Testicular cryptorchidism, cryptorchism, cryptorchidism, retained testis, unilateral cryptorchidism. bilateral cryptorchidism
A testis absent from the normal scrotal position can be found:
In addition to quite common congenital forms, other – rare forms exist:
Undescended testes are associated with reduced fertility, high rate of anomalies of the epididymis, increased risk of testicular germ cell tumors, and psychological problems when the boy is grown. Undescended testes are also more susceptible to testicular torsion and infarction, and inguinal hernias. To reduce these risks, undescended testes are usually brought into the scrotum in infancy by a surgical procedure called an orchiopexy.
One of the strongest arguments for early orchiopexy is prevention of testicular cancer. About 1 in 500 men born with one or both testes undescended develop testicular cancer, roughly a 4 to 40 fold increased risk. The peak incidence occurs in the 3rd and 4th decades of life. The risk is higher for intra-abdominal testes and somewhat lower for inguinal testes. The most common type of testicular cancer occurring in undescended testes is seminoma (65%); in contrast, after orchiopexy, seminomas represent only 30% of testis tumors.
It is usually treatable if caught early, so urologists often recommend that boys who had orchiopexy as infants be taught testicular self-examination, to recognize testicular masses and seek early medical care for them. Cancer developing in an intra-abdominal testis would be unlikely to be recognized before considerable growth and spread, and one of the advantages of orchiopexy is that a mass developing in a scrotal testis is far easier to recognize than an intra-abdominal mass.
Risk factors include premature birth, genetic predisposition, small-for-gestational-weight (SGA), birth weight < 2500 g as well as environmental factors (nicotine, alcohol, pesticides) and endocrine disorders (e.g. disrupted hypothalamic-pituitary-gonad axis). 10 % of the cases are bilateral and are commonly associated with complex syndromes or other congenital malformations such as abdominal wall defects or neural tube defects.
At least one contributing mechanism for reduced spermatogenesis in cryptorchid testes is temperature. The temperature of testes in the scrotum is at least a couple of degrees cooler than in the abdomen and the temperature rising may damage fertility. Some circumstantial evidence suggests tight underwear and other practices that rise testicular temperature for prolonged periods can be associated with lower sperm counts. Nevertheless, research in recent decades suggests that the issue of fertility is more complex than a simple matter of temperature. It seems likely that subtle or transient hormone deficiencies or other factors that lead to lack of descent also impair the development of spermatogenic tissue.
There is no way to prevent this condition because the exact cause is not known.
Usually, there are no symptoms other than the absence of the testicle in the scrotum (an empty scrotum.) In the minority of cases with bilaterally non-palpable testes, further testing to locate the testes, assess their function, and exclude additional problems is often useful. Pelvic ultrasound or magnetic resonance imaging performed and interpreted by a radiologist can often, but not invariably, locate the testes while confirming absence of a uterus. A karyotype can confirm or exclude forms of dysgenetic primary hypogonadism, such as Klinefelter syndrome or mixed gonadal dysgenesis. Hormone levels (especially gonadotropins and AMH) can help confirm that there are hormonally functional testes worth attempting to rescue, as can stimulation with a few injections of human chorionic gonadotropin to elicit a rise of the testosterone level. Occasionally these tests reveal an unsuspected and more complicated intersex condition.
European Society of Paediatric Urologists' (ESPU) is in favour of using gonadotrophin releasing hormone (GnRH) analogues to improve fertility in boys with undescended testis, particularly in those with bilateral disorders. Although the number of studies is limited and patient numbers are relatively low, GnRH analogues (in some studies used in combination with hCG) do appear to have a statistically significant beneficial effect on fertility indices both when used before orchidopexy and after. A series of human chorionic gonadotropin (hCG) injections (10 injections over 5 weeks is common) is given and the status of the testis/testes is reassessed at the end. Hormone treatment does have the occasional incidental benefits of allowing confirmation of Leydig cell responsiveness (proven by a rise of the testosterone by the end of the injections) or inducing additional growth of a small penis (via the testosterone rise, if the defect in the hypothalamic-pituitary-gonadal axis was present).
In the absence of testosterone generated by Leydig cells or in the case of non functional or absent androgen receptors, testicular descent is arrested at inguino-scrotal stage. In boys, testosterone replacement is initiated most frequently with testosterone enanthate 50 mg per month intramuscularly, with increasing dose every 6 months until 250 mg is given every 3 weeks in the third year. While testosterone treatment effectively induces virilisation including penile growth, pubic and male hair and beard growth, change of voice, libido, and pubertal growth spurt, testicular volume remains small, lacking spermatogenesis. LH stimulates intratesticular testosterone secretion by Leydig cells inhibiting Anti-Müller’s hormone production of the Sertoli cells, FSH induces testis growth via proliferation of seminiferous tubules, and both stimulate Inhibin B secretion by the Sertoli cells and sperm maturation.
