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

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 sperm retrieval rate between superficial and deep dissection during microscopic testicular sperm extraction

Objective

The purpose of the study was to compare the outcome of microscopic testicular sperm extraction (micro-TESE) between superficial and deep dissection on the same testicle in terms of sperm retrieval rate (SRR).

Patients and Methods

In a retrospective study from June 2019 to October 2021, 44 patients with nonobstructive azoospermia who underwent micro-TESE with positive results (mature sperm identified) were included. Eight patients were excluded from the study due to deficient documentation on superficial and deep dissection. A total of 36 patients were included; 60 testicles were examined for superficial and deep biopsies. Testicular histopathology was performed in all patients, and a hormonal evaluation was obtained before the micro-TESE attempt.

Results

Thirty-six patients and 60 testicles were included in the study. Of them, 47 (78.3%) testicles had positive results. Superficial TESE was positive in 38 (63.3%) testicles, and deep TESE was successful in 45 (75.0%) testicles. An improvement of 13.9% in the SRR was observed, following deep dissection. However, there was no statistically significant difference (P = 0.166). Rates of positive sperm retrieval (from any side) did not differ significantly based on patients' age, microdissection testicular sperm extraction sides, and hormonal concentrations; these differences were not apparent after superficial or deep TESE.

Conclusion

The presented findings suggest that although successful SRRs of deep TESE were higher than that of its superficial counterpart, there was no significant statistical difference. A larger body of evidence is needed to provide a higher grade of recommendation.

Microdissection Testicular Sperm Extraction

Nonobstructive azoospermia (NOA) is among the most common causes of male infertility. For men with NOA seeking fertility treatment, microdissection testicular sperm extraction (microTESE) is the best option for retrieving sperm, which can be used with in vitro fertilization-intracytoplasmic sperm injection to achieve pregnancy in their partner. With the aid of the operating microscope, microTESE allows for thorough evaluation of the testis tissue and selection of seminiferous tubules that appear most capable of sperm production. Rates of success with microTESE vary depending on the underlying cause of NOA and the center at which the procedure is performed. Not all patients are candidates for microTESE, and those who are candidates should be counseled on the likelihood of sperm retrieval and the potential for changes in postoperative testis function.

Efficacy of stepwise mini-incision microdissection testicular sperm extraction for nonobstructive azoospermia with varied etiologies

Stepwise mini-incision microdissection testicular sperm extraction (mTESE) is a procedure that attempts to minimize testicular damage. However, the mini-incision approach may vary in patients with different etiologies. Here, we performed a retrospective analysis of 665 men with nonobstructive azoospermia (NOA) who underwent stepwise mini-incision mTESE (Group 1) and 365 men who underwent standard mTESE (Group 2). The results showed that the operation time (mean ± standard deviation) for patients with successful sperm retrieval in Group 1 (64.0 ± 26.6 min) was significantly shorter than that in Group 2 (80.2 ± 31.3 min), with P <0.001. The total sperm retrieval rate (SRR) was 23.1% in our study, and there was no significant difference between Group 1 and Group 2 ( P >0.05), even when the etiologies of NOA were taken into consideration. The results of consecutive multivariate logistic regression analysis (odds ratio [OR]: 0.57; 95% confidence interval [CI]: 0.38-0.87; P =0.009) and receiver operating characteristic (ROC) analysis (area under the ROC curve [AUC]=0.628) showed that preoperative anti-Müllerian hormone (AMH) level in idiopathic NOA patients was a potential predictor for surgical outcomes after initial three small incisions made in the equatorial region without sperm examined under an operating microscope (Steps 2-4). In conclusion, stepwise mini-incision mTESE is a useful technique for NOA patients, with comparable SRR, less surgical invasiveness, and shorter operation time compared with the standard approach. Low AMH levels may predict successful sperm retrieval in idiopathic patients even after a failed initial mini-incision procedure.

Microdissection Testicular Sperm Extraction Versus Multiple Needle-pass Percutaneous Testicular Sperm Aspiration in Men with Nonobstructive Azoospermia: A Randomized Clinical Trial

BACKGROUND

Surgical extraction of testicular spermatozoa is needed in men with nonobstructive azoospermia (NOA) who wish to become biological fathers. Based on available uncontrolled studies with unspecific patient selection, microdissection testicular sperm extraction (mTESE), having a sperm retrieval rate (SRR) of 50%, is considered the most efficient sperm retrieval procedure. However, no randomized clinical trials for comparison of different sperm retrieval procedures exist. Testicular sperm aspiration (TESA) is simple and commonly used, and we hypothesized that this technique using multiple needle passes would give similar SRRs to mTESE.

