A prospective study of multiple needle biopsies versus a single open biopsy for testicular sperm extraction in men with non-obstructive azoospermia

Little is known about the efficacy and the factors affecting the outcome of fine needle aspiration biopsy of the testis for sperm retrieval in azoospermic men with defective spermatogenesis. A prospective study was designed to compare the efficacy of needle and open (window) testicular biopsies for testicular epididymal sperm extraction (TESE) in 35 consecutive men with azoospermia due to defective spermatogenesis undergoing testicular biopsy for intracytoplasmic injection of oocytes. Each of the consecutive 35 patients underwent TESE using a 19 gauge butterfly needle followed by a window (1-1.5 cm-sized incision) testicular biopsy in the same procedure. The extraction of spermatozoa into culture medium was compared with the assessment of testicular biopsies by histology, the mode of biopsy (needle or open biopsy) and the amount of tissue retrieved by either method. Testicular spermatozoa were retrieved in 22 (63%) who had an open testicular biopsy compared with five (14%) patients who had multiple needle biopsies, respectively; the difference was statistically significant. Open testicular biopsy retrieves more testicular tissue than needle biopsy. Needle testicular biopsy retrieved testicular spermatozoa in 50% of those with hypospermatogenesis, 10% with focal spermatogenesis and in no patients with maturation arrest or Sertoli cell-only pattern. In contrast, sperm retrieval was successful in 100%, 90% and 66% of those with respective histologies using open testicular biopsy. Other than bruising, for which they required no analgesia, none of the patients suffered any obvious complications associated with traditional testicular biopsy. We conclude that open testicular biopsy is more effective than needle biopsy for the retrieval of testicular spermatozoa in azoospermic men with defective spermatogenesis. The difference observed may be related to the amount of testicular tissue retrieved and to the influence of testicular histology.      

MRI defecography of the ileal pouch-anal anastomosis—contributes little to the understanding of functional outcome

Purpose

Variability in functional outcome after ileal pouch-anal anastomosis (IPAA) is to a large extent unexplained. The aim of this study was to use MRI to evaluate the morphology, emptying pattern and other pathology that may explain differences in functional outcome between well-functioning and poorly functioning pouch patients. A secondary aim was to establish a reference of normal MRI findings in pelvic pouch patients.

Methods

From a previous study, the best and worst functioning patients undergoing IPAA surgery between 2000 and 2013 had been identified and examined with manovolumetric tests (N?=?47). The patients were invited to do a pelvic MRI investigating pouch morphology and emptying patterns, followed by a pouch endoscopy.

Results

Forty-three patients underwent MRI examination. We found no significant morphological or dynamic differences between the well-functioning and poorly functioning pouch patients. There was no correlation between urge volume and the volume of the bony pelvis, and no correlation between emptying difficulties or leakage and dynamic MRI findings. Morphological MRI signs of inflammation were present in the majority of patients and were not correlated to histological signs of inflammation. Of the radiological signs of inflammation, only pouch wall thickness correlated to endoscopic pouchitis disease activity index scores.

Conclusion

It seems MRI does not increase the understanding of factors contributing to functional outcome after ileal pouch-anal anastomosis. Unless there is a clinical suspicion of perianal/peripouch disease or pelvic sepsis, MRI does not add value as a diagnostic tool for pelvic pouch patients. Endoscopy remains the golden standard for diagnosing pouch inflammation.

     

Stent placement in patients with acute subarachnoid haemorrhage: when is it justified?

Purpose

Endovascular stents are widely used for the elective treatment of cerebral aneurysms. Acute stenting is performed in the management of dissections, pseudo-aneurysms, broad-based aneurysms or as a ‘bail out’ measure after coil migration. The purpose of this study is to review the safety of using stents in acute subarachnoid haemorrhage.

Methods

The stent registry of our institution was reviewed for procedures in patients with acute subarachnoid haemorrhage. Imaging studies were reviewed on the hospital’s PACS system and the patients’ notes were retrieved to assess complications and clinical outcomes. Procedures were analysed according to the type of stent, treatment indication, antiplatelet regime, complications and outcomes.

