ROLE OF FNAC TESTIS IN

MALE INFERTILITY

DR Spandana 1st year pg

Moderator: Dr Grace Madhuri

Assistant professor, Department of pathology

Overview
 Introduction
 What is Infertility?
 Types of infertility
 Indication of Testis FNAC
 Reporting of Testicular FNAC
 Advantages
 Limitations
Introduction.
 Fine needle aspiration cytology (FNAC) recently has
gained popularity for its diagnostic and therapeutic
role in male infertility

 .Since times the wife has always been blamed for

infertility especially in third world countries.

 Failure to find sperms in post coital test, conducted

by Max Huhner in 1913, raised the possibility that
husband could be responsible for infertility.
 In 1965, Obrant and Persson described FNAC for
getting material for cytological evaluation of
spermatogenesis.

 Long time testicular FNAC for evaluation of male

infertility was not popular as many clinicians were
afraid of trauma and hemorrhage.

 However, FNAC of testis is almost free of

complications. FNAC is a relatively easy and quick
procedure
INFERTILITY
WHAT IS INFERTILITY?

 Inability of a couple to
conceive after one year
of regular unprotected
intercourse.
 It effects about 15% of
couples.
 Approximately 30%
cases of infertility are
caused entirely by
male factor.
Anatomy and Histology of Testis

 Each testis is approximate 4 cm long and 2–3 cm

wide.

 Testis develops in the abdominal cavity and then

descends in the scrotal sac dragging a part of
peritoneum known as tunica vaginalis
 Testis is composed of numerous seminiferous
tubules.

 These tubules are lined by spermatogenic cells and

sertoli cells.

 Within the seminiferous tubule the germ cells

undergo maturation through various stages:
spermatocytes to spermatids to spermatozoa.
 Sertoli cells provide mechanical and nutritive
support for the spermatogenic cells.

 Leydig cells, located in the interstitial tissue ,

constitute the endocrine component of the testis. 

 Leydig cells synthesise and secrete testosterone

 Spermatogenesis
 Development of male gamete into a motile sperm known as
spermiogenesis

 Production of male gametes occurs in seminiferous tubules

 Undifferentiated germ cells in basal compartment of tubules

type A spermatogonia.

 These multiply and form spermatogonia typeB.

 Type B spermatogonia are committed to production of

spermatozoa.
Spermatogenesis:
Types of infertility
1 Primary or secondary.
2 Location of the abnormality.
-Pre testicular.
- Testicular
- Post testicular
3 Sperm parameter
Azoospermia
Oligospermia
Asthenospermia.
Teratospermia.
Aspermia.
4-Obstructive or non obstructive
 There are two classes of male infertility: primary and
secondary.

 PRIMARY INFERTILITY: In the case of primary infertility,

the male was never fertile.

 This affects 15% of couples, with a work up

demonstrating a male etiology most of the time.

 SECONDARY INFERTILITY: The male was previously

fertile, but is now unable to conceive.

 The most common factor for secondary infertility is a

varicocele. 
Based on location
Based on parameter

-Azoospermia
-Oligospermia
-Asthenospermia.
-Teratospermia.
-Aspermia.
Normal and Abnormal morphology
 Azoospermia

4-Obstructive or non obstructive

 Diagnosis Of Male Infertility

It is important to evaluate both partners in parallel.

Proper history to be taken.

Physical examination:
1)Degree of virilization
2)Gynecomastia
3)Testicular size and consistancy
4)Status of epididymis
5)Vas deferens
6)Varicocele
7)Penis and prostate
 Lab investigations
Semen analysis is the primary source of information on
sperm production and reproductive tract patency.
– Sample collection:
– Abstinence for 48-72 hours, but less than 7 days.
– Sample should be examined within one hour.
– Two samples should be taken as a baseline, one month
apart.
– -Ensure complete sample collection.
– - Store the sample at body temperature.
Semen analysis :WHO 2010
 For men with a zero sperm count
(azoospermia)

 testicular biopsy is done to determine if a

blockage is present or if primary testicular failure
is the cause

 in vitro fertilization/intracytoplasmic sperm

injection has become the major reproductive
treatment option if testicular sperm can be
retrieved.
 For obstructed patients with normal
spermatogenesis

 Testicular sperm retrieval is relatively simple.

 A repeat testicular biopsy or aspiration can procure sperm
with high success rates because sperm production is
unaffected.

