Male infertility refers to the disease of the male reproductive system which leads to difficulty or inability in conceiving, depending on the underlying causes. The male reproductive system is responsible for the production of male sex hormones in addition to the synthesis, transport, and ejaculation of sperms (male sex cell). Any alteration in the concentration, delivery or genetics of the sperm may result in male infertility. A normal sperm count should be in the range of 15 to 200 million per mL of the ejaculate. Lower sperm count is known as oligospermia while zero sperm count is called azoospermia. Azoospermia causes can be divided into two major groups: Obstructive and Non-Obstructive. Non-obstructive azoospermia (NOA) is the more common of the two. NOA results in lower or no production of sperms, which in turn can be due to the presence of varicocele i.e. damage in the valves of the veins surrounding the testes. Varicocele azoospermia is reported in about 14% of the cases leading to male infertility. Most people still maintain an impression that the female in the couple shoulders the total blame for not being able to conceive. Nevertheless, data concludes that in over 30% to 50% of cases of infertility, the male factor is either the sole reason or at least plays a partial role in the inability to achieve pregnancy. It is, therefore, important to consider ruling out symptoms of infertility in both, the man and the woman, before moving on to alternate options for becoming parents.
How does varicocele azoospermia cause Infertility?
The primary reproductive organ in the male reproductive system is the testes, which are situated outside the body, along with the scrotum and the penis. Sperms are generated in the testes and the production of primary sex hormone, testosterone is also at this site. The anatomy of the human body at every hierarchy is such that the form follows function. Since spermatogenesis and maintenance of sperms require a temperature below 98.6 °F, major male reproductive organs are situated outside the body. Additionally, the scrotum also ensures temperature control around the testes. Understanding homeostasis of temperature in the testes is important to rationalize varicocele azoospermia. Varicocele causes a temperature elevation of the testes, and an accumulation of deoxygenated blood also results in the generation of oxygen free radicals, threatening the genetic integrity of the sperms. The sperm count may greatly be affected because of the varicocele, but varicocele repair can restore fertility in men.
Varicocele and azoospermia repair – There’s always a solution
In most cases, the patient realizes they have azoospermia once they go through several failed attempts at intentional conceiving and have ruled out everything else. Although specific azoospermia symptoms are not as prominent, the symptoms of underlying conditions may present themselves. In the case of varicocele azoospermia, a slight discomfort/pain and swelling around the testes are the eminent signs. Once azoospermia is confirmed in a patient, there is no need for them to panic, especially if this is due to varicocele. Varicocele infertility is reversible in most cases. If the underlying cause of azoospermia is varicocele, then azoospermia and varicocele repair can go hand in hand. To diagnose varicocele, a special Scrotal Doppler ultrasound is performed, which requires the patient to be examined first in a lying position and then in a standing position. To build intra abdominal pressure that allows for an easy visualization of any enlarged veins, valsalva maneuver is performed. This is a method wherein the patient is asked to take a deep breath, hold it and apply pressure downwards, similar to that when defecating, and then start breathing out. Last but not the least, It is substantial that a DNA fragmentation test of the sperm is also conducted to assess the extent of DNA damage and viability remaining in the sperms.
3-D Precision Guided Endovascular treatment
Azoospermia treatment in Pakistan which is linked to varicocele has long been rendered outdated due to its invasive and recurrent nature. The best varicocele treatment in Pakistan to reverse azoospermia is conducted by Dr Imtiaz Ahmad. One of the most versatile and successful approaches towards azoospermia and varicocele repair is the 3-D precision-guided endovascular treatment, which is a non-surgical procedure involving embolization and has been introduced in Pakistan by Dr Imtiaz Ahmad, a pioneer of this technique. No incisions or general anesthesia is required during the 45–60-minute procedure. To begin, a microcatheter is passed through the femoral or the jugular vein and guided under live x-ray imaging towards the testicular/gonadal vein. A contrast dye is then introduced to visualize the damage in veins, which enables an easy correction procedure. FDA approved drugs, that can only be released to and administered by licensed physicians in the US, are used to perform the embolization of the faulty veins. Once the blood is stopped, it flows through a different vein along the normal route, only this time, the varicocele is not disturbed and complications like azoospermia are, thus, solved. The patient is examined and sent home the same day, in most cases. The entire procedure has gained a lot of patient compliance as opposed to the surgical techniques, where the recovery time, alone, is of 2 to 3 weeks. Reports have suggested sperm count improvement in about 83% of patients post embolization method, versus 63% via surgical ligation.
