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Asian Journal of Andrology (2019) 21, 1–7
www.asiaandro.com; www.ajandrology.com

Open Access
ORIGINAL ARTICLE

Testicular ultrasound inhomogeneity is an

Male Fertility

informative parameter for fertility evaluation

Giorgia Spaggiari1,2, Antonio R M Granata2, Daniele Santi1,2

Testicular volume (TV) is proposed to be a positive predictor of male fertility status, because of the relation known between the
TV and the seminiferous tubule content. Independently of the measurement methodology, the role of TV and testicular ultrasound
(US) assessments is still debated in andrological clinical practice. In this retrospective cohort study, we evaluated TV and testis US
role in the diagnostic workup of andrological patients. All consecutive outpatients undergoing single-operator testis US (Modena,
Italy) from March 2012 to March 2018 were enrolled, matching sonographic, hormonal, and seminal data. A total of 302 men
were referred and evaluated for gynecomastia, suspected hypogonadism, couple infertility (CI), or sexual dysfunction. In the
hypogonadal group, TV was lower compared to that in other groups (P < 0.001), and a significant, direct correlation between TV
and testosterone level was observed in nonandrogen-treated patients (R = 0.911, P < 0.001), suggesting that testicular size could
be related to the testosterone-secreting compartment. In the CI group, normozoospermic patients showed higher TV compared to
men with impaired semen quality (P = 0.003) and azoospermia (P = 0.003). However, TV was not able to discriminate between
patients presenting normal and altered semen quality. On the contrary, testis US inhomogeneity was more frequent in patients with
impaired sperm quality (55.0%; P = 0.007) and azoospermia (40.0%; P = 0.012), compared to patients with normozoospermia
(5%), identifying thereby the sonographic pattern as an informative parameter of the fertility status. Therefore, in the CI workup,
US evaluation seems to be more informative than the TV assessment alone.
Asian Journal of Andrology (2019) 21, 1–7; doi: 10.4103/aja.aja_67_19; published online: 2 July 2019

Keywords: male hypogonadism; male infertility; testicular diseases; testis

INTRODUCTION number of seminiferous tubules contributes to about 80% of TV,

Physical examination of external genitalia is one of the most important this parameter is considered to be particularly informative of the
steps in the workup of patients undergoing andrological evaluation fertility status.9,10 Indeed, TV reduction seems to be a clinical sign
for any reason. In particular, the assessment of testicular volume of both impaired semen quality (oligo- and/or astheno- and/or
(TV), tone, and consistency provides indirect information about both teratozoospermia, detected by conventional semen analysis) and
spermatogenic and hormonal compartment, guiding the subsequent hypogonadism.11–13 Recently, a logistic regression-based nomogram
diagnostic and therapeutic choices.1 In clinical practice, TV is measured was proposed to predict hypogonadism in infertile men, based on
using Prader’s orchidometer, which provides overestimation of data derived from physical examination, such as TV and body mass
testicular size compared to ultrasound (US) assessment.2–5 Although index, and on the seminal finding of azoospermia.14 This mathematical
testis US represents the most reliable and accurate tool to evaluate TV, approach is able to predict andrological diseases with 68% of accuracy,
a strict and direct correlation between US and Prader’s orchidometer limiting its application in clinical practice.14,15 In general, the real
in volume measurements was demonstrated,4,5 justifying the use of predictive significance of TV for the andrological workup remains
orchidometer-derived TV in the clinical setting.5 unclear, considering the absence of validated cutoffs being able to
Independently of the method used, an accepted consensus about predict testicular function in relation to TV.
TV reference ranges has not been reached so far and different values Testis US assessment is recommended in the flowchart of the
have been proposed, depending on ethnic, environmental, and infertile male, according to the most recent guidelines.16,17 Alongside
geographical factors.5,6 Considering the cumulative volume of the TV measurement, the added value of the sonographic evaluation is
right and the left testes, the suggested cutoff of normality is ≥30 ml by given by the possibility to accurately examine the testicular structure.
orchidometer evaluation or ≥20 ml by US.7 Considering individual Testicular US echogenicity increases during testis maturation and
testis, the TV should be >14–15 ml by orchidometer or ≥11–12 ml the US appearance of the normal testis mimics the homogenous
by US.8 structure of the normal thyroid gland.18 However, the testis US structure
The TV relevance is due to its relationship with testicular evaluation is an operator-dependent variable5 and inhomogeneity
spermatogenic and steroidogenic capabilities.7 Since the intratesticular is defined as the absence of the uniform structure otherwise
1
Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena 41126, Italy; 2Unit of Endocrinology,
Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Ospedale Civile of Baggiovara, Modena 41126, Italy.
Correspondence: Dr. D Santi ([email protected])
Received: 10 September 2018; Accepted: 26 March 2019
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The testis US role in the andrological setting
G Spaggiari et al

