The Complete Guide to Male Fertility Preservation by Ahmad Majzoub & Ashok Agarwal

Author:Ahmad Majzoub & Ashok Agarwal
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Testes

The testicular exam is going to be the most useful in predicting preservation issues, as many problems of either production or obstruction can be predicted by exam. The testicular exam first focuses on size, because 80% of testicular volume is comprised of cells associated with spermatogenesis [76], giving significant insight into the level of function. There are multiple methods of measuring testicle size, including measuring with a caliper, use of an orchidometer, or testicular ultrasound, which is considered the gold standard, though each method has some intra-observer variability [77, 78]. Depending on the volume equation used, median testicular size varies from 12.7 to 18.9 mL on ultrasound [79], with volumes less than 12 cm3 correlated with abnormal semen parameters [76]. Small testicles may suggest syndromic issues with testosterone metabolism or spermatogenesis such as Kallmann or Klinefelter’s syndrome [5, 80], or atrophy after vascular injury from torsion or inguinal hernia repair [54].

Evaluation and documentation of testicular smoothness and contour are important in patients presenting for infertility. Infertile men have an increased incidence of testis cancer and testis cancers are known to affect fertility [81]. There should be low threshold to supplement the exam with ultrasound if there is any doubt or difficulty in evaluation.

Presence of the genitourinary ductal system should be evaluated. In the testicles, presence and fullness of the epididymis should be palpated. Then entire epididymis should be palpated, as due to embryologic differences, the head is rarely missing but a missing midbody or tail of the epididymis can indicate a Wolffian duct abnormality or CBAVD related to cystic fibrosis. Unilateral absence of the vas and epididymis suggests Wolffian duct abnormalities that may have involved the ureteric bud and should be evaluated for solitary kidney with ultrasound [82].

Spermatic vein exam is performed to determine the presence and severity of varicocele. Varicoceles are graded from I to III based on exam with grade I felt only with valsalva, grade II palpable without valsalva, and grade III visible through scrotal skin [83]. Smaller varicoceles can be difficult to palpate. Any varicocele should be checked for reduction when laying supine, especially for large or right-sided varicoceles, as these can rarely be associated with retroperitoneal malignant processes and are less likely to reduce due to the nature of venous obstruction [84]. Such findings may help predict issues with cryopreservation and subsequently direct patients to the necessary treatment.

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