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Testicular Strain Elastography in Fertile and Infertile Men- a Comparative Cross Sectional Study

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Testicular Strain Elastography in Fertile and Infertile Men- a Comparative Cross Sectional Study TESTICULAR STRAIN ELASTOGRAPHY IN FERTILE AND INFERTILE MEN- A COMPARATIVE CROSS SECTIONAL STUDY Dissertation submitted to THE TAMILNADU Dr.M.G.R. MEDICAL UNIVERSITY In partial fulfillment of the requirements Of M.D. DEGREE EXAMINATION BRANCH- VIII- RADIODIAGNOSIS GOVT KILPAUK MEDICAL COLLEGE CHENNAI- 600010 THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY CHENNAI- TAMILNADU, INDIA MAY 2020 CERTIFICATE This is to certify that the dissertation “TESTICULAR STRAIN ELASTOGRAPHY IN FERTILE AND INFERTILE MEN- A COMPARATIVE CROSS SECTIONAL STUDY” titled submitted by Dr. AKASH KUMAR. B.Y appearing for M.D (RADIODIAGNOSIS) degree examination in May 2020 is a bonafide record of work done by him under my guidance and supervision in partial fulfillment of requirement of the TamilNadu Dr.M.G.R. Medical University, Chennai. I forward this to the TamilNadu Dr.M.G.R Medical University, Chennai. Dr.J.DEVIMEENAL,MD.,DMRD.,DNB Dr. P. CHIRTRARASAN, MDRD Guide Guide, Professor & Head of Department, Associate Professor, Department of Radiodiagnosis, Department of Radiodiagnosis, Govt Kilpauk Medical College & Hospital, Govt. Kilpauk Medical College, Kilpauk, Chennai- 10. Chennai-600010 Prof.Dr. P. VASANTHAMANI, M.D., D.G.O.,MNAMS.,DCPSY.,MBA DEAN, Govt Kilpauk Medical College, Chennai-600010 DECLARATION I, Dr. AKASH KUMAR. B.Y, solemnly declare that this dissertation “TESTICULAR STRAIN ELASTOGRAPHY IN FERTILE AND INFERTILE MEN- A COMPARATIVE CROSS SECTIONAL STUDY”is a bonafide work done by me at Government Kilpauk Medical College, under the supervision of Dr. J. Devimeenal, Professor and HOD, and Dr. P.Chirtrarasan, Associate Professor, Dept. of Radiodiagnosis, Government Kilpauk Medical College. This dissertation is submitted to the Tamil Nadu Dr. M.G.R Medical University, towards partial fulfillment of requirement for the award of M.D. Degree Radiodiagnosis. Place: Chennai Signature of the candidate Date: Dr. AKASH KUMAR. B.Y CERTIFICATE – II This is to certify that this dissertation work titled dissertation “TESTICULAR STRAIN ELASTOGRAPHY IN FERTILE AND INFERTILE MEN - A COMPARATIVE CROSS SECTIONAL STUDY” of the candidate Dr. AKASH KUMAR. B.Y with Registration Number 201718251 for the award of M.D degree in the branch of RADIODIAGNOSIS. I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion pages and result shows 7% of plagiarism in this dissertation. Guide & Supervisor sign with Seal. ACKNOWLEDGEMENT I express my heartful gratitude to the Dean, Prof.Dr.P.VASANTHAMANI,M.D.,D.G.O.,MNAMS.,DCPSY.,MBA Government Kilpauk Medical College for permitting me to do this study. I express my gratitude to my guides Prof Dr. J. Devimeenal, Professor and Head of Department and Prof Dr. P. Chirtrarasan, Associate professor, Dept of Radiodiagnosis, Govt. Kilpauk medical college for their valuable guidance in doing the dissertation work .Their encouragement created an interest for me to pursue this study .Further their constant supervision and support, that made me possible to finish this study without much difficulty. I am extremely thankful to my Professor Dr. K.GOPINATHAN, MD(RD), Associate professor Dr. K. Geetha MD(RD) and other Assistant professors of Department of Radiodiagnosis, Govt.Kilpauk Medical College, Chennai for their constant support, encouragement and advice during my study. I also thank my past and present fellow postgraduates who helped me in carrying out my work and preparing this dissertation. I thank all Radiology technicians, staff nurses, and all the paramedical staff members of our department for their co-operation in conducting the study. I thank my family members for their understanding and co-operation for completion of this work. Last but not the least; I owe my sincere gratitude to the patients and their relatives who co-operated for this study, without whom the study could not have been possible. CONTENTS 6 CONTENTS PAGE 1. INTRODUCTION 1 2. REVIEW OF LITERATURE 3 3. AIMS AND OBJECTIVES 36 4. MATERIALS AND METHODS 37 5. CASES 40 6. STATISTICAL ANALYSIS AND RESULTS 48 7. DISCUSSION 76 8. CONCLUSION 79 9. BIBLIOGRAPHY Abbreviations Proforma Patient Consent Form Patient Information Sheet Master Chart Ethical Committee Certificate Plagiarism 1 INTRODUCTION “Infertility is defined as the inability of a non-contracepting sexually active couple, to achieve spontaneous pregnancy within one year”. It affects one fifth to one sixth of couples in the reproductive age1. When compared to other species, human beings are inefficient in terms of reproduction. The fertility rate per cycle is thought to be around 20% and the accumulated pregnancy rate in those