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RESEARCH ARTICLE
Year : 2003  |  Volume : 19  |  Issue : 2  |  Page : 140-144
 

Role of fine needle aspiration cytology (FNAC) of testes in male infertility


1 Department of Urology, Christian Medical College and Hospital, Ludhiana, India
2 Department of Pathology, Christian Medical College and Hospital, Ludhiana, India

Correspondence Address:
Kim Mammen
Department of Urology, Christian Medical College and Hospital, Ludhiana - 141 008
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Fine needle aspiration of the testis, which is minimally traumatic, has questioned the need of a more invasive open biopsy in the evaluation of male infertility. This study aims to evaluate the efficacy of fine needle aspiration cytology (FNAC) as compared to open testicular biopsy in the evalu­ation of male infertility by correlating diagnoses from tes­tis FNA cytology with biopsy histology. We have also studied the necessity of bilateral or unilateral FNACs in the workup of the infertile man. This study was a prospec­tive study of 57 infertile men in whom bilateral testicular fine needle aspiration as well as testicular biopsy was done. The correlation between the 2 methods was 91.9%. Dis­crepancies between cytology and histology were mainly the result of insufficient smears. These data also suggest that bilateral FNACs and biopsies can be restricted to patients in whom there is appreciable difference in tes­ticular size or consistency.


Keywords: Needle aspiration, testis, infertility, histology, cytology.


How to cite this article:
Kurien A, Mammen K, Jacob S. Role of fine needle aspiration cytology (FNAC) of testes in male infertility. Indian J Urol 2003;19:140-4

How to cite this URL:
Kurien A, Mammen K, Jacob S. Role of fine needle aspiration cytology (FNAC) of testes in male infertility. Indian J Urol [serial online] 2003 [cited 2018 Dec 10];19:140-4. Available from: http://www.indianjurol.com/text.asp?2003/19/2/140/37146



   Introduction Top


Male infertility is a common problem that can be dev­astating to a couple trying to conceive. The statistics of infertility shows that 15% of all marriages face in future the problems of infertility. The WHO has reported a core global prevalence of 5% infertility in the mid 70s, in a multi-centric epidemiological study on infertility in vari­ous countries including India. [1],[2] In approximately 30% of cases, significant abnormalities are found in the man alone, in another 20% of the cases abnormalities are found in both the man and the woman. Thus in roughly 50% of infertile couples, the male factor is at least partially re­sponsible for the failure to conceive. [3],[4]

Testicular biopsy can help us to differentiate a post-tes­ticular, obstructive etiology of male infertility from an in­trinsic testicular cause. [5] When post-testicular azoospermia or severe oligospermia is demonstrated, surgical correc­tion may be indicated.

Another alternative to open testicular biopsy is the fine needle aspiration cytology (FNAC) method for obtaining material for cytological evaluation of spermatogenesis and interstitial cells. Fine needle aspiration cytology (FNAC) of the testis is being increasingly used as a minimally in­vasive method of evaluating testicular function.

We have done this study to evaluate the efficacy of fine needle aspiration cytology (FNAC) as compared to open testicular biopsy in the evaluation of male infertility. We have also studied the necessity of bilateral or unilateral FNACs in the workup of the infertile man.