OBJECTIVE

To compare mTESE and multiple needle-pass TESA in men with NOA.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial was performed between June 2017 and April 2021, with inclusion of 100 men with NOA from four centers in Denmark and Sweden. All participants received treatment at the same institution.

INTERVENTION

Participants were randomized to mTESE (n = 49) or multiple needle-pass TESA (n = 51). Patients with failed multiple needle-pass TESA proceeded directly to salvage mTESE.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was SRR. Secondary outcomes included complications and changes in reproductive hormones after surgery.

RESULTS AND LIMITATIONS

Spermatozoa were retrieved in 21/49 (43%) men after mTESE and in 11/51 (22%) men after multiple needle-pass TESA (rate difference -0.21; 95% confidence interval -0.39 to -0.03; p = 0.02). The combined SRR for multiple needle-pass TESA + salvage mTESE was 15/51 (29%). No complications occurred after multiple needle-pass TESA only, while 5/89 (6%) men having mTESE experienced a complication requiring surgical intervention. Overall, no statistically significant differences in reproductive hormones were observed between groups after 6 mo. Limitations include the low number of patients in secondary outcome data.

CONCLUSIONS

In direct comparison, SRR was higher in mTESE than in multiple needle-pass TESA.

PATIENT SUMMARY

Men with azoospermia need surgical extraction of spermatozoa to become biological fathers. In this randomized trial, we compared two surgeries (microdissection testicular sperm extraction [mTESE] and testicular sperm aspiration [TESA]) and found that mTESE gives a higher sperm retrieval rate than multiple needle-pass TESA.

Development and validation predictive models of sperm retrieval for azoospermic men undergoing testicular sperm aspiration: a multicentre, retrospective, cohort study

PURPOSE

Testicular sperm aspiration (TESA) is widely used to retrieve sperm from testis. Diagnostic testicular biopsy should not be routinely performed for azoospermia. Therefore, a good predictive model is needed before TESA.

METHODS

A total of 1972 azoospermia patients constituted the modelling set, and 260 azoospermia patients from two other centres constituted the validation set. An integrated predictive model was built using logistic regression. Receiver operating characteristic (ROC), calibration and decision curve analyses were performed to evaluate the performance of follicle-stimulating hormone (FSH), semen volume, testicular volume and the integrated model.

RESULTS

The FSH level was the best univariate predictor for successful sperm retrieval (SSR) and was better than semen volume and testicular volume alone (p<0.001, threshold 6.17 IU/L, modelling set area under receiver operating characteristic curve (AUC) 0.80, accuracy 0.79; validation set AUC 0.87, accuracy 0.78). The integrated predictive model had excellent accuracy for predicting SSR (modelling set: AUC 0.93, accuracy 0.89; validation set: AUC 0.96, accuracy: 0.89). Calibration curve analysis indicated that the integrated model calibration was good and better than that of FSH, semen volume and testicular volume alone. Decision curve analysis indicated with a threshold probability between 0.05 and 0.98, the integrated model added more benefit than treating either all or no patients.

CONCLUSIONS

The integrated model has excellent discrimination and good calibration. It can help azoospermic men make better decisions before TESA. It should be noted that TESA is not the first-line treatment for non-obstructive azoospermia because of a low sperm retrieval rate.

Testosterone levels among non-obstructive azoospermic patients 2 years after failed bilateral microdissection testicular sperm extraction: a nested case-cohort study

PURPOSE

To define the risk of hypogonadism following microdissection testicular sperm extraction in cases of non-obstructive azoospermia. While sperm retrieval by open testicular sperm extraction can be associated with an increased risk of hypogonadism, there is limited data addressing which procedures and which patients harbor the greatest risk.

METHODS

We report on a community-acquired, nested, case-cohort of non-obstructive azoospermic patients referred to one clinic after failed bilateral microdissection testicular sperm extraction. Patients were health-matched (1:2) to surgically naïve controls and divided into 2 cohorts based on risk factors for hypogonadism. Among microdissection patients, we compared total testosterone and gonadotropin levels before and > 6 months after surgery. Biochemical hypogonadism was defined as a total serum testosterone level ≤ 300 ng/dL. Hormone levels were compared to risk-matched controls. Comparative statistics were used to assess hormone levels within and between cohorts.

