Can the rapid identification of mature spermatozoa during microdissection testicular sperm extraction guide operative planning?

Performing Microdissection Testicular Sperm Extraction: Surgical Pearls from a High-Volume Infertility Center

Microdissection testicular sperm extraction (mTESE) has been demonstrated to be the gold-standard surgical technique for retrieving testicular sperm in patients with non-obstructive azoospermia (NOA) as it enables the exploration of the whole testicular parenchyma at a high magnification, allowing the identification of the rare dilated seminipherous tubules that may contain sperm, usually surrounded by thinner or atrophic tubules. MTESE requires a skilled and experienced surgeon whose learning curve may greatly affect the sperm retrieval rate, as demonstrated in previous reports. The present review is intended to offer a precise and detailed description of the mTESE surgical procedure, accompanied by an extensive iconography, to provide urologists with valuable information to be translated into clinical practice. Advice about the pre-surgical and post-surgical management of patients is also offered.

Is a contralateral testicular exploration required at microdissection testicular sperm extraction for men with nonobstructive azoospermia, cryptozoospermia or severe oligozoospermia?

OBJECTIVES

Men with nonobstructive azoospermia (NOA), cryptozoospermia and severe oligozoospermia are candidates for microdissection testicular sperm extraction (micro-TESE) and intracytoplasmic sperm injection (ICSI). We sought to evaluate micro-TESE outcomes and the need for bilateral testicular exploration in the three groups of men.

METHODS

We conducted a retrospective study of 233 consecutive micro-TESEs in men with nonobstructive azoospermia (n = 173), cryptozoospermia (n = 43) and severe oligozoospermia (n = 17). The decision to terminate the micro-TESE after a unilateral or bilateral testicular exploration was determined at the time of surgery and was based on the presence or absence of mature spermatozoa in the harvested micro-biopsies. Final assessment of sperm recovery, on the day of ICSI, was reported as successful (available spermatozoon for ICSI) or unsuccessful (no spermatozoon for ICSI).

RESULTS

Unilateral testicular exploration resulted in successful sperm retrieval in 43% (75/173), 79% (34/43) and 100% (17/17) of men with NOA, cryptozoospermia and severe oligozoospermia respectively. Therefore, 57%, 21% and none of the men with NOA, cryptozoospermia and severe oligozoospermia, respectively, required a bilateral micro-TESE. Overall, micro-TESE resulted in successful sperm retrieval in 52% (90/173), 91% (39/43) and 100% (17/17) of men with NOA, cryptozoospermia and severe oligozoospermia respectively.

CONCLUSION

Our data indicate that men with severe oligozoospermia are unlikely to require a bilateral testicular exploration at micro-TESE. Moreover, most cryptozoospermic men will have a successful sperm retrieval by micro-TESE with the majority of these patients requiring a unilateral exploration. In contrast, over 50% of the men with nonobstructive azoospermia will require a bilateral micro-TESE.

Sperm recovery and ICSI outcomes in men with non-obstructive azoospermia: a systematic review and meta-analysis

BACKGROUND

Factor affecting sperm retrieval rate (SRR) or pregnancy rates (PR) after testicular sperm extraction (TESE) in patients with non-obstructive azoospermia (NOA) have not been systematically evaluated. In addition, although micro-TESE (mTESE) has been advocated as the gold standard for sperm retrieval in men with NOA, its superiority over conventional TESE (cTESE) remains conflicting.

OBJECTIVE AND RATIONALE

The objective was to perform a meta-analysis of the currently available studies comparing the techniques of sperm retrieval and to identify clinical and biochemical factors predicting SRR in men with NOA. In addition, PRs and live birth rates (LBRs), as derived from subjects with NOA post-ICSI, were also analysed as secondary outcomes.

SEARCH METHODS

An extensive Medline, Embase and Cochrane search was performed. All trials reporting SRR derived from cTESE or mTESE in patients with NOA and their specific determinants were included. Data derived from genetic causes of NOA or testicular sperm aspiration were excluded.