 For patients with non-obstructive azoospermia

 the presence of sperm within the testicle is not

guaranteed.
 These men may choose to have a more comprehensive
procedure called microdissection testicular sperm
extraction to look for sperm.
 Why FNAC of testis in male infertility
has gained popularity
 Any technique to assess spermatogenesis must
minimally invasive and must conserve testicular tissue

 It provides both qualitative and quantitative

information about spermatogenesis.
 With advances in field of reproductive medicine,
even a single sperm can now give men with NOA
chance to enjoy biological fatherhood.

 Simple, quick, minimally invasive and painless

procedure.

 The sample can be obtained in outpatient , can be

more representative than biopsy
HOW FNAC OF TESTIS IS DONE?
 Testicular FNA is done under local anesthesia.

 The scrotal skin is cleaned and spermatic cord

block is achieved by 5 to 7 ml of two percent
lidocaine.

 To quicken the distribution of anesthetic,

spermatic cord is gently massaged after injection.

.
 After several minutes the testis is firmly palpated
to ensure absence of pain.

 Then the testis is positioned with epididymis and

vas deferens directed posteriorly, safe from injury.

 The scrotal skin is stretched taut over the testes by

wrapping the scrotal skin behind the testes with a
sponge
The scrotal skin is stretched taut over the testis by
wrapping the scrotal skin behind the testes with a sponge
 Testis is aspirated at three different sites, upper,
middle and lower part, using 21-23 G needle with
10 ml-20 ml syringe attached to it

 Precise gentle in and out movement is done.

 Transfer the aspirate into centrifuge tube to
remove excess fluid or if contaminated with excess
blood
 Both testis should be sampled when FNA is done
for evaluation of spermatogenesis.

 The patient should rest for at least ten minutes

after the procedure
Fixation and Staining
 Slides are prepared from the aspirated material and are
fixed in alcohol, stained with Papanicolaou (Pap) stains or

 Air dried and stained with Giemsa stain.

 Both staining methods should be used together in order

to use advantage of each stain

 Giemsa stain defines cell borders of spermatogenic cells

 Pap stain defines tail of spermatozoa btter

 Reporting of Testicular FNAC for Evaluation of
Spermatogenesis
 SPECIMEN ADEQUACY :
Two cell populations are evident in cytology.
 Sertoli cells
 Cells in various stages of spermatogenesis
 Spermatogonia
 Primary spermatocytes
 Secondary spermatocytes
 Spermatids
 Spermatozoa
 Leydig cells

 Reporting of Testicular FNAC for
Evaluation of Spermatogenesis
 FNA INTERPRETATION

 Normal spermatogenesis
 Hypospermatogenesis
 Sertoli cell only (SCO
 Maturation arrest.
 Atrophic pattern
 Specimen adequacy
 If at least 200 cells could be counted on minimum
one well spread slide, specimen is considered
adequate.

 Approximately 97% testicular FNA yield adequate

specimen for evaluation of spermatogenesis.
Cytologic features of these cells:
 Sertoli cells: These cells have round vesicular
nucleus with finely granular chromatin and large
nucleolus. The nuclear outline is smooth.
Cytoplasm is abundant, pale and vacuolated with
poorly delineated border. These cells are fragile
and so naked nuclei are common.
 Spermatogonia:
These are uninucleated mainly but may be
binucleated or multinucleated. The nuclei are round
or oval, slightly eccentric and dark or pale
depending upon their chromatin density. The
cytoplasm is homogenous and has well defined
border. In air dried Geimsa stained smears the
spermatogonia may resemble lymphomatoid blast.
Primary spermatocytes:

These cells have large nucleus with thread like or

coarse chromatin. Nuclear outline may be irregular.
The cytoplasm is basophilic and imore deeply stained
at the periphery of the cell. Binucleated primary
spermatocytes are common. Primary spermatocytes
are either isolated or are present in groups with other
spermatogenic cells or sertoli cells.
Secondary spermatocytes:

These cells are rarely identified because of their

shorter life span and immediate transformation to
spermatids
Spermatids:

They have smaller nucleus than spermatocytes,

corresponding to their haploid set of chromosomes.
The nucleus is centrally placed and finely granular.
They may also be binucleated and have cytoplasmic
vacuoles. They may be found in groups in normal
testes, resembling sheets of epithelial cells.
Spermatozoa:

