Varicocele from Coolsaet classified into 3 gr
ades according to their intensity. For this classification is necessary physical
examination and Doppler ultrasonography of the spermatic cord . In grade I, the
veins are small and are palpable in situations of stress (Valsalva maneuver) in
grade II veins are palpated easily maneuvers without effort, in grade III (seve
re) shows a mass scrotal visible without palpation.)) Diagnosis. For diagnostic
manual palpation is used both supine and standing and Doppler ultrasound to demo
nstrate venous dilation. Varicoceles in the right side, making differential diag
nosis with other patologísa (especially tumors) as the presentation on the right
side is very rare. Treatment. Several treatments have been used in open surgery
(ligation of the spermatic veins) or transfemoral percutaneous sclerosis using
occlusive catheters or sclerosing agents.
The treatment is preventive, to avoid potential testicular involvement, infertil
ity and pain. No one knows the reasons why the germinal epithelium is affected i
n the varicocele, although it is thought that strongly influences the thermal dy
sregulation and hypoxia, the accumulation of toxic metabolites, chronic testicul
ar edema ... others. Varicoceles can be managed with the use of a scrotal suppor
t. However, if pain continues or causes infertility or testicular atrophy may be
needed further treatment, which may include surgical removal, laparoscopic remo
val and catheter embolization. Both open and laparoscopic varicocelectomy (surgi
cal correction of varicocele) are performed on an outpatient basis.€The incision
is usually made in the lower abdomen but can be used several techniques. Binds
cremasteric vein above the inguinal ring, the movement of venous return venous n
etworks will explore why the drain. It should keep ice packs in the area during
the first 24 hours after surgery to reduce swelling. Catheter ablation is also p
erformed as an outpatient procedure is done with a small incision in the crease
where the leg joins the body. Ice and is recommended to wear a scrotal support f
or some time after surgery. Possible complications of this operation are: hemato
ma, infection or tissue damage or structure of the scrotum. In addition, there m
ay be injury to the artery supplying the testis. The patient who has offspring b
y varicocele and has no reason to alert about the barrenness, the interest is in
those patients pre / puberty that may be affected when having children. 4. PERS
ISTENCE OF INGUINAL RING (PAI). There may be a sliding inguinal hernia (intestin
al loops). (In class not say anything more about it). 5. Hydrocele. Introduction
. It is a fluid-filled sac located along the spermatic cord within the scrotum.
This increased fluid appears as a testicular swelling of variable size. Etiology
. Hydroceles are common in newborn babies and fluid accumulation may occur in on
e or both sides of the scrotum. During normal development, the testicles descend
down a tube (tract) from the abdomen into the scrotum. The
hydroceles result when this tube fails to close and the liquid drains from the a
bdomen through the open tube. The fluid accumulates in the scrotum, where it is
trapped, which makes it bigger. Hydroceles usually resolve after a few months af
ter birth, but their appearance may worry new parents. Occasionally, a hydrocele
may be associated with an inguinal hernia. Hydroceles can be easily demonstrate
d by shining a flashlight through the enlarged portion of the scrotum, if the sc
rotum is full of clear liquid, as in a hydrocele, the scrotum will light up (by
transillumination), while the inguinal hernia, by transillumination, give a pict
ure of a heterogeneous appearance due to the different densities of the herniate
d material (bowel). Hydroceles may be caused at all ages by inflammation or trau
ma of the testicle or epididymis, or by fluid or blood blockage within the sperm
atic cord. This type of hydrocele is more common in older men. Clinic. The main
symptom is a painless testicular swelling in one or both sides that feels like a
balloon filled with water. During a physical exam, the doctor an enlarged scrot
um that is usually not sensible. Often, the testicle can not be felt because of
the surrounding fluid. The size of fluid-filled sack can sometimes be increased
or decreased by pressure to the abdomen or scrotum. If the size of the fluid col
lection varies, it is more likely to be associated with an inguinal hernia. The
fluid in a hydrocele usually is clear, therefore, can shine through the scrotum
(trasniluminación), outlining the testis, indicating the presence of clear liqui
d. You can do an ultrasound to confirm the diagnosis. Diagnosis. For the clinica
l examination, transillumination, the ECO and ultrasound (Duplex Ultrasound) if
necessary. The most common differential diagnosis is with inguinal hernias, as I
said, and we help of transillumination and ultrasound. Medical treatment. Usual
ly, a simple hydrocele goes away without intervention by the doctor. Where surge
ry is necessary, it is a simple procedure in the hands of a skilled surgeon, and
the result is usually excellent. Normally, hydroceles are not dangerous and usu
ally only treated if they cause discomfort or embarrassment, or reach a size so
large that threaten the testicle's blood supply. One option is to remove the flu
id in the scrotum with a needle (aspiration), but this aspiration can cause infe
ction is common fluid from accumulating again. Therefore, aspiration is not a ro
utine procedure and surgery is generally preferred. On the other hand, aspiratio
n may be the best alternative for people who have certain surgical risks.