OUTCOMES

Out of 1236 studies, 117 studies met the inclusion criteria for this study, enrolling 21 404 patients with a mean age (± SD) of 35.0 ± 2.7 years. cTESE and mTESE were used in 56 and 43 studies, respectively. In addition, 10 studies used a mixed approach and 8 studies compared cTESE with mTESE approach. Overall, a SRR per TESE procedure of 47[45;49]% (mean percentage [95% CI]) was found. No differences were observed when mTESE was compared to cTESE (46[43;49]% for cTESE versus 46[42;49]% for mTESE). Meta-regression analysis demonstrated that SRR per cycle was independent of age and hormonal parameters at enrolment. However, the SRR increased as a function of testis volume. In particular, by applying ROC curve analysis, a mean testis volume higher than 12.5 ml predicted SRR >60% with an accuracy of 86.2% ± 0.01. In addition, SRR decreased as a function of the number of Klinefelter's syndrome cases included (S = -0.02[-0.04;-0.01]; P < 0.01. I = 0.12[-0.05;0.29]; P = 0.16). Information on fertility outcomes after ICSI was available in 42 studies. Overall, a total of 1096 biochemical pregnancies were reported (cumulative PR = 29[25;32]% per ICSI cycle). A similar rate was observed when LBR was analysed (569 live births with a cumulative LBR = 24[20;28]% per ICSI cycle). No influence of male and female age, mean testis volume or hormonal parameters on both PR and LBR per ICSI cycle was observed. Finally, a higher PR per ICSI cycle was observed when the use of fresh sperm was compared to cryopreserved sperm (PR = 35[30;40]%, versus 20[13;29]% respectively): however, this result was not confirmed when cumulative LBR per ICSI cycle was analysed (LBR = 30[20;41]% for fresh versus 20[12;31]% for cryopreserved sperm).

WIDER IMPLICATIONS

This analysis shows that cTESE/mTESE in subjects with NOA results in SRRs of up to 50%, with no differences when cTESE was compared to mTESE. Retrieved sperms resulted in a LBR of up to 28% ICSI cycle. Although no difference between techniques was found, to conclusively clarify if one technique is superior to the other, there is a need for a sufficiently powered and well-designed randomized controlled trial to compare mTESE to cTESE in men with NOA.

Use of mini-incision microdissection testicular sperm extraction in men with cryptozoospermia and non-obstructive azoospermia

INTRODUCTION

Microdissection testicular sperm extraction (micro-TESE) is a procedure commonly utilized to harvest spermatozoa in severe male factor infertility. We have developed a technique involving a mini tunica albuginea incision with superficial tissue dissection (mini-incision micro-TESE). The modification is designed to reduce potential tissue injury, and we studied its effectiveness to harvest spermatozoa in men with cryptozoospermia and non-obstructive azoospermia.

MATERIALS AND METHODS

We performed a retrospective analysis of 103 infertile men with NOA and cryptozoospermia who underwent a mini-incision micro-TESE between March 2015 and August 2018 at the OVO fertility clinic. We consider the mini-incision micro-TESE procedure successful when at least five spermatozoa are identified in the micro-biopsies obtained from the superficial tissue exposed by the 1-cm mini-incision. If no spermatozoa are identified through the mini-incision, we can easily extend the incision to the standard micro-TESE.

RESULTS

The mini-incision procedure allowed for successful recovery of spermatozoa (intra-operative recovery of ≥ 5 spermatozoa) in 58% of men with cryptozoospermia and 25.6% of men with NOA. Overall, a successful sperm retrieval (with conversion to conventional micro-TESE if mini-incision was not successful) was achieved in 89% of men with cryptozoospermia and 48% of men with NOA. A successful mini-incision micro-TESE was associated with a significantly lower number of biopsies than conventional micro-TESE (8.8 vs 24.2, P < .0001). Moreover, in men undergoing a redo micro-TESE after a previously successful micro-TESE, 64% (9/14) had spermatozoa found and 21% (3/14) of these men only required a mini-incision micro-TESE.

CONCLUSION

Our data suggest that mini-incision micro-TESE is a useful approach in men undergoing micro-TESE, allowing for a shorter incision and a high sperm retrieval rate in men with cryptozoospermia. Furthermore, the findings of our study offer insight into the distribution of spermatogenesis in men with cryptozoospermia and NOA.