   Patients and Methods Top


The study was a prospective study of 57 infertile men evaluated at the department of urology, Christian Medical College and Hospital, Ludhiana, from October 1999 to April 2001, in whom 3 consecutive semen analyses showed oligospermia or azoospermia. All semen analysis was done only after a period of abstinence of at least 4 days. A clini­cal examination was then conducted and relevant personal and clinical data were noted. Patients were then subjected to a fine needle aspiration of the testes for cytological evalu­ation. A specimen for histopathological correlation was obtained by open testicular biopsy. The procedures of the fine needle aspiration of the testes were done in the surgi­cal outpatient department of the Christian Medical College and Hospital, Ludhiana. With the patient in the su­pine position the skin of the scrotum was prepared with 5% betadine solution. 5 ml of 1% xyldcaine was injected into the spermatic cord bilaterally. Aspiration was done with a 22-gauge needle attached to a 20 ml disposable syringe. The syringe was fixed on to a syringe holder. The needle was inserted into the middle ofthe anterior surface of the testes opposite the epididymis. The needle was in­troduced in different directions to ensure that different ar­eas were aspirated. Two such aspirates from each testis were taken. Air-dried and alcohol-fixed smears were pre­pared from the aspiration obtained and then subsequently stained with May-Grunwald-Giemsa (MGG) and haema­toxylin and eosin (H&E) stains respectively. If too much pressure is applied while preparing the smear it may lead to marked distortion and crushing artifacts. Open testicu­lar biopsy was performed immediately following the pro­cedure of FNAC of the testes. Bilateral 1 cm transverse incisions provided good exposure with minimal scrotal skin bleeding. A small specimen of the seminiferous tu­bules was excised.


   Results Top


A total of 57 patients were included in this study. Three men out of the total had unilateral testis. The mean age of the patients studied was 29.9 years with a range from 22 years to 56 years. The duration of infertility of the patients studied ranged from 1 year to 15 years with a mean dura­tion of 4.9 years. Almost all patients were primarily infer­tile except for 3 patients who were having secondary infertility. The average volume of all the 111 testes stud­ied was 16.3 cc. The testicular volume ranged from 8 cc to 22 cc. All the scrotums examined had retroverted epidi­dymis. 2 of the patients had bilaterally impalpable vas def­erens, which were later confirmed to be absent on subsequent surgical exploration. 12 patients were detected to have varicoceles. 37 patients were confirmed to be azoospermic after 3 semen analyses. The remaining was oligospermic with a mean semen density of 10.8 million per milliliter with a range from 2 to 20 million per milliliter.

A total of 111 fine needle aspiration cytology smears and biopsy specimens obtained from 57 infertile men were studied (3 men had unilateral testis). The following were the diagnosis on cytological examination :

  1. Normal Spermatogenesis - The most frequent diag­nosis on cytological evaluation was normal sperma­togenesis with 56 cases (50.5%). They were cellular smears, which consisted of the total spectrum of sper­matogenic cells admixed with  Sertoli cells More Details. The sper­matogenic cells showed transitional forms from spermatogonia to spermatozoa characterized by dimi­nution in nuclear size and condensation of chromatin.
  2. Hypospermatogenesis - The next common diagno­sis was hypospermatogenesis with 17 cases (15.3%). The smears had less than normal amount of sperma­tozoa admixed with the other cells.
  3. Early Maturation Arrest - The smears showed a high percentage of spermatogonia and primary spermatocytes along with absence of spermatids and spermatozoa. In our study there were 5 cases (4.5%) of early maturation arrest.
  4. Late Maturation Arrest - In these the smears were characterized by the total absence of spermatozoa and significant relative increase in proportions of round and elongated spermatids along with spermatocytes and Sertoli cells. Late maturation arrest was seen in 8 cases (7.2%).
  5. Sertoli Cell Only Syndrome The smears were cel­lular characterized by complete lack of germ cells and showed only Sertoli cells. In our study 4 cases (3.6%) showed Sertoli cell only syndrome.
  6. Testicular Atrophy - In our study there were 14 cases (12.6%) of testicular atrophy. The smears had scanty cellularity mainly consisting of few Sertoli cells.


In our study a good correlation was found in 102 (91.9%) testes between the cytological findings and the results of open biopsy. The correlation was similar in the right and the left testes with an accuracy of 92.6% and 91.2% re­spectively. In 7 cases (6.3%) the material was scanty and therefore insufficient for diagnosis. In 5 out of the 7 cases the corresponding histopathological diagnosis was testicu­lar atrophy. The other 2 were from testes in which histopa­thology showed normal spermatogenesis and early maturation arrest. These 2 were from patients who were studied in the beginning part of this study. Discordant find­ings were recorded in 2 cases (1.8%). In both these cases, significant late maturation arrest was recognized in sam­ples obtained by fine needle aspiration whereas hyposper­matogenesis was demonstrated by samples obtained by open surgical biopsy.