After needle aspiration, medication may be injected sclerosing (thickening or ha
rdening)€as tetraclina, sodium tetradecyl sulfate or urea, to close the opening
through the scrotal sac and thus help prevent re-accumulation of fluid. Possible
 complications after these procedures are, among others: infection, fibrosis, mi
ld to moderate pain in the scrotal area and recurrence of the hydrocele. Surgica
l treatment. The hydrocelectomy. This is a minor surgical procedure is often per
formed on an outpatient basis under general or spinal anesthesia to correct a hy
drocele. An incision in the scrotum or lower abdomen. The procedure may require
a scrotal drainage tube and bulky dressing over the area of the scrotum. In addi
tion, apply ice packs to the area during the first 24 hours after the procedure
to reduce swelling in the area and wear a scrotal support for some time after su
rgery. Possible complications of this procedure include the formation of a hemat
oma (blood clot), infection or injury to the scrotal tissue or structures. - The
hydrocele associated with inguinal hernia should be repaired surgically as quic
kly as possible. - The hydroceles that do not resolve spontaneously over a perio
d of months should be evaluated to carry out a possible surgery. 6. Sebaceous cy
st. In class virtually did not say anything about it, only showed two or three i
mages of this disease: multiple sebaceous cysts testicles in the scrotum. Lesion
s are yellowish appearance.
Male infertility.
Continuation of the class of Urology on Tuesday November 14, 2006, the day after
recovery gowns (09/11/2006). This is what is said in the last 25 minutes of cla
ss ...
Patients who consult for infertility (inability to achieve pregnancy after ≥ 12
months of unprotected intercourse or contraception) should be subject to study,
both, both men and women.
To us in this occasion we want to talk about infertility or male infertility, th
e possible causes of damage or alter the quality of sperm, preventing fertilizat
ion. The causes of infertility include a wide range of both physical and emotion
al factors. Approximately 30 to 40% of all infertility cases are due to a factor
of origin "masculine" (female causes are 40-50% from 10 to 30% of cases of infe
rtility can be caused by contributing factors by both partners or no cause can b
e identified.). These causes include: the retrograde ejaculation, impotence, hor
mone deficiency, exposure to environmental pollutants, scarring from sexually tr
ansmitted diseases, or decreased sperm count, and many others, bearing in mind t
hat age influences a lot. Some factors affecting sperm count are heavy marijuana
or drugs like cimetidine, spironolactone, and nitrofurantoin. In addition to ag
e-related factors, the increased risk of infertility is associated with the foll
owing: - Alcohol and snuff. - Having multiple sexual partners, increasing the ri
sk of STDs - Having a sexually transmitted disease - History of PID (pelvic infl
ammatory disease) - History of orchitis or epididymitis in men - Mumps (men) - V
aricocele (men) - History of DES exposure (men or women) - Long-term (chronic) a
nd diabetes (men or women, microvascular damage). The man must first make a phys
ical examination to rule out processes that may encourage or impede proper steri
lity and complete ejaculation, such as: cryptorchidism, varicocele, prostate dis
ease, etc. We can use the ECO or other complementary examinations (if necessary)
to assess the integrity of the structures we are studying (prostate, ampulla va
s deferens, seminal vesicle). The study of semen quality of men is called sperm
count or sperm. Spermiogram The term refers to the study of sperm quality, from
the point of view of analysis of the male sex cells. The term sperm is broader c
onceptually and theoretically encompasses the study of the quality of ejaculated
semen (sexual cells ejaculates + other products). Throughout this class we will
use interchangeably. These studies are both quantitative and qualitative.
