Fertility and the management of scrotal injury

Jackson Kirkman-BrownScience Lead & Hon Reader

BWH & UoB

2

Background

• Mid 2009 soldier, having spoken to a friend who was a GP, asked for sperm storage

• @2 months post injury - total orchidectomy

• no sperm present

2

Three main challenges?

• Improvement of patient-specific treatment– including in the field– evolution and validation of techniques

• ID and reduction of threat injury poses to fertility

• Increase safe and effective fertility options

• What currently happens in Birmingham– Contact when signal arrives (18-24h before)– Team prepare for case– Medical review / request– Procedure (generally) on 1st theatre visit

• The procedure– Retrieval by Urologist of:

• vas deferens• epididymal tissue

Observed original patterns of blast injury to the testis

A

D

C

B

EF

Level of injury

Description %

A Loss of gonad to ext. ring 25

B Head of epididymis spared 30

C Head and body of epididymis and upper pole testis spared

10

D Lower pole testis + epididymal tail loss

5

E Scrotal skin laceration 20

F Scrotal contusion only 10

Sperm recovery• Epididymis & vas excision started March 2010• Tissue into media• Immediate transfer to GMP cleanroom facilities @BWH

7

Vas storage data

• Cases : 34 (since March 2010)• Successful retrieval : 29/34

– 2 deceased and sperm disposed of– 1 declined storage

– 2 failures have alternate testicular material left– 2 failures deceased– note 1:50 azoospermia ‘expected’

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So what does this currently mean for an individual in the future??

• Treatments using intra-cytoplasmic sperm injection

• Future re-checks?

• No sperm available for storage = support and other treatment options

• Ongoing– Patients positive about system

– Systems now established and in place

– Number of those with sperm banked are currently seeking treatment

– Two couples have ongoing pregnancies

Successes

• Pelvic protection has had huge effect in reducing the number of testicular losses and the severity

• Understand the short and long-term effects of blast to the testis

• Blast with fragmentation / rupture• Blast without rupture

• Can we further evolve protection

• Ongoing androgenic and spermatogenic function

The future

Thank you

This is a real interdisciplinary team effort, key colleagues:

Wendy Ross, Michelle Jewell, Yongjian Chen, Ingride Krasauskaite and BWFC Team

Dr Sue Avery & James Lawford-Davies

John Clark, Vic Long, Steve Jeffrey, Ian SargeantMilitary Burns & Plastics team; Sir Keith Porter

UhB Urology Team especially Richard Viney; Steve Cumley & UhB management

Davendra Sharma, David Woods, Peter Wink, Rhodri Phillip, Wendy Frappell-Cooke Wendy Williams, Richard Broadbridge, Jo Palmer