In evaluating the different patterns of diagnoses in azoospermic and oligospermic patients it was found that in a majority of the azoospermic patients, the diagnosis was normal spermatogenesis (42.5%) suggestive of an obstruc­tive pathology. The accuracy in which these patients were diagnosed by FNAC was 100%. The next common diagno­sis in azoospermic patients was testicular atrophy. This was closely followed by hypospermatogenesis and maturation arrest. In the oligospermic patients the most common pa­thology detected was hypospermatogenesis.

Of the 12 patients with varicoceles 6 (50%) of them proved to have normal spermatogenesis in both cytologi­cal and histopathological studies. The other 6 had abnor­malities in their testes that included hypospermatogenesis in 2 patients (16.7%) and late maturation arrest, testicular atrophy and sertoli cell only syndrome in I patient (8.4%) each. The last patient with varicocele had an atrophic left testis and normal spermatogenesis in the right testis.

Critical evaluation was made of the necessity of bilat­eral or unilateral testicular aspirates and biopsies in this study. The cytological and histopathological diagnoses of both left and right testes were reviewed. Fine needle aspi­rations of only 48 patients were reviewed as 3 patients had only a unilateral testis and in 6 patients the smears were inadequate. Concordant results were obtained in testicular cytology of 46 patients (95.8%). Discordant results were seen in only 2 patients. Of the 2 patients. 1 had a testis which cytology proved to have normal spermatogenesis while the contralateral testis showed hypospermatogenesis. The other patient had a cytology proven atrophic testis on 1 side while the other showed normal spermatogenesis. Of these 2 patients who had discordant findings I was found to have significant differences in the volume of the testes.

Of the biopsies reviewed in 54 patients (3 had unilateral testis), concordant results were obtained in testicular bi­opsies of 50 patients (92.6%). Of the 4 patients who had discordant results, 3 had a testis showing normal sperma­togenesis while the contralateral testis showed testicular atrophy. The remaining 1 patient had a testis showing nor­mal spermatogenesis while the contralateral testis showed hypospermatogenesis. Of these patients who had discord­ant biopsy results. 3 were found to have significant differ­ences in the volurne of the testis. The affected side was found to be smaller.


   Discussion Top


Posner and Huhner first used testicular puncture biop­sies in the investigation of human infertility that exam­ined unstained samples for spermatozoa.[6] Later fine needle aspiration of the testis pioneered by Obrant and Persson (1965) was proposed as a non-invasive technique. [7] Char­acterizing the cell types in cytological smears was straight­forward, with not much difficulty in recognizing germ cells and Sertoli cells. The material aspirated by FNAC is ad­equate and the various cell types can be identified by their distinctive morphology. Some authors have attempted to quantitatively analyze the population of germ cells. Ser­toli cells and spermatozoa in the cytological smear so as to reach a diagnosis.[8] In the 111 FNACs in our study the cytological patterns encountered showed that 50.4% had normal spermatogenesis while the remaining were show­ing impaired spermatogenesis.

The accuracy of fine needle aspiration cytology was determined by comparing the FNAC findings with that of the histological findings obtained from an open surgical biopsy, which was taken as the gold standard for the diagnosis. In our study there was good agreement between the cytological and histological diagnosis. An accuracy of 91.9% was achieved in our study. In 2 testicular aspirates diagnosed as hypospermatogenesis by histopathology, fine needle aspiration smears diagnosed them as late matura­tion arrest.

