Andrology

Andrology is a relatively young field of medicine, particularly in the Czech Republic. Its name is derived from the Greek word "andros" which means the „male”. Its task is to take care of fertility, sexual functions and overall male health related to those functions. The primary focus of andrology is diagnosis and treatment of male fertility disorders, and thus it is closely connected to the centres for assisted reproduction.

In addition to reproductive problems, andrology deals with erectile dysfunctions (penile erection) in men and other problems associated with the penis, testicles, prostate and ejaculation. Given the significant demographic changes in the "age pyramid", the care for aging men (the "male andropause") and the issue of male contraception have recently increased in andrology. It is an interdisciplinary field, primarily related to urology, endocrinology, psychiatry, psychology, sexuology and genetics. In Gest, the andrological diagnostics, treatment and sperm collection are the fields of activity of MUDr. Jaroslav Jarabák.

Which problems can the patients address to the andrology doctor’s office:

• The issues of male fertility and infertility, semen analysis (spermiogram);
• Erectile dysfunction (penile erection dysfunctions) and sexual disorders;
• Ejaculation disorders – especially premature ejaculation;
• Disorders of production of male sex hormones in older age, and hormone replacement therapy;
• Functional and developmental disorders of male sexual organs in adolescence and adulthood, such as delayed puberty, primary and secondary hypogonadism, etc.;
• Inflammation and infections of the male reproductive system;
• Sperm freezing;
• Genital disability requiring plastic or aesthetic surgery, such as constricted foreskin, short frenulum, penile curvature, etc.;
• Male contraception;
• Andrological prevention

Most problems have identifiable causes and can be treated nowadays. New non-invasive, painless diagnostic procedures, new medicines, most careful microsurgical operations to genitals in ambulatory general anaesthesia and micromanipulation techniques of assisted reproduction allow the treatment of even such problems which were only hardly solvable or even unsolvable in the past. The procedure is individualized for each patient. Just as no two people are exactly the same, there are no universal medical procedures. It is therefore necessary to follow the real possibilities allowed by the current medicine with high-tech equipment. It is often necessary to solve complex problems in patients with complicated findings and repeated treatment. Even here it is possible to reach good results provided that there is good cooperation and patience of both the patient and the doctor. This requires combining the diagnostic, therapeutic and surgery medical art with knowledge, communication skills and the personality of the patient's physician.

In case of absence of sperm in the ejaculate (azoospermia) or when the ejaculate contains only a low sperm count and the sperms show abnormal morphological structure or they are present in the ejaculate only in developmental forms of sperm, there comes the possibility of obtaining sperm surgically from the epididymis (PESA, MESA) or the testicle (TESE, TESA).

PESA – Percutaneous Epididymal Sperm Aspiration, MESA – Microsurgical Epididymal Sperm Aspiration

In both methods (PESA, MESA) sperm is obtained from epididymis due to the impaired transport of sperm between the epididymis and urethra (obstructive azoospermia). For example, this is carried out in the patients after sterilization or the men who were injured in their youth and their vas deferens (the organ transporting sperm into the urethra) was damaged by this injury. It is also for patients with congenital malformation of vas deferens. In men who do not produce sperm there is also lack of cells in the epididymis.

MESA – The procedure is performed under general anaesthesia on an outpatient basis and takes about 1 hour. The access to the epididymis is obtained by about 15 mm cut in the scrotum. The epididymis is pulled into the wound and extended channels are seeked under optical magnification (10-20 times higher). If they contain sperm, they optically have a typical yellowish colour. After selecting the collection point, the content of a dilated duct is punctured and aspirated by a thin needle into a sterile set and immediately forwarded to the laboratory and then tested under high magnification for the count, motility and morphology. Based on the assessment of the quality and quantity of the sperm obtained, it is then recommended either to change the point of collection or repeat collection from a successful place. This procedure is repeated until enough sperm is collected for immediate use or for freezing. The performance ends upon the embryologist’s order after a sufficient sperm yield from punctatum.

PESA– it is a similar method as MESA. Sperm is obtained from the epididymis, but the liquid is aspirated through the skin (percutaneously). This method allows the patient to avoid the cut in the scrotum. The method is faster and can be performed under local anaesthesia. Its main disadvantage is lower sperm quality.

TESE – Testicular Sperm Extraction

It is the method of choice for patients with non-obstructive azoospermia whose primary cause of the absence of sperm in the ejaculate is in the testicle, e.g. patients with Klinefelter's syndrome, patients after testicular inflammatory diseases, etc. The TESE is also performed in the case when no sperms have been obtained by PESA/MESA.

TESE - is a microsurgical method where after opening the scrotum the testicle is subsequently cut open "like a book". Then, under an operating microscope, tubules containing sperm are searched for. They are easily recognizable - the white colour distinguishes them from translucent empty tubules. Testicular tubules are taken out and directly passed to the laboratory, where under large microscope magnification sperm or its developmental stages are searched for. This method needs 5-10 samples. If the sex cells are not yet fully developed, they are further cultured. Although this procedure is more invasive, it is simple and ultimately less traumatic than multiple minor collections from the testicle (biopsy). The procedure is performed on an outpatient basis in a short general anaesthesia. An alternative to the TESE method is TESA (Testicular Sperm Aspiration), in which the testicular tissue is not picked up, but aspired with a thin needle. The method is less invasive. The quality of sperm obtained is roughly the same as in TESE and this method is therefore suitable for the treatment of obstructive azoospermia. It can also be used for the forms of obstructive azoospermia, but the quality of such obtained sperm puts it to the third method of choice after MESA and PESA. When evaluating the results, TESE is far ahead of TESA.

Risks of sperm collection

Prior to in vitro fertilization using the sperm retrieved by the MESA or TESA methods, a man should undergo genetic testing as azoospermia is often caused by genetic defects, chromosomal defects or mutations, such as in cystic fibrosis. MESA is a method with minimal complications. All other methods such as PESA, TESA and TESE are complicated by postoperative pain in the scrotum which is often hypersensitive to touch and friction. The postoperative phase can get complicated by infection or quite common haematoma. Men are often afraid of testicular injury when having the TESE performed, but their worries are totally pointless because the tissue removed by the surgeon is very small and the ulosis does not harm the testicles in any way. The procedure has no negative effect on testicular hormonal function (production of male sex hormones) and does not affect erection (penile erection).

The specialized andrology care is not covered by public health insurance. We always inform the patient of the cost in advance, before making an appointment.