RESULTS

There were no significant differences in baseline testosterone levels between microdissection patients (n = 26) and risk-matched controls (n = 52). At a mean of 26 months (range 6.2-112.8) post-procedure, mean testosterone levels decreased significantly (73 ng/dL or 16%; CI - 27, - 166; p < 0.01, paired t-test). Among microdissection patients with baseline testosterone > 300 ng/dL, 8/22 (36%) experienced hypogonadism post-procedure. There was a corresponding increase in follicle stimulating hormone (p = 0.05) and a trending increase in luteinizing hormones (p = 0.10).

CONCLUSION

A durable decrease in testosterone levels occurs after failed microdissection testicular sperm extraction regardless of baseline risk of hypogonadism. In addition, a significant proportion of eugonadal patients will become hypogonadal after failed testicular microdissection procedures.

For patients with non-obstructive azoospermia, the outcome of testicular sperm extraction correlates with self-esteem, sexual health and the quality of the couple's relationship

BACKGROUND

A very small number of studies have indicated that azoospermia or negative testicular sperm extraction (TESE) outcomes are linked to depression or erectile dysfunction. However, the data are often weak, conflicting and gathered with non-validated questionnaires. Hence, we performed a cross-sectional study of 44 men with non-obstructive azoospermia. Levels of self-esteem and the quality of the couple's sex life and overall relationship were assessed with validated questionnaires before and after the TESE procedure as a function of the TESE outcome.

RESULTS

A positive TESE outcome (n = 24) was associated with a statistically significant increase in self-esteem (particularly with regard to family aspects), sexual health and couples' adjustment quality. In contrast, a negative TESE outcome (n = 20) was associated with statistically significant decreases in self-esteem, erectile function, intercourse satisfaction, orgasmic function, couples' adjustment quality and all aspects of the couple's relationship (consensus, cohesion, satisfaction and affection).

CONCLUSION

For men with non-obstructive azoospermia (NOA), negative TESE outcomes may have a negative impact on self-esteem and the quality of the couple's sex life and overall relationship. This should be borne in mind when counselling men with NOA and their partners to (ideally) help them to cope with and decrease the harmful impacts of azoospermia and negative TESE.

Endocrine Follow-Up of Men with Non-Obstructive Azoospermia Following Testicular Sperm Extraction

Testicular sperm extraction (TESE) is a surgical procedure which, combined with intracytoplasmic sperm injection, constitutes the main treatment for achieving biological parenthood for patients with infertility due to non-obstructive azoospermia (NOA). Although it is effective, TESE procedures might cause structural testicular damage leading to Leydig cell dysfunction and, consequently, temporary or even permanent hypogonadism with long-term health consequences. To a lesser extent, the same complications have been reported for microdissection TESE, which is considered less invasive. The resulting hypogonadism is more profound and of longer duration in patients with Klinefelter syndrome compared with other NOA causes. Most studies on serum follicle-stimulating hormone and luteinizing hormone concentrations negatively correlate with total testosterone concentrations, which depends on the underlying histology. As hypogonadism is usually temporary, and a watchful waiting approach for about 12 months postoperative is suggested. In cases where replacement therapy with testosterone is indicated, temporary discontinuation of treatment may promote the expected recovery of testosterone secretion and revise the decision for long-term treatment.

Reproductive Chances of Men with Azoospermia Due to Spermatogenic Dysfunction

Non-obstructive azoospermia (NOA), or lack of sperm in the ejaculate due to spermatogenic dysfunction, is the most severe form of infertility. Men with this form of infertility should be evaluated prior to treatment, as there are various underlying etiologies for NOA. While a significant proportion of NOA men have idiopathic spermatogenic dysfunction, known etiologies including genetic disorders, hormonal anomalies, structural abnormalities, chemotherapy or radiation treatment, infection and inflammation may substantively affect the prognosis for successful treatment. Despite the underlying etiology for NOA, most of these infertile men are candidates for surgical sperm retrieval and subsequent use in intracytoplasmic sperm injection (ICSI). In this review, we describe common etiologies of NOA and clinical outcomes following surgical sperm retrieval and ICSI.