Azoospermia does equate to zero sperm count, but it does not translate into an absolute possibility of never being able to have biological children. Males must be mindful about the activities that involve straining their reproductive organs, including sports. Additionally, knowing the logical reasoning behind the optimal temperature required for spermatogenesis, one must avoid wearing garments that are too tight, making frequent visits to the sauna or other habits that may alter the thermal homeostasis of the testes. These are some of the pointers that should help prevent azoospermia. As a rule of thumb, the health of a person largely depends on their dietary and lifestyle habits. These may not present their pros or cons immediately, but irreversible effects become prominent with age.
Information about Gamma block bariatric arterial embolization treatment strategies. Treatment of obesity and saying goodbye to the extra inches shaking your confidence. Bariatrics is a field which studies therapies pertaining to weight loss and management. This includes surgical procedures and behavioral therapies. Gamma block bariatric arterial embolization treatment strategies (Dr Imtiaz Ahmad is the pioneer of this technique and named it as Gamma block bariatric arterial embolization in Nov 2017 after performing the first ever Gamma block bariatric arterial embolization procedure in Karachi Pakistan)also fall under the umbrella of this field and is a modern approach towards treatment of obesity. Approximately, 39% of the world’s adult population is suffering from either obesity or being overweight.
A person is regarded as obese if his/her body mass index (BMI) is greater than 30kg/m2 in which case, they can make good use of Gamma block bariatric arterial embolization treatment strategies. Obesity may occur due to metabolic dysregulation which could be genetic, lack of physical inactivity, diseases such as PCOS in women or simply because of overeating. Making balanced lifestyle choices is the way forward towards losing all that extra weight.
However, many men and women try to fight obesity by incorporating these lifestyle changes but are often demotivated by the weighing balance’s consistent reading. This may be due to a disease, medication, or psychological stress. Bariatric surgery for weight loss is often advised to people that are suffering from diseases that have either occurred due to obesity or are getting much worse because of it. These patients may have a BMI of 35–40 kg/m2 which is alarming and must be addressed in due time. Bariatric surgery has been around since a while and has proved beneficial. Average weight loss with bariatric surgery has been about 5 to 15 pounds in only the first 30 days. However, bariatric surgery is invasive and therefore, variations to the procedure have been introduced under interventional radiology.
What are the health risks following Obesity?
Obesity imposes several health risks and becomes the starting point of multiple chronic diseases. Ranging from metabolic dysfunctionality to cardiovascular and respiratory diseases, obesity is a defining factor in their progression. It is easy to understand why excess fat in the body would be so detrimental to health. Greater body mass affects almost every part of the body, from bones to muscles and from heart to brain, every organ faces the consequence. Risk of getting diabetes mellitus type 2, hypertension, osteoarthritis, coronary heart disease, respiratory problems, and some cancers, increase manifolds because of obesity. Moreover, in the recent age of social media, selfies, and fashion, being overweight or obese also contributes towards lower self-confidence, eventually leading a person into depression. Health risks following obesity and increasing mortalities have shifted attention towards studying ways in which weight could be reduced or the process of weight reduction could be hastened.
Treatment Of Obesity
The most obvious treatment plan for losing weight is to strike a balance between physical activity and healthy eating. It is no secret that losing weight is less about what you do to shed it and more about how consistently you are doing it. It is a lifestyle shift and being aware of the choices you make in your day-to-day routine. Special diets include intermittent fasting, calorie restricted diet and keto diet, to name a few. Most people require external help for their weight management where specialists plan a personalized routine for a person and conduct sessions to check up on the progress. Weight management programs under a specialist have proven more beneficial than being on your own and trying to lose weight since there is little accountability in the latter case.