In 7 cases, in our study, the material aspirated was scanty and therefore insufficient for a diagnosis. The correspond­ing histopathological diagnoses were a majority of 5 cases with testicular atrophy, 1 case of early maturation arrest and 1 case of normal spermatogenesis. Thus it may be pointed out that insufficient aspiration was mostly because of the relatively acellular, fibrosed, atrophied testes.

In diagnosing a correctable posttesticular cause for in­fertility in those patients with azoospermia and cytology­proven normal spermatogenesis the accuracy of fine needle aspiration cytology compared to histopathology was 100%.

Many similar studies have been conducted correlating the efficacy of cytological diagnosis with histological di­agnosis. Most of these studies show a similar degree of good correlation. [9],[10],[11]


   Conclusions Top


  1. The technique of testicular FNAC is simple, inex­pensive and minimally traumatic. More than 1 speci­men can be taken safely.
  2. Testicular FNAC gives an accuracy of 91.9% in the diagnosis of patients with male infertility.
  3. The material aspirated by FNAC is adequate and the various cell types can be identified by their distinc­tive morphology. This study proves that FNAC can evaluate accurately all classically defined histologic types.
  4. FNAC obtained insufficient smears mainly in atro­phied testes.
  5. The accuracy of diagnosing normal spermatogenic activity in obstructive azoospermia by FNAC was 100%.
  6. For evaluating the spermatogenic activity in male in­fertility it appears that a unilateral FNAC or biopsy is sufficient for diagnosis. Bilateral FNACs and bi­opsies can be restricted to patients in whom there is appreciable difference in testicular size or consist­ency.


 
   References Top

1.World Heath Organization. The epidemiology of infertility. WHO Tech. Rep. Ser. No 582 p5 1975.  Back to cited text no. 1    
2.Cates W, Farley TMM, Rowe PJ. Worldwide patterns of infertility: Is Africa different' Lancet 1985: ii. 596.  Back to cited text no. 2    
3.Toren P, Oshima H. The male factor. New Engl J Med 1980; 303: 751.  Back to cited text no. 3    
4.Fisch H, Lipshultz Ll. Diagnosing male factors of infertility. Arch Pathol Lab Med 1992: 116: 398.  Back to cited text no. 4    
5.Buch JP, Johansson SL. Testis biopsy in male infertility : Current status. In Lytton B (ed): Advances in Urology, Vol 5. St Louis: Mosby Year Book Inc, 1992; 209.  Back to cited text no. 5    
6.Huhner M. Aspirations of the testicle in the diagnosis and progno­sis of sterility. J Urol 1928; 19(1): 31.  Back to cited text no. 6    
7.Persson PS, Ahren C, Obrant KO. Aspiration biopsy smear of testis in azoospermia: cytology versus histological examination. Scand J Urol Nephrol 1971; 5: 22.  Back to cited text no. 7    
8.Foresta C, Varotto A, Scandellari C. Assessment of testicular cytol­ogy by fine needle aspiration as a diagnostic parameter in the evalu­ation of the azoospermic subject. Ferti Steril 1992; 57: 858.  Back to cited text no. 8    
9.Odabas 0, Ugras S, Aydin S, et al. Assessment of testicular cytol­ogy by fine needle aspiration and the imprint technique : are they reliable diagnostic modalities? Br J Urol 1997; 79: 445.  Back to cited text no. 9    
10.Yadav SP, Gopal M, Chadha I, et al. Comparative evaluation of the needle aspiration cytology and biopsy of testis in diagnosis of male infertility. Journal of Indian Medical Association 1997; 95(5): 129­-34.  Back to cited text no. 10    
11.Gottschalk-Sabag S, Glick T, Weiss DB. Fine needle aspiration of the testis and correlation with testicular open biopsy. Acta Cytol 1993;37:67.  Back to cited text no. 11  [PUBMED]  



 
 
    Tables

  [Table - 1], [Table - 2]

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2 Discordant clinical and histological findings predict failure of reconstruction in suspected obstructive azoospermia
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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    Conclusions
    References
    Article Tables

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