Evaluating the quality of reported outcomes for microsurgical TESE in men with non-obstructive azoospermia: A methodological analysis

BACKGROUND

Publications of microsurgical testicular sperm extraction (mTESE) techniques and outcomes are heterogeneous, which may limit creation of best surgical practices.

OBJECTIVE

To study the quality and heterogeneity of published mTESE outcomes via a methodological analysis.

MATERIALS/METHODS

A systematic methodological analysis of all published literature on the use of mTESE in men with non-obstructive azoospermia from 1999 to the July 2020 was performed. PubMed and MEDLINE searches were performed using the search terms "microdissection TESE OR microsurgical TESE." Publications were evaluated on their reporting of pre-operative factors, intraoperative techniques, surgical and clinical outcomes, and adverse events.

RESULTS

Fifty-five studies met inclusion criteria. Surgical technique and sperm retrieval rates were the most reported criteria. Reporting on the presence of an embryologist intraoperatively was observed in approximately 30% of articles, while other procedural details including method of sperm quantification, quantity retrieved, and number of cryopreserved vials were observed in fewer than 10% of articles. Clinical outcomes, including pregnancy rates and live birth rates, were reported in fewer than 40% of the articles. Fetal outcomes including fetal and neonatal anomalies were rarely reported. Fetal growth restriction, preterm delivery, small or large for gestational age, and NICU admissions were never reported.

CONCLUSION

There are inconsistencies in reporting quality of mTESE outcomes, specifically a lack of information on the quantity and quality of sperm retrieved, the role of embryology intraoperatively, and clinical outcomes, such as live birth rate and fetal anomalies. These gaps may guide development of standardized reporting guidelines to better assess and compare clinical outcomes across institutions and maintain focus on couples-centric fertility outcomes in future mTESE studies.

How Successful Is Surgical Sperm Retrieval in Klinefelter Syndrome?

Klinefelter Syndrome (KS) is characterized by the presence of an extra X chromosome. It was first diagnosed in 1942 in a group of azoospermic men. KS is the most common chromosomal abnormality encountered in infertile men and accounts for more than 10% of the causes of azoospermia. Men who are azoospermic may still father children via testicular sperm extraction followed by intracytoplasmic sperm injection (ICSI). This review article summarizes the success rates of the available techniques for surgical sperm retrieval (SSR) in KS including conventional testicular sperm extraction (cTESE) and micro testicular sperm extraction (mTESE), as well as the risks of these procedures for future fertility. The evidence indicates that the SSR rate is as successful in non-mosaic men with KS as those with normal karyotypes, with retrieval rates of up to 55% reported. The influence of different factors that affect the chances of a successful outcome are discussed. In particular, the impact of aneuploidy rate, physical characteristics, co-morbidities, reproductive endocrine balance and the use of different hormone management therapies are highlighted. Evidence is presented to suggest that the single most significant determinant for successful SSR is the age of the patient. The success of SSR is also influenced by surgical technique and operative time, as well as the skills of the surgeon and embryology team. Rescue mTESE may be used successfully following failed TESE in KS patients in combination with hormone stimulation.

The evolution of testicular sperm extraction and preservation techniques

Along with the advent of intracytoplasmic sperm injection in 1992, sperm retrieval procedures now allow the possibility of conception from male sterility. In cases of sterility due to blockages in the reproductive tract, sperm retrieval procedures are relatively straightforward and reliable. In nonobstructive azoospermia or testis failure, sperm often can be difficult to retrieve. For this reason, the field of testicular sperm retrieval has witnessed tremendous change and innovation to achieve higher sperm yields, increasing efficiency and safety, along with fewer complications. We review the history and evolution of testicular sperm retrieval since its inception. Using the findings from randomized controlled trials, basic science studies, meta-analyses, case-controlled or cohort studies, best-practice policies, and literature reviews, we outline the concepts, facts, and principles that have been elucidated over several decades of experience with sperm retrieval. We also appraise the merits and issues of the most popular sperm retrieval techniques and strategies. Finally, we define areas of future clinical and laboratory development that will further refine the field of testicular sperm retrieval.

