Fine-needle and large-needle percutaneous aspiration biopsy of testicles in men with nonobstructive azoospermia: Safety and diagnostic performance

High sperm DNA fragmentation: do we have robust evidence to support antioxidants and testicular sperm extraction to improve fertility outcomes? a narrative review

To date, infertility affects 10% to 15% of couples worldwide. A male factor is estimated to account for up to 50% of cases. Oral supplementation with antioxidants could be helpful to improve sperm quality by reducing oxidative damage. At the same time, there is a growing interest in the literature on the use of testicular sperm in patients with high DNA fragmentation index (DFI). This narrative review aims to evaluate the effectiveness of supplementation of oral antioxidants in infertile men with high DFI compared to testicular sperm retrieval. The current evidence is non-conclusive because of serious risk of bias due to small sample sizes and statistical methods. Further large well-designed randomised placebo-controlled trials are still required to clarify the exact role of these to different therapeutic approaches.

Diagnostic yield and safety of ultrasound-guided percutaneous testicular biopsies in children

BACKGROUND

Traditionally, testicular biopsy is performed using an open surgical approach. Ultrasound-guided percutaneous biopsy is a less invasive alternative and can be performed in children.

OBJECTIVE

The aim of this study is to report our technique and to assess the diagnostic accuracy and safety of ultrasound-guided percutaneous biopsy of testicular masses in children.

MATERIALS AND METHODS

This is a 16-year retrospective review of ultrasound-guided percutaneous testicular biopsies at a single pediatric hospital.

RESULTS

We performed nine ultrasound-guided testicular biopsies in 9 patients (median age: 3 years, range: 4 months-11 years; median weight: 20.9 kg, range: 8.4-35 kg; median volume of testicular lesion biopsied: 4.4 mL, range: 1.2-17 mL). A percutaneous co-axial technique was used for 5/9 biopsies with absorbable gelatin sponge tract embolization performed in 4 of those biopsies. A non-co-axial technique was used in 4/9 biopsies. A median of three cores, range 2-6, were obtained. The diagnostic yield was 89% with one biopsy yielding material suggestive of, but insufficient for, a definitive diagnosis. The most common histological diagnosis was leukemic infiltration, occurring in 6/9 biopsies. Of the remaining three biopsies, one biopsy was suggestive of, but not confirmatory for, juvenile granulosa cell tumor and two biopsies confirmed normal testicular tissue; the long-term follow-up of which demonstrated normal growth and no lasting damage. There was one (clinically insignificant) complication out of nine biopsies (11%, 95% confidence interval 0-44%): a mild, self-resolving scrotal hematoma.

CONCLUSION

Ultrasound-guided testicular biopsy can be performed safely in children as an alternative to open surgical biopsy, with a high diagnostic yield and low complication rate.

Is testicular microdissection the only way to retrieve sperm for non-obstructive azoospermic men?

Men presenting with non-obstructive azoospermia are the most challenging clinical scenario for an infertile couple. Intracytoplasmic Sperm Injection (ICSI) with testicular sperm retrieval gave a chance for biological fatherhood once sperm can be found, but unfortunately sperm recovery rate (SSR) is something near 50%, leading to a discussion about what surgical retrieval technique is the best. Historically sperm have been retrieved using conventional Testicular Sperm Extraction (c-TESE), Testicular Sperm Aspiration (TESA), a combination of Testicular Fine Needle Aspiration (TfNA)/c-TESE, Testicular Microdissection (TM) and Open Testicular Mapping (OTEM). c-TESE published in 1995 by Devroey and cols. consists of testis delivery, a large unique albuginea incision and extraction of a portion from the majority of testicular tubules. TESA published in 1996 by Lewin and cols. is done percutaneously using a 21–23 gauge needle and a syringe to aspire testicular tubules. TfNA was published in 1965 by Obrant and Persson as an aspiration biopsy and cytological exam to verify sperm production. In 1999 Turek and cols. published the use of TfNA combined with c-TESE for sperm retrieval. In 1999, Peter Schlegel published a technique using a microsurgical approach to identify more probable sperm production areas inside the testicle that could be excised with better precision and less tissue. OTEM is a multiple biopsy approach, published in 2020 by Vieira and cols., based on TfNA principles but done at the same time without albuginea opening or surgical microscope need. Since Testicular Microdissection publication, the method became the gold standard for sperm retrieval, allowing superior SSR with minimal tissue removal, but the amount of testicular dissection to find more probable spermatogenesis areas, difficulties in comparative design studies, diversity TM results among doctors and other methods that can achieve very similar results we question TM superiority. The objective is review existing literature and discuss advantages and disadvantages of all the methods for sperm retrieval in non-obstructive azoospermia.

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.

Testicular needle aspiration: Is it a safe method for breeding soundness evaluation in bulls?