characterizing normal testicular parenchyma. A 5-point grade scale Axial and longitudinal scans allowed to obtain depth, transverse,
was proposed to quantify testis US inhomogeneity.11,19 However, an and longitudinal diameter of each testis. TV was calculated using the
accepted validation of this method does not exist so far. Similarly, the ellipsoid formula: length (cm) × width (cm) × depth (cm) × 0.71.
predictive value of the US detection of microlithiasis is still debated, Although not definitely validated, we used this mathematical formula
since data about its relationship with male infertility and testicular since its superiority in the prediction of real TV was described.13
malignancy are contradictory.20–24 In such cases, a tailored follow-up of Parenchyma homogeneity/inhomogeneity is an operator-
the patients is recommended, considering the presence of further risk dependent nonobjective parameter. In 1993, Lenz et al.11 proposed
factors.25 The current clinical guidelines shifted the predictive accuracy a 5-grade scale classification of testis inhomogeneity, but in clinical
of microlithiasis from cancer detection to nonspecific structure practice, the parenchymal echostructure is heterogeneously reported.
alterations, which should be monitored over years. Thus, we chose to classify testis US echostructure into only three
With this in mind, TV and testicular US assessment could play a different categories: Type 1, testicular homogeneity; Type 2, testicular
fundamental role in the diagnostic flowchart of male infertility. The inhomogeneity; Type 3, suspected tumor (Figure 1).
aim of the present study was to retrospectively evaluate the role of testis The pampiniform plexus was evaluated during US, and the
US in the diagnostic workup of andrological patients, with a special presence of varicocele was detected both in resting conditions and after
focus on male infertility. Valsalva maneuver. When present, varicocele was graded according to
the “Sarteschi” 5-item scale (Supplementary Table 1).29
PATIENTS AND METHODS Considering epididymis, the head was detected at the upper pole of
A retrospective observational cohort study was carried out, including the testis and measured in a longitudinal scan from the top to the base
302 patients consequently undergoing US andrological examination by of the triangle.5 Epididymis body and tail were detected posteriorly to
a single operator from March 2012 to March 2018 at the Andrology Unit the testis and measured considering the anterior–posterior diameters.5
of the Department of Biomedical, Metabolic and Neural Sciences of the The vas deferens was searched as a straight duct, slightly hypoechoic
University of Modena and Reggio Emilia (Modena, Italy). All clinical compared with the epididymis, originating from the epididymal tail.5
conditions leading to andrological consultation were considered
Blood examination
eligible. Patients were clinically evaluated considering the reason for
After a fasting blood sample in the morning (8:00 a.m.), the following
referral, and proper diagnostic flowcharts were applied, according
hormonal measurements were performed in all patients: total
to clinical guidelines, recommendations, and suggestions approved
testosterone, luteinizing hormone (LH), follicle-stimulating hormone
by scientific societies.15,16,26–28 Patients referred for testicular pain or
(FSH), and prolactin serum levels. Serum total testosterone levels were
infections were excluded from the analysis. The following reasons for
measured by Chemiluminescent Microparticle Immunoassay (Architect,
referral were considered separately: gynecomastia (Group 1), suspected
Abbott, Dundee, UK), with inter- and intra-assay coefficients of variation
hypogonadism (Group 2), couple infertility (Group 3), and sexual
(CV) of 5.2% and 5.1%, respectively. The blood samples were collected
dysfunctions (Group 4). The patients’ subgrouping was not performed
approximately 3 h after the gel application in case of hypogonadal
according to the final diagnosis, but the initial clinical request. Thus,
patients under transdermal replacement therapy and 1 week before
the clinical approach was slightly different for each patient, based on
the subsequent injection in case of hypogonadal patients treated
the hypothesized andrological problem. However, in all four groups,
with testosterone undecanoate. FSH and LH were measured by
the following initial workup was performed: (1) personal and familial Chemiluminescent Microparticle Immunoassay (Architect, Abbott,
history collection, with particular attention to possible risk factors
for andrological diseases and to ongoing therapies, (2) physical and
andrological examination, (3) blood examination, (4) testicular US, and
(5) conventional semen analysis in those patients searching fatherhood.
All patients undergoing testicular US were included in the study. No
further inclusion or exclusion criteria were provided. A dataset was
created and US data were connected to the parameters collected during
a
the diagnostic workup. Hormonal evaluations were performed in all
patients, whereas only men presenting for untreated hypogonadism
looking for fatherhood and men presenting for infertility (part of
Group 2 and all the Group 3) underwent conventional semen analysis.
All examinations were approved by the Azienda Ospedaliero-
Universitaria of Modena, Ospedale Civile of Baggiovara, Hospital b
management (Modena, Italy), which is the Ethic Committee internal to
the Hospital, and all patients provided informed consent to participate.
Testicular ultrasound
Testicular US scan was performed by a single operator using a single
machine (Esaote® My Lab25 Gold, Malmesbury, Wiltshire, UK). The c
US operator was blind to the seminal and hormonal status of each
patient, since the US examination was performed during the first Figure 1: Testicular ultrasound parenchymal classification. (a) Testis with
visit, before biochemical and semen analyses. The following testicular homogeneous isoechoic echo pattern (Type 1 homogeneity). (b) Testis with
Type 2 inhomogeneous hypoechoic echo pattern and diffuse hyperechoic
characteristics were evaluated by US and collected in the dataset: spots. (c) Testis with Type 3 inhomogeneity (lesion suspected for malignancy).
TV, parenchyma homogeneity/inhomogeneity, pampiniform plexus, Numbers (1, 2 and 3) represent the three diameters taken during US
epididymis, and proximal vas deferens.5 evaluation. US: ultrasound; D: diameter; V: volume.

