INTERPRETATION OF

TESTICULAR BIOPSY
By Major Nitu Sharma
Guide Lt Col Reena Bharadwaj
 INTRODUCTION
Testis is the male gonad & measures 4 x 3
x2.5cms.
It weighs 20 gms, Rt being heavier than left.
It comprises of 3 layers :T .vaginalis
:T.albuginea
:T.vasculosa.
 HISTOLOGY OF NORMAL
TESTIS
It is made up of 250 lobules.
Each lobule consists of :4 seminiferous tubules&
connective tissue stroma with leydig cells.
Seminiferous tubule forms the main structure.
At birth the diameter is 60micron &150 in adults.The
limiting membrane is made of the basal lamina&
alternate layers of smooth muscle cells& collagen.
The sertoli or the sustentacular cells lie with their nuclei
mostly near the basement membraneof the ST.
SERTOLI CELLS: nuclear membrane is
distinct; chromatin is relatively pale;
nucleolus is eosinophilic ,round or oval.
Spermatogonia :most immature germ cell;
located basally in the ST;round to oval
nucleus with dense chromatin.
Primary spermatocytes:nucleus slightly
large with dark aggregates of chromatin.
Sec. spermatocytes:nucleus slightly elongated
characteristic of sperm head& tail is elaborated.
The normal maturation takes 70 days& final
maturation occurs in the epididymis.
INTERSTITIUM: contains blood vessels
&lymphatic vessels with testosterone secreting
leydig cells.
Leydig cells: round to oval nuclei with stainable
lipid, contain eosinophilic Reinke crystals.
 INDICATIONS OF BIOPSY
1. Male infertility investigations
2. Role in testicular cancers: controversial
 CAUSES OF INFERTILITY

PRE TESTICULAR:
1.Hypogonadism:
prepubertal:craniopharyngoma ;hypogonadotropic
enuchoidism
post pubertal :chromophobe adenoma
2.Estrogen excess
3. Androgen excess
4. Hyperprolactinemia
5.Glucocorticoid excess
6.DM, hypo/hyper thyroidism
 TESTICULAR:
1.Diseases of spermatogenesis
2. Klinefelter syndrome
3.Cryptorchidism
4.Radiation &chemotherapy
5.Mumps
6.Iatrogenic
 POST TESTICULAR:
1. Anomalies of excretory ducts & accessory
glands
2. Impaired sperm motility
 CLINICAL EVALUATION FOR
MALE INFERTILITY
1.History
2.General physical examination & routine
laboratory investigations.
3.Semen analysis
4.Hormonal studies
5.Testicular biopsy
 HISTORY

h/osurgery in genital area,mumps,STD.

h/o viremia of recent onset
h/ometabolicdisorder,DM,cirrhosis,uremia,
obesity
h/o CT,RT,trauma
Occupational history
 SEMEN ANALYSIS
Two examinations at least
Abstinence for 2 days before examination
Examined within 2 hours of collection
VOL : 1.5 - 5.0 ml
COUNT : >50million
MOTILITY : >50%
MORPHOLOGY:head, acrosome, mid
piece , tail
 CHEMICAL ANALYSIS:
1. Fructose: obstruction
2. Alpha glucosidase:epidydmis
3. CK activity: fertilizing potential
Classification of infertility by semen
analysis
1. Absent ejaculation
2. Azospermia:no living sperms
ST sclerosis
germinal aplasia
maturation arrest
duct obstruct
endocrinal
 Oligospermia: counts <20 m/ml
conditions :Idiopathic
:cryptorchidism
:varicocele
:drugs
Asthenospermia:<50% motility
conditions :spermatozoa structural defects
:prolonged abstinence
:antisperm Abs
:idiopathic
:infection
Teratospermia :altered sperm morphology
 HORMONAL STATUS
LH FSH PROLAC DIAGNOSIS
TIN
low low low Hypoth/pit
hypogonadism
low low high Prolactinoma
High High normal Testicular failure
Prim spermt failure
Normal high -
idiopathic
Normal Normal -
 TESTICULAR BIOPSY
1960:1st by Charney
1987:Pesce ;1990: Magid ;1991: Wheeler
INDICATIONS
Absolute:azospermia
:oligospermia
:teratospermia
:atypical cells in ejaculate
 Relative:varicocele
:cryptorchidism
:chronic infection
:FSH>3 times normal
:hypogonadism
 TECHNIQUE

