ANDROLOGY
ISSN: 2047-2919
ORIGINAL ARTICLE
Correspondence: Sandro Francavilla, Department of Life, Health and Environment Sciences, Andrology Unit, University of L’Aquila, Via Vetoio, 67100 L’Aquila, Italy. E-mail:
[email protected]
Keywords: azoospermia, epididymis, infertility, ultrasonography Received: 23-May-2012 Revised: 18-Jul-2012 Accepted: 2-Aug-2012 doi: 10.1111/j.2047-2927.2012.00010.x
Ultrasonographic determination of caput epididymis diameter is strongly predictive of obstruction in the genital tract in azoospermic men with normal serum FSH A. Pezzella,* A. Barbonetti,* A. Micillo,* S. D’Andrea,* S. Necozione,† L. Gandini,‡ A. Lenzi,‡ F. Francavilla* and S. Francavilla* *Andrology Unit, † and Epidemiology Unit, Department of Life, Health and Environment Sciences, University of L’Aquila, L’Aquila, and ‡Department of Experimental Medicine, University of “La Sapienza”, Rome, Italy
SUMMARY The relationship between epididymis ultrasonography (US) and infertility is poorly defined probably owing to lack of objective and reproducible criteria of US evaluation. Here, we evaluated US size of testes, caput and of corpus epididymis in infertile men: 165 with total sperm count 39 9 106, 187 with total sperm count 0.5). A patient with FSH < 7.8 IU/mL had a 63.6% chance (CI 40.1– 83.2%) of being affected by obstructive azoospermia. US Caput-M 10.85 mm, which represented the cut-off value with the highest combination of sensitivity (58.8%, CI 32.9–81.6%) and specificity (91.4%, CI 81.0–97.1%) applied in cases with FSH < 7.8 IU/mL increased the probability for obstructive azoospermia from 63.6% up to 92.3% (CI 76.5–98.8%). US evaluation of the caput epididymis diameter helped in predicting the obstructive origin of azoospermia when FSH was not increased, whereas it was not relevant in non-azoospermic men.
INTRODUCTION Scrotal ultrasonography (US) represents a non-invasive diagnostic procedure extensively proposed in the evaluation of infertile men (Behre et al., 1995; Oyen, 2002; Dogra et al., 2003; Moon et al., 2006; Du et al., 2010). In particular, ultrasonographic measure of testicular volumes is a reproducible correlate of spermatogenic function and is positively correlated with ejaculated sperm number, and negatively correlated with serum level of FSH (Lenz et al., 1993, 1994; Sakamoto et al., 2008). Reduced testicular volume is therefore a useful predictor of deranged spermatogenesis, and prospective variation in testicular volume represents a valuable indicator for spermatogenesis improvement during pharmacological treatment of hypogonadotropic hypogonadism (Kliesch et al., 1994). On the contrary, in spite of © 2012 American Society of Andrology and European Academy of Andrology
the physiological contribution of the epididymis in human spermatozoa maturation (Hinrichsen & Blaquier, 1980; Moore et al., 1983; Dacheux et al., 1987; Yeung et al., 1993), the relevance of epididymis in infertility (de Kretser et al., 1998; Pelliccione et al., 2004, 2009, 2011) and the role of epididymis US in the work-up of male infertility still remains elusive. Descriptive changes in both caput and corpus epididymis were reported in cases of obstructive azoospermia (Moon et al., 2006; Du et al., 2010). An enlarged diameter of caput and of corpus epididymis would occur in 14% of undefined andrological patients, after considering a normal caput epididymis diameter as being under 10 mm and a normal corpus being under 3 mm (Behre et al., 1995). A caput epididymis diameter ranging between 10 and 12 mm was considered normal along with a corpus of 2–5 mm (Rifkin Andrology, 2013, 1, 133–138
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ANDROLOGY
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et al., 1984; Oyen, 2002; Dogra et al., 2003), although no information was provided regarding the source of data. More recently, a comparative analysis of 112 undefined infertile men and a reference group with undefined fertility status failed to show differences in the mean value of diameter of caput and of corpus epididymis (Puttemans et al., 2006). Taken together such data suggest that the relevance of epididymis US in the evaluation of infertile men needs to be determined by introducing objective and reproducible criteria of ultrasound evaluation coupled with well-defined patient selection criteria. Here, we evaluated US size of the caput and of the corpus epididymis in azoospermic and in non-azoospermic infertile men. Epididymis diameters were compared with US testicular volume, serum level of FSH and semen parameters to define the clinical value of epididymis ultrasonography in subfertile men.
Figure 1 (a) Longitudinal ultrasonographic image of caput epididymis appearing as a pyramidal structure above the upper pole of the testis. The maximal diameter is measured from the top to the base of the pyramid (dotted line). (b) The maximal antero-posterior diameter of the corpus is measured at its middle portion on a longitudinal scan (dotted line). (c) Longitudinal image of caput epididymis containing two microcysts (arrow).
(a)
MATERIALS AND METHODS Four hundred and twenty-seven men (aged 36 ± 5 years) who had sought medical care because of couple infertility of least 18 months were included in a retrospective study, which evaluated semen parameters, hormones levels and scrotal US. Patients with scrotal pain and/or scrotal enlargement indicative for orchiepididymitis were excluded from the study. The local institutional human research committee approved the study. FSH blood levels and total testosterone were measured by a chemiluminescent microparticle immunoassay (ARCHITECT System; Abbott, Longford, Ireland); according to the manufacturer, the analytical sensitivity was