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The testis US role in the andrological setting
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Longford, Ireland) with inter- and intra-assay CV of 4.1% and 3.1% for mean age was different among groups (P < 0.001), and post hoc analysis
LH, and 4.6% and 4.2% for FSH, respectively. Prolactin was evaluated by showed that Group 4 was older than the other groups (P < 0.001).
Chemiluminescent Immunoassay (Beckman Coulter, Brea, CA, USA) Right and left TVs were directly related together (R = 0.868,
with inter- and intra-assay CV of 4.2% and 1.6%, respectively. P < 0.001), justifying the evaluation of a single testis TV for the overall
volume consideration. TV was significantly different among groups
Semen analysis
(Table 1 and Figure 2). Post hoc analyses showed that TV was lower
Conventional semen analyses were requested and reported for all men
in Group 2 compared to that of the other groups (P < 0.001, Figure 2).
seeking andrological consultation for both untreated hypogonadism and
On the contrary, TV was not significantly different among Groups 1,
couple infertility. Semen samples were collected after an abstinence period
3, and 4 (Figure 2), confirming that men referring for hypogonadism
of 3–7 days, and analysis was performed according to the WHO criteria.30
generally present smaller testes.
Statistical analyses Testicular US inhomogeneity (Type 2) was more frequent in Group 2
Patients were first divided into four groups, according to the reason for (53.9%) compared to that in the other groups (P < 0.001), and in Group
referral. TV was considered both as single and combined TV. Moreover, 3 (37.8%) compared to that in both Groups 1 (9.8%) and 4 (10.8%)
patients seeking andrological consultation for hypogonadism were (P < 0.001) (Figure 3). Moreover, Type 2 inhomogeneity was more
further divided into two subgroups, treated and untreated, depending on frequent in Group 2 than in Group 3 (P < 0.001, Figure 3). No tumor
whether the patients were or were not on androgen replacement therapy (Type 3 inhomogeneity) was suspected in our cohort. The detection of
when enrolled in the study. Men seeking andrological consultation for microlithiasis was not different among groups (P = 0.115). In particular,
couple infertility were further subdivided according to the seminal the frequency of microlithiasis was 14.9% in Group 2 (15 patients),
status in normozoospermic (when all semen parameters were above the 5.1% in Group 3 (6 patients), and 10.9% in Group 4 (5 patients). On
normal range), with reduced sperm quality (when oligo- and/or astheno- the contrary, no microlithiasis was detected in Group 1. Similarly,
and/or teratozoospermia were detected), and azoospermic patients. macrocalcifications were detected in 2.7% of Group 1 (1 patient), 4.0% of
Data distribution was evaluated using Kolmogorov–Smirnov Group 2 (4 patients), and 2.2% of Group 4 (1 patient), without significant
test. Differences among groups and subgroups were evaluated using differences (P = 0.211). TV was lower comparing patients with and
ANOVA univariate analysis when the data were normally distributed without microlithiasis (right: 7.46 ± 6.93 ml vs 12.15 ± 8.22 ml, P = 0.003;
and using Kruskal–Wallis/Mann–Whitney U test when nonnormally left: 7.02 ± 6.59 ml vs 12.12 ± 7.89 ml, P = 0.001). However, this difference
distributed. Dunnett’s test was used for post hoc analyses, choosing was lost within each group (Group 2: P = 0.081; Group 3: P = 0.262; and
unequal variances. Differences among categorical variables were Group 4: P = 0.979). Patients with US Type 2 inhomogeneity showed a
evaluated by Fisher’s exact test or Kendall’s test, considering the number reduced TV compared to those with US homogeneity (right: 7.83 ± 7.66
of categories to be compared. These analyses were first performed ml vs 14.41 ± 7.53 ml, P < 0.001; left: 7.61 ± 7.81 ml vs 13.87 ± 7.06 ml,
considering the entire cohort of patients and then considering each P < 0.001). This difference was also present in Group 1 (P = 0.001 and
group of patients separately. Moreover, after subgrouping, correlations P < 0.001, respectively) and 2 (P < 0.001 for both testes). Epididymis
among continuous variables were evaluated using Pearson and head, corpus, and cauda diameters (P = 0.076, P = 0.078, and P = 0.182,
Spearman Rho coefficients, for normal and abnormal distributed respectively), as well as the incidence of varicocele (P = 0.410), did not
parameters, respectively. differ among groups.
Finally, multivariate analyses were performed in order to identify Although serum total testosterone levels were not different
those parameters which could predict TV variations. Thus, multiple (P = 0.535) among groups, LH (P = 0.003) and FSH (P = 0.006) showed
linear pairwise regression analyses were performed in each group and
in further subgroups, using TV as a dependent variable and hormonal
and semen parameters as independent variables.
Statistical analysis was performed using the “Statistical Package
for the Social Sciences” software for Macintosh (version 20.0; SPSS
Inc., Chicago, IL, USA). For all comparisons, P < 0.05 was considered
statistically significant.

