Serial ultrasonography, hormonal profile and antisperm antibody response after testicular sperm aspiration

The European Academy of Andrology (EAA) ultrasound study on healthy, fertile men: An overview on male genital tract ultrasound reference ranges

BACKGROUND

So far, male genital tract color-Doppler ultrasound (MGT-CDUS) was not standardized. Recently, the European Academy of Andrology (EAA) published the results of a multicenter study assessing the CDUS characteristics of healthy-fertile men (HFM) to obtain normative parameters.

OBJECTIVES

To report the EAA US study (i) standard operating procedures (SOPs) for assessing MGT-CDUS, (ii) main MGT-CDUS normative parameters, and (iii) compare the EAA and previously published "normal" CDUS values.

METHODS

A cohort of 248 HFM (35.3 ± 5.9 years) was studied, evaluating MGT-CDUS before and after ejaculation following SOPs.

RESULTS

SOPs for MGT-CDUS assessment are summarized here. All subjects underwent scrotal CDUS and 188 men underwent transrectal ultrasound before and after ejaculation. The main CDUS reference ranges and characteristics of the HFM-MGT are reported here. The mean testicular volume was ∼17 mL. The lower limit for right and left testis was 12 and 11 mL, defining testicular hypotrophy. The upper limit for epididymal head, body, tail, and vas deferens was 11.5, 5, 6, and 4.5 mm, respectively. Testicular and epididymal arterial reference ranges are reported. The EAA varicocoele classification is reported. CDUS-varicocoele was detected in ∼37% of men. Prostate mean volume was ∼25 mL, while lower and upper limits were 15 and 35 mL, defining hypotrophy and enlargement, respectively. Prostate arterial reference ranges are reported. Prostate calcifications and inhomogeneity were frequent; midline prostatic cysts were rare and small. Ejaculatory duct abnormalities were absent. The upper limit for periprostatic venous plexus was 4.5 mm. Lower and upper limits of seminal vesicles (SV) anterior-posterior diameter were 6 and 16 mm, defining hypotrophy or dilation, respectively. Seminal vesicle volume and ejection fraction reference ranges are reported. SV-US abnormalities were rare. Deferential ampullas upper limit was 6 mm. A discussion on the EAA and previously published "normal" CDUS values is reported here.

CONCLUSIONS

The EAA findings will help in reproductive and general male health management.

Historical trends for the standards in scrotal ultrasonography: What was, what is and what will be normal

BACKGROUND

Ultrasonography is the gold standard imaging method for scrotal investigation. Colour Doppler ultrasonography, contrast-enhanced ultrasonography and sonoelastography allow sonographers to assess size, echotexture, vascular features and stiffness of the scrotal organs and abnormalities. Scrotal ultrasonography has been used to investigate male reproductive health, scrotal pain, masses and trauma. However, ultrasonography thresholds/classifications used to distinguish normal and pathologic features of the scrotal organs have changed over time, and have not yet been fully standardized.

OBJECTIVES

To evaluate historical trends for the standards in scrotal ultrasonography: what was, what is and what will be normal.

METHODS

An extensive Medline search was performed identifying the most relevant studies in the English language from inception to date.

RESULTS

We provide here (i) a brief overview of the history of ultrasonography, (ii) current indications for scrotal ultrasonography and (iii) previous and current normal values, cut-offs and classifications of the main colour-Doppler ultrasonography parameters/characteristics of the scrotal organs, as derived from recent guidelines and evidence-based studies. In addition, we report recommendations and the clinical utility of contrast-enhanced ultrasonography and sonoelastography. Finally, we discuss critical issues needing further evidence and future directions to fill in the current gaps.

DISCUSSION

Several studies on scrotal ultrasonography are available. However, guidelines/recommendations dealing with specific ultrasonography applications have been published only in recent years. More recently, the European Academy of Andrology published evidence-based scrotal colour-Doppler ultrasonography reference ranges/normative parameters derived from a cohort of healthy, fertile men. In addition, a standardization of the methodology to evaluate qualitative and quantitative colour-Doppler ultrasonography parameters was reported. Other international societies reported indications, methodological standards, clinical utility and limitations of contrast-enhanced ultrasonography and sonoelastography.

CONCLUSIONS

To date, colour-Doppler ultrasonography normative values for the scrotal organs are available. However, a wide international consensus on assessment and classification of several ultrasonography parameters is still lacking. An alignment of the world societies on these issues is advocated.