Unfortunately, in some cases, a good diet and greater physical activity is also ineffective. Weight loss medicines and devices are advised to people who do not respond to management therapies, but it comes as no surprise that anti-obesity medications come with their fair share of side effects. Additionally, bariatric arterial embolization for weight loss has gained attention as being a minimally invasive procedure for obese people with comorbidities.
Gamma Block Bariatric Arterial Embolization
While the main cause of obesity remains ambiguous, hormones have been linked with controlling hunger, appetite, and weight gain by signaling the brain. Some of the hormones involved in the appetite regulation include oxyntomodulin, cholecystokinin, adiponectin, and ghrelin. Ghrelin is a hormone made from peptides and is released from the PD1 cells of the fundus, which is an important part of the stomach. Release of ghrelin is directly proportional to the food intake. Studies show that hunger increases on administration of ghrelin in subjects and during fasting or weight loss diets, levels of ghrelin rise, while once the hunger is quenched, ghrelin levels decrease. This variation points towards its role in hunger management.
The decrease in ghrelin level has been reported after bariatric surgery and believed to be associated with the weight loss process. Understanding the role of ghrelin is important to rationalize the bariatric embolization procedure which is an improved version of bariatric surgery. Fundus contributes to producing 90% of the ghrelin in the body. Blood supply to the fundus of the stomach is through the left gastric artery. right gastroepiploic artery and Short gastric arteries.
Dr Imtiaz Ahmad is the pioneer of Gamma block bariatric arterial embolization
procedure. This is a highly improved and precision guided procedure in which three blood vessels supplying the gastric funds are targeted as compared to rest of the world where only 1-2 blood vessels are targeted. The first ever “Gamma-Block” was performed in Pakistan in the month of Nov 2017. Patient was a 55 year male who lost approximately 67 pounds over a period of 3 months.
The procedure is a non-surgical alternative to bariatric surgery and does not involve the removal of any part of the digestive system. This aspect makes it minimally invasive yet achieves a similar goal to that of bariatric surgery. Gamma-block procedure is performed under image guidance. Catheter is introduced through the radial or the femoral artery to reach the left gastric artery,right gastro-epiploic artery followed by short gastric arteries supplying the Gastric fundus . Once image guidance confirms the correct position, embolization of the arteries is performed to disrupt the blood supply to the fundus. where “Hunger Center” The 90% ghrelin released from the” Hunger Center” located in gastric fundus causing hunger and overeating in already obese people is now “significantly”inhibited. Weight loss and management now yields much more promising results.
It is crucial to understand that while bariatric arterial embolization alone can prove quite effective, for an enhanced outlook, lifestyle changes and pharmacotherapy may become adjuvant to the treatment. It is helpful to remember that sometimes a loss is also a gain.
Penile venous insufficiency or corporal veno-occlusive dysfunction, commonly known as venous leak is often a consequence of a vascular disease since the vascular network is well connected throughout the body. Vascular diseases comprise faults in vessels, veins or arteries but may also influence the blood flow to different tissues. To understand venous leak, the mechanism of tumescence, or erection must first be understood. Under normal physiology during tumescence, the blood inflow to the penis is faster than the outflow due to arterial dilation and venous occlusion, helping sustain the state of erection. One of the causes of not being able to do so is venous leak, wherein the blood that must be stored in the sinusoids from a few minutes up to half an hour, leaves too quickly, much like a bottle of water with a hole in it. This happens due to inefficient sinusoidal relaxation and expansion which results in a poor attempt to close the emissary veins that drain the sinusoids. The process of constricting blood outflow under normal physiology is known as veno occlusion but the failure of it may be due to venous leak. Venous leak has been attributed to being the most common cause of venogenic impotence or erectile dysfunction (ED) in men but cannot always be concluded as the sole reason for impotence, owing to a multiplex of factors involved. Statistically, one in five men suffer from ED and seek venous leak easy treatment after they notice venous leak symptoms. Such men may complain about abnormality in tumescence but experience a normal libido, otherwise.