RESULTS
Three hundred and two men were enrolled, with a mean age of
39.8 (standard deviation [s.d]: 15.2) years. Considering the reason
for andrological consultation, patients were divided into Group
1 (37 patients, 12.3%), Group 2 (101 patients, 33.4%), Group 3 Figure 2: Right and left TV among groups. **P < 0.001, the hypogonadism
(118 patients, 39.1%), and Group 4 (46 patients, 15.2%) (Table 1). The group compared with other three groups. TV: testicular volume.

Table 1: Patients’ characteristics

Parameters Entire cohort Group 1 Group 2 (suspected Group 3 (couple Group 4 (sexual P (Kruskal–
(gynecomastia) hypogonadism) infertility) dysfunction) Wallis)
Patients (n) 302 37 101 118 46
Age (year), mean±s.d. 39.75±15.24 38.41±25.09 38.91±16.43 37.11±7.05 49.71±14.03 <0.001
Right testicular volume (ml), mean±s.d. 11.62±7.88 13.07±7.03 6.70±6.35 13.83±6.80 15.29±9.03 <0.001
Left testicular volume (ml), mean±s.d. 12.15±8.22 13.94±6.53 6.74±6.70 14.96±7.45 15.33±8.62 <0.001
s.d.: standard deviation

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a different distribution, with higher serum gonadotropin levels in in men treated with androgen replacement therapy (testosterone:
men seeking consultation for couple infertility (10.16 ± 11.15 IU l−1 R = −0.122, P = 0.536; LH: R = −0.056, P = 0.849; FSH: R = −0.078,
and 16.41 ± 19.57 IU l−1, respectively). Prolactin did not differ among P = 0.769; and prolactin: R = −0.355, P = 0.557). On the contrary, in
groups (P = 0.478). untreated patients, a significant, direct correlation between serum
Considering conventional semen analysis, no differences were total testosterone levels and TV was detected (R = 0.370, P = 0.003).
observed between Groups 2 and 3 in terms of total sperm number Moreover, in this subgroup, FSH was directly related to TV (R = 0.361,
(P = 0.344). On the contrary, sperm motility was lower in Group 2 P = 0.014), differently from LH (R = 0.274, P = 0.075).
(5.94% ± 13.85%) compared to Group 3 (25.09% ± 24.75%) (P = 0.016). TV was directly correlated to both total sperm number (R = 0.806,
P < 0.001) and sperm motility (R = 0.477, P = 0.046). However, this
Men seeking andrological consultation for hypogonadism
information was only available for hypogonadal, untreated men, since
At the time of the first visit, 30 men (29.7% of Group 2) were on
conventional semen analyses were not available for men undergoing
androgen replacement therapy, whereas none of the patients were
androgen replacement therapy.
on gonadotropin treatment. The mean age was higher in the treated
subgroup compared to that in the untreated one (P = 0.009) (Table 2). Men seeking andrological consultation for couple infertility
TV was lower in men treated with androgen replacement therapy, Men seeking andrological consultation for couple infertility were
compared to untreated patients (P = 0.006, Table 2). The prevalence divided into normozoospermic (30 patients, 25.4%), impaired semen