The European Academy of Andrology (EAA) ultrasound study on healthy, fertile men: Scrotal ultrasound reference ranges and associations with clinical, seminal, and biochemical characteristics

BACKGROUND

Scrotal color Doppler ultrasound (CDUS) still suffers from lack of standardization. Hence, the European Academy of Andrology (EAA) has promoted a multicenter study to assess the CDUS characteristics of healthy fertile men (HFM) to obtain normative parameters.

OBJECTIVES

To report and discuss the scrotal organs CDUS reference ranges and characteristics in HFM and their associations with clinical, seminal, and biochemical parameters.

METHODS

A cohort of 248 HFM (35.3 ± 5.9years) was studied, evaluating, on the same day, clinical, biochemical, seminal, and scrotal CDUS following Standard Operating Procedures.

RESULTS

The CDUS reference range and characteristics of the scrotal organs of HFM are reported here. CDUS showed a higher accuracy than physical examination in detecting scrotal abnormalities. Prader orchidometer (PO)- and US-measured testicular volume (TV) were closely related. The US-assessed TV with the ellipsoid formula showed the best correlation with the PO-TV. The mean TV of HFM was ~ 17 ml. The lowest reference limit for right and left testis was 12 and 11 ml, thresholds defining testicular hypotrophy. The highest reference limit for epididymal head, tail, and vas deferens was 12, 6, and 4.5 mm, respectively. Mean TV was associated positively with sperm concentration and total count and negatively with gonadotropins levels and pulse pressure. Subjects with testicular inhomogeneity or calcifications showed lower sperm vitality and concentration, respectively, than the rest of the sample. Sperm normal morphology and progressive motility were positively associated with epididymal head size/vascularization and vas deferens size, respectively. Increased epididymis and vas deferens sizes were associated with MAR test positivity. Decreased epididymal tail homogeneity/vascularization were positively associated with waistline, which was negatively associated with intratesticular vascularization. CDUS varicocele was detected in 37.2% of men and was not associated with seminal or hormonal parameters. Scrotal CDUS parameters were not associated with time to pregnancy, number of children, history of miscarriage.

CONCLUSIONS

The present findings will help in better understanding male infertility pathophysiology, improving its management.

Testicular Mapping: A Roadmap to Sperm Retrieval in Nonobstructive Azoospermia?

Guiding a couple with nonobstructive azoospermia requires an integrated approach to care by the urologist and the reproductive endocrinologist. After informing the couple of the implications of the diagnosis, care must be taken to outline the options of parenthood. Most experts agree that sperm retrieval in men can be challenging. This article describes various options of sperm retrieval, historic and contemporary, and highlights the advantages and disadvantages of each. The authors find that using a testicular map can invariably help guide sperm retrieval and overall fertility care. The right approach is one that involves a shared decision with the couple.

The risk of TESE-induced hypogonadism: a systematic review and meta-analysis

BACKGROUND

Testicular sperm extraction (TESE) is a surgical procedure to retrieve spermatozoa from the testes of men with azoospermia to help them achieve biological parenthood. Although effective, the surgical procedure is not without complications and haematoma, devascularization, inflammation and a decrease in testosterone levels have been described as such. The prevalence and duration of hypogonadism and associated symptoms after TESE have not been studied systematically.

OBJECTIVE AND RATIONALE

In this systematic review we addressed the following research questions: Are serum testosterone levels decreased after TESE and, if so, do these levels recover over time? What is the prevalence of symptoms and signs related to hypogonadism after TESE and are they related to testosterone levels?

SEARCH METHODS

We searched the databases Pubmed and Embase from 1 January 1993 to 26 June 2017. We combined subject headings with terms in title and/or abstract for participants, intervention and outcomes. We included all studies that reported on TESE, regardless of the specific technique used, that measured testosterone and/or LH, and/or had information on signs or symptoms related to hypogonadism as defined by hypogonadism guidelines. An additional inclusion criterion was that studies described these measurements both before and after TESE. The quality of the included studies was assessed using the Risk Of Bias In Non-randomized Studies-of Interventions tool.

OUTCOMES

We identified 15 studies reporting on total testosterone levels of which five studies also reported on testicular volume and one study on erectile dysfunction. Men with Klinefelter syndrome and men with non-obstructive azoospermia had the strongest decrease in total testosterone levels 6 months after TESE, with a mean decrease of 4.1 and 2.7 nmol/l, respectively, which recovered again to baseline levels 26 and 18 months after TESE, respectively. At 6 months after TESE, some studies reported serum total testosterone concentrations below a cut-off value of 12 nmol/l, where symptoms and signs related to hypogonadism may appear. Furthermore, an increased prevalence of erectile dysfunction related to decreased total testosterone levels 6 months after TESE was reported. Also, in some men a decrease in testicular volume was reported. However, it is not clear if this is related to low testosterone levels.