They have oval nuclei with very dense

chromatin. The tail is found on opposite side of
acrosome.
Leydig cells:

The aspiration of interstitial tissue is difficult and hence

Leydig cells are usually not visualized in cytologic smears.
If present, in smears they appear singly or in clusters.
They are somewhat smaller than the sertoli cells and have
central spherical or oval nucleus. Some are bi nucleated.
They have abundant finely granular eosinophilic cytoplasm
 FNA interpretation
Normal spermatogenesis:

Smears show abundant cellularity with 10-20

spermatozoa per 400x field (HPF). Abundant primary
spermatocytes and spermatids are present.The ratio
of spermatogenic to sertoli cell is at least 1.5:1
Hypospermatogenesis:

Smears show relative decrease in all three germ cell

types as compared to normal spermatogenesis.
Less than 10 spermatozoa are visualized in each
400x field (HPF). Overall paucity of cell is seen,
however all three kinds of germ cells are present
including primary spermatocytes, spermatid and
spermatozoa. Ratio of spermatogenic to sertoli cell
is less than 1.5:1.
 Sertoli cells only/Germ cell aplasia:

Smears show mainly sertoli cells.

 Maturation arrest:

Maturation arrest is divided into early maturation arrest

and late maturation arrest.

 In early (premeiotic) maturation arrest:

Smears have adequate cellularity and show
numerous primary spermatocytes. No or only
occasional spermatids or spermatozoa are visualized.

 In Late maturation arrest (Post meiotic arrest):

Normal number of primary spermatocytes and
spermatids are present but spermatozoa are not seen
or are only occasionally seen.
 Atrophic pattern:

Smears show mainly proteinaceous material and

scant sertoli and leydig cell.
Fine Needle Aspiration Mapping
 FNA mapping is defined as aspiration of more than
four FNA sites per testis.

 This is performed most commonly to detect

presence and distribution of sperms in testis

 The idea behind FNA mapping is that there is

geographic variation in presence of sperm in testis
and these patches can be discovered by mapping
even if biopsy shows absent sperm.
Testicular FNA in Assisted Reproduction

 Testicular FNAC is useful in assisted reproduction

in two ways.

First FNA (MS) mapping can locate the area of

spermatogenesis in failing testis and thus biopsy
for retrieval can be directed to that particular site.

FNA itself can use for sperm retrieval instead of

biopsy.
Advantages of FNAC
 FNAC is less invasive and gives informative data on
spermatogenesis of entire testes

 Report can be issued quickly as compared to biopsy.

 Complications related to procedure are rare.

 It is simple, quick and inexpensive, because surgical

instruments are not required.
 Local scarring doesn’t occur.

 It is well tolerated by patient. Infertile patients feel

more secure with aspiration than with biopsy.

 The material shows excellent preservation and

various cell types can be identified.

 Material obtained can be used for quantization of

spermatogenesis by DNA Flow cytometry.
Limitations of FNAC Testis
 FNAC is unable to provide architectural information
of testes.

 It doesn’t give information about thickness of

tubular basement membrane, tubular diameter or
status of interstitial tissue.

 Testicular disorders leading to azoospermia such

as atrophy, fibrosis and Leydig cell hyperplasia can
be diagnosed on basis of histology but are difficult
to assess by FNA.
Limitations of Fnac Testis
 Some patients complain of prolonged pain, but
this can be relieved by scrotal support and
analgesics.

 Neurogenic shock have been reported in patients

who failed to rest after the procedure

 Hematoma formation can be expected, when thick

needle (20G) is used.

 Fairly experienced pathologist is needed, to

interpret the smears.
Conclusion
 Inspite of limitations, Testicular FNAC represent an
important diagnostic procedure in azoospermic
men
 A reliable prognostic parameter for successful
sperm retrieval, particularly in NOA.
 Also sperm may be retrieved with fine needle
aspiration alone for use in assisted reproduction.

 The combination of testicular aspiration and clinical

evaluation for male infertility ,is becoming more
important ,because new technologies allow men
,previously considered infertile to have fatherhood
References
1. WHO male genital tract
2. Orell aspitaion cytology male genetal tract

3. Male Best Practice Policy Committee of the

American Urological Association;

4. Practice Committee of the American Society for

Reproductive Medicine

5. .Ramasamy, R. and P. N. Schlegel  Microdissection

testicular sperm extraction: effect of prior biopsy
on success of sperm retrieval.
THANK
YOU