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13 Ultrasound inMale Infertility
227
levels, elevated FSH, and impaired sperm density
in patients undergoing orchiectomy compared to
orchiopexy [120, 121].
Transrectal Ultrasonography
Transrectal ultrasonography (TRUS) is frequently utilized during the evaluation of male
infertility in cases of low-volume ejaculate, azoospermia on semen analysis, or palpable asymmetry on digital rectal exam in order to rule out
ejaculatory duct obstruction or to evaluate for the
presence/absence of seminal vesicles. TRUS
identies pathologic ndings (hypoplastic/atrophic SVs, vasal agenesis, etc.) in 75% of azoospermic males, compared to no pathology in
65% of non-azoospermic males [122].
TRUS is frequently performed with a 6.5–
7.5MHz probe with the bladder partially lled.
Patients are placed in the lateral decubitus and
knee-to-chest position and may alternatively be
placed in the prone jackknife or dorsolithotomy
positions depending on the surgical scenario.
contain sperm, while paramedian cysts are typically of Wolfan duct origin and may contain
sperm upon aspiration [123, 124]. Midline cysts
may further be differentiated into utricular cysts
which are typically 15 mm in diameter or true
Mullerian cysts which may be larger and extend
posteriorly beyond the prostatic base (Fig.13.11).
Peripheral cysts may be acquired following infectious processes or rarely may represent benign or
malignant processes including multilocular cystadenoma/cystadenocarcinoma [125, 126].
a
Prostate
Transrectal ultrasonography is an excellent
modality to assess obstructive etiologies of
infertility, including prostatic cysts and ejaculatory duct obstruction (EDO), and may be used
as an adjunctive measure in cases of suspected
prostatic infections or abscesses. Infertile males
with EDO or prostatic cysts may present with
varied accompanying symptoms including perineal pain, low-volume ejaculate, hematospermia, painful ejaculation, or epididymal
tenderness [32, 34].
Cysts
Prostatic cysts are frequently identied in cases of
obstructive azoospermia/severe low-volume oligospermia and may be further classied based on
location, including peripheral/parenchymal, midline, or paramedian. Midline cysts are typically of a
Mullerian embryologic origin and usually do not
b
Fig. 13.11 The following image shows a Mullerian duct
cyst as indicated by the arrow and prostate as indicated by
the arrowhead on (a) sagittal T2-weighted and (b) axial
T1-weighted post-contrast MRI
228
I. S. Lam et al.
Ejaculatory Duct Obstruction
The ejaculatory duct is minimally visualized on
ultrasonography in the absence of obstruction
and enters the urethra at the level of the verumontanum with standard lengths of approximately
4–8mm and a lumen of 2mm. In contrast, ejaculatory duct obstruction (EDO) is often well demonstrated in the sagittal view and is commonly
associated with dilation of the ejaculatory duct,
seminal vesicles, and occasional ejaculatory ductal calcications.
Ejaculatory duct obstruction may occur secondary to congenital processes including compression by prostatic cysts or ejaculatory duct
atresia/stenosis or may be acquired from infections (UTI, sexually transmitted diseases, tuberculosis), inammatory conditions, traumatic
strictures, stone formation, or following prior surgical procedures (transurethral resection of the
prostate, exstrophy repair, colorectal surgery)
[127–130] (Fig. 13.12). Partial EDO may result
from any of the above etiologies and has a variable
presentation including low volume with varied
sperm densities/total sperm on semen analysis
and dilation of one or both of the SVs [131, 132].
Although TRUS ndings may suggest EDO,
conrmatory tests are commonly required given
the relatively low specicity of TRUS alone. In
males with azoospermia/severe oligospermia suspected of having EDO, TRUS with concurrent SV
aspiration demonstrating the presence of sperm
(common denition requiring three or more per
high-power eld) conrmed obstruction in 49.1%
of cases [122, 133–135]. Similarly, Purohit and
colleagues compared adjunctive testing including
chromotubation, SV aspiration, and seminal
vesiculography with conrmation of EDO in 52,
48, and 36% of cases, respectively [136]. An additional measure which is less commonly utilized
includes ejaculatory ductal manometry which
identies higher opening pressures in men with
EDO compared to fertile controls [137].
The treatment of EDO is frequently performed
in combination with TRUS to conrm treatment
success and assist in localization or extent of
obstruction where indicated. Isolated cysts resulting in compression of the ejaculatory duct may
a
b
Fig. 13.12 Stone in dilated ejaculatory duct: transverse
(a) and longitudinal (b) transrectal sonograms show a
very small hyperechogenic stone (arrows) in the dilated
right ejaculatory duct
be treated with aspiration alone when not in communication with the ejaculatory system or with
transurethral resection of the ejaculatory duct
(TURED) when communication exists [129,
138]. Results of TURED for complete EDO dem-
onstrate improved semen quality in 50–92% of
patients with complete EDO with subsequent
spontaneous (without need for ART) paternity
rates of 13–29% [139–143]. An alternative therapy for the treatment of EDO includes ejaculatory ductal dilation utilizing seminal vesicoscopy,
with one study demonstrating equal efcacy and
fewer complications compared to TURED [144].
