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Print Posted on 05/14/2018 in Fertility Treatment Options

Advanced Male Fertility Testing: if Previous Tests Fail, What Should You Expect?

Advanced Male Fertility Testing: if Previous Tests Fail, What Should You Expect?

Male infertility in most cases is caused by conditions affecting sperm production, sperm function, or both, or blockages that prevent the delivery of sperm. Causes of male infertility include congenital or acquired urogenital abnormalities, genetic and immunological factors, endocrine disturbances, genital tract infections and erectile dysfunction. These can be conveniently divided into pre–testicular, testicular and post–testicular causes. Male fertility testing in 80% shows what has caused male infertility and what should be done to treat it.

The diagnostic workup of male infertility includes a thorough medical and reproductive history, physical examination, and semen analysis, followed by imaging. The main role of imaging is the identification of the causes of infertility, such as congenital anomalies and disorders that obstruct sperm transport and may be correctable. Scrotal ultrasonography is the most common initially performed noninvasive examination used to image the male reproductive system, including the testes and extratesticular structures such as the epididymis. If these tests fail to identify the reason, you may undergo additional invasive and non–invasive tests.

And here, probably, in your mind all the thoughts became synchronized in a glimpse and the urgent questions ‘What…?’, ‘What if…?’, and ‘What should be done to change that’… are hustling in their flows. What other tests can be recommended by my doctor to undergo if the previous testing failed to identify the cause of my infertility? How are these tests performed? What should I expect? Wondering what to expect? Stop asking your mind, glance through this article. It was designed especially for men with the answers you should know. 

YES, and we are starting from the test number eleven, it is not the mistake.

(11) Color–Doppler Ultrasonography 

Your doctor may recommend you undergo scrotal and transrectal colour–Doppler ultrasonography (CDU), the latter before and after ejaculation. Color–Doppler ultrasound (CDUS) is used to assess the abnormalities of the male reproductive system which cause infertility, testicular malignancy, and male accessory gland infection.

Scrotal Color–Doppler ultrasound is very useful in assessing (1) scrotal organs and abnormalities when physical examination is unreliable; (2) signs of testicular dysgenesis, often related to sperm abnormalities and to a higher risk of cancer, and testicular lesions suggestive of malignancy; (3) scrotal pain, signs of inflammation and andrological emergencies (including testicular torsion); (4) varicocele; and (5) congenital absence of vas deferens (along with transrectal Color–Doppler ultrasound).

Transrectal Color–Doppler ultrasound is useful in detecting signs of (1) male genital tract obstruction, including ejaculatory duct abnormalities, prostate median cysts, or seminal vesicles (SV) enlargement/emptying impairment and (2) prostate and seminal vesicles (SV) inflammation.

Along with Color–Doppler ultrasound, your doctor may propose you to undergo more advanced imaging techniques, such as contrast–enhanced ultrasound, elastography, and magnetic resonance imaging (MRI).

(12) Dynamic Color–Doppler Ultrasound of the Penis

Penile ultrasound is performed when evaluating physical causes of erectile dysfunction. These include structural penile abnormalities, problems with arterial inflow and malfunction of the venous occlusive mechanism.

Greyscale ultrasound is initially performed to exclude structural abnormalities, including fibrotic plaque diseases, focal cavernosal fibrosis or calcification, and tunica albuginea disruption. Greyscale ultrasound is also used in the evaluation of the dilatation of the testicular veins.

Your doctor will give you an intracavernosal injection of prostaglandin to stimulate an erection. The transducer is placed on the ventral surface of the base of the penis, and the cavernosal artery is sampled with Doppler angle correction to allow for accurate velocity measurements.

(13) Testicular Mapping

After that Testicular Mapping takes place. Testicular mapping is a non–surgical technique developed to detect sperm in the testicles of men who have poor sperm production (non–obstructive azoospermia).

(14) Testicular Biopsy

Then the doctor may perform the Testicular Biopsy. If your semen analysis shows no sperm, a testicular biopsy can be done to evaluate whether there is sperm in the testicles. A testicular biopsy involves taking a small sample from the testicles under the local anesthesia. Testicular Biopsy helps to diagnose whether the lack of sperm is caused by a blockage or low sperm production.

(15) Elastography

As the scrotal ultrasonography is limited to the functional analysis of testicular tissue, the elastography is a more accurate technique for this. Elastography gives a visual representation of the tactile information conventionally obtained by physical palpation of the tissue. In fact, Elastography is an imaging technique that shows the images of tissue elasticity and stiffness, or, in other words, ‘offers’ a ‘Virtual Palpation’.

Currently, there are two main types of elastography in use. One is multi–frame real–time elastography, and the other one is strain elastography. Elastography is used especially for testes’ evaluation. Due to limited overlying tissue, the testes are ideally suited for assessment using multi–frame real–time shear wave elastography.