of testicular US inhomogeneity did not differ between treated and quality (58 patients, 49.2%), and azoospermic (30 patients, 25.4%). The
untreated patients (P = 0.199), as well as the occurrence of testicular mean age among subgroups was not different (P = 0.625), whereas TV
microcalcifications (P = 0.221). Neither epididymis head, corpus, and resulted in higher values in normozoospermic patients compared to
cauda diameter (P = 0.913, P = 0.219, and P = 0.702, respectively) nor the other groups (P = 0.014) (Table 3). Conversely, there were no TV
the incidence of varicocele differed between groups (P = 0.707). differences between men with reduced sperm quality and azoospermic
Serum total testosterone levels were higher in men undergoing patients (P = 0.714). Testis US inhomogeneity (Type 2) was more
androgen replacement therapy compared to those untreated (P = 0.025, frequent in patients with reduced sperm quality (54.9%) (P = 0.007),
Table 2). On the contrary, no differences were observed between treated compared to azoospermic (44.1%) and normozoospermic (5.0%) men.
and untreated men in terms of LH (P = 0.465), FSH (P = 0.517), and Moreover, Type 2 inhomogeneity was more frequent in azoospermic
prolactin (P = 0.644) (Table 2). than that in normozoospermic patients (P = 0.012). The US finding
Considering the whole group of hypogonadal men, TV was not of microcalcifications did not differ (P = 0.090). Neither epididymis
correlated to hormonal variables (testosterone: R = 0.155, P = 0.147; head, corpus, and cauda diameters (P = 0.991, P = 0.108, and P = 0.312,
LH: R = −0.196, P = 0.202; FSH: R = −0.255, P = 0.083; and prolactin: respectively) nor the incidence of varicocele differed among groups (P
R = −0.099, P = 0.622). Similarly, no correlation with TV was found = 0.103).
Serum total testosterone levels, LH, and prolactin did not differ
among subgroups (Table 3), whereas FSH levels were different
(P = 0.004). Post hoc test showed higher serum FSH levels in azoospermic
patients compared to those in the other two groups (P = 0.006), whereas
no differences were detected between normozoospermic patients and
those with reduced sperm quality.
Considering the entire group of men seeking andrological
consultation for infertility, an indirect correlation was detected between
TV and LH (R = −0.449, P < 0.001), FSH (R = −0.435, P < 0.001),
and prolactin (R = −0.389, P < 0.001). On the contrary, a significant,
direct correlation was detected between TV and both total sperm
count (R = 0.480, P < 0.001) and sperm motility (R = 0.443, P < 0.001).
Subdividing patients according to the seminal status, significant
Figure 3: Percentage of ultrasound Type 2 inhomogeneity detection among
different groups. **P < 0.001, the hypogonadism group compared with group correlations were confirmed in normozoospermic patients. In particular,
of patients with gynecomastia and sexual dysfunction. significant inverse correlations between TV and LH (R = −0.400,