Calcications of the prostate are commonly
visualized on transrectal ultrasonography and
are of unlikely signicance in regard to infertility. Increasing calcications are associated with
age and are present in 23% of asymptomatic
males aged 20–29 versus 83% in males
60–69years old [145].
13 Ultrasound inMale Infertility
229
Seminal Vesicles
The SVs are clearly visualized on TRUS cephalad to the prostate and posterior to the bladder
and may result in decreases to semen volume,
pH, and fructose concentration when abnormalities are present. Although there is variability in
reported standard SV lengths, normal, hypoplastic, and atrophic are commonly classied as
occurring at >24, 17–24, and <17 mm, respectively, without signicant change following ejaculation [145–147].
Dilation of the SVs resulting from mechanical
obstruction, particularly when >15mm, is most
commonly associated with EDO as described
previously. Dilation may also be seen in patients
with adult polycystic disease and infertility, ipsilateral upper urinary tract agenesis (Zinner syndrome), or diabetes mellitus and is thought to be
secondary in these cases to SV hypotonicity
rather than anatomic obstruction [148–150].
Absence of the SVs is associated with cystic
brosis and unilateral/bilateral absence of the vas
deferens as well as renal anomalies including
renal agenesis, ectopia, and horseshoe, among
others [58, 59, 62, 63]. Infections of the seminal
vesicles may also be visualized on ultrasound and
have been reported to impact fertility with
improved semen parameters following antibiotic
therapy [151].
fewer TPUs [152]. A similar study performed in
patients with nonobstructive azoospermia demonstrated successful sperm extractions in 38 and
14% of patients with subjective good versus poor
vascularity, respectively [153]. A more recent
Cochrane review evaluating the efcacy of various techniques for sperm aspiration demonstrated
no statistically signicant improvement in
ultrasound- guided testicular sperm aspiration
versus aspirations performed without ultrasound
[154]. It is not clear, however, how these techniques compare to the results reported by Herwig
and colleagues, and therefore the role for ultrasound at the time of sperm extraction remains
unknown.
Further techniques to enhance extraction of
sperm at the time of TESE are being developed,
with Ramkumar and colleagues recently reporting their initial experience with microdissection
probe-TESE (MP-TESE) [155]. The procedure
utilizes a microfabricated silicon microprobe
with an ultrasonic horn actuator and strain gauges
to detect tissue interface boundaries between
seminiferous tubules. This reportedly improves
size discrimination of seminiferous tubules with
the average diameter of sperm-containing tubules
noted to be 41.2±1.6μm per report. Although
this technology reports intriguing ndings, it has
yet to be validated by other groups and remains
experimental at the present time.
Assisted Reproductive Techniques
In addition to the initial evaluation of the infertile
male, ultrasound has been increasingly utilized in
the performance of sperm retrieval for use in
ARTs. Several studies have examined the use of
power Doppler at the time of TESE to identify
regions with increased sperm density to improve
the likelihood of sperm retrieval.
Herwig and colleagues reported on the use of
a laser Doppler scanner to determine perfusion
rates and noted higher sperm quality and quantity
based on underlying tissue perfusion. In patients
with at least 70 tissue perfusion units (TPU),
72.3% of biopsies identied progressive sperm
compared to 13.3% among those with ten or
Conclusion
Ultrasonography, including adjunctive techniques of power and duplex Doppler, is increasingly utilized in the evaluation and management
of male-factor infertility. Scrotal and transrectal
ultrasonographies provide both anatomic and
functional information to assist in identifying
underlying etiologies for infertility including
infectious processes and varicoceles as well as
differentiating between obstructive (EDO, epididymal obstruction, absence of the vas deferens)
and nonobstructive causes. Ultrasonography may
additionally detect associated ndings including
testicular/paratesticular lesions, upper tract renal
anomalies, testicular microlithiasis, hydroceles,
230
I. S. Lam et al.
and cysts. Although ultrasound currently has a
limited role with ARTs, an emerging body of
investigative literature suggests that its use at the
time of TESE may enhance the yield of sperm
obtained, thereby improving overall outcomes.
As ultrasound technology continues to evolve, it
will likely play an increasingly prominent role in
the evaluation and treatment of male-factor
infertility.
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Part VI
Ultrasound and ART Techniques