Acute effect of microdissection testicular sperm extraction on blood total testosterone and luteinising hormone levels

Testicular sperm extraction is a common surgical procedure to retrieve spermatozoa from men with azoospermia which may affect the tissue and cause hypogonadism (Human Reproduction Update, 24, 2018, 442). We aimed to evaluate the acute effect of micro-TESE on blood total testosterone (TT) and luteinising hormone (LH) levels. Between April 2018 and September 2019, 60 selected NOA (i.e. with normal TT and LH) patients were included in the study. After procedure, blood samples were collected to evaluate the levels of TT and LH at 1st and 24th hour and first week. Values were compared. In addition, patients were divided into two groups according to their body mass index. Mean age of patients was 27.37 ± 4.52 years, and mean of body mass index was 24.49 ± 3.78 kg/m² . Mean TT levels at the 1st hour, 24th hour and the 1st week were 3.81, 3.50 and 3.05 ng/ml respectively. Mean LH levels at the 1st hour, 24th hour and the 1st week were 5.03, 5.15 and 5.46 IU/L respectively. Statistically significant differences between pre- and post-operative 24th hour and 1st week values were detected (p = .001, p < .001 respectively). No statistical differences were found between two BMI's groups. TT decreased in acute period after the procedure, whereas the increase of LH levels was observed after 24th hour.

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.

Open testicular mapping: A less invasive multiple biopsy approach for testicular sperm extraction

This study proposes a testicular sperm extraction technique that was inspired by testicular fine-needle aspiration. Here, we have described the technique of open testicular mapping (OTEM) and evaluated the successful sperm recovery in 92 patients with nonobstructive azoospermia (NOA). All patients underwent an OTEM biopsy. Patients were divided into two groups; group I included men with spermatozoa recovered and group 0 included men without spermatozoa recovered. Age, follicle-stimulating hormone (FSH) level and testicular volume were compared between the groups. In 50 of 92 men (54%), viable spermatozoa were found after OTEM. No differences were noted in age, FSH level or testicular volume. Using OTEM, it was possible to retrieve spermatozoa in 54% of the NOA men.

Novel method of histopathological analysis after testicular sperm extraction in patients with nonobstructive and obstructive azoospermia

Objective

To assess whether the “testicular pool” could be used for histological analysis and whether it gave more accurate information than the standard testicular biopsy.

Methods

Between January 2017 and March 2018, this single-center prospective study included 60 azoospermic men undergoing conventional bilateral testicular sperm extraction. Six samples were excised from each testicle and transferred to an embryologist. One additional biopsy was randomly taken from each testis for a histological analysis. After processing, the testicular pool was also sent for a histological analysis, which showed normal spermatogenesis (NS), hypospermatogenesis (HYPO), maturation arrest (MA), Sertoli cell-only syndrome (SCOS), and tubular atrophy (TA).

Results

Twenty of the 60 patients (33.3%) had obstructive azoospermia (OA), while the remaining 40 (66.6%) had nonobstructive azoospermia. Their mean age was 40.5 years. All patients with OA had previously undergone unsuccessful testicular fine-needle aspiration. Successful sperm retrieval (SSR) occurred in 93.3% of patients. Histological analysis of the testicular biopsy revealed NS in 12 patients (20%), HYPO and TA in 28 patients (46.6%), MA in eight patients (13.3%), and SCOS in 12 patients (20%). The testicular pool analysis showed NS in 12 patients (20%), HYPO and TA in 44 patients (73.3%), MA in four patients (6.6%), and SCOS in no patients. In four patients with MA (6.6% of the total sample) and 12 patients with SCOS (20% of the total sample) according to the standard testicular biopsy, the embryologist found SSR with cryopreservation. Overall, in 44 patients (73.3%), the testicular pool analysis confirmed the histological findings of the standard testicular biopsy. In the 16 cases (26.6%) with a discrepancy between the single-biopsy histological findings and SSR, the testicular pool analysis confirmed the embryological data on SSR.

Conclusion

The testicular pool proved to be easily analyzable, practical, manageable, and more accurate for predicting sperm retrieval than standard testicular biopsy.

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.

Advances in sperm retrieval techniques in azoospermic men: A systematic review

OBJECTIVE

To evaluate various methods of operative sperm retrieval in men with non-obstructive azoospermia (NOA) and to determine the optimal surgical approach in terms of effectiveness, morbidity, and complications.

MATERIALS AND METHODS

PubMed and Cochrane databases were searched to identify five recent reviews and meta-analyses evaluating outcomes for sperm retrieval in men with NOA.

