Three-dimensional simulation analysis of microdissection testicular sperm extraction for patients with non-obstructive azoospermia

Anatomical considerations, testicular, and scrotal anatomy of nonobstructive azoospermia patients

ABSTRACT

Infertility, defined as the inability to conceive after 1 year of regular unprotected intercourse, impacts 10%-20% of couples globally. Both male and female factors contribute equally to this condition. Azoospermia, particularly nonobstructive azoospermia (NOA), which affects 10%-15% of infertile men, represents a significant challenge in male infertility. The advent of assisted reproductive technology (ART), specifically microdissection testicular sperm extraction (micro-TESE) followed by intracytoplasmic sperm injection (ICSI), offers a possibility for men with NOA to father biological children. Recent studies have focused on the predictors of sperm retrieval in NOA patients, such as age, testicular volume, and follicle-stimulating hormone (FSH) level. This review aims to explore the limited data on the anatomical characteristics of NOA patients and provide surgical considerations for micro-TESE, thereby enhancing understanding and improving outcomes for this challenging condition.

A Comparative Study of Equatorial and Longitudinal Incision Techniques in Microdissection Sperm Extraction for Nonobstructive Azoospermic Patients

OBJECTIVE

To compare sperm retrieval rates (SRR), postoperative pain, testicular volume, and postoperative testosterone levels between equatorial incisional microdissection testicular sperm extraction (micro-TESE) and longitidunal incisional micro-TESE in nonobstructive azoospermic (NOA) patients.

METHODS

Fifty NOA patients undergoing equatorial incisional micro-TESE were retrospectively assigned to group 1, while 50 patients undergoing longitidunal incisional micro-TESE were prospectively assigned to group 2. Demographic data, operative time, postoperative pain assessed via the visual analog scale, complications, SRR, and hormonal evaluations (FSH, LH, total testosterone) were recorded. Both groups compared in terms of preoperative demographic and clinical characteristics. SRR, testicular volume and postoperative testosterone, FSH, LH compared between study groups.

RESULTS

SRR were significantly higher in group 2 (62%) compared to group 1 (42%) (P=.045). No significant differences in operative time, visual analog scale pain scores, or postoperative complications were observed between groups. Hormonal evaluations showed a statistically significant decrease in testosterone levels for both groups at 3months, but no significant differences between groups. Testicular volume decreased postoperatively in both groups, with no significant differences between them.

CONCLUSION

Longitidunal incisional micro-TESE significantly improves SRR without increasing complication rates compared to equatorial incisional micro-TESE. These findings suggest that the longitidunal incisional micro-TESE may be a valuable advancement in the surgical management of NOA patients, warranting further research and clinical validation.

Micromapping testicular sperm extraction: A new technique for microscopic testicular sperm extraction in nonobstructive azoospermia

Purpose

In microscopic testicular sperm extraction (mTESE) for nonobstructive azoospermia (NOA), sperm can be recovered relatively easily in some cases, and mTESE may be retrospectively considered excessive. However, mTESE is routinely performed in the majority of NOA patients because of the difficulty in predicting tissue status. A minimally invasive and comprehensive sperm retrieval method that allows on-the-spot tissue assessment is needed. We have developed and evaluated a novel sperm retrieval technique for NOA called micromapping testicular sperm extraction (MMTSE).

Methods

MMTSE involves dividing the testis into four sections and making multiple small needle holes in the tunica albuginea to extract seminiferous tubules and retrieve sperm. The sperm-positive group by MMTSE (Group I) underwent additional tissue collection (ATC) via a small incision, whereas the sperm-negative group by MMTSE (Group 0) underwent mTESE.

Results

In total, 40 NOA participants underwent MMTSE. Group I included 15 patients and Group 0 included 25 patients. In Group 1, sperm were recovered from all patients by ATC. In Group 0, sperm were recovered in 4 of 25 cases using mTESE.

Conclusions

MMTSE shows promise as a simple method that comprehensively searches testicular tissue and retrieves sperm using an appropriate method while minimizing patient burden.

Comparison of unilateral and bilateral microdissection testicular sperm extraction (MD-TESE) in patients with non-obstructive azoospermia: a prospective study

OBJECTIVE

To compare sperm retrieval rates between unilateral and bilateral microdissection testicular sperm extraction (MD-TESE) procedures in patients with non-obstructive azoospermia and to contribute to the literature by comparing them with literature data.

METHODS

This prospective study included 84 males with primary infertility who had azoospermic NOA, who had been married for at least one year, and whose female partners did not have a history of infertility. The study was conducted between January 2019 and January 2020. MD-TESE was applied bilaterally to 48% (n:41) (Group 1) and unilaterally to 52% (n:43) (Group 2) of the patients, and sperm retrieval rates were compared.

RESULTS

There was no statistically significant difference between Group 1 patients and Group 2 patients in terms of sperm availability (61%, 56.5%, p=0.495, respectively). In addition, while no complications were observed in unilateral MD-TESEs, 3 complications were observed in bilateral MD-TESEs.

CONCLUSIONS

In our study, it was determined that there was no significant difference between the groups in terms of sperm availability in patients with NOA. Considering the operative time and complication rates of bilateral MD-TESE in patients diagnosed with NOA and the possible MD-TESE procedures that may be performed later, we believe that unilateral MD TESE is a more preferable procedure for the patient and surgeon in this patient group.