Orchiopexy (or orchidopexy) is a surgery to move an undescended (cryptorchid) testicle into the scrotum and permanently fix it there. Orchiopexy typically also describes the surgery used to resolve testicular torsion. The undescended testicle may be located within the normal line of descent (for example, in the inguinal canal) or high in the scrotum or ectopically (i.e. the abdomen). During laparoscopy the surgeon uses an endoscope through the umbilicus to locate the testicle, and through other small opening(s) performs the procedure to complete the orchiopexy. The higher the testicle, the less successful the procedure. However, the procedure has a high success rate overall. In the open orchiopexy, if the testis isn’t found in the inguinal canal, a retroperitoneal and intraperitoneal exploration is carried out through the deep ring. In both approaches, the viable testis is brought down into the scrotum by mobilization of the spermatic pedicle; spermatic vessel ligation isn’t employed in any patient in this series. The finding of blind-ending vas and vessels indicated vanishing testis and further exploration is abandoned after removal of the nubbin of tissue at the termination of the vas and vessels. The considered atrophic testes are removed.
The incidence of azoospermia in unilateral cryptorchidism is 13% and this figure increases to 89% in untreated bilateral cryptorchidism, making cryptorchidism the most common etiologic factor of azoospermia in the adult. A major advancement in recent years has been the introduction of IVF with ICSI which allows successful fertilization with the sperm obtained directly from testicular tissue. IVF-ICSI allows for pregnancy in couples where the man has irreversible testicular azoospermia as long as it is possible to recover sperm material from the testes. Pregnancies have been achieved in situations where azoospermia was associated with cryptorchism and sperm where obtained by testicular sperm extraction (TESE).
Complete absence of sperm in the ejaculate of a man.
The inability (that lasts more than 6 months) to develop or maintain an erection of the penis during sexual activity.
The set of symptoms that result from two or more X chromosome in males.
A genetic condition where the primary symptom is a failure to start puberty or a failure to fully complete puberty.
Complete absence of sperm in the ejaculate due to testicular failure.
Semen with a low concentration of sperm and is a common finding in male infertility.
A medical term which describes a diminished functional activity of the gonads – the testes and ovaries.
Antibodies that bind to sperm, inhibiting their movement, stopping recognition and entry into the egg.
Cancer that develops in the testicles.
Emergency medical condition occurring when the spermatic cord twists and cuts off the testicle's blood supply.
A condition in which fertility impairment occurs spontaneously or due to an unknown cause.
An accumulation of clear fluid in the tunica vaginalis, the most internal of membranes containing a testicle.
A rare disorder characterized by a phenotypic female with an XY karyotype.
Any congenital developmental disorder of the reproductive system characterized by a progressive loss of germ cells on the developing gonads.
Decreased functional activity of the gonads, with retardation sexual development, associated with high levels of hormones that stimulate the gonads.
The epididymis is a tube that connects a testicle to a vas deferens in the male reproductive system.
A region of the forebrain that regulates body temperature, some metabolic processes and governs the autonomic nervous system.
An endocrine gland, about the size of a pea, whose secretions control the other endocrine glands and influence growth, metabolism, and maturation.
Scrotum is an anatomical male reproductive structure that consists of a suspended sack of skin and smooth dual-chamber muscle located under the penis.
Tube structures within the testes where spermatogenesis occurs.
Male gonads which produce both sperm and androgens, such as testosterone, and are active throughout the reproductive lifespan of the male.
The cell found in interstitial tissue of testicles responsible for production of androgens - male hormones.
The cell in seminiferous epithelium responsible for nutrition and development of germ (sperm) cells.
An undifferentiated male germ cell with self-renewing capacity representing the first stage of spermatogenesis.
A hormone, that provokes the regression of male fetal Müllerian ducts.
FSH is a hormone secreted by the anterior pituitary gland. It regulates the development, growth, pubertal matur and reproductive functions of the body
A releasing hormone responsible for the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary.
A hormone, that stimulates ovulation and the development of the corpus luteum in females, and the production of androgens in males.
Steroid hormone, secreted by the ovaries, whose function is to prepare the uterus for the implantation of a fertilized ovum and to maintain pregnancy.
Steroid hormone produced primarily in the testes of the male; responsible for the development of secondary sex characteristics in the male.
The fusion of an ovum with a sperm to initiate the development of a new individual organism.
Process in which spermatozoa are produced from male primordial germ cells in testicles by way of mitosis and meiosis.
A protrusion of abdominal-cavity contents through the inguinal canal.
A congenital condition characterized by the disruption of fetal testicular development.
Birth of the baby before 37 completed weeks of gestational age.
A normal sperm morphology of less than 4% of sperms in an ejaculate.
The medical condition of a man whose semen contains no sperm.
A birth defect of the urethra in the male where the urinary opening is not at the usual location on the head of the penis.
A condition in which spermatozoa in semen are either immobile or dead.
The failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.
A condition refers to semen with a low concentration of sperm.
A condition in which a man has an unusually low ejaculate (or semen) volume, less than 1.5 ml.
The decreased ability of sperm cell to move progressively.
Abnormally small testicular volume.
The absence of one or both testes from the scrotum.
Process by which a woman donates eggs for purposes of assisted reproduction or biomedical research.
A micromanipulative fertilization technique in which a single sperm is injected directly into an egg.
Surgery to move an undescended testicle into the scrotum used as a treatment of cryptorchidism.
Hormonal replacement therapy, which is used as a therapeutic option for undescended testicles.
The term PGS is used to denote procedures that do not look for a specific disease but to identify embryos at risk of de-novo occurring aneuploidies
The procedure in which a man (sperm donor) provides his sperm for fertility treatment.
A process in which an egg is fertilised by sperm outside the body: in vitro. Own or donated gametes may be used.