WIDER IMPLICATIONS

The transient, but statistically significant, decrease in total testosterone levels indicates that men are at risk of developing a temporary hypogonadism after TESE, but there is insufficient evidence for whether patients actually experience clinical symptoms in case of decreased serum testosterone levels. To be able to properly counsel TESE patients, more large-scale monitoring on signs and symptoms of hypogonadism, in combination with testosterone measurements, needs to be performed in men undergoing TESE.

Scrotal hemorrhage after testicular sperm aspiration may be associated with phosphodiesterase-5 inhibitor administration: a retrospective study

Background

Scrotal hemorrhage after testicular sperm aspiration (TESA) is uncommon in clinical operation. Phosphodiesterase-5 inhibitors (PDE5i) are commonly given to men who have difficulty providing a sperm sample for assisted reproductive technique such as in vitro fertilization. In this study, we examine the incidence of scrotal hemorrhage after TESA in men who received a PDE5i.

Methods

In this retrospective study, 504 men with TESA operation in Center for Reproductive Medicine, Nanfang Hospital, Southern Medical University were collected. Men in the drug group had taken orally PDE5i before TESA. Men in the control group only operated TESA. The testis volume, coagulation function were measured. Sonographic examination with Doppler imaging was performed when scrotal hemorrhage appeared.

Results

A total of 504 men with a mean age of 28.63 ± 4.22 years were included in the analysis. Of these, 428 did not receive a PDE5i prior to TESA and 76 received a PDE5i prior to TESA. Measures of coagulation function were not different between the groups. The incidence of hemorrhage was 0.0% in the control group and the drug group was 5.3%. The incidence of hemorrhage between two groups was different significantly (P = 0.000).

Conclusion

In summary, the results of this study suggest that a PDE5i administration increases the risk of scrotal hemorrhage in men undergoing TESA, although the study design does not allow drawing a conclusion of cause and effect. Given the potential risk of scrotal hemorrhage after the ingestion of PDE5i, it may be wise not to administer it to men in whom a TESA may be performed.

Testicular Damage following Testicular Sperm Retrieval: A Ram Model Study

The aim of this study was to evaluate the possible development of histological abnormalities such as fibrosis and microcalcifications after sperm retrieval in a ram model. Fourteen testicles in nine rams were exposed to open biopsy, multiple TESAs, or TESE, and the remaining four testicles were left unoperated on as controls. Three months after sperm retrieval, the testicles were removed, fixed, and cut into 1/2 cm thick slices and systematically put onto a glass plate exposing macroscopic abnormalities. Tissue from abnormal areas was cut into 3 μm sections and stained for histological evaluation. Pathological abnormalities were observed in testicles exposed to sperm retrieval (≥11 of 14) compared to 0 of 4 control testicles. Testicular damage was found independently of the kind of intervention used. Therefore, cryopreservation of excess sperm should be considered while retrieving sperm.

A step-by-step guide to office-based sperm retrieval for obstructive azoospermia

A variety of surgical options exists for sperm retrieval in the setting of obstructive azoospermia (OA). With appropriate preparation, the majority of these techniques can safely be performed in the office with local anesthesia and with or without monitored anesthesia care (MAC). The available techniques include percutaneous options such as percutaneous epididymal sperm aspiration (PESA) and testicular sperm aspiration (TESA), as well as open techniques that include testicular sperm extraction (TESE) and microsurgical epididymal sperm aspiration (MESA). In addition to providing a step-by-step description of each available approach, we introduce and describe a new technique for sperm retrieval for OA called minimally invasive epididymal sperm aspiration (MIESA). The MIESA utilizes a tiny keyhole incision, and the epididymis is exposed without testicular delivery. Epididymal aspiration is performed in the style of MESA, except using loupe magnification rather than an operating microscope. MIESA is a safe, office-based procedure in which millions of motile sperm can be retrieved for cryopreservation. While we prefer the MIESA technique for OA, there remain distinct advantages of each open and percutaneous approach. In the current era of assisted reproductive technology, sperm retrieval rates for OA should approach 100% regardless of the technique. This reference provides a roadmap for both advanced and novice male reproductive surgeons to guide them through every stage of sperm retrieval for OA, including preoperative evaluation, patient selection, procedural techniques, and complications. With the incredible advances in in vitro fertilization (IVF), combined with innovative surgical treatment for male factor infertility in recent years, OA is no longer a barrier for men to become biologic fathers.