Open surgical incisional biopsy

Percutaneous testis biopsy
Percutaneous testis aspiration.
FIXATIVES
Bouins fluid/Zenker fluid/ Stieves fluid
Formalin Contra Ind:shrinkage of tubules
:poor preservation if nuc details
Stains : H&E
:TRICHROME
:VAN GIESON
:WEIGERT ELASTIC
:PAS GLYCOGEN
Role of electron microscopy
Adequacy of biopsy:
gross: atleast 3mmsec
histo:3-5 lobules with septa OR
:100 profiles of ST
 EVALUATION
Overall morphology
Size & structure of ST
Interstitial tissue
Spermatogenesis
Quantitative assessment
 HISTOLOGICAL PATTERNS OF
INFERTILE MALE
Normal histology
Immature testis in adult
Sloughing of immature cells
Hypospermatogenesis
Maturation arrest
Sertoli cell only syndrome
Peritubular fibrosis & tubular hyalinization
 NORMAL HISTOLOGY

Ductal obstruction
Varicocele
ST hyper curvature
Branching of ST
Isolated impaired sperm motility
Sampling error
Toxic, metabolic or infectious agent
Most commonly in azospermic males with obstr.of
excurrent ducts of testis
 IMMATURE TESTIS INADULT

Histo. similar to prepubertal testis

No peritubular elastic fibres
Few spermatogonia
Remaining intratubular cells are Sertoli
cells
No mature leydig cells
 Causes of immature testis
Abnormalities of hypothalamic-pituitary
function
Prepubertal panhypopituitarism
Congenital
Acquired
Hypogonadotropic enuchoidism
Kallmanns syndrome
Laurence-Moon-Biedl syndrome
Prader-Willi syndrome
Prepubertal androgen excess
Androgen-producing tumor
Adrenogenital syndrome
Exogenous androgen administration
 Sloughing of Immature Cells
In oligospermic men
Tubules normal or reduced in diameter with
central lumina obliterated and containing sloughed
spermatogenic cells
Sloughed cells consist of spermatocytes with
mature elements
Orderly pattern of spermatogenesis is disrupted
and epithelium has a jumbled disorganized
appearance
Centre of tubules appear cellular than periphery
and may produce hypocellularity of germinal
epithelium lining
Scattered tubules with complete
spermatogenesis present
Mild degree of peritubular fibrosis and
collagenous deposits in intertubular area
Leydig cells normal
Classify in this group if more than 50%
tubules affected
Sertoli cells and spermatogonia normal at
periphery
Causes of sloughing of immature
cells
Varicocele
Prior Vasectomy
Mumps orchitis
Idiopathic
 Hypospermatogenesis
Also called germinal cell hypoplasia
Seminiferous tubule diameter is within normal limits
Quantitative reduction of spermatogenesis
Overall thinning of the germinal epithelium and lumen
enlarged
Paucity of germinal cell causing sertoli cells to be more
conspicuous; thereby resembling sertoli cell only
syndrome
Tubules contain sloughed immature spermatogenic cells
Leydig cells normal
Patients oligo spermic with normal hormonal levels
Causes of hypospermatogenesis
Malnutrition
Chronic wasting illness
Advancing age
Exposure to excessive heat
Idiopathic
Downs syndrome
Klinefelters mosaic
Ductal obstruction
Glucocorticoid excess
Hypothyroidism
Fertile eunuch syndrome
Chemotherapy
Spermatogenic mature arrest
One of the most prevalent causes of infertility
Failure of spermatogenesis to proceed beyond
the primary spermatocyte level
Arrested cells increased in number and
sloughed in the tubular lumina
Tubular diameter, normal sertoli cells, basement
membrane,T.propria and leydig cells normal
Patients oligospermic or azospermic. Hormone
levels normal
 Causes of Spermatogenic
Maturation Arrest
Idiopathic Exposure to heat
XYY Post pubertal
Varicocele gonadotropin deficiency
Abnormal meiosis Mumps orchitis
Downs syndrome Sickle cell disease
Uremia Glucocorticoid excess