Table 2: Men seeking andrological consultation for suspected hypogonadism (Group 2)

Parameters Entire group Treated men Untreated men P (Mann–Whitney U test)
Patients (n) 101 30 71 NA
Age (year), mean±s.d. 38.91±16.43 45.42±16.51 36.16±15.71 0.009
Right testicular volume (ml), mean±s.d. 6.70±6.35 3.83±4.00 7.94±3.84 0.006
Left testicular volume (ml), mean±s.d. 6.74±6.70 3.90±3.22 7.81±3.90 0.006
Total testosterone (ng dl−1), mean±s.d. 482.83±309.40 586.60±335.19 434.19±286.47 0.025
LH (IU l−1), mean±s.d. 10.17±11.15 9.36±13.21 10.34±11.20 0.465
FSH (IU l−1), mean±s.d. 16.41±19.57 13.14±20.72 16.67±19.69 0.517
Prolactin (ng dl−1), mean±s.d. 26.68±55.87 11.30±8.10 24.10±17.87 0.644
Total sperm count (106 per ejaculate), mean±s.d. 18.14±50.28 NA 18.14±50.28 NA
Sperm motility (%), mean±s.d. 5.94±13.85 NA 5.94±13.85 NA
NA: not available; s.d.: standard deviation

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Table 3: Men seeking andrological consultation for couple infertility (Group 3)

Parameters Entire group Normozoospermia Reduced sperm quality Azoospermia P (Kruskal–Wallis)
Patients (n) 118 30 58 30 NA
Age (year), mean±s.d. 37.11±7.05 35.36±7.52 37.76±8.94 34.39±10.22 0.625
Right testicular volume (ml), mean±s.d. 13.83±6.80 17.07±8.41 12.81±5.92 7.85±7.73 0.001
Left testicular volume (ml), mean±s.d. 14.96±7.45 17.04±6.43 12.04±5.71 6.27±5.71 0.001
Total testosterone (ng dl−1), mean±s.d. 535.38±231.14 523.37±247.33 498.12±178.68 469.56±230.47 0.348
LH (IU l−1), mean±s.d. 5.13±5.01 3.95±5.34 5.29±4.33 10.13±8.28 0.098
FSH (IU l−1), mean±s.d. 8.13±9.42 4.91±7.39 7.61±7.90 19.17±15.78 0.004
Prolactin (ng dl−1), mean±s.d. 10.53±13.98 8.91±3.00 11.39±4.35 11.25±4.84 0.136
Total sperm count (106 per ejaculate), mean±s.d. 33.24±25.70 200.98±182.18 28.17±35.06 0 <0.001
Sperm motility (%), mean±s.d. 25.09±24.75 51.09±35.22 23.26±19.08 0 <0.001
s.d.: standard deviation; FSH: follicle‑stimulating hormone; LH: luteinizing hormone; NA: not available