Variation of spermatogenic and Sertoli cell number detected by fine needle aspiration cytology (FNAC) in Iberian red deer during and out of the breeding season

The aim of the present study was to evaluate spermatogenesis in Iberian red deer, a short-day seasonal breeder, using the fine needle aspiration cytology (FNAC) technique. Reports on spermatogenesis in deer are limited and here, for the first time, FNAC has been used to evaluate changes in such physiological process during and out of the breeding season. Testes were collected from 51 stags from November 2010 to February 2011. The Sertoli index and spermatic index were significantly higher during the breeding season than out of the breeding season (P = 0.0477 and P = 0.0125, respectively). A similar pattern was described by histological analysis, in which both Sertoli cell number per tubular cross-section and Johnsen score decreased significantly from the breeding season to the non-breeding season (P = 0.0131 and P = 0.0010, respectively). Data provided by FNAC were correlated with histology: the Sertoli index was positively correlated with Sertoli cell number per tubular cross-section (P = 0.0015), whereas the spermatic index was correlated with the Johnsen score (P = 0.0497). The results of the present study indicate that FNAC is a reliable technique to evaluate spermatogenesis in Iberian red deer and suggest that Sertoli cell number is not stable in these species, reaching highest values during the breeding season.

Impact of sperm retrieval [corrected] on testis and epididymis: an experimental study using Wistar albino rats

The aim of this study was to analyze pathophysiological changes after testicular sperm aspiration (TESA) and microsurgical epididymal sperm aspiration (MESA) procedures. Twenty four mature male Wistar albino rats with a proven breeding history, weighing approximately 200-250 gm were used for the study. Animals were randomly divided into four groups (n = 6), i.e., control, sham-control, unilateral TESA, and MESA. Using a 22G needle, the aspiration procedures were done in testis or caudal epididymis. At the end of 60 days of survival, blood samples were collected and processed for antisperm antibody detection by enzyme-linked immunosorbent assay (ELISA). After euthanasia, testes and epididymides were collected and processed for paraffin embedding. Sections were stained with hematoxylin and eosin, and TUNEL technique. Serum antisperm antibody titer significantly increased in TESA (P < 0.001) when compared to MESA. Histomorphometric analysis indicated testicular alterations in TESA and MESA, with significant damage in TESA in both testes (P < 0.001). Following the MESA procedure, ipsilateral caudal and carpus epididymis showed significant alterations (P < 0.001) and no such alterations were seen in the ipsilateral caput and intact contralateral epididymis. TUNEL staining revealed an up-regulation of apoptosis in both contra- and ipsilateral testes of TESA. Needle prick had produced drastic and irreversible alterations in testis of TESA. Ensuing processes of immunological and inflammatory reaction had the potential to disrupt spermatogenesis and increase germ cell apoptosis. However, extrapolating conclusions from the experimental model to the clinic needs to be done cautiously.

The value of testicular 'mapping' in men with non-obstructive azoospermia

As the field of assisted reproduction has advanced, many previously untreatable men are now biological fathers. Although finding sperm in men with obstructive azoospermia is not difficult, locating and retrieving spermatozoa in men with non-obstructive azoospermia remains a clinical challenge, largely because sperm production in these men can be patchy or focal in nature. In response to this challenge, strategies such as fine-needle aspiration (FNA) mapping have been developed to find spermatozoa. This review discusses the history, evolution and current clinical utility and findings with FNA mapping for male infertility). Review of the current literature in the English language on FNA (diagnostic or therapeutic) with a keyword focuses on sperm detection, retrieval, safety and complications. FNA was described in human medicine over 100 years ago. Testis FNA was described 45 years ago and FNA 'mapping' of spermatozoa was described in 1997. This comparative review of the literature on sperm detection and complication rates with FNA and open testis biopsy or microdissection procedures suggests that FNA is highly informative, minimally invasive and is associated with fewer complications than other commonly used approaches to sperm detection in non-obstructive azoospermic patients. FNA mapping has gained considerable traction as an informative, 'testis sparing' technique for sperm detection in non-obstructive azoospermia. With knowledge of sperm presence and location prior to sperm retrieval, FNA maps can help clinicians tailor sperm retrieval to optimize time, effort and extent of procedures needed to procure spermatozoa in these difficult cases.