Cystic fibrosis Spinal cord injury
Adrenogenital Chemotherapy
syndrome
 Sertoli Cell only Syndrome
Also called germinal aplasia or del Castillo's
syndrome, first described in 1947
11 to 20% of testicular biopsy
Complete absence of germinal cells from ST
without impairment of sertoli or leydig cells
ST decreased in diameter and devoid of germ
cells
Tubular basement membrane normal
Patients with azospermia and increased FSH
levels
 Causes of Sertoli cell only
Syndrome
Idiopathic(congenital) Mumps
Chemotherapy Hyperprolactinemia
Klinefelters mosaic Isolated FSH
Downs syndrome deficiency
Varicocele
Uremia
Irradiation damage
Adrenogenital
syndrome
Peritubular Fibrosis and Tubular
Hyalinisation
Germinal epithelium damaged by increased fibrous
tissues
May involve tunica propria only with increased
peritubular myoid cells or hyalinized material between
the basement membrane and myoid cells of T. propria
When changes > 10% of tubular fertility is reduced
With increasing fibrosis and hyalinization germinal
epithelium is progressively lost followed by atrophy of
sertoli cells
Tubules reduced in diameter
Leydig cells reduced in number
 Causes of peripubular fibrosis and
tubular hyalinization
Idiopathic Alcoholism
Klinefelters syndrome Diabetes mellitus
Adrenogenital syndrome Cystic fibrosis
XYY Spinal cord injury
Chronic orchitis Chemotherapy
Estrogen excess Androgen insensitivity in
Irradiation damage otherwise normal men
Post pubertal hypopituitarism Hyperprolactinemia
Post pubertal androgen excess
Testicular trauma
Decreased test. vas. supply
Myotonic muscular dystrophy
Varicocele
 QUANTITATION OR
ASSESSMENT OF TESTICULAR
BIOPSY
JOHNSONS SCORING SYSTEM
Score 1 to 10, each ST is examined & scored.
10- germinal epithelium is multilayered around a open central lumen
that count spermatozoa.
9-many spermatozoa but disorganised spermatogenesis
8- few spermatozoa seen
7-no spermatozoa but spermatids
6-few spermatids seen
5-no spermatozoa,spermatids but spermatocytes seen
4-few spermatocytes
3-only spermatogonia
2-No germ cells only sertoli cells
1-No cells inside tubule
Mean score calculated
N: 60% of ST- score of 10
:<10%- score of 8
Mean: 9.39+/- 0.24
1970- added leydig cell scored
LS 1- complete absence of leydig cells
LS6 - nodular/diffuse hyperplasia of leydig
cells
Heller: Germ Cell/Sertoli Cell Ratio
Counting at least 30 tubules cross section
Stained- identified all stages
Spermatogonia
Pr. Spermatocyte
Sec.spermatocyte and spermatids
SCR= total no of germ cells each type
total no of sertoli cell
 Normal
Spermatogonia-1.8
Spermatocytes- 2.0
Spermatids 5.2
OR: 12 Sertoli cell per tubular cross
section
 Makler
Inner diam of tubules Degree of ST maturation
5:150-250 micron 5: matured to
1:25-50 micron spermatozoa
0:obliterated tubule 0: sertoli cell only
Thickness of BM Intra tubular cell layers
5: 3 micron 5: >4 cell layers
1: 10-13 microns 0: no cells
0:hyalinized

TOTAL SCORE 0-20

 Sigg
Classified testicular atrophy
Diffuse
Focal : 5 CS tubule atrophy
Mixed
Scale 1-5
1 mild atrophy
2 moderate atrophy
3 marked atrophy
4 sertoli cell only syndrome
5 hyalinisation
 Role in carcinoma

Controversial
Used for staging for disease in
contralateral testis
 References
Steven G Silverberg, Ronald A Delellis, William J
Frable. Principles& Practice of Surgical
Pathology& Cytopathology.III rd Edition. Vol III,
2237-51.
PP Anthony, RNM Mac Sween. Recent
Advances in Histopathology 11, 135-147.
Juan rosai.Ackermans Text Book of Surgical
Pathology,Vol I, Ch18,1257-62.
Campell Urology VII th Edition Vol II.
Andersons Text Book of Pathology.
THERAPEUTIC ROLE