What Causes Venous leak?
Venous leak may occur in men eventually over the course of life but can also be congenital, meaning, faults in the venous drainage system around the penis may be persisting since birth. The pathophysiology of a venous leak is rather ambiguous, to date, however, studies have found venous leak to be of a more common incidence in elderly men, men with diabetes mellitus, or those who have undergone prostatectomy, hormone therapy and radiation therapy. Causes of a venous leak may also include accidents and physical injury. Interestingly, many men seeking treatment for erectile dysfunction end up finding diseases they are at a risk of developing and would have, otherwise, found out once the symptoms had worsened. It is, therefore, crucial for the overall well-being of a man to reach out to a specialist rather than shying away from the symptoms of venous leak erectile dysfunction.
Venous Leak Symptoms and Diagnosis
The most obvious symptom of a venous leak is facing difficulty in maintaining tumescence. This may include a short span of erection, not being able to get one at all, difficulty sustaining it unless manual stimulation is provided, penis shrinkage (Peyronie’s disease), or cold glans syndrome wherein the vascular structure forming at the tip of the penis called glans, does not fully swell during tumescence.
Psychogenic factors leading to erectile dysfunction are first ruled out and history taking is streamlined to include only organic causes. If the specialist suspects a venous leak in the patient, a penile doppler ultrasound is performed. The procedure first requires the administration of a Vasodilator that causes an erection as the blood flows and fills the sinusoids in the penis. An ultrasound probe is then kept in a longitudinal arrangement (from tip to the belly) and is used to record the velocities of inward and outward blood flow at regular intervals. Ideally, the inward blood flow velocity(systolic) should be 25 to 35 cm/s and outward flow velocity(diastolic) of less than 3-5 cm/s is regarded as normal. In case of lesser values of systolic velocity, an arterial disease may be diagnosed while diastolic diseases like venous leak can be concluded if velocity is greater than 5cm/s. Venous leak cure foundations on finding the location of the leak and is a complex process. Additionally, certain blood tests are also performed to have a clear idea about the hormone levels and other comorbidities. Once venous leak is suspected over the doppler ultrasound, cavernosometry and cavernosography may be performed to locate specific sites of venous leak.
Venous Leak Treatment Options
Treatment approach largely depends on a lot of factors such as age and comorbidities. The first choice of treatment is the administration of PDE-5 inhibitors like Cialis, Viagra and Stendra, to help alleviate the symptoms, however, they have a lower success rate, regardless. Additionally, sclerosing agents may also be administered to achieve tumescence. Being the most common approach towards venous leak treatment, surgical treatment options available are not only invasive but also criticized for having a very low success rate (approximately 25%). The ligation of veins results in a painful state of erection post-surgery along with high recurrence and is therefore, frowned upon as an approach towards venous leak treatment.
Non-Surgical Treatment for Venous Leak
Venous Leak treatment in Pakistan is being conducted by Dr Imtiaz Ahmed and is a non-surgical, minimally invasive procedure to treat venous leak erectile dysfunction. Men who are young and respond, certainly not very well, but to some extent to PDE5 inhibitors are strongly advised to undergo venous leak non-surgical treatment. The non-surgical endovascular treatment takes on two main approaches: antegrade and retrograde. Both approaches aim to embolize the peri-prostatic venous plexus along with other veins that may seem irregular in shape or function. Antegrade endovascular treatment is performed via the deep dorsal penile vein while retrograde treatment involves transfemoral path via the internal iliac vein. Fluoroscopic guidance helps the catheter reach the selective veins after which glue therapy is performed using specialized FDA approved drugs. Out of the two approaches, specialists prefer using the antegrade approach, which provides a much straighter route to the periprostatic veins. The non-surgical treatment for venous leak is a complex and challenging procedure which requires expertise in the field.