Impact of fine or large needle aspiration on the dog's testis: in vitro ultrasonographic, bacteriological, gross anatomy and histological assessment

Despite its extensive use for evaluation of spermatogenesis and assisted reproduction, the safety and consequences of fine (FNA) and large needle aspiration (LNA) to the testicular parenchyma and its normal function have not been established. This study was performed in order to accurately assess, by serial in vitro ultrasonographic, bacteriologic, gross anatomic and histological examinations, the type and extent of the effect of FNA or LNA on the dog's testis. Twenty three sexually mature, 1 to 2 years old, healthy laboratory Beagles were randomly assigned to 2 groups: (1) 5 dogs without testicular aspiration (control group) and (2) 18 dogs in which one of their testes was aspirated using a 23 G butterfly needle and the other using a 19 G butterfly needle (experimental group). Two dogs at a time were castrated 10 minutes, 60 minutes, 2, 14, 29, 63, 76, 90 or 180 days post-aspiration. The control group was also castrated 2, 29, 63, 90 or 180 days after the beginning of the experiment. Following castration, in vitro ultrasonographic, gross anatomic, cytological examinations of epididymal sperm, bacteriologic and histological examinations of the testes were performed. Following testicular FNA and LNA bacteriologic, gross anatomic, histologic, epididymal sperm findings and the in vitro ultrasonographic appearance of the testis were normal, except of intratesticular haemorrhage, detected the first days post-aspiration, and degeneration of less than 1.5% of the seminiferous tubules. Within the parameters of this experiment, testicular FNA and LNA have no ill effect on the canine testis and therefore, both FNA and LNA should be considered safe.

Long term effects of micro-surgical testicular sperm extraction on androgen status in patients with non obstructive azoospermia

BACKGROUND

The aim of our study was to review the results of microsurgically performed testicular sperm extraction (TESE) and to evaluate its possible long term effects on serum testosterone (T).

METHODS

We operated on 48 men (35 +/- 8 years) with non-obstructive azoospermia (NOA). If no spermatozoa were found following a micro epididymal sperm extraction (Silber et al., 1994) and testicular biopsy, testicular microdissection was performed or multiple microsurgical testicular biopsies were taken. The mean follow-up of the serum T was 2.4 +/- 1.1 years.

RESULTS

Sperm was retrieved in 17/48 (35%) of the men. The per couple take home baby rate if sperm was retrieved was 4/17 (24%). Serum T decreased significantly at follow-up (p < 0.05) and 5/31 (16%) de novo androgen deficiencies developed

CONCLUSION

In patients with non-obstructive azoospermia in whom no spermatozoa were found following a micro epididymal sperm aspiration and a simple testicular biopsy, we were able to retrieve spermatozoa in 35% of the men. The take home baby rate was 24% among couples with spermatozoa present upon TESE. De novo androgen deficiency occurred in 16% of the male patients following TESE indicating that, in men with NOA, long term hormonal follow up is recommended after TESE.

How Harmful is Contralateral Testicular Biopsy?—An Analysis of Serial Imaging Studies and a Prospective Evaluation of Surgical Complications

OBJECTIVE

Testicular biopsy has recently gained a role in early detection of testicular cancer. However, its use is still limited mainly because of the fear of untoward consequences. There is a paucity of data regarding unfavourable effects of testicular biopsy. Therefore, we systematically looked to the consequences of the procedure by using clinical observational methods and by modern imaging techniques, respectively.

PATIENTS, METHODS

1874 patients with testicular cancer enrolled in a nation-wide contralateral biopsy study were prospectively analyzed in regard to surgical complications. Serial scrotal imaging was performed by scrotal sonography (7.5 Mhz) in 55 patients and by magnetic resonance tomography (1.5 Tesla machine, surface coil, contrast media) in 60 patients, respectively. Imaging examinations were done preoperatively and again at 1 week, 6 months, 12 months, and 18 months respectively. Imaging results were tabulated according to an abnormality score and analyzed by descriptive statistics.

RESULTS

52 patients (2.78%; 95% confidence intervals 2.05-3.60) experienced surgical complications. Forty minor complications were managed conservatively. Twelve patients (0.64%) required repeat surgery; 1 testicle was ultimately lost following a sequence of unfortunate events. No pre-existing clinical parameter was associated with complications. One week after surgery, abnormalities were detected in 33% by sonography and in 45% by MRI, respectively. Importantly, the abnormalities resolved in 96% of the cases, as found in both of the imaging modalities in the serial scans.