The aim of this study was to evaluate the impact of successive bovine testicular punctures using different needle sizes. Fifteen bulls were submitted to testicular needle aspiration (TNA) in the left and right testis using 18-gauge (40×12mm) or 22-gauge (25×7mm) needles, respectively, once every 30 days. Animals were randomly divided into three groups, which were submitted to bilateral orchiectomy two days after the last puncture. Group 1 (G1): only one puncture (n=5); Group 2 (G2): three consecutive punctures in a period of three months (n=5); Group 3 (G3): six consecutive punctures in a period of 6 months (n=5). Fragments from the medial portion of the testicular parenchyma were excised and fixed in Bouin's fluid for histological analysis. No differences were observed in the percentage of seminiferous tubules degeneration between G1, G2 and G3 (P>0.05). Higher amounts of erythrocyte were found in G1 and G2 groups compared to G3, in the intra- and intertubular tissue (P<0.05). There was no interaction between the needle gauge and the occurrence of testicular damage in animals submitted to one (G1) or three (G2) punctures. However, a higher percentage of tubular degeneration was associated to 18-gauge compared to 22-gauge fine needles in G3. In conclusion, multiple testicular needle aspiration can be safely conducted using fine needles. Large needles are recommended only for a single TNA, since multiple punctures may result in increased tubular degeneration and compromise testicular architecture and functionality.

Current status of percutaneous testicular biopsy for focal lesions

OBJECTIVE

The purpose of this review is to evaluate the current role of percutaneous testicular biopsy in the diagnosis of focal testicular lesions.

CONCLUSION

Percutaneous testicular biopsy can be either fine needle aspiration biopsy or trucut core needle biopsy. It is a well-tolerated and effective procedure useful in small testicular lesions, multifocal lesions, hematological malignancies, and focal lesions in single testis.

Testicular fine-needle aspiration for the assessment of intratesticular hormone concentrations

Measurement of intratesticular sex steroid concentrations in men informs both the development of male hormonal contraceptives and the understanding of male infertility. Given the challenges of using invasive techniques to measure testicular hormone physiology, our group has used a minimally-invasive fine-needle aspiration technique to measure intratesticular hormones in normal healthy men. Herein, we present a post-hoc analysis of the safety and efficacy of testicular fine-needle aspiration (FNA) completed as part of six clinical trials. From 2001 through 2011, a total of 404 procedures were conducted among 163 research volunteers, 85.9% of which were successful in obtaining sufficient fluid for the measurement of intratesticular steroid concentrations. Pain was the most common side effect, with 36.8% of procedures associated with moderate procedural pain and 4.7% with severe procedural pain. Postprocedural pain was uncommon and abated within a few days. Mild local bruising occurred with 14.9% of procedures. Two serious adverse events (0.5%) required surgical intervention. The risk of an adverse event was not associated with age, body mass index, testicular size, or the volume of fluid aspirated. Testicular FNA to obtain fluid for measurement of intratesticular steroid concentrations frequently causes mild to moderate procedural pain, but serious adverse events occur rarely. Testicular FNA has been instrumental for defining human intratesticular hormone physiology and is a minimally-invasive, safe, effective method for obtaining fluid for research on testicular physiology and pathology.

Surgical management of nonobstructive azoospermia

Nonobstructive azoospermia (NOA) is characterized by the complete absence of sperm in the ejaculate due to testicular failure. The evaluation and management of patients with NOA offer a challenge to the reproductive urologist. In the era of in vitro fertilization with intracytoplasmic sperm injection, surgical sperm extraction techniques can afford men with NOA biologic paternity. To provide a comprehensive review of surgical sperm retrieval approaches in the patient with NOA emphasizing complications, success rates and outcome optimization, a Medline search was conducted querying surgical approaches used to manage NOA. Four sperm extraction techniques are described including: testicular sperm aspiration, testicular sperm extraction, fine needle aspiration mapping and microdissection testicular sperm extraction. In addition, the roles for pre-extraction varicocelectomy and sperm cryopreservation are discussed. The management of NOA continues to evolve as newer tools become available. Several modalities of sperm acquisition exist. An understanding of their complications and success rates is fundamental to the treatment of NOA.

Sperm retrieval and quality evaluation

Technical refinements in sperm retrieval methods and the application of advanced reproductive technologies (ART) using surgically retrieved sperm have enabled biological paternity in azoospermic men who were considered untreatable 20 years ago. Achievement of optimal reproductive outcomes in these patients benefits greatly from a multistep, interdisciplinary process of sperm acquisition that involves reproductive endocrinologists, urologists, or other specialists in male subfertility, and laboratory personnel with expertise in characterizing and isolating sperm from surgically retrieved specimens. The critical steps in this process are discussed in this chapter.

