Azospermisi olan İnfertil Erkeğe Yaklaşım

Yıl 2022, Cilt: 24 Sayı: Special Issue, 36 - 43, 30.10.2022

Mesut Tek Erdem Akbay

https://doi.org/10.18678/dtfd.1192672

Öz

Azospermi ejakülat incelemesinde sperm bulunmaması hali olarak tanımlanmaktadır. Azospermi testiste spermatozoa üretiminin olmamasından ya da üretilen spermatozoaların emisyon ile dışarı atılan ejakülata ulaşamamalarından kaynaklanabilir. Azospermi genel olarak obstrüktif ve non-obstrüktif olmak üzere iki grupta değerlendirilmektedir. Pretestiküler nedenler genellikle spermatogenezi etkileyen endokrin bozuklukları içerir, testiküler nedenler primer testis patolojilerini içerir ve posttestiküler nedenler ise obstrüktif patolojileri içerir. Doğru ve kesin bir tanıya ulaşabilmek için, iyi bir ürolojik, hormonal ve genetik değerlendirme yapılmalıdır. Azospermik olgularda tedavi stratejisini altta yatan etiyolojik neden belirler. Eğer ejakülatta sperm görülmesi mümkün ise bu spermlerle, ya da ejakülatta sperm görülmeyen olgularda girişimsel sperm elde etme teknikleri ile elde edilen spermlerle, yardımcı üreme teknikleri kullanılarak gebelik elde edilmesi amaçlanmaktadır. Azospermi etiyolojisi iyi anlaşılıp, tedavi yöntemleri geliştikçe, hem ejakülatta sperm görülme oranları hem de girişimsel metotlarla sperm elde edilme oranları artacak, bu sayede gebelik elde edebilme olasılığının da daha yüksek olacağı düşünülmektedir. İnsan üzerinde başlayan gen terapilerinde ve mezenkimal kök hücre çalışmalarında önemli gelişmeler kaydedilmesi nedeniyle yakın gelecekte azospermi tedavisinde de önemli gelişmelerin olabileceği düşünülmektedir.

Anahtar Kelimeler

Azospermi, infertilite, tanı, tedavi

Management of the Infertile Male with Azoospermia

Öz

Azoospermia means the complete absence of spermatozoa upon examination of the semen. Azoospermia may result from a lack of spermatozoa production in the testicles, or from an inability of produced spermatozoa to reach the emitted semen. Azoospermia is generally examined in two groups as obstructive and non-obstructive. Pretesticular causes usually include endocrine disorders that affect spermatogenesis, testicular causes include primary testicular pathologies, and posttesticular causes include obstructive pathologies. In order to make the exact diagnosis, a good urological, hormonal and genetic evaluation is required. The underlying etiologic cause determines the treatment strategy in azoospermic cases. If it is possible to see sperm in the ejaculate, pregnancy is tried to be achieved with ejaculate sperm, if not, with the spermatozoa obtained by interventional methods, by using assisted reproductive techniques. As the etiology of azoospermia is understood and treatment methods are improved, it is thought the rate of obtaining sperm both in the ejaculate and with interventional methods will increase, and as a result, higher pregnancy rates should be achieved. It is thought that there will be important developments in the treatment of azoospermia in the near future, as there have been significant advances in gene therapies and mesenchymal stem cell studies started on humans.