CONCLUSIONS

Testicular biopsy is associated with a low burden of clinically significant complications. However, scrotal imaging discloses intratesticular abnormalities in a high proportion of cases one week after the biopsy. These changes represent focal haematoma, oedema or circumscript injury to vascular supply. Most of these lesions resolve with time and are thus not significant, clinically. Evidently, testicular biopsy is a safe procedure provided the vascular anatomy of the testis is respected upon surgery.

Sperm Recovery Prediction in Azoospermic Patients Using Doppler Ultrasonography

PURPOSE

To evaluate power Doppler ultrasonography to predict sperm recovery in azoospermic patients.

METHODS

Color Doppler and power Doppler ultrasonography of testis were performed in 38 patients before testicular sperm extraction. Analysis of blood flow included the pulsatility and resistance index of intratesticular vessels and testicular artery, and power Doppler of testis. The results of power Doppler of testis were classified into three categories: 0, no vessels found; 1, one to three vessels; 2, more than three vessels found.

RESULTS

Power Doppler of both testis showed a significant difference between obstructive azoospermia and non-obstructive azoospermia (Fisher's exact test - P = 0.02), and between the groups with and without sperm recovery (Fisher's exact test - P = 0.001). Doppler indices of intratesticular vessels and testicular artery were similar between the groups.

CONCLUSIONS

Testicular Power Doppler assessment showed that patients with obstructive azoospermia have better blood flow than patients with non-obstructive azoospermia, and power Doppler is able to predict sperm recovery in azoospermic patients.

Serial follow-up study of serum testosterone and antisperm antibodies in patients with non-obstructive azoospermia after conventional or microdissection testicular sperm extraction

Testicular sperm extraction (TESE) combined with intracytoplasmic sperm injection is becoming a first-line treatment even for non-obstructive azoospermia. The current focus of TESE is the identification of seminiferous tubules that contain spermatozoa and minimization of testicular damage. Although microdissection TESE has been introduced as a preferred procedure for sperm retrieval, no serial follow-up studies of testicular damage have been reported. In the present study, we assayed serum testosterone concentrations and for the presence of antisperm antibodies (ASA) for 1 year after conventional multiple TESE or microdissection TESE and compared postoperative testicular damage between procedures. Thirteen patients who underwent conventional multiple TESE and 12 patients who underwent microdissection TESE were included in this study. Serum total and free testosterone concentrations were evaluated before operation and 1, 6 and 12 months after TESE. Serum ASA was also evaluated before and 12 months after TESE. Serum total and free testosterone concentrations in all patients in both groups showed no significant postoperative decrease. A comparison between the two groups of serum total and free testosterone concentrations showed no significant difference (total testosterone, p = 0.2477; free testosterone, p = 0.3098). No incidence of new ASA formation was identified in the present study. In conclusion, TESE procedures cause neither a decrease of serum testosterone nor formation of ASA. Serum testosterone concentration are similar between patients in the conventional multiple TESE and microdissection groups. Therefore, microdissection TESE is safe with respect to testicular damage, particularly for patients with hypogonadism.

Impact of repeated testicular fine needle aspirations (TEFNA) and testicular sperm extraction (TESE) on the microscopic morphology of the testis: an animal model

BACKGROUND

The aim of this work was to compare testicular histological changes occurring following testicular fine needle aspiration (TEFNA) and testicular sperm extraction (TESE).

METHODS

TESE or TEFNA were performed on normal male rats, in a similar manner to azoospermic men. The animals were killed after 7, 14 and 31 days and their testes were examined.

RESULTS

TESE caused chronic inflammation, occasional necrosis and degenerative changes in testicular germ cells in only approximately 10% of the remaining testicular tissue. TEFNA caused widespread architectural distortion of seminiferous tubules into irregular and deformed lumens lined by Sertoli cells only, as well as focal chronic inflammation, necrosis and degenerative changes accompanied by decreased spermatogenesis. Similar but less extensive changes were noted when fewer punctures were performed. When negative suction pressure was not applied during TEFNA, similar histological changes occurred, indicating that testicular damage was related to the puncture itself. Following either procedure, the contralateral non-operated testes were unaffected.

CONCLUSION

In this animal model, TEFNA inflicts severe, progressive and irreversible damage on the architecture of the tubules in the needle's path. The multi-focal nature of this technique eventually leads to widespread tubular atrophy that is proportional to its extent. In contrast, TESE causes localized scarring and fibrosis, rendering most of the remaining testicle intact. The clinical relevance of such findings, produced in normal animal testes, to testes of azoospermic men, is yet to be determined.