A sample of semen during ejaculation. The method to collect the sample should be
agreed with the doctor.€The sample can be obtained by masturbation into a steri
le container or also through sexual intercourse using a special condom supplied
by the physician. The sample must be analyzed within 2 hours after collection, b
ecause the faster you analyze, the more reliable the results. It is important th
at male sexual arousal is considerable (it complete?, So to speak) at the time o
f ejaculation, because if no ejaculation is incomplete and the evaluation of eja
culate material will be limited. The ejaculate material usually has a volume of
2-4 ml (1.5-5 ml IN) and has a distribution such that: - 30% of ejaculate volume
comes from the prostate - 10% coming from the deferential ampulla, and - 60% co
mes from the seminal vesicle. The passage of spermatozoa through the epididymis
is very important, is the critical stage: maturity. Then the vial is stored in t
he vas deferens, where there are different stages of maturation. All this we adv
ised the patient to maintain sexual abstinence (total) during the 4-5 days befor
e the study, which does not mean that a study will be conclusive, but on the con
trary, it takes a minimum of 2-3 separate studies in time to obtain reliable inf
ormation. In the study of material quality and quantity of ejaculate (sperm / se
men) must be assessed: sperm count, mobility of the same morphology, the integri
ty of the head and tail, and the membrane, on the other hand, we analyze the con
sistency (viscosity), acidity and sugar content of semen. The sperm count varies
from 20 to 150 million per ejaculation. If the sperm count is too low or too hi
gh, there is the possibility of being less fertile. But there is a single mature
sperm, capable and completely normal, we can not guarantee that you can not get
pregnant ... you can always be the case, although it really is rare. The morpho
logy is also important to achieve fertilize the egg, so it is important to speci
fy the percentage of normal forms and abnormal forms. We have to study mobility.
At least 60% of sperm should have a normal shape and show normal movement and s
traight forward (motility), called type movement, active, well qualified with th
ree crosses (+++). But we can find other types of movements.
Types of movement of sperm.
Movement Movement Type A Type B
Straight ahead, active Coiled, non-progressive
Optimum; + + + Anomalous
Movement Type C
No movement
Anomalous
If the problem is only in mobility, in the lab we can reproduce the phenomenon o
f "sperm collection": sperm with hypermotility, very active and swimming breakth
rough. We use "media training" to recreate the environment that the sperm would
be found in the cervical mucus at the optimal stage for fertilization of the egg
. This is done by placing in a test tube ejaculate material (A), and this places
a special medium with fructose (B) so that the fittest sperm will swim toward t
he solution of fructose, located above them (represented by arrows). Subsequentl
y, this medium contains fructose, collecting the sperm have swum up to it (which
will be the most capable and mobile) and used for assisted reproduction techniq
ues. The acidity of the semen and the presence of white blood cells (suggesting
infection) may influence fertility. We must assess the integrity of the membrane
of the sperm head, which should be free. Is assessed by staining with hematoxyl
in-eosin (HE), so if you are in full color at no sperm because the membrane is i
mpermeable to this dye, and conversely, if the membrane is full sperm stained wi
th HE. The study of membrane integrity of the queue is done in an environment ot
her than osmolarity of the cellular compartment: If the tail is wound it is not
fully and adequately respond to this change of osmolarity, if on the contrary no
t roll up, it would mean that no membrane integrity. Much is known about male in
fertility and possibly the results of the tests fail to explain the cause of the
problem. If there is a low sperm count or abnormal semen, you may need further
testing. Therefore, once we have made the seminal study will make the patient co
mplete hormonal study: levels of FSH, LH and testosterone. This study is essenti
al in cases of azoospermia4 (absence of sperm in the ejaculate material.
