Increased evidence for routine ultrasound examination in male infertility patients.
11 October 2000
We read with great interest the results of the cohort study undertaken by Jacobsen et al (1), which revealed a significant increased risk of testicular cancer in men with low semen quality. This increased risk gives further support to the role of routine scrotal ultrasound in the investigation of male factor infertility. For many years it has been taught by many that a careful testicular examination is all that is usually required in such patients. However, there are several reasons that has increased the usefulness and importance of ultrasound examination.
Firstly, the technology has improved such that modern high frequency linear array probes can accurately determine small intratesticular lesions which are not palpable.
The other main use of modern ultrasound machines is the ability to perform Doppler studies of the vascular flow. This is important to confirm the presence of a varicocele which may be clinically obvious but also to detect a subclinical varicocele. The diagnosis of a subclinical varicocele is still of uncertain importance as various evidence exists as to the extent of improvement of semen quality and more importantly pregnancy rates (2). However, patients who attend for treatment of poor semen quality are often very keen to know the cause condition. As few definitive treatments exist for oligospermia patients are often willing to try corrective treatment for their varicocele if present, and many urologists continue to treat this condition. There is definite scope for greater research in this area. In addition to assessing the extent of testicular venous reflux Doppler ultrasonography is of increasing importance in the investigation of testicular arterial flow. Although presently only in the domain of infertility research there is growing evidence to suggest that focal areas of spermatogenesis exist (3). These areas correspond to arterial flow and can be selectively sampled to provide spermatozoa for assisted reproductive techniques.
Anecdotal evidence for a link between male infertility and testicular malignancy has revealed 3 testicular tumours in patients attending the infertility clinic in the past 3 years in one consultant urologists practice. This has led to a recent audit of patients attending the infertility clinic and in particular the use of scrotal ultrasound in these patients. This has revealed that of the hundred patients investigated 33 sonographic abnormalities were demonstrated. These include varicoceles in 18, testicular microlithiasis in 2 and testicular tumour in 2. Importantly, thirty-two percent of findings were not identified by physical examination which included important pathology like one testicular tumour, the 2 cases of microlithiasis and 3 varicoceles.
The importance of testicular microlithiasis is well recognised (4) as there is a significant association with testicular malignancy. Testicular microlithiasis cannot be detected by clinical examination and there is growing evidence that its detection should lead to increased patient awareness regarding the possibility of developing a testicular tumour and the importance of self examination as well as the practise in some departments of annual ultrasound follow-up.
The evidence put forward in the study by Jacobsen et al. in combination with the fact that new ultrasound technology can improve the diagnosis and management of male infertility and in particular can detect conditions such as testicular microlithiasis means that routine scrotal ultrasonography should be performed in all patients with poor sperm quality.
1. Jacobsen R, Bostofte E, Engholm G, Hansen J, Olsen JH, Skakkebæk NE, et al. Risk of testicular cancer in men with abnormal semen characteristics: cohort study. BMJ 2000; 321: 789-792.
2. Yamamoto M. Hibi H. Hirata Y. Miyake K. Ishigaki T. Effect of varicocelectomy on sperm parameters and pregnancy rate in patients with subclinical varicocele: a randomized prospective controlled study. Journal of Urology. 155(5):1636-8, 1996 May
3. Foresta C, Garolla A, Bettella A, Ferlin A, Rossato M, Candiani F. Doppler Ultrasound of the Testis in Azoospermic Subjects as a Parameter of Testicular Function. Human Reproduction 1998; 13: 3090-3093
4. Ganem JP. Testicular Microlithiasis. Current Opinion in Urology. 10(2):99-103, 2000 Mar.
Competing interests: None declared
St.Bartholomew's & Homerton Hospitals
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