ABSTRACT

CORRESPONDING AUTHOR:
Dr. Mandakini T. Kotaiah,
Plot No. 123, Ravi Society,
Mahindra Hills, East Marredpally,
Secunderabad-500026, Telangana State.
E-mail: mandakinikt14@gmail.com

­­­­ABSTRACT: AIM: To evaluate the Tubular Fertility Index in children with undescended testis and assess its correlation with age, laterality and location of testis. MATERIALS AND METHODS: Children with undescended testis located in the inguinal canal and superficial inguinal ring were recruited over a period of 30 months. Single stage standard open orchiopexy was done in all patients during which a testicular biopsy was taken from the affected side. Under light microscopy 100 seminiferous tubules were counted and the number of tubules containing germ cells was expressed as tubular fertility index. In children with bilateral undescended testes, mean of TFI of both sides was calculated. TFI was statistically correlated with patient’s age, laterality and location. RESULTS: Total of 31 patients (Median age: 5yrs, range 1.3-12) were included. Of them, 27(87%) had unilateral and 4(12.9%) of them had bilateral undescended testes. 21(67.7%) patients had testes located in the inguinal canal while 10(32.2%) had testes located at the superficial inguinal ring. Mean (±SD) TFI was 25.37(±9.17). Though there was a trend towards negative correlation between age and TFI           (r=-0.22), it was not statistically significant (p=0.2). There was no statistically significant correlation between TFI and unilaterality or bilaterality of undescended testes (p=0.2). There was a highly significant correlation (r=0.79, p=<0.001) between TFI and location of testis. CONCLUSION: TFI in children with undescended testis is lower than that in normal children. TFI and hence, the fertility potential appear to be better in children with testis located in the superficial inguinal ring than in the inguinal canal.

KEYWORDS: Tubular Fertility Index, Undescended Testis.

INTRODUCTION: Undescended testis is one of the common conditions that we encounter as pediatric surgeons. The incidence of undescended testis is 3-5% in all male neonates.¹ The histological appearance of the undescended testis show pathological differences from that described for the normal testis and early changes have been identified as early as 6 months of age by electron microscopy.² Tubular Fertility Index is the percentage of seminiferous tubules containing germ cells.³ TFI appears to closely correlate to location of testis.

MATERIALS AND METHODS: 31 boys below the age of 12 years who presented with undescended testis located in the inguinal canal or superficial inguinal canal were recruited over a period of 30 months between Jan 2006 to April 2008. All children underwent standard open orchidopexy along with testicular biopsy from the affected side. Biopsy was sent to the pathology laboratory in Bouin’s solution. With the help of the pathologist Tubular Fertility Index was determined using light microscopy with 40x magnification.

100 seminiferous tubules were counted and the percentage of seminiferous tubules that contained germ cells were noted and recorded as Tubular Fertility Index (Figure 1). In children with bilateral undescended testes, mean of TFI was calculated. TFI was statistically correlated with child’s age, laterality and location of the testis.

Figure.1: Histopathological picture showing spermatogonia in seminiferous tubules in a 2 year boy.

Figure-1

RESULTS: All children below 12 years who presented with undescended testis located in the inguinal canal and superficial inguinal ring were included in this study. Children with undescended testes in any other location other than the mentioned above locations, associated anomalies, ambiguous genitalia were excluded. 31 boys (median age: 5years range 1.3-12) were considered. The youngest was 15months old and the oldest was 12 years old. Of them, 27(87%) had unilateral and 4(12.9%) had bilateral undescended testes. 21 (67.7%) patients had testis located in the inguinal canal while 10(32.2%) had testis located in the superficial inguinal ring. Mean (±SD) TFI was 25.37(±9.17).