4
B A
Azoospermia is the absence of sperm in the ejaculate material; oligozoospermia i
s when
There are few but well in the samples; criptozoospermia is the situation in whic
h a hard time finding sperm, but there are other, and the criptozoospermia is be
tween
Azoospermia can be two types: 1 - Secretory: germinal epithelium is affected not
produce sperm. In this group the most common causes are chromosomal or genetic,
cryptorchidism, (the testicles have not descended into the scrotum), orchitis (
testicular infection as in the case of mumps), hormone deficiency, radiotherapy
or chemotherapy. 2 - excretory (or obstructive): the germinal epithelium is heal
thy, the problem is in the conduction pathways of the sperm. That is, they produ
ce sperm in the testicles, but passage that connects the testicles to the penis
are blocked. Most common causes congenital absence of vas deferens (present in p
atients with cystic fibrosis), infections of the seminal ducts to close up the b
lock, section of the vas deferens by vasectomy or surgical complication of ingui
nal hernia operation. Excretory secretory (obstructive) elevated FSH and LH, tes
tosterone deficiency
(Gonadotrophic hypogonadism)
FSH, LH and normal testosterone
Obstructive azoospermia with normal hormone levels occur. We assess the state of
the seminal ducts and spermatic pathways by surgery, to know at what level is t
he obstruction or stenosis of the same. The diagnosis of obstruction is usually
done by iodinated contrast Deferentografía, so fill in the light of other defere
ns and seminal ducts. Surgery is often performed in the context of a process of
assisted reproduction, since the process allows us to extract sperm. Worth notin
g that the azoospermia is the most common symptoms of Klinefelter syndrome (47 X
XY). The patient may have the following signs: small penis, small testes (hypogo
nadism FSH by secretory azoospermia) and firm, pubic, armpit and facial hair, se
xual dysfunction, gynecomastia, Tall stature, abnormal body ratio (long legs, sh
ort trunk) . Adults can go to the doctor because of infertility, and children of
school age, they can take and assess learning disabilities. You can find the fo
llowing test results: - Karyotyping shows 47 XXY - Low serum testosterone level
- high FSH level
azoospermia and oligozoospermia.
- Low sperm count - high serum LH level - high serum estradiol levels
In these patients, testosterone therapy can accomplish the following: Increase s
trength, improve the appearance of muscles, promote the growth of body hair, imp
rove self-esteem and mood; Increase energy and sex drive, improve concentration.
Most patients with Klinefelter can not father children. However, there are case
s of men with an extra X chromosome have healthy offspring, sometimes with the h
elp of infertility specialists. In general, azoospermic patients have treatment
when: - The secretory azoospermia is due to altered levels of the hormones FSH,
LH and testosterone. Some patients intracitosólica or intracytoplasmic). - The e
xcretory or obstructive azoospermia is treatable only when injuries are tax duct
s or reconstructive surgery can perform IVF with ICSI. The latter is the most ef
fective. When the sperm quality is low (morphological or enzymatic acrosomal dam
age) usually resort to assisted reproduction, we will use IVF with ICSI when sem
en quality is poor (the recovery of viable sperm may require testicular biopsy).
If the condition can not be corrected or get retrieve sperm, sperm donation may
be an option when it comes to having children. Abenza Jesus Campuzano A greetin
g and a thousand kisses to my girls Erasmus (Nico, Mary-Hellin, Mary-Z, Mary-Bal
lesta and Esther, also Martix) and a big hug for male Erasmus (Edu-EML, Trocus,
Guille R.), and one that surely I forget. Moha And that you have not see it. (JA
C & EML, ducklings & Racy). azoospermic testes remain areas that can be extracte
d sperm for in vitro fertilization (IVF) with ICSI (injection