Results

Between 2008 and 2016, 51 stents were placed during 50 stenting procedures in 49 patients with acute subarachnoid haemorrhage. This included 24 patients with saccular aneurysms, 10 with blister aneurysms, 10 dissections and five fusiform aneurysms. Stents were deployed in ‘bail out’ situations on eight occasions. In six cases, flow-diverting stents were used. Eighteen patients (37%) in the cohort suffered a stroke. Nine patients (18%) suffered persistent clinical deficits as a result of the stenting procedure, all but one of which occurred within 24 h. Two patients had a transient ischaemic episode, and there was evidence of asymptomatic ischaemia on imaging in four cases (8%). Five patients died, three (6%) as a result of procedural complications. Twelve patients (25%) required a further embolisation procedure.

Conclusion

The use of stents in acute subarachnoid haemorrhage incurs a considerable complication risk and should be reserved for exceptional circumstances.

     

Monitoring cerebral blood flow change through use of arterial spin labelling in acute ischaemic stroke patients after intra-arterial thrombectomy

Objectives

To evaluate the ability of arterial spin labelling perfusion-weighted imaging (ASL-PWI) to identify reperfusion status and to predict the early neurological outcome of acute ischaemic stroke patients after intra-arterial (IA) thrombectomy.

Methods

A total of 51 acute ischaemic stroke patients who underwent IA thrombectomy were retrospectively reviewed. Asymmetrical index before and after IA thrombectomy (AICBF_pre and AICBF_post) and volume ratio of the reperfused territory to the baseline perfusion abnormality (reperfusion volume ratio) were calculated on ASL-PWI. A paired t-test was used to compare AICBF_pre and AICBF_post. Pearson correlation and multiple linear regression were performed to evaluate correlations between the imaging parameters and NIHSS scores.

Results

Mean AICBF_post was significantly higher than mean AICBF_pre (0.923±0.352 vs. 0.312±0.191, p<0.001). AICBF_pre had a significant correlation with NIHSS_pre (pr=–0.430, p=.004). ?AICBF had significant correlations with NIHSS_{24 h}, NIHSS_{5-7 days} and ?NIHSS_{5-7 days} (r=–0.356, p=0.028; r=–0.597, p<0.001; r=–0.346, p=0.033, respectively). ?AICBF, reperfusion volume ratio and baseline infarct volume were significant independent predictors for NIHSS_{5-7 days}.

Conclusions

ASL-PWI has the potential to serve as a non-invasive imaging tool to monitor the reperfusion status and predict the early neurological outcome of acute ischaemic stroke patients after IA thrombectomy.

Key Points

? CBF change on ASL-PWI after IA thrombectomy correlated with NIHSS scores. ? ASL-PWI can non-invasively monitor reperfusion in AIS patients after IA thrombectomy. ? ASL-PWI may predict early outcome of AIS patients after IA thrombectomy.

     

Comparison of the clinical performance of upper abdominal PET/DCE-MRI with and without concurrent respiratory motion correction (MoCo)

Purpose

To compare the clinical performance of upper abdominal PET/DCE-MRI with and without concurrent respiratory motion correction (MoCo).

Methods

MoCo PET/DCE-MRI of the upper abdomen was acquired in 44 consecutive oncologic patients and compared with non-MoCo PET/MRI. SUVmax and MTV of FDG-avid upper abdominal malignant lesions were assessed on MoCo and non-MoCo PET images. Image quality was compared between MoCo DCE-MRI and non-MoCo CE-MRI, and between fused MoCo PET/MRI and fused non-MoCo PET/MRI images.