RESULTS AND CONCLUSION

Micro-TESE is the most efficient method for retrieving sperm but requires special expertise and can be traumatic for the testes. Conventional biopsies are twice more likely to retrieve sperm than fine-needle aspiration. Testicular aspiration performed by multiple passes into the testis is traumatic and is not efficient for sperm retrieval. Needle-aspiration biopsy and open real-time testicular mapping by the single seminiferous tubule technique can offer less traumatic methods for sperm retrieval, which can be tried before proceeding to micro-TESE. The first attempt at sperm retrieval is the best chance the patient has and should combine various techniques sequentially to give the highest chance of success with the least morbidity.

Microdissection testicular sperm extraction in men with nonobstructive azoospermia: Experience of King Saud University Medical City, Riyadh, Saudi Arabia

Objectives:

Microdissection testicular sperm extraction (micro-TESE) is an optimal technique of sperm extraction for intracytoplasmic sperm injection. This study is to present our experience in micro-TESE and evaluate the relation of its sperm retrieval rate (SRR) with patients' characteristics, testicular functions, and histological parameters as well as previous sperm retrieval interventions.

Materials and Methods:

We retrospectively reviewed records of 255 patients with nonobstructive azoospermia who underwent micro-TESE between 2011 and 2014. Medical records were reviewed for the results of follicle stimulating hormone (FSH), luteinizing hormone (LH), total testosterone levels, karyotype analysis, and testicular histology pattern. Testicular volume was measured with an ultrasound scale.

Results:

The mean patients' age was 35.8 ± 7.2 years, duration of infertility 7.7 ± 4.5 years, right testicular volume 13.1 ± 5 ml, and left testicular volume 12.9 ± 5 ml. The overall SRR was 43.9%. SRR was significantly higher in testes with hypospermatogenesis histology pattern (P = 0.011). Patients' age, testicular size, serum FSH, LH, prolactin, and testosterone or failed previous sperm retrieval interventions showed no significant impact on SRR. Eleven (4.3%) patients had nonmosaic Klinefelter syndrome with a mean age of 37.8 ± 3.3 years. Sperms were retrieved in 6 (54.5%) patients. Post micro-TESE androgens significantly deteriorated with near complete recovery after 1 year.

Conclusions:

Micro-TESE has a high SRR, minimal postoperative complications, and reversible long-term androgen deficiency. Sperm retrieval depends on the most advanced pattern of testicular histology. Hypospermatogenesis pattern has the highest SRR. We demonstrated a high SRR with micro-ESE in men with Klinefelter syndrome.

Use of testicular versus ejaculated sperm for intracytoplasmic sperm injection among men with cryptozoospermia: a meta-analysis

OBJECTIVE

To examine outcomes of intracytoplasmic sperm injection (ICSI) using testicular versus ejaculated sperm among men with cryptozoospermia.

DESIGN

Meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Men with cryptozoospermia undergoing consecutive ICSI cycles using ejaculated or testicular sperm.

INTERVENTION(S)

A systematic search was performed using PubMed (inception to August 2015). Inclusion criteria were studies comparing ICSI outcomes among men with cryptozoospermia using ejaculated and testicular sperm.

MAIN OUTCOME MEASURE(S)

Primary outcomes included ICSI fertilization or pregnancy rates (PRs). Secondary analysis included number of retrieved oocytes, maternal and paternal ages. Meta-analysis of weighted data using a random effects model was performed. Results are reported as relative risk or weighted mean differences (WMD) with 95% confidence intervals (CI).

RESULT(S)

Five cohort studies were included, encompassing 272 ICSI cycles and 4,596 injected oocytes. There were no differences in ICSI PRs (relative risk [RR] 0.53, 95% CI 0.19-1.42, I(2) = 67%) or fertilization rates (RR 0.91, 95% CI 0.78-1.06, I(2) = 73%) between testicular and ejaculated sperm groups. There was a significant trend toward increasing maternal age (WMD 1.69 years, 95% CI -2.71 to -0.66) and paternal age (WMD 2.61 years, 95% CI -4.73 to -0.48) with testicular sperm. There was no difference between numbers of oocytes retrieved (WMD 0.95, 95% CI -0.15 to 2.05). Post-hoc power analysis revealed pβ <20% for PR analysis and pβ <10% for fertilization rate analysis.

CONCLUSION(S)

The existing literature does not support a recommendation for men with cryptozoospermia to use testicular sperm in preference over ejaculated sperm for ICSI.