Altered mRNAs Profiles in the Testis of Patients With "Secondary Idiopathic Non-Obstructive Azoospermia"

Background: Non-obstructive azoospermia (NOA) is the most severe form of male infertility. Currently, known causative factors, including congenital and several acquired causes only account for approximately 30% of NOA cases. The causes for NOA remain unclear for most patients, which is known as idiopathic (iNOA). However, whether iNOA is due to congenital defects or acquired abnormalities is a confusing problem due to the delayed diagnosis of this frustrating condition until the childbearing age. Therefore, we collected several cases with "secondary idiopathic NOA" and detected the altered mRNAs profiles in the testicular tissues to explore the possible molecular basis. Materials and Methods: In this study, several patients with a previous history of natural pregnancy with their partners before, who were diagnosed as iNOA based on the outcomes of routine semen analysis and multiple testis biopsies now, were enrolled. Some known risk factors and genetic factors were excluded. Therefore, we defined this phenotype as "secondary idiopathic NOA." To explore the possible molecular basis of this disease, we performed mRNA expression analysis through next-generation sequencing on three cases and other three patients with obstructive azoospermia as controls. Bioinformatics analyses were conducted to assess differentially expressed genes and possible biological mechanisms involved in the disease. Quantitative real-time reverse transcription polymerase chain reaction assays were applied to confirm the results in several selected mRNAs involved in stages and metabolism of Sertoli cells. Results: A series of mRNAs were found to be altered in testicular tissues between patients with "secondary idiopathic NOA" and controls, including 6,028 downregulated and 3,402 upregulated mRNAs. Gene Ontology (GO) analysis and Kyoto Encyclopedia of Genes and Genome (KEGG) analyses revealed a range of GO and KEGG terms, such as cellular process involved in reproduction, protein degradation, and absorption. Conclusion: The present study introduces a novel classification called "secondary idiopathic NOA." We provide a global view of the altered mRNAs involved in spermatogenetic failure in these cases. Regarding the limited samples, further studies should be taken to understand this new classification.

Use of contrast enhanced ultrasound in testicular diseases: A comprehensive review

Background

Contrast‐enhanced ultrasound (CEUS) is a sonographic technique that increases the diagnostic accuracy of ultrasound and color Doppler ultrasound (CDUS) when studying testicular abnormalities. However, its role in clinical practice is still debatable because there are no accepted standards regarding how and when this technique should be used for patients with testicular disease.

Objectives

To perform a nonsystematic review of the current literature to highlight the strength and flaws of performing CEUS and to provide a critical overview of current research evidence on this topic.

Materials and methods

A thorough search of published peer‐reviewed studies in PubMed was performed using proper keywords.

Results

Strong enhancement of neoplastic lesions (both benign and malignant) during CEUS aids in differential diagnosis with non‐neoplastic lesions, which usually appears either nonenhanced or enhanced in a manner similar to that of the surrounding parenchyma. CEUS enhancement has a high predictive value in the identification of neoplastic lesions, whereas a similar or complete absence of enhancement may be interpreted as strong evidence of benignity, although there are exceptions. Literature on quantitative analysis is still scarce, though promising, particularly in distinguishing benign from malignant neoplasms. Furthermore, CEUS may be useful in many emergency situations, such as acute scrotum, blunt scrotal trauma, and focal infarction of the testis. Finally, CEUS can help increase the probability of sperm recovery in azoospermic males.

Discussion and conclusion

CEUS is a safe, easy‐to‐perform, and cost‐effective diagnostic tool that can provide a more accurate diagnosis in testicular lesions and acute scrotal disease. However, further studies with larger cohorts are required to refine the differential diagnosis between benign and malignant neoplasms. Finally, these preliminary results can instigate the development of innovative research on pre‐testicular sperm extraction to increase the chances of sperm recovery.

Three-dimensional simulation analysis of microdissection testicular sperm extraction for patients with non-obstructive azoospermia

Background

Microdissection testicular sperm extraction (microTESE) is considered the gold standard method of sperm retrieval from patients with non‐obstructive azoospermia (NOA). For careful and thorough examination of seminiferous tubules during microTESE, maximizing surface area of the testicles which we are able to search is essential.

Objectives

To develop a systematic procedure for microTESE to maximize surface area and to achieve high sperm retrieval rate (SRR) in microTESE.

Materials and methods

We simulated microTESE using three‐dimensional (3D) simulation model and analyzed mathematically the sum of the surface area in various methods. The best method obtained from this simulation model was applied to 102 patients with NOA from 2014 to 2018. These new clinical results were compared with those of 56 patients who underwent a previous method of microTESE from 2011 to 2014.

Results

The mathematical 3D simulation model of microTESE indicated that a longitudinal incision on the tunica albuginea and following transverse slicing incisions of testicular parenchyma maximized the surface area coverage. Forty‐six (45%) out of 102 patients who underwent microTESE with the new method had successful retrieval of testicular spermatozoa compared with 16 (29%) of 56 patients with the previous method of microTESE (P = .04).

Discussion

Transverse resections of parenchyma in our method run parallel to the courses of intratesticular arteries and do not interfere with the blood supply. The small amount of extracted seminiferous tubules was equivalent to that of the previous method, and no patients exhibited post‐operative symptoms of androgen deficiency in our study. As for post‐operative pain, our new method was comparable with the previous method. Although our study needs a longer follow‐up, there will be limited effects on testicular functions.

Conclusion

Longitudinal incision on the tunica albuginea and following transverse slicing incisions in the testicular parenchyma maximized the surface area and improved the SRR of microTESE.