Results

MoCo PET resulted in higher SUVmax (10.8?±?5.45) than non-MoCo PET (9.62?±?5.42) and lower MTV (35.55?±?141.95 cm³) than non-MoCo PET (38.11?±?198.14 cm³; p?<?0.005 for both). The quality of MoCo DCE-MRI images (4.73?±?0.5) was higher than that of non-MoCo CE-MRI images (4.53±0.71; p?=?0.037). The quality of fused MoCo-PET/MRI images (4.96?±?0.16) was higher than that of fused non-MoCo PET/MRI images (4.39?±?0.66; p?<?0.005).

Conclusion

MoCo PET/MRI provided qualitatively better images than non-MoCo PET/MRI, and upper abdominal malignant lesions demonstrated higher SUVmax and lower MTV on MoCo PET/MRI.

     

Norethisterone concentration in breast milk and infant and maternal plasma during ethynodiol diacetate administration

Twelve women with established lactation of 4–8 weeks duration were given a low-dose progestogen-only contraceptive, ethynodiol diacetate 0.5 mg (Femulen) daily. On the seventh and eighth day of the study, prior to the mother's taking the pill, a blood sample was taken from her and from the infant. Further blood samples were collected from the mother 4 and 12 hours later. Breast milk samples were collected at every feed on day 7 and day 8.

Ethynodiol diacetate is rapidly metabolised in humans, changing into the metabolite norethisterone which is found in both blood and milk. Hence, norethisterone concentrations were estimated.

On day 7 and day 8, four hours after ingestion of the pill, the median norethisterone maternal plasma concentration was 1.60 ng/ml and it fell to a median level of 0.30 ng/ml prior to the next dose of the pill. At this time the median infant concentration was 0.10 ng/ml but the maximum observed level was 0.50 ng/ml.

In the breast milk the norethisterone concentration appears to peak at around 4–8 hours following the ingestion of the pill. The maximum observed concentration in breast milk was 0.84 ng/ml. The amount of norethisterone ingested by the infant averaged 0.02% (6.65 μg) of the dose of ethynodiol diacetate ingested by the mother. The maximum observed on any one day was 0.07% (27.52 μg).

The above results indicate that the amount of progestogen ingested by the infant from its mother's milk is small and is unlikely to pose a risk to the infant.     

Comparison between stimulated in-vitro fertilization and stimulated intrauterine insemination for the treatment of unexplained and mild male factor infertility

A prospective trial was undertaken to evaluate the efficacy of stimulated in-vitro fertilization (SIVF) and stimulated intrauterine insemination (SIUI) in couples with unexplained and mild male factor infertility. In all, 80 couples were allocated to treatment with SIVF or SIUI, both treatments following the same protocol [clomiphene citrate and follicle stimulating hormone (FSH) injection], except that higher doses of FSH were used in the SIVF treatment cycles. Initially, 41 couples were allocated to and started treatment with SIVF but eight cases were eventually converted to SIUI because of under-response. Similarly, although 39 couples were initially allocated to SIUI treatment, five of these converted to SIVF because of over-response. The treatment cycles that were converted either to SIUI or to SIVF were not considered as treatment failures but as treatment changes and so were included in the analyses. Of the final 38 SIVF cycles, four were cancelled (dysfunctional response), failed fertilization occurred in five cycles and 29 subjects reached embryo transfer. There were two biochemical pregnancies [positive human chorionic gonadotrophin (HCG) only], two clinical abortions and seven live births. Of the final 42 SIUI cycles, only two were cancelled, insemination being performed in the remaining 40 cases. The result was one clinical abortion, three ectopics and eight live births. The proportion of cycles with positive HCG was identical (28.9% per cycle treated for SIVF and 28.6% for SIUI) and the livebirth rates were also not different (18.4% per cycle treated for SIVF and 19.0% for SIUI). The cost per maternity of SIUI was approximately half that of SIVF (Pounds Sterling 1923 versus Pounds Sterling 4611) and so we conclude that, as SIUI had an efficacy that was not significantly different from SIVF (using similar protocols) but was more cost-effective, it must be considered the more appropriate form of management for the treatment of unexplained and mild male factor infertility. Indeed, it is hard to justify the routine use of IVF, as a first approach, in unexplained infertility.