Children below 2 years had better TFI when compared to older than 2 years. Though there was a trend towards negative correlation between age and TFI (r=-0.22), it was not statistically significant (p=0.2). Children with bilateral undescended testes had lower TFI when compared to those with unilateral undescended testis. There was no statistically significant correlation between TFI and unilaterality and bilaterality of undescended testis (p=0.2). The average TFI in the group who had undescended testes located in the superficial inguinal ring was 35.75 (range 15-45) which was better than the children inguinal undescended testes with 20.4 (range 10-28). There was a highly significant correlation (r=0.79, p=<0.001) between TFI and location of testis.

DISCUSSION: The two negative outcomes associated with cyrptorchism are infertility and malignancy.⁴ in bilateral cyrptorchidism the incidence of infertility is 56% and in unilateral it is 8%.

Nistal et al.⁵ found that TFI in infancy compared with spermatogeneitic development in adulthood, provided the most precise information regarding germ cell evolution after puberty.

Our study revealed an average TFI of 25.37 (10-28). Normal testes have a TFI of 100% at the age of 15.³ Studies have shown children with cyrptorchidism show a decrease in the spermatic index.⁶ by 15 months -18 months of age with a markedly critical low value of spermatic index by 8-9 m of age.

However in our study we found that there was a decrease in TFI (21.58) in children older than 2 yrs. although not significant, which correlates with Wilkerson’s study.⁶

Our study comparing the location of the testis to TFI shows that the test is located near the superficial inguinal ring (35.75) had a better TFI compared to those located near to the deep ring (20.4). Farrington.⁵ et al showed the TFI in testis at superficial inguinal ring was 42.4%. Wilkerson et al⁶ showed there was no difference in the fertility potential in intra-abdominal testis compared to intracanalicular testis up to age of 5 years but they showed a marked decrease in spermatic index 8-9m.

The TFI in those children with bilateral disease (18.4) was lower than those with unilateral cyrptorchidism (26.4). This compares to studies by showing decreased fertility in bilaterally cyrptorchid males.⁴ they have shown that the paternity rate for bilateral cyrptorchid patients was 65.3% compared to unilateral 89.7%.

They also found that all patients with history of bilateral cryptorchism had sperm counts well below normal with a mean of 5.20 million sperm/ml compared to unilateral 42.5 million/ml.

There are five milestones of germ cell maturation1. Gonocytes appear at 8 weeks of gestation, 2. Spermatogonia represent at 15 weeks of gestation, 3. Adult’s dark spermatogonia appear at 3 months of age and remain for the rest of their life, 4. Primary spermatocytes (forst meiotic form) appear at 4 years of age and 5. Spermatogenesis begins are puberty.²

Normal total germ cell counts are dependent upon the two steps in maturation of germ cells that normally occur in prepeubertal testis. First at 2-3 months there is surge in gonadotrophin and testertosterone (Mini puberty) that triggers the transformation of the fetal stem cell pool (Gonocytes) in to the adult sperm cell pool (Adult dark spermatogonia). At 4-5 years there is rise in urinary LH which is associated with Adult dark sperm cell in primary spermatocytes (Onset of meiosis). These steps are deficient in cryptorchid patients brining down their fertility inspite of a successful orchidopexy.¹ There are studies which recommend the use of gonadtorphin releasing hormone therapy in adjuvant to orchidopexy to increase fertility potential.

CONCLUSION: Tubular Fertility Index (TFI) in children with undescended testes is lower than that in normal children. Despite noticeable trends, we could not statistically demonstrate that TFI decreases with increasing age, probably because most of our patients were older than 2 years. Our study does not show any significant difference in TFI of children with unilateral or bilateral undescended testes.

                The fertility potential appears to be better in children with testis located in the superficial inguinal ring than in the inguinal canal. The stages of spermogenesis are impaired in cryptrochidism. Surgery alone will not suffice to improve fertility. There are current studies.^1,4,7,8,9 showing the addition of gonadotrophin releasing hormone therapy to improve fertility potential. We recommend there need to further study the long term outcome of adjuvant therapy in cyrptorchid patients.

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