guwahati tesa dr anand shinde

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Dr. Anand K Shinde MD (Gyn) Director Andrology @ ‘IVF-Pune’ Deenanath Mangeshkar Hospital Pune President Elect POGS (PUNE OBGYN SOCIETY ) Founder Member Indian Menopause Society Member Safe Motherhood Committe FOGSI Consultant & P.G. Teacher Dept OBGYN D.M.H

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Page 1: Guwahati tesa dr anand shinde

Dr. Anand K ShindeMD (Gyn)

• Director Andrology @ ‘IVF-Pune’

Deenanath Mangeshkar Hospital Pune

• President Elect POGS (PUNE OBGYN SOCIETY )

• Founder Member Indian Menopause Society

• Member Safe Motherhood Committe FOGSI

• Consultant & P.G. Teacher Dept OBGYN D.M.H

Page 2: Guwahati tesa dr anand shinde

Welcome to S I G A

SIGA - ANDROMEDAGreetings for 2010 !

Dr. Anand K ShindeMD (Gyn)

Director Andrology

‘IVF-Pune’

Deenanath Mangeshkar Hospital

Pune - 411 004

Cell - 09822012166, Tel. 020-40151777

Page 3: Guwahati tesa dr anand shinde

Waist to Hip Ratio

Page 4: Guwahati tesa dr anand shinde

The Soil, the Tree & the seeds !

Page 5: Guwahati tesa dr anand shinde

Diagnostic TESA

What Do We Diagnose ?

1. Presence of Sperm in Testis

2. Histopathological picture to explain the

Azoospermia

3. Carcinoma In Situ (C.I.S.)

Dr. Anand K Shinde

Page 6: Guwahati tesa dr anand shinde

TESA

TESA as a method to retrieve sperms in Azoospermia

( For ICSI = Yes ! ) but...TESA as a method of

Testicular Biopsy ?

Yes it is possible to get Testicular Biopsy by TESA ! (Diagnostic use ? )

Dr. Anand K Shinde

Page 7: Guwahati tesa dr anand shinde

HPE Seminiferous Tubule (N)

Dr. Anand K Shinde

Page 8: Guwahati tesa dr anand shinde

HPE Spermatogenic arrest

Dr. Anand K Shinde

Page 9: Guwahati tesa dr anand shinde

Mixed Phenotypes

SCO + Normal Heterogenous Tubules High chance of success at TESE ShowingTesticularDamage

Page 10: Guwahati tesa dr anand shinde

Sertoli Cell Only Syndrome

SCOS as in Idiopathic infertility, Y Microdeletions, Orchitis, Chemo/ Radiotherapy, Embryonal failure of Germ Cell migration to the Gonadal

Ridge….TESE -25% successful..due to mixed variants…

Page 11: Guwahati tesa dr anand shinde

Klinefelter’s Syndrome can have Sperms !

(E) The typical appearance of a biopsy from a man with Klinefelter’s syndrome is shown composed of seminiferous tubule hyalinization (arrows), aggregations of LC and occasional tubules with Sertoli cells only. This pattern is not diagnostic of Klinefelter’s syndrome and can result from a range of pathological processes (×10). (F) A biopsy from a man with Klinefelter’s syndrome illustrating a tubule showing full spermatogenesis surrounded by aggregations of LC (×25). All tissues are fixed in GR fixative, except F, which is fixed in Cleland’s fixative, and all are haematoxylin–eosin (HE) stained. R.I.McLachlan et al.

Page 12: Guwahati tesa dr anand shinde

CIS

Page 13: Guwahati tesa dr anand shinde

Positive Negative

Positive Semen

PositiveCIS Tubule

Immunocytological semen analysis for CIS

Page 14: Guwahati tesa dr anand shinde

Indications of Tesicular Biopsy(in general are as follows…)

1. Detection of severity & type of

Spermatogenic falilure

A. Prognostic factor for subsequent ICSI

B. Phenotyping in clinical research.

Dr. Anand K Shinde

Page 15: Guwahati tesa dr anand shinde

Indications of Tesicular Biopsy(in general are as follows…)

2. Differentiating Obstructive Azoospermia (OA) from

Non-obstructive Azzospermia (NOA)

A. Equivocal Endocrine (FSH, inhibin B)

B. Equivocal Clinial findings (Testicular Vol.)

C. Prior to reconstructive surgery for OA

Dr. Anand K Shinde

Page 16: Guwahati tesa dr anand shinde

Indications of Tesicular Biopsy(in general are as follows…)

3. Evaluation for Testicular Neoplasia / CIS

A. At Pubertal / Adult Orchiopexy

B. For at Risk Population

- NOA

- H/O Cryptorchidism

- Scrotal USG - Microlithiasis

- In Ca Testis case for other sideDr. Anand K Shinde

Page 17: Guwahati tesa dr anand shinde

Indications of Tesicular Biopsy(in general are as follows…)

4. Failure of prolonged Gonadotrophin therapy in Hypogonadotrophic Hypogonadism

If Testicular Biopsy for diagnosis

(and subsequent Rx) is so important…..

Is TESA the best way to do it ?

Let us see …..

Dr. Anand K Shinde

Page 18: Guwahati tesa dr anand shinde

TESA Efficacy & Ease

100%

Let us see !

100%

Let us see !

OA

NOA

TESE : Sperms RecoveryTESA : Sperms Recovery

Dr. Anand K Shinde

Page 19: Guwahati tesa dr anand shinde

TESA Efficacy

NS39.5% (30)40.8%(31)38 (76)Aridogan et al(2003)

<0.001 †24.1% (21)62.1% (54)87 (167)Hauser (2006)

NS30% (8)33% (9)27Qublan et al (2002)

…7.1% (1)64.3% (9)14Tournaye (1999)

.02‡11% (4)43% (16)37Freodler et al (1997)

<.0001†14% (5)63% (22)35Ezeh et al (1998)

…60% (6)70% (7)10 (16)19 gauge*

…16.7% (2)50% (6)12 (17)21 gauge*

Rosenlund et al(1998)

PSperm Recovery by

TESA

Sperm Recovery by

TESE

No of Men

Study

Page 20: Guwahati tesa dr anand shinde

Efficacy of TESAHow much tissue is obtained ?

How many sperms are recovered ?

<.001† 0.6 ± 1.14.4 ± 5.4No. of frozen straws per subject

<.001†0.3 ± 0.80.9 ± 1.1No. of locations with motile sperm cells per testis

<.001†0.7 ± 1.01.3 ± 1.3No. of locations with spermatogenesis per testis

<.001†0.5 ± 0.51.1 ± 1.1Quantity of sperm cells (Scale of 1-3)*

PTESATESEParameters Compared

RON HAUSER, et al (2006) J of Andrology Vol. 27 No. 1 2006

Page 21: Guwahati tesa dr anand shinde

Efficacy of TESA

Do we get sufficient material for

Histopath Exam by TESA ?

Yes, if multifocal TESA is

performed, on both testes.

Dr. Anand K Shinde

Page 22: Guwahati tesa dr anand shinde

How can CIS be picked up by blind TESA ?

Testicular Biopsy is important in the evaluation of men at risk of CIS or Testicular cancer.

TESA is not the ideal way.

Open procedures with magnification to look for micronodules are better suited

Towards a non –invasive method for early detection

C.E. Hoei-Hansen, N.E.Skakkebaek ,

Human Reproduction Vol 22 No.1 (2007)

Page 23: Guwahati tesa dr anand shinde

Dr. Anand K Shinde

Page 24: Guwahati tesa dr anand shinde

Can Needle biopsy give Histology Specimen ?

Open Versus Percutaneous

Dr. Anand K Shinde

Page 25: Guwahati tesa dr anand shinde

TESA DROPLET UNDER INVERTED MICROSCOPE

Page 26: Guwahati tesa dr anand shinde

Open biopsy

Needle biopsy

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If in azoospermic man percutaneous TESA, HPE shows Sertoli Cell only (SCO) pattern & if Clinical exam & / or USG Scrotum shows micronodule, you must go for open TESE

2Maligmant neoplasm

2In - situ carcinoma

4Leydig cell hyperplasia

3Leydig cell tumour

09Nodule removed

110Ultrasound nodule

5938Patients

No Sertoli cell-only syndrome (Group B)

Sertoli cell-only syndrome (Group A)

97 Azoospermic biopsies

M.Mancini et al , Human Reproudction Vol.22 (2007)

Page 28: Guwahati tesa dr anand shinde

Take Home messages

1) Diagnostic TESA is important as it gives

Sperms for freezing, tissue for

Histopathology which helps in

Prognostication for ICSI

Dr. Anand K Shinde

Page 29: Guwahati tesa dr anand shinde

Take Home messages

1) In Azoospermic men think of CIS testis & do

not forget Clinical exam for nodules &

ultrasound for testicular microlithiasis

(Prevalence 1:250).

Addition of Immunohistochemistry helps the

pickup rate

Dr. Anand K Shinde

Page 30: Guwahati tesa dr anand shinde

M.Mancini et al , Human Reproudction Vol.22 (2007)

Page 31: Guwahati tesa dr anand shinde

Take Home messages

Percutaneous TESA needs to be multifocal &

bilateral before you resort to TESE.

Andrologists prefer GA while Uro-Surgeons

may manage with Local Anaesthesia !.

Page 32: Guwahati tesa dr anand shinde

Take Home messages

Lower FSH (< 10 mIu / ml)

Larger Testis Vol ( > 10 ml)

means TESA will be

satisfactory

otherwise TESE is better.

Page 33: Guwahati tesa dr anand shinde

Take Home messages

TESA may be less disruptive for testis

- Hematoma,

- infarcts,

- raised LH, FSH &

- lowered Testosterone

than open Biopsies.

Page 34: Guwahati tesa dr anand shinde

Stem cells research !!!

Page 35: Guwahati tesa dr anand shinde

Dr. Anand K. ShindeM.D (Gyn)• IVF - Consultant at IVF Pune,

DMH Pune - 4 • Director Andrology IVF Pune,

Deenanath Mangeshkar Hospital

Pune - 411 004

Thank you !

Page 36: Guwahati tesa dr anand shinde

A.I.C.O.G.- 2010GUWAHATI

Dr. Anand K. ShindeM.D (Gyn)M.D (Gyn)