Step-by-step loupes-mTESE in non-obstructive azoospermic men, a retrospective study

Background

Men with non-obstructive azoospermia (NOA) may have sperm in their testes and a procedure of sperm retrieval and assisted reproduction is required in them to allow fertility. Standard procedures such as fine needle aspiration (FNA) and conventional testicular sperm extraction (cTESE) harvest random samples with a sperm retrieval rate (SRR) of 45%. Microdissection testicular sperm extraction (mTESE) is nowadays considered to be the most accurate technique to retrieve sperm in men with NOA. This procedure can identify dilated tubules that are more likely to contain viable sperm with a SRR of 60%.

Results

In our center, testicular biopsy was conducted in a standard fashion in 321 patients with NOA until March 2003. From then to December 2017, due to the lack of an operating microscope, we used 6 fold magnifying loupes to perform a step-by-step macro- mTESE in 1050 patients. Sperm was found in the first testis in 61% of the cases, leading to stop the procedure with less testicular damage. We increased our SRR from 43 to 51.8% in an acceptable operating time of 75mn for both sides.

Conclusions

In institutions where surgeons cannot afford an operating microscope, this modified mTESE technique using × 6 magnifying loupes is reliable, especially in patients with low testicular volumes and high FSH, in whom dilated tubules can be easily identified from the surrounding tissue.

Intraoperative assessment of tubules in predicting microdissection testicular sperm extraction outcome in men with Sertoli cell-only syndrome

Objective

This study aimed to assess the value of measuring the tubule diameter during microdissection testicular sperm extraction (micro-TESE) in predicting outcomes in patients with Sertoli cell-only syndrome (SCOS).

Methods

Fifty-six consecutive patients with SCOS were included. Patients were classified into two groups on the basis of the diameter of seminiferous tubules measured against 5/0 surgical suture (≥100 µm or <100 µm).

Results

The sperm retrieval rate (SRR) in men with a tubule diameter ≥100 µm was significantly lower than that in those with <100 µm (3.1% vs. 25.0%). The SRR from the contralateral testis in men with a tubule diameter ≥100 µm was lower than that in those with <100 µm (0% vs. 14.3%). Men with a tubule diameter ≥100 µm had a significantly larger testis and lower follicle-stimulating hormone levels than did men with <100 µm (8.1 ± 2.4 vs. 5.3±1.8 mL, 19.9 ± 9.7 vs. 25.9 ± 7.1 mIU/mL, respectively).

Conclusions

The diameter of tubules is a useful predictor for a successful SRR in men with SCOS. Intraoperative assessment of homogeneous large tubules allows some men to perform a limited (superficial) contralateral micro-TESE after no spermatozoa are initially identified.

Heterogenicity of testicular histopathology and tubules as a predictor of successful microdissection testicular sperm extraction in men with nonobstructive azoospermia

Only a few studies evaluate the presence of spermatozoa intraoperatively. The study aimed to assess whether the heterogenicity of testicular histopathology and seminiferous tubules can predict the outcome of microdissection testicular sperm extraction (micro-TESE) in men with nonobstructive azoospermia (NOA).The study comprised a retrospective analysis of 94 patients with azoospermia who were referred from 2016 to 2017. Under optical magnification, they were classified into 2 groups based on the diameter of tubules intraoperatively, namely homogeneous tubules and heterogeneous tubules. Postoperatively, patients were divided into 2 groups of heterogeneous histopathology and homogeneous histopathology according to the 8 histopathological classification subgroups. The sperm retrieval rate was the main outcome.Testicular spermatozoa were successfully retrieved in 27 men (28%). The sperm retrieval rate in those with heterogeneous histopathology was higher than men with homogeneous histopathology (47% vs 12%; P < .001). The sperm retrieval rate of each histopathological subgroup in men who had the heterogeneous histopathology was higher, compared with the homogeneous histopathology (Sertoli cell only [SCO]: 30% vs 6%; maturation arrest [MA]: 38% vs 0%; tubular hyalinization: 42% vs 20%, respectively). Under the optical magnification, the sperm retrieval rate was significantly higher in men with heterogeneous vs homogeneous tubules (65% vs 15%, P < .001). Moreover, the sperm retrieval rate of the contralateral testicular was higher in men who had heterogeneous tubules, compared with the homogeneous tubules (25% vs 3%; P = .036).Heterogenicity of histopathology is an effective predictor in men with histopathological information available from a previous diagnostic biopsy or conventional TESE attempt preoperatively for successful sperm retrieval. Homogeneous tubules seem beneficial for some patients to perform a limited (superficial) contralateral micro-TESE after no spermatozoa were identified initially.