couples with proven fertility is approximately 90% after 12 months and 94% after 2 years1. In approximately 20% of infertile couples, male infertility is the sole cause, and in about 30%–40% of these couples, male and female factors are the causes. Therefore, a condition involving the male partner contributes to approximately 50% of cases of infertility. The diagnostic workup of male infertility should include a thorough medical and reproductive history, physical examination, and semen analysis, followed by imaging. Ultrasound is the first-line imaging modality which is used for the evaluation of male genital tract as it is noninvasive, safe and there is no exposure to radiation. In addition to physical examination and semen analysis, ultrasonography of scrotum may be helpful in demonstrating obstruction or testicular dysgenesis2. Its sensitivity and specificity increase even more by using Doppler. 2 Conventional ultrasonography has the limitation of only functional analysis of testicular tissue, whereas elastography is a promising technique in this field. New insights for the structural and functional evaluation of testicular tissue have been provided by the recent technical advances in ultrasound applications and post-processing developments3. Elastography was first described by Ophir et al. It is a new imaging technique which displays the images of tissue stiffness. These images that are created by elastography are thought to be an extension of the ancient palpation techniques. It gives a better information regarding the spatial localization and is also less subjective. Real time elastography, a method which shows stiffness of tissue under real time conditions demonstrates different values of elasticity dependent on volume and function of testis. Elastography assesses elasticity of testis. It is defined as the tendency of the tissue to resist deformation when a force is applied, or to resume its original shape after the removal of the force. The principle of sonoelastography is to use repeated, slight pressure on the examined organ with the ultrasound transducer. Ultrasound elastography techniques can be categorized as: 1) Strain imaging, and 2) Shear wave imaging. Here in this study, we study only the Strain elastography and its diagnostic value in male infertility. 3 REVIEW OF LITERATURE ANATOMY OF MALE REPRODUCTIVE SYSTEM: The male reproductive system consists of external (penis, scrotum, epididymis, and testes) and internal (accessory) organs. Primary functions of the male reproductive organs are: 1. Production, maintenance, transportation, nourishment and protection of the semen. 2. Discharge of sperm into the female genital tract. 3. Production and secretion of male sex hormones4. SCROTUM: It is a dual-chambered sac of skin and smooth muscle containing the testes, and is homologous to the labia majora in females. It is located between the penis and anus as an extension of perineum. In humans, increased testosterone secretion during puberty causes skin darkening and pubic hair development on the scrotum. The left testis is usually lower than the right, which functions to avoid compression when there is impact. There is also more cooling of testis due to this asymmetry4. 4 Functions of scrotum: The function of the scrotum is to maintain the temperature of the testes slightly lower than that of the rest of the body. Higher temperatures causes damage to the sperm count. The temperature is controlled by movement of the testis away or towards the body based on the temperature of environment. By moving the testes away from the abdomen and increasing the exposed surface area, there is faster dispersion of excess heat. This is achieved by the contraction and relaxation of the cremaster muscle and the dartos fascia in the scrotum. Temperature regulation is not the only function of the scrotum. It has been also suggested that if testes were located within the abdominal cavity, they would be subjected to the changes in abdominal pressure exerted by the abdominal musculature, which would result in more rapid emptying of sperm from the testes and epididymis before the sufficient maturation of spermatozoa for fertilization4. 5 Fig.1: Image of the external, muscle and deep tissue views of the scrotum4. TESTIS: The testis is the male gonad. It is homologous to ovary in females. They are components of both the reproductive system and the endocrine system. The testes produce sperm (spermatogenesis) and androgens, primarily testosterone. Luteinizing hormone results in testosterone release. The presence of both testosterone and follicle-stimulating hormone (FSH) is needed to support spermatogenesis. 6 Fig.2: A diagram of the major components of an adult human testis. 1. Tunica albuginea, 2. Septula testis, 3. Lobulus testis, 4. Mediastinum testis, 5. Tubuliseminifericortorti, 6. Tubuliseminiferi recti,
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