TESTICULAR BIOPSY & SCROTAL EXPLORATION IN THE
MANAGEMENT OF MALE INFERTILITY

by

DR PETER H C LIM,
AM, MB, BS, MMed(Surg), D.Urol(Lond), FICS,
Head & Senior Consultant Urological Surgeon,
Division of Urology, Dept of Surgery,
Toa Payoh Hospital, Singapore 1129.



Testicular biopsies in infertile men was first advocated by
Charny in 1940 to distinguish cases of obstructive aspermia
from non-obstructive, to classify cases of oligospermia & to
aid in prognosis. Meihard et al (1973) found that clinical
examination & semen analysis were no guide to the severity of
the lesion & advocated biopsy for the complete assessment of
the case & for identifying those which were potentially
treatable.

Scrotal exploration & testicular biopsy is a simple procedure
that can be done under regional or general anaesthesia.
Additionally, it permits evaluation of vasal patency, the
status of the epididymis & surgical treatment of a varicocele
if this was diagnosed pre-operatively. In our own TPH
studies, routine examination, semen analyses & hormonal
studies could not provide an accurate guide to the severity
of the lesions.  Biopsy was more precise for assessing
oligospermia & azoospermia in which the histology can vary
considerably.  With the current use of the Johnson Scoring
Technique when reading testicular biopsies, we were more
precise in offering a prognosis as this method afforded a
quantitative evaluation of germ cells & leydig cells over &
above routine microscopic study.  The pattern with varicocele
was not pathognomic but maturation arrest was common in
younger patients while older men tend to have sclerosis &
intraluminal sloughing irrespective of the grade of venous
reflux.

FSH & LH levels were only useful when either or both were
raised more than three times. Normal FSH could be found in
germinal aplasia or maturation arrest. In the latter, the
testes were often of good size; thus diagnosis would not have
been made without biopsy. Examination of the testes,
epididymis and the vas was always done at the time of biopsy
and when indicated, vasography helped elucidate the nature &
site of obstruction causing azoospermia. If the testicular
biopsies demonstrated good functioning testicles this
justified proceeding to vasovasostomy or vasoepididymostomy.
When a varicocele was present, biopsy of the testes at the
time of ligation can provide assessment of the pathological
changes & provide a prognosis especially when additional
hormonal treatment was being considered. The greatest value
of biopsy was in cases confirmed beyond salvage by histology.
This enabled appropriate action to be taken ie. AID, adoption
etc.


References:

Charny CW: Testicular biopsy - its value in male sterility.
JAMA 1940; 115:1429-32

Meihard E, McRae CU, Chisholm GD: Testicular biopsy in
evaluation of male infertility. BR Med J 1973; 3:577-81

Tan KH, Peter H C Lim: Testicular biopsy & scrotal
exploration in the management of male infertility. Sing Med J
1991; 32:41-46

Agger P, Johnsen SG: Quantitative evaluation of testicular
biopsies in varicocele. Feril Steril 1974; 29-52

Hargreave TB: Value of bilateral testicular biopsies prior to
corrective surgery for obstruction. Personal communication
1987.