It is a good test that can be used in the assessment of male infertility with clinically detectable varicocele, and its results may predict semen parameter improvement after varicocelectomy.

(16) Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging (MRI) is another accurate noninvasive high–resolution imaging modality used in the pelvis to evaluate possible obstructive lesions involving the ductal system. MRI is more advanced method than transrectal ultrasound for examining patients with male infertility. Furthermore, it is an alternative to traditional invasive vasography.

MRI can depict the detailed anatomy and pathophysiologic features of the reproductive tract, including the prostate, seminal vesicles, and ejaculatory ducts. MRI is the modality of choice for imaging the accessory sex glands and their ducts and can help guide diagnostic or corrective interventional procedures.

(17) Computed Tomography (CT)

Computed tomography (CT) facilitates limited soft-tissue resolution and is used less frequently to evaluate infertility. Computed tomography is most useful for evaluating calcifications and stones along the reproductive tract that are causing obstruction. It should be done prior to invasive tests and prior to any kind of surgical intervention.

(18) Vasography

Vasography also termed as ‘seminal vesiculography’, involves cannulation of the vas deferens under anesthesia. Owing to the widespread acceptance of MRI, this invasive test is no longer commonly used to evaluate the male reproductive system. Currently, vasography may be performed to diagnose aplasia or occlusion of the ejaculatory ducts in males with azoospermia who are found to have normal spermatogenesis at testicular biopsy. This procedure involves risk for infection and strictures of the vas deferens at the injection site.

If vasography is performed, then the radiographic dye is injected into the testicles and an image of the testicles is done via X–Rays or via ultrasound. This image shows whether any blockages are present or not. This test is primarily aimed at determining whether the sperm-carrying tubes in the testicles – the vas deferens – are obstructed or there is no obstruction.

It is better to undergo not only Vasography but Vasography under the ultrasound guidance. Vasography cannot always represent the accurate images, and the ultrasound can do that. The contrast dye injected into the testicles travels through the vas deferens and shows up clearly on the ultrasound screen. If there is a blockage and the dye is unable to pass the whole way through, this will be clearly visible. If the blockage in the ejaculating duct is found, then your doctor may suggest you undergo the surgical correction.

(19) Venography 

A Venogram is an X–ray imaging of the veins. It uses contrast dye and an X–ray camera (fluoroscopy) to visualize the veins. Without the use of the contrast dye, the veins are invisible under fluoroscopy. The contrast dye is injected through a soft, flexible catheter that is guided from a vein in the groin and moved to the appropriate site by navigating through the vascular system.

Once the catheter is in the right position, a dye is injected into the veins. X–ray is then taken at the precise time the dye flows through the veins. Images of the veins are then generated to identify abnormal blood flow patterns. You may experience a warm sensation in the abdominal and pelvic region when the dye is injected.

During this test, you will be given the anesthetic medications through your IV, but you will be awake. The local anesthetic is usually given in the groin area where a needle will be inserted. The catheter is threaded through this needle. A warm feeling may be felt when the injected dye spreads through the veins. You will be asked not to move because the images that will be taken are clear. After that, the catheter is removed and the area where the catheter was removed is pressed firmly for about 20 minutes to prevent bleeding. The venogram usually takes about an hour.

There are three main risks which are closely associated with this test:

(1) Catheter–related risks;

(2) Allergic reaction to X–ray contrast dye;

(3) X–ray exposure.

This test shows whether you have a varicocele or not. The varicocele occurs when the network of veins that leave the testes (pampiniform plexus) become elongated and enlarged, and results in pain, testicular atrophy and infertility.

(20) Surgical intervention

If the tests show the abnormalities which can be treated only surgically, your doctor may propose you the surgery. Before signing the papers, find out if there are some other treatment options which you can try prior to surgery. Try those treatment options which are minimally invasive because the surgery not always is the best treatment option. But if the surgery is inevitable [if it is impossible to be healthy without surgery], ask your doctor all the information you want to know, schedule the necessary tests before the surgery and glance through the PROS, CONS, RISKS, and BENEFITS. Remember that you have the choice and you have a right to THINK about the surgery [if it is not an EMERGENCY] at least during two or three days. 

CONCLUSION: 

The diagnostic workup of male infertility may be the most embarrassing time for you. It includes a thorough medical and reproductive history, physical examination, and semen analysis, followed by imaging. The main role of imaging is the identification of the causes of infertility, such as congenital anomalies and disorders that obstruct sperm transport and may be correctable. Scrotal ultrasonography is the most common initially performed noninvasive examination used to image the male reproductive system, including the testes and extratesticular structures such as the epididymis. If these tests fail to identify the reason, you may undergo those additional invasive and non–invasive tests we have represented for you in this article. Remember that you have the right to CHOOSE, the right to DELAY, the right to CANCEL, and the right to THINK prior to putting your signature in the medical documents, and even if you have already signed those papers, you have the right to CHOOSE among the fertility tests those which are minimally invasive.

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