Diagnosis and Management of Azoospermia in a Patient with Megacolon Surgery History

You are a world-class andrology expert specializing in male infertility. Now there is a patient who has suffered from azoospermia since puberty. No semen comes out after masturbation orgasm. After examination, six sex hormones are normal, but prolactin is slightly higher and inhibin B is lower. He had a megacolon surgery in childhood. What is the cause? What tests are needed? What treatments can be done?

Azoospermia, the absence of sperm in the ejaculate, can be caused by a variety of factors, including hormonal imbalances, genetic conditions, obstructive issues, or testicular failure. Given the patient's history and current findings, let's break down the potential causes, necessary tests, and possible treatments.

Potential Causes

1. Hormonal Imbalance: Although the six primary sex hormones are normal, the slightly elevated prolactin and lower inhibin B levels suggest a possible endocrine issue. Elevated prolactin can inhibit the secretion of gonadotropin-releasing hormone (GnRH), which in turn affects the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), crucial for spermatogenesis.

2. Obstructive Azoospermia: Given the history of megacolon surgery, there could be a possibility of an obstructive issue in the reproductive tract. Surgical procedures in the pelvic area can sometimes lead to scarring or damage to the vas deferens or ejaculatory ducts.

3. Testicular Failure: Lower inhibin B levels are often indicative of impaired spermatogenesis, which could be due to primary testicular failure.

Necessary Tests

1. Repeat Hormonal Profile: Confirm the levels of prolactin, inhibin B, FSH, LH, testosterone, and estradiol. Elevated prolactin should be further investigated with an MRI of the pituitary gland to rule out a prolactinoma.

2. Genetic Testing: Karyotyping and Y-chromosome microdeletion analysis to rule out genetic causes of azoospermia, such as Klinefelter syndrome or Y-chromosome deletions.

3. Scrotal Ultrasound: To assess the testicular size, structure, and presence of any masses or abnormalities.

4. Transrectal Ultrasound (TRUS): To evaluate the seminal vesicles and ejaculatory ducts for any obstruction.

5. Testicular Biopsy: To determine if spermatogenesis is occurring within the testes. This can help differentiate between obstructive and non-obstructive azoospermia.

6. Semen Analysis: Even though no semen is produced, a post-ejaculate urine sample can be analyzed to check for retrograde ejaculation.

Possible Treatments

1. Medical Management:

   • Hyperprolactinemia: If a prolactinoma is found, treatment with dopamine agonists (e.g., bromocriptine or cabergoline) can normalize prolactin levels and potentially restore spermatogenesis.
   • Hormonal Therapy: If there is a hormonal imbalance, appropriate hormone replacement or suppression therapy can be considered.

2. Surgical Intervention:

   • Obstructive Azoospermia: If an obstruction is identified, surgical correction (e.g., vasovasostomy or transurethral resection of the ejaculatory ducts) may be possible.
   • Sperm Retrieval Techniques: In cases where spermatogenesis is present but there is an obstruction, techniques like testicular sperm extraction (TESE) or micro-TESE can be used to retrieve sperm for use in assisted reproductive technologies (ART) such as intracytoplasmic sperm injection (ICSI).

3. Assisted Reproductive Technologies (ART):

   • Intrauterine Insemination (IUI) or In Vitro Fertilization (IVF): If viable sperm can be retrieved, these techniques can be used to achieve pregnancy.

4. Counseling and Support: Psychological support and counseling for the patient and their partner are crucial, as infertility can be a significant emotional burden.

Conclusion

The patient's azoospermia could be due to a combination of hormonal imbalance and potential obstructive issues related to his surgical history. A thorough evaluation with the outlined tests will help pinpoint the exact cause and guide appropriate treatment. Collaboration with a multidisciplinary team, including endocrinologists, urologists, and reproductive specialists, will be essential for optimal