Anahtar Kelimeler

Azoospermia, infertility, diagnosis, treatment

Kaynakça

• Jarow JP, Espeland MA, Lipshultz LI. Evaluation of the azoospermic patient. J Urol. 1989;142(1):62-5.
• Honig SC, Lipshults LI, Jarow J. Significant medical pathology uncovered by a comprehensive male infertility evaluation. Fertil Steril. 1994;62(5):1028-34.
• Schoor RA, Elhanbly S, Niederberger CS, Ross LS. The role of testicular biopsyin the modern management of male infertility. J Urol. 2002;167(1):197-200.
• Ron-El R, Strassburger D, Friedler S, Komarowski D, Bern O, Soffer Y, et al. Extended sperm preparation: an alternative to testicular sperm extraction in non-obstructive azoospermia. Hum Reprod. 1997;12(6):1222-6.
• Chillón M, Casals T, Mercier B, Bassas L, Lissens W, Silber S, et al. Mutations in the cystic fibrosis gene in patients with congenital absence of the vas deferens. New Engl J Med. 1995;332(22):1475-80.
• Pierik FH, Vreeburg JT, Stijnen T, De Jong FH, Weber RF. Serum inhibin B as a marker of spermatogenesis. J Clin Endocrinol Metab. 1998;83(9):3110-4.
• Bergmann M, Behre HM, Nieschlag E. Serum FSH and testicular morphology in male infertility. Clin Endocrinol (Oxf). 1994;40(1):133-6.
• Chen CS, Chu SH, Lai YM, Wang ML, Chan PR. Reconsideration of testicular biopsy and follicle-stimulating hormone measurement in the era of inracytoplasmic sperm injection for non-obstructive azoospermia. Hum Reprod. 1996;11(10):2176-9.
• Aydos K. Erkek infertilitesi. In: Anafarta K, Arıkan N, Bedük Y, editors. Temel üroloji. 4th ed. Ankara: Güneş Tıp Kitabevleri; 2011. p.1037-90. Turkish.
• Thakker S, Persily J, Najari B. Kalmann syndrome and central non-obstructive azospermia. Best Pract Res Clin Endocrinol Metab. 2020;34(6):101475.
• McLachlan RI, O'Donnell L, Meachem SJ, Stanton PG, de K, Pratis K, et al. Hormonal regulation of spermatogenesis in primates and man: insights for development of the male hormonal contraceptive. J Androl. 2002;23(2):149-62.
• Eggert-Kruse W, Schwalbach B, Gerhard I, Tilgen W, Runnebaum B. Influence of serum prolactin on semen characteristics and sperm function. Int J Fertil. 1991;36(4):243-51.
• Casella R, Maduro MR, Misfud A, Lipshultz LI, Yong EL, Lamb DJ. Androgen receptor gene polyglutamine length is associated with testicular histology in infertile patients. J Urol. 2003;169(1):224-7.
• Chehrazi M, Rahimiforoushani A, Sabbaghian M, Nourijelyani K, Sadighi Gilani MA, Hoseini M, et al. Sperm retrieval in patients with Klinefelter syndrome: a skewed regression model analysis. Int J Fertil Steril. 2017;11(2):117-22.
• Weedin JW, Khera M, Lipshultz LI. Varicocele repair in patients with non-obstructive azoospermia: a meta-analysis. J. Urol. 2010;183(6):2309-15.
• Flannigan R, Bach PV, Schlegel PN. Microdisection testicular sperm extraction. Transl Androl Urol. 2017;6)4):745-52.
• Cocuzza M, Pagani R, Lopes RI, Athayde KS, Lucon AM, Srougi M, et al. Use of subinguinal incision for microsurgical testicular biopsy during varicocelectomy in men with nonobstructive azoospermia. Fertil Steril. 2009:91(3):925-8.
• Lee JS, Park HJ, Seo JT. What is the indication of varicocelectomy in men with nonobstructive azoospermia? Urology. 2007 69(2):352-5.
• Mathers MJ, Sperlin H, Rubben H, Roth S. The undescended testis: diagnosis, treatment and long-term consequences. Dtsch Arztebl Int. 2009;106(33):527-32.
• Zitzmann M, Aksglaede L, Corona G, Isidori AM, Juul A, T'Sjoen G, et al. European academy of andrology guidelines on Klinefelter Syndrome Endorsing Organization: European Society of Endocrinology. Andrology. 2021;9(1):145-67.
• Grasso M, Bounaguidi A, Lania C, Bergamaschi F, Castelli M, Rigatti P. Postpubertal cryptoorchidism: review and evaluation of the fertility. Eur Urol. 1991;20(2):126-8.
• Arap MA, Vicentini FC, Cocuzza M, Hallak J, Athayde K, Lucon AM, et al. Late hormonal levels, semen parameters, and presence of antisperm antibodies in patients treated for testicular torsion. J Androl. 2007:28(4):528-32.
• Cırakoğlu A, Benli E. Azospermik hastanın değerlendirilmesi. In: Gül Ü, Turunç T, editors. Erkek cinsel sağlığı ve fertilitesi. İstnabul: Galenos Yayınevi; 2021. p.139-52. Turkish.
• Neto FT, Bach PV, Najari BB, Li PS, Goldstein M. Spermatogenesis in humans and its affecting factors. Semin Cell Dev Biol. 2016;59:10-26.
• Weber-Schoendorfer C, Chambers C, Wacker E, Beghin D, Bernard N, Network of French Pharmacovigilance Centers, et al. Pregnancy outcome after methotrexate treatment for rheumatic disease prior to or during early pregnancy: a prospective multicenter cohort study. Arthritis Rheumato. 2014;66(5):1101-10.
• Bonomi M, Libri DV, Guizzardi F, Guarducci E, Maiolo E, Pignatti E, et al. New understandings of the genetic basis of isolated idiopathic central hypogonadism. Asian J Androl. 2012;14(1):49-56.
• Los E, Ford GA. Klinefelter syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021.