Office-based sperm retrieval for treatment of infertility

This article describes sperm retrieval procedures that may be performed in an office setting. Indications for sperm retrieval, preprocedural preparation, and anesthetic considerations are discussed. Vasal sperm aspiration, percutaneous epididymal sperm aspiration, microsurgical epididymal sperm aspiration, testicular sperm aspiration, conventional, and microdissection testicular sperm extraction are reviewed. Success and complication rates as well as factors that may influence success (histopathology, cancerous cause, Klinefelter syndrome, Y microdeletions, varicocele, and hormone administration) are reviewed.

Androgen synthesis in the gonadotropin-suppressed human testes can be markedly suppressed by ketoconazole

CONTEXT

The concentration of intratesticular testosterone (IT-T) required for human spermatogenesis is unknown because spermatogenesis can persist despite the markedly reduced IT-T concentrations observed with LH suppression. Methods to lower IT-T further are needed to determine the relationship between IT-T and spermatogenesis.

OBJECTIVE

The objective of the study was to determine the effect of inhibiting the synthesis and metabolism of testosterone (T) on IT-T in gonadotropin-suppressed human testes.

DESIGN/SETTING/PATIENTS

Forty normal men participated in a blinded, placebo-controlled, randomized trial at an academic center. INTERVENTION/OUTCOME MEASURES: All men were first administered the GnRH antagonist acyline to suppress LH. Forty-eight hours after acyline administration, subjects were randomly assigned to placebo, ketoconazole (to inhibit T synthesis) at 400 or 800 mg, dutasteride (to inhibit T metabolism) 2.5 mg, or anastrazole (to inhibit T metabolism) 1 mg, daily for 7 days (n = 8/group). Intratesticular steroid concentrations were measured 48 hours after acyline administration alone and again after 7 days of combination treatment.

RESULTS

After 7 days of combination treatment, the median IT-T (25th, 75th percentile) in the placebo group was 14 (8.0, 21.2) ng/mL. IT-T was reduced to 3.7 (2.5, 7.1) ng/mL in the ketoconazole 400 mg group and 1.7 (0.8, 4.0) ng/mL in the ketoconazole 800 mg group (P < .001 vs placebo for both comparisons). IT-T concentrations in the dutasteride and anastrazole groups were similar to placebo.

CONCLUSION

Combining inhibition of steroidogenesis with gonadotropin suppression lowers IT-T more than gonadotropin suppression alone. This combination might be useful to determine the minimum IT-T concentration necessary for human spermatogenesis, information essential for developing male hormonal contraceptives.

An update on sperm retrieval techniques for azoospermic males

The use of non-ejaculated sperm coupled with intracytoplasmic sperm injection has become a globally established procedure for couples with azoospermic male partners who wish to have biological offspring. Surgical methods have been developed to retrieve spermatozoa from the epididymides and the testes of such patients. This article reviews the methods currently available for sperm acquisition in azoospermia, with a particular focus on the perioperative, anesthetic and technical aspects of these procedures. A critical analysis of the advantages and disadvantages of these sperm retrieval methods is provided, including the authors' methods of choice and anesthesia preferences.

Surgical techniques for the management of male infertility

Evaluation and surgical treatment of male infertility has evolved and expanded, now leading to more precise diagnoses and tailored treatments with diminished morbidity and greater success. Surgeries for male infertility are divided into four major categories: (i) diagnostic surgery; (ii) surgery to improve sperm production; (iii) surgery to improve sperm delivery; and (iv) surgery to retrieve sperm for use with in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI). While today we are more successful than ever in treating male infertility, pregnancy is still not always achieved likely due to factors that remain poorly understood. Clinicians treating infertility should advocate for couple-based therapy, and require that both partners have a thorough evaluation and an informed discussion before undergoing specific surgical therapies.

Percutaneous biopsy of the testicle: a mini review with a proposal flow chart for non-obstructive azoospermia

A general consensus on the role of testicular biopsy in non-obstructive azoospermia (NOA) is needed. This paper reviews and updates technical aspects and clinical performance of the percutaneous testicular biopsy techniques, in particular large-needle aspiration biopsy (LNAB), and proposes a flow chart for the management of NOA. The English literature and original data were reviewed or analyzed. Large-needle biopsy (LNB) includes large-needle cutting biopsy (LNCB) and large-needle aspiration biopsy (LNAB). LNCB usually requires scrotal incision for the insertion of relatively large needles. Fine-needle aspiration biopsy (FNAB) does not require surgical equipment or expertise, employs the smallest needles (23- to 20-gauge), and permits sperm cytologic detection. LNAB also does not require surgical equipment or expertise, employs needles of size from 20- to 18-gauge, is safe, and can be used for testicular histology and sperm recovery. An operative flow chart is proposed for the management of NOA in which FNAB, LNAB and open surgical biopsy are used for the optimal management of NOA.

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.