Increased evidence for routine ultrasound examination in male infertility patients.
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
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
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.