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The 'omics revolution, as it is termed, refers to the study of genes genomics , transcripts transcriptomics , proteins proteomics and the various metabolites metabolomics. The application of 'omics technologies to spermatozoa, in concert with detailed assessments of their functional competence, may provide insights into the biochemical basis of defective semen quality.
Vasography is indicated in a few select cases of obstructive azoospermia and when there is reason to suspect a unilateral obstruction e. Vasography and seminal vesiculography are usually undertaken by scrotal or transrectal routes. The presence of sperm upon microscopic analysis of the fluid recovered from the vas deferens and seminal vesicles indicates a distal obstruction and rules out a testicular or epididymal obstruction. Currently, vasography is only performed concomitantly with a surgical approach to resolve an obstruction. Testis Biopsy. Testis biopsies are suggested in select cases of azoospermia or severe oligozoospermia to distinguish between obstructive and non-obstructive cases.
This distinction is necessary to accurately determine the histopathology of the testis, which may reveal normal spermatogenesis, hypospermatogenesis, germ cell maturation arrest, germ cell aplasia Sertoli-cell-only syndrome , tubular sclerosis or a combination of these conditions. Biopsies can be performed using percutaneous or open approaches. In cases in which biopsies are obtained for diagnostic purposes only, the authors' technical choice is to perform the procedure either percutaneously or using the ''window'' open technique without testis delivery from the scrotum.
Specimens should be placed in a fixative solution such as Bouin's, Zenker's or glutaraldehyde; formalin should not be used as it may disrupt the tissue architecture. In cases of NOA, histology results provide important prognostic information regarding the likelihood of retrieving spermatozoa that can be used in ART However, as spermatogenesis is often limited and focal in NOA patients, the biopsy should ideally be performed in specialized assisted reproduction centers to allow for sperm cryopreservation and to avoid the need for repeated procedures.
A precise and detailed medical history, physical examination, semen analyses and complementary tests, as appropriate, are the key to obtaining a correct diagnosis and to determining the best treatment strategies. Figure 4 depicts algorithms that may aid in the initial assessment of the infertile male. Semen parameters within the reference interval do not guarantee fertility, nor do values outside those limits necessarily imply male infertility or pathology.
They must be interpreted within the context of the patient's clinical information. The reference limits provided by the WHO manual are derived from semen samples used to initiate natural conceptions; they may indicate a need for infertility treatment but not the nature of that treatment. When no clear cause of infertility can be determined, additional tests such as genetic testing, sperm DNA fragmentation and anti-sperm antibody assessments should be considered.
Novel molecular sperm function tests are emerging in the field of andrology. The application of proteomics, transcriptomics and metabolomics to analyze sperm should provide a more comprehensive analysis of the biochemical basis of defective semen quality. Genetic evaluation is recommended in cases of severe oligozoospermia and azoospermia, as this analysis may aid in identifying cases in which sperm retrieval is actually possible and may also help in counseling couples about their potential offspring.
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Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Color Doppler ultrasound investigation of varicocele. World J Urol. Do the results of semen analysis predict future fertility? A survival analysis study. Esteves SC. Infertilidade Masculina. Editora Atheneu, Sao Paulo, Brasil, World Health Organization. Cambridge: Cambridge University Press, , p. World Health Organiation. Cambridge, Cambridge University Press, , p.
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Urology ;, doi: Y chromosome microdeletions and alterations of spermatogenesis. Endocr Rev. A decade of experience emphasizes that testing for Y microdeletions is essential in American men with azoospermia and severe olygozoosper- mia. AZF microdeletions of the Y chromosome and in vitro fertilization outcome. Clinical characterization of 42 oligospermic and azoospermic men with microdeletion of AZFc region of the Y chromosome, and of 18 children conceived with ICSI. The incidence and possible relevance of Y-linked microdeletions in babies born after intracystoplasmic sperm injection and their infertile fathers.
Mol Hum Reprod. Transurethral resection of partially obstructed ejaculatory duct: seminal parameters and pregnancy outcome according to the etiology of obstruction. Differential diagnosis of azoospermia and etiologic classification of obstructive azoospermia: role of scrotal and transrectal US. A high stress level may occur owing to a continuous high stress in daily life without occurrence of specific stressful exposures.
This might explain the uncertain results, and a study setup based on stress due to environmental disasters or war should be preferably accompanied by an assessment of perceived stress [ 12 , 22 , 23 , 24 , 25 , 26 ]. Many studies show that men undergoing infertility treatment [ 27 , 28 , 29 ] or men from the general population [ 30 ] have a decline in semen parameters during infertility treatment, but it is difficult to distinguish whether stress is a cause or a consequence of decreased semen quality in such studies. Stress can increase after diagnosis of male infertility, follow-up appointments, and failed in vitro fertilization treatments [ 11 ].
Men undergoing infertility treatment met the criteria for having an anxiety disorder or depression, the latter being more common [ 12 ]. Coping with various lifestyles may also affect fertility. It was reported that actively coping with stress, such as being assertive or confrontational, may negatively impact on fertility, by increasing adrenergic activation, leading to more vasoconstriction in the testes [ 31 ].
This vasoconstriction results in a lower testosterone level and decreased spermatogenesis. While men are not often thought to report their anxiety or sexual stress, the link between anxiety and sexual stress was surprisingly strong [ 32 ]. One study detected linear negative associations between perceived stress and sperm motility, sperm concentration, and percentage of morphologically normal spermatozoa [ 33 ]. The other study did not find any association between stress and semen parameters, but found that fecundability decreased with increasing stress score in men with low semen quality [ 34 ].
Thus, a negative association between self-reported stress and semen quality reported in many studies represents a public health concern Table 1. Psychological stress might be a modifiable or reversible factor, which is important in a clinical setting [ 5 ]. Future studies should objectively assess the impact of stress and prospectively evaluate whether timely counseling aimed at lowering stress levels may restore semen quality, and attempt to clarify the underlying biological mechanisms by which stress affects semen quality.