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RESEARCH ARTICLE |
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| Year : 2003 | Volume
: 19
| Issue : 2 | Page : 140-144 |
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Role of fine needle aspiration cytology (FNAC) of testes in male infertility
Abraham Kurien1, Kim Mammen1, Sunitha Jacob2
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
 Source of Support: None, Conflict of Interest: None  | Check |
 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 |
| Introduction | |  |
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 | | |
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 | | |
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 :
- 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.
- 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.
- 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.
- 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%).
- 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.
- 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 | | |
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 | | |
- The technique of testicular FNAC is simple, inexpensive and minimally traumatic. More than 1 specimen can be taken safely.
- Testicular FNAC gives an accuracy of 91.9% in the diagnosis of patients with male infertility.
- 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.
- FNAC obtained insufficient smears mainly in atrophied testes.
- The accuracy of diagnosing normal spermatogenic activity in obstructive azoospermia by FNAC was 100%.
- 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 | | |
| 1. | World Heath Organization. The epidemiology of infertility. WHO Tech. Rep. Ser. No 582 p5 1975.  |
| 2. | Cates W, Farley TMM, Rowe PJ. Worldwide patterns of infertility: Is Africa different' Lancet 1985: ii. 596. |
| 3. | Toren P, Oshima H. The male factor. New Engl J Med 1980; 303: 751. |
| 4. | Fisch H, Lipshultz Ll. Diagnosing male factors of infertility. Arch Pathol Lab Med 1992: 116: 398. |
| 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. |
| 6. | Huhner M. Aspirations of the testicle in the diagnosis and prognosis of sterility. J Urol 1928; 19(1): 31. |
| 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. |
| 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. |
| 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. |
| 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. |
| 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. [PUBMED] |
[Table - 1], [Table - 2]
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| Sahay, S.C. and Iyer, V.K. and Kumar, R. | | Indian Journal of Urology. 2012; 28(1): 43-46 | | [Pubmed] | |
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