P = 0.031), FSH (R = −0.350, P = 0.018), and prolactin (R = −0.456, alteration in semen quality, from a mild decline (oligo- and/or
P = 0.022) were detected, whereas a significant, direct correlation astheno- and/or teratozoospermia) to azoospermia. On the contrary,
between TV and sperm count (R = 0.577, P = 0.010) was found. In men gonadotropin levels are higher in men presenting for infertility
with reduced sperm quality and azoospermia, no correlation was found. compared to those in other andrological patients, identifying LH
and FSH as informative markers of male fertility status. In particular,
Multivariate analyses
FSH levels are increased in azoospermic patients, whereas no LH and
Multivariate linear analyses were performed considering TV as a
FSH differences between normozoospermic men and patients with
dependent variable and hormonal and semen analyses as independent,
impaired semen quality are detected. This finding could be due to
pairwise parameters in each group of patients. No significant models were
our choice to evaluate the alterations in semen quality irrespective
generated for men seeking andrological consultations for gynecomastia,
of the parameter involved (sperm count and/or motility and/or
hypogonadism, and sexual dysfunction (Groups 1, 2, and 4). In Group 3,
morphology), the alterations degree, and the presence of combined
a significant model was generated in which total sperm count and serum
sperm abnormalities. In men seeking andrological consultation for
FSH levels entered (R 10.735, P < 0.001). This result suggests that TV in
couple infertility, multivariate analyses develop a model in which FSH
this category of patients could be better predicted by the two variables,
levels and sperm number are identified as the most relevant variables to
total sperm count and serum FSH levels. This result was lost repeating the
predict TV. Hence, TV could be interpreted both as a consequence of
analyses for subgroups of patients according to semen quality, probably
a FSH-mediated effect and a parameter of spermatogenic function.34–36
due to the reduced number of patients after further grouping.
The model developed, interconnecting TV, FSH, and sperm number,
DISCUSSION could add rationale to the therapeutic use of FSH, which is currently
In this study, testicular sonographic data collected during andrological proposed on an empirical base for improving sperm quality in men
consultation show that US-derived TV is lower in hypogonadal affected by idiopathic infertility.37 Nevertheless, subdividing patients
patients compared to other conditions. Indeed, hypogonadal men according to their seminal status, correlations are only confirmed
generally show impairment of both testosterone-secreting and when normozoospermia occurs. This result could be simply due to the
spermatogenic compartments. Accordingly, TV is directly related to low patient number impacting the statistical power. However, other
serum testosterone and FSH levels, as well as to sperm number and pathophysiological phenomena, not evaluable by simple hormonal
motility in such patients. However, the impact of the testosterone- and sonographic assessments, could be involved, e.g., at testicular
secreting compartment on TV seems to be particularly relevant, histology level. Indeed, TV and FSH levels were proposed in direct
considering the difference detected between hypogonadal patients and and indirect correlation with histological structure detected by testis
patients evaluated for infertility. In particular, in hypogonadal patients, biopsy,38 respectively; TV and FSH levels were also proposed in direct
TV seems to be informative of both spermatogenic function and the and indirect correlation with the prediction of successful testicular
androgen-secreting compartment. sperm extraction.39,40
As expected, within the group of hypogonadal men, testicular Testicular echostructure evaluation highlights an increased
sizes result lower in androgen-treated patients compared to untreated frequency in US inhomogeneity in Group 2 and Group 3 compared
men, confirming that the exogenous administration of testosterone to the other groups. Thus, US inhomogeneity seems to better
could impact TV. As demonstrated both in humans and in animal characterize hypogonadism and infertility,41,42 rather than other
models, this effect is due to the testosterone-mediated suppression of andrological conditions. The testicular parenchyma alteration seems
the gonadotropin pulsatile secretion, which acts as a trophic factor to be an informative marker of testicular function, including both
on the testicular tissue.31,32 No further significant differences were testosterone production and the spermatogenic compartment. Due to
found between androgen-treated and untreated patients concerning the difficulty to categorize the testis US echostructure and to objectify
both the hormonal pattern and the testicular ultrasound features, an operator-dependent parameter, we chose to evaluate a dichotomous
with the exception of testosterone levels resulting in higher levels in variable (presence/absence of a characteristic). This classification is
testosterone-treated patients. Although several authors suggested a easily applicable in the clinical practice and able to provide useful
relationship between TV and the presence of microlithiasis,33 we do information about the testicular functionality, at least in our population.
not find a correlation between these two parameters. An inhomogeneous echo pattern does not add relevant information in
In patients evaluated for infertility, TV does not appear informative the setting of male hypogonadism; on the contrary, it seems extremely
of the fertility status, since it cannot discriminate the degree of useful in infertility workup, in which the frequency of testis US

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The testis US role in the andrological setting
G Spaggiari et al

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Supplementary Table 1: “Sarteschi” 5‑item scale for ultrasound grading of the varicocele
Grade Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Presence of No Presence of small Presence of overt Evident varicosities in all positions Evident venous dilatation in all
varicosities varicosities varicosities positions
Testis hypotrophy No No No Usual Yes
Venous reflux During Valsalva During Valsalva Evident during Spontaneous, increased with Valsalva Spontaneous at rest, not
maneuver maneuver Valsalva maneuver maneuver or standing station changed by Valsalva maneuver