Sperm retrieval techniques

Since the advent of intracytoplasmic sperm injection in 1992, sperm retrieval procedures have been routinely employed to treat male infertility owing to azoospermia. With obstructive azoospermia, sperm is potentially harvestable from the vas deferens, epididymis, and testicle using percutaneous and open sperm retrieval procedures that are relatively straightforward and reliable. In nonobstructive azoospermia, sperm is generally found only in the testicles and can often be difficult to retrieve. Several approaches aimed at maximizing sperm yield in this condition have been developed, but only 50% of men with nonobstructive azoospermia will have clinically usable sperm. Multibiopsy testicular sperm extraction (TESE), microdissection TESE, and fine-needle-aspiration map-guided TESE are three common methods currently employed to locate and retrieve sperm in these difficult cases. Other factors that influence the use of surgically retrieved sperm for assisted reproduction include differences in sperm DNA integrity, the expertise of the surgeon and the andrology laboratory, and the described differences in the viability of sperm from different anatomical sources after freezing and thawing.

Azoospermia due to spermatogenic failure

This article summarizes the current literature regarding azoospermia caused by spermatogenic failure. The causes and genetic contributions to spermatogenic failure are reviewed. Medical therapies including use of hormonal manipulation, whether guided by a specific abnormality or empiric, to induce spermatogenesis are discussed. The role of surgical therapy, including a discussion of varicocelectomy in men with spermatogenic failure, as well as an in-depth review of surgical sperm retrieval with testicular sperm extraction and microdissection testicular sperm extraction, is provided. Finally, future directions of treatment for men with spermatogenic failure are discussed, namely, stem cell and gene therapy.

High prevalence of androgen deficiency and abnormal lipid profile in infertile men with non-obstructive azoospermia

In men with non-obstructive azoospermia (NOA), the risk of hypogonadism is often overlooked. Testicular sperm extraction (TESE) may increase this risk. The objective of this study was to elucidate the prevalence of hypogonadism in NOA-patients, the impact of TESE on hormone balance and the association between testosterone deficiency and dyslipidaemia. Men with NOA who had undergone TESE during the period 2004-2009 were eligible. Hypogonadism was defined as total testosterone <10 nmol/L and/or LH >10 IU/L and/or ongoing androgen replacement therapy. Sixty-five consecutive men who had undergone TESE owing to NOA and from whom post-TESE serum testosterone levels measured before 1100 h were available. Furthermore, 141 fertile men served as controls. Serum concentrations of testosterone, LH and lipids were assessed. Odds ratios (OR) for biochemical hypogonadism were calculated. Pre- and post-TESE hormone levels were compared. Lipid profile was related to testosterone levels. Hypogonadism was found in 47% (95% CI, 0.36, 0.59) of the NOA-men. As compared with fertile controls, the OR for hypogonadism post-TESE was 17 (95% CI 6.6-45). Serum LH (p = 0.03), but not testosterone (p = 0.43), differed significantly pre- and post-TESE. Compared with eugonadal NOA-men, the OR for having deviations in lipid profile was 3.3 (95% CI 1.3-8.8) for the hypogonadal NOA-men. NOA-men are at very high risk of androgen deficiency, which even in young subjects is associated with dyslipidaemia. Medical management of these men should therefore include endocrinological evaluation and follow-up after completion of infertility treatment.

In the era of micro-dissection sperm retrieval (m-TESE) is an isolated testicular biopsy necessary in the management of men with non-obstructive azoospermia?

OBJECTIVES

To assess the outcome of sperm retrieval using micro-dissection-TESE (m-TESE) and simultaneous diagnostic biopsy in NOA to determine if the final definitive histology correlated with the outcome of sperm retrieval by m-TESE in men with NOA. To determine if there was a correlation between FSH levels and positive sperm retrieval rates and assessed the success rate of m-TESE as either a primary or a salvage procedure after previous negative sperm retrieval. The EAU guidelines (2010) recommend that in men with non obstructive azoospermia 'a testicular biopsy is the best procedure to define the histological diagnosis and the possibility of finding sperm'. However, these guidelines do not identify which patients should have a diagnostic biopsy and if this biopsy should be performed as an isolated procedure or synchronously with sperm retrieval. It is also suggested that there is a correlation between the histological diagnosis and possibility of finding sperm on testis biopsy.