• Wong EC, Ferguson KA, Chow V, Ma S. Sperm aneuploidy and meiotic sex chromosome configurations in an infertile men XYY male. Hum Reprod. 2008;23(2):374-8.
• Dénes FT, Cocuzza MA, Schneider-Monteiro ED, Silva FA, Costa EM, Mendonca BB, et al. The laparoscopic management of intersex patients: the preferred approach. BJU Int. 2005;95(6):863-7.
• Hopps CV, Mielnik A, Goldstein M, Palermo GD, Rosenwaks Z, Schlegel PN. Detection of sperm in men with Y chromosome microdeletions of the AZFa, AZFb and AZFc regions. Hum Reprod. 2003;18(8):1660-5.
• Le Bot N. miRNAs and cell-cycle control in ESCs. Nat Cell Biol. 2012;14(7):658.
• Barceló M, Mata A, Bassas L, Larriba S. Exosomal microRNAs in seminal plasma are markers of the origin of azoospermia and can predict the presence of sperm in testicular tissue. Hum Reprod. 2018;33(6):1087-98.
• Yao C, Yuan Q, Niu M, Fu H, Zhou F, Zhang W, et al. Distinct expression profiles and novel targets of microRNAs in human spermatogonia, pachytene spermatocytes, and round spermatids between OA patients and NOA patients. Mol Ther Nucleic Acids. 2017;9:182-94.
• Hussein A, Ozgok Y, Ross L, Rao P, Niederberger C. Optimization of spermatogenesis-regulating hormones in patients with non-obstructive azoospermia and its impact on sperm retrieval: a multicentre study. BJU Int. 2013;111(3 Pt B):E110-4.
• Reifsnyder JE, Ramasamy R, Husseini J, Schlegel PN. Role of optimizing testosterone before microdissection testicular sperm extraction in men with nonobstructive azoospermia. J Urol. 2012;188(2):532-6.
• Mangum CL, Patel DP, Jafek AR, Samuel R, Jenkins TG, Aston KI, et al. Towards a better testicular sperm extraction: novel sperm sorting technologies for non-motile sperm extracted by microdissection TESE. Transl Androl Urol. 2020;9(Suppl 2):S206-14.
• Li H, Chen LP, Yang J, Li MC, Chen RB, Lan RZ, et al. Predictive value of FSH, testicular volume, and histopathological findings for the sperm retrieval rate of microdissection TESE in nonobstructive azoospermia: a meta-analysis. Asian J Androl. 2018;20(1):30-6.
• Ramasamy R, Trivedi NN, Reifsnyder JE, Palermo GD, Rosenwaks Z, Schlegel PN. Age does not adversely affect sperm retrieval in men undergoing microdissection testicular sperm extraction. Fertil Steril. 2014;101(3):653-5.
• Berookhim BM, Palermo GD, Zaninovic N, Rosenwaks Z, Schlegel PN. Microdissection testicular sperm extraction in men with Sertoli cell-only testicular histology. Fertil Steril. 2014;102(5):1282-6.
• Schlegel PN, Berkeley AS, Goldstein M, Cohen J, Alikani M, Adler A, et al. Epididymal micropuncture with in vitro fertilization and oocyte micromanipulation for the treatment of unreconstructable obstructive azoospermia. Fertil Steril. 1994;61(5):895-901.
• Ferlin A, Raicu F, Gatta V, Zuccarello D, Palka G, Foresta C. Male infertility: role of genetic background. Reprod Biomed Online. 2007;14(6):734-45.
• Claustres M. Molecular pathology of the CFTR locus in male infertility. Reprod Biomed Online. 2005;10(1):14-41.
• McCallum T, Milunsky J, Munarriz R, Carson R, Sadeghi-Nejad H, Oates R. Unilateral renal agenesis associated with congenital bilateral absence of the vas deferens: phenotypic findings and genetic considerations. Hum Reprod. 2001;16(2):282-8.
• Baker K, Sabanegh E Jr. Obstructive azoospermia: reconstructive techniques and results. Clinics (Sao Paulo). 2013;68 Suppl 1(Suppl 1):61-73.
• Schwarzer JU. Vasectomy reversal using a microsurgical three-layer technique: one surgeon's experience over 18 years with 1300 patients. Int J Androl. 2012;35(5):706-13.
• Jow WW, Steckel J, Schlegel PN, Magid MS, Goldstein M. Motile sperm in human testis biopsy specimens. J Androl. 1993;14(3):194-8.
• Practice Committee of the American Society for Reproductive Medicine. Vasectomy reversal. Fertil Steril. 2004;82(Suppl 1):S194-8.
• Silber SJ. Microsurgery for vasectomy reversal and vasoepididymostomy. Urology. 1984;23(5):505-24.
• Takihara H. The treatment of obstructive azoospermia in male infertility--past, present, and future. Urology. 1998;51(5A Suppl):150-5.
• Kadioglu A, Cayan S, Tefekli A, Orhan I, Engin G, Turek PJ. Does response to treatment of ejaculatory duct obstruction in infertile men vary with pathology? Fertil Steril. 2001;76(1):138-42.
• Orhan I, Onur R, Cayan S, Koksal IT, Kadioglu A. Seminal vesicle sperm aspiration in the diagnosis of ejaculatory duct obstruction. BJU Int. 1999;84(9):1050-3.
• El-Assmy A, El-Tholoth H, Abouelkheir RT, Abou-El-Ghar ME. Transurethral resection of ejaculatory duct in infertile men: outcome and predictors of success. Int Urol Nephrol. 2012;44(6):1623-30.
• Özkaya M, Gültekin MH, Özkara H. Obstrüktif azoospermi tedavisi. In: Gül Ü, Turunç T, editors. Erkek cinsel sağlığı ve fertilitesi. İstnabul: Galenos Yayıncılık; 2021. p.152-60. Turkish.
• Schuster TG, Ohl DA. Diagnosis and treatment of ejaculatory dysfunction. Urol Clin North Am. 2002;29(4):939-48.