FNAC and Azoospermic Males
FNAC in Evaluation of Azoospermic Males
FNAC has been used as a diagnostic modality for evaluation of male infertility. It is particularly helpful in differentiating obstructive azoospermia from spermatocytic arrest which is important since the treatment is entirely different.
In our analysis of 60 cases of azoospermic males subjected of FNAC, we concluded that FNAC is a simple, non-traumatic alternative to histology in assessment of male infertility.
Introduction
Absence of sperms in the ejaculate doesn’t allow conclusions as to the functional status of the seminiferous epithelium. Hence, further evaluation of testicular function in azoospermic individuals is a must because only examination of testicular architecture and cell population can discriminate between an endogenous or exogenous etiology of disturbed fertility. The difference is of paramount importance since the treatment is entirely different (hormonal vs surgical correction).
Fine needle aspiration cytology (FNAC) of the testis pioneered by Obrant and Person (1965) and Person et. al.,(1971) has long been used as a diagnostic modality for evaluation of male infertility not only for documentation but also for quantification of spermatogenesis in azoospermic individuals. Various studies have shown FNAC to be a very reliable and reproducible method for evaluating spermatogenic activity with excellent correlation between cytologic and histologic diagnosis.
Technique
For FNAC, the scrotal skin is thoroughly cleaned with spirit with the patient in a recumbent position. An inguinal block is given with 2-2.5 ml of Lignocaine hydrochloride injected around the spermatic cord. After waiting for around five minutes, aspiration is performed with the help of a 23 G hypodermic needle. The testis is gently held between the thumb and the index finger, a single pass with a to-and-fro motion of the needle once or twice is made under suction. The material obtained is spread into the clean glass slides taking care to properly spread out the threads when obtained. The smears are air-dried and stained with May-Grunwald Giemsa.
A single smear is prepared from each testicle and examined under the light microscope. The different cell types are classified using the identification criteria described by Schenk and Schill.
Spermatogenesis
Spermatogenesis is a hormonally regulated process where germ cells differentiate into mature spermatozoa by passing through several stages of meiosis. These intervening stages are of spermatogonia type A and B, primary spermatocytes which undergo meiosis to form two secondary spermatocytes, secondary spermatocytes undergo second meiotic division to form two spermatids, and spermatids finally transform into spermatozoa.
Observations
Depending upon the state of spermatogenesis in a particular patient, a variety of cell types-including Sertoli cells, spermatogonia, primary spermatocytes, secondary spermatocytes, spermatocytes (early and late) and spermatozoa are encountered in the smears. Based on various proportions of the different cell types, the smears are categorized into six groups.
1. Normal spermatogenesis – This pattern is described when the smears show spermatogonia, primary spermatogonia, spermatids, many spermatozoa and a proportional number of Sertoli cells forming roughly one third of the total spermatogenetic cells.
2. Hypospermatogenesis – This pattern is described when all cell types up to spermatozoa are present in the smears but the proportion of Sertoli cells to germ cells is increased.
3. Sertoli cell only – In this category, the smears reveal only Sertoli cells and a total absence of germ cells whatsoever.
4. Maturation arrest – Either early or late when there is an arrest at the stage of spermatogonia (spermatogonial arrest) or at the stage of spermatids (spermatidic arrest) with absence of spermatozoa.
5. Deficient spermatogenesis-maturation up to spermatozoal level is seen but number is too few.
6. Non-committal group.
Analysis of 60 Cases
In our analysis, 60 cases of azoospermic males were subjected to FNAC. Applying the above mentioned criteria, the breakdown of the morphologic patterns observed were:
normal pattern in 28.3%,
hypospermatogenesis in 3.3%
Sertoli cell only in 28.3%,
maturation arrest in 15%,
dual pattern in 11.6%,
non-committal in 12.6%.Out of the eight cases of hypogonadism, one showed maturation arrest, two showed Sertoli cells only, three only showed sparse numbers and one showed a combination of Sertoli cell only in one and maturation arrest in the other testis. One smear had inadequate material for diagnosis.
Discussion
Azoospermic individuals showing normal spermatogenesis can be presumed to have obstruction as the cause of infertility. In our series, 28.3% of the cases showed normal spermatogenesis and hence were cases of obstructive azoospermia. This group accounted for 5% of the cases in the series by Ali et. al., 10.6% by Carlo Forresta et. al., 22% by Papic et. al., and 33% by Batra W. et. al..
In cytology smears, a distinction between Sertoli cell only syndrome and diffuse severe atrophy without spermatogenesis may not be possible as both the conditions would show presence of Sertoli cells only. This group comprised of 28.3% of the cases in our series. These cases are among the severely affected and further investigation and treatment in them seems not worthwhile and patients may appreciate the prognostic information following such a diagnosis.
Thus, the cytologic spectrum encountered provides a definitive diagnosis of “Sertoli cell only” at one end and normal pattern with presumed duct obstruction at the other end. The patterns that lie between these two extremes, represent the group where more objective quantification would play a role.
Clinical Focus
In the assessment of male infertility, semen analysis and histological examination of testicular biopsy are the most accepted methods of evaluating testicular morphology and function.
FNAC as an alternative to histology, has the added advantage of being simple and non-traumatic and hence easily acceptable to the clinicians as well as the patients.
Conclusion
FNAC of the testis is a very simple, reproducible and cost-effective modality for evaluating azoospermic individuals.
It is specially helpful in differentiating obstructive azoospermia from spermatocytic arrest. This helps in correct choice of therapy and obviating the need for other costlier and traumatic investigations.
References
- Al-Jitawi SA, et. al., Diagnostic role of testicular FNAC in male infertility. Acta Cytol 1997 ; 41:1705-1708.
- Rajwanshi A, et. al., FNAC in azoospermic males. Diagn Cytopathol 1991;7:3-6.
- Batra VV, et. al., Correlation of cell counts and indices in testicular FNAC with histology in male infertility. Acta Cytol 1999;43(4);617-623.
- Saikia B and Gupta SK, Role of FNAC in evaluating azoospermic males. Bull PGI 2000;34:56-59.
Prof. S.K. Gupta ,
Head, Dept. of Cytology and Gynec Pathology,
PGIMER, Chandigarh.