PATIENTS AND METHODS

100 men with NOA underwent a m-TESE sperm retrieval between 2005 and 2010 at a single centre. All patients underwent hormonal analysis (serum FSH, Testosterone and LH levels) and genetic analyses after full counselling including; Y-deletion, CF-gene analysis and karyotype. Thirty five men had previously undergone unsuccessful TESA/TESE or diagnostic biopsy at other centres. All patients underwent synchronous sperm retrieval and biopsy of the testis, which was sent for histopathological examination on the day of an ICSI cycle or as an isolated procedure.

RESULTS

Mean age of patients was 37.25 (range 29-56 years). The mean serum FSH levels in the Sertoli cell only, maturation arrest and hypospermatogenesis groups were 21.3 IU/L (2.8-75), 16.18 (1.6-67) and 14.17 IU/L (0.8-42.3) respectively. SR rates in the respective groups were 42.85%, 26.6% and 75.86% (P= 0.023). There were no post-operative complications. In the 35 men who had previously undergone unsuccessful procedures elsewhere, the SR rates were 57.1%. The overall sperm retrieval rate was 50%. There was no correlation between SR and FSH levels (P= 0.28).

CONCLUSION

M-TESE should be considered the gold standard for retrieval of testicular sperm in NOA, even in cases where there has been previously unsuccessful attempts. FSH levels and histology cannot be used to predict the success of sperm retrieval. An isolated diagnostic testicular biopsy is not recommended in men with NOA, as a significant proportion of men undergoing m-TESE will have successful a sperm retrieval irrespective of previous histology or previous unsuccessful surgery.

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.

Microdissection testicular sperm extraction: prediction, outcome, and complications

Testicular spermatozoa can be retrieved successfully by the testicular sperm extraction (TESE) procedure and used for intracytoplasmic sperm injection in cases of non-obstructive azoospermia (NOA). The successful application of TESE depends on the identification of seminiferous tubules containing spermatozoa; testicular tubules of patients with NOA are usually heterogeneous, and TESE may not always be successful in these patients. Microdissection TESE with an operative microscope is advantageous because larger, more opaque, and whitish tubules, presumably containing germ cells with active spermatogenesis, can be identified directly. This procedure is currently the best method for the certain identification of sperm, resulting in a high spermatozoa retrieval rate and minimal postoperative complications. The present review considers the surgical procedure, outcome, prediction for spermatozoa retrieval, and postoperative complications of microdissection TESE.

Which is the best sperm retrieval technique for non-obstructive azoospermia? A systematic review

Our objective was to establish which is the best sperm retrieval technique in non-obstructive azoospermia based on the available evidence. To date, no randomized controlled trial has compared the efficiency of these strategies and thus current recommendations are based on cumulative evidence provided by descriptive, observational and controlled studies. Three outcome measures were assessed for the sperm retrieval techniques: sperm retrieval rate (SRR), complications and live birth rate. Twenty-four descriptive studies reporting on the results of testicular sperm extraction (TESE) were encountered. Seven controlled studies that compared microdissection (MD) TESE with conventional TESE and seven controlled studies comparing fine needle testicular aspiration (FNA) with TESE were identified. The mean SRR for TESE was 49.5% (95% CI 49.0-49.9). TESE with multiple biopsies results in a higher SRR than FNA especially in cases of Sertoli-cell-only (SCO) syndrome and maturation arrest. Current evidence suggests that MD performs better than conventional TESE only in cases of SCO where tubules containing active focus of spermatogenesis can be identified. MD appears to be the safest technique regarding post-operative complications followed by FNA. Only three studies could be identified concerning the influence of the sperm retrieval technique on clinical pregnancy and live birth rate, hence no definitive conclusions can be made. However, so far there appears to be no impact of the technique itself on success rates.

The importance of diagnosis in the clinical management of infertility in the male

This paper examines the importance of a clinical diagnosis in the management of infertility in the male and discusses the reasons for this statement. The treatment of male infertility is now often carried out solely by gynaecologists. These specialists have frequently had little training in the examination of the male genital tract nor have they had any teaching in either urology or in the pathology of the lower genito-urinary tract. The routine application of IVF may be a consequence of these failings and should this form of treatment be shown to have been unnecessary or, especially, should it result in a clinical disaster, then a serious medico-legal problem may result. The degree of training that is given to the gynaecologist working in this field is also examined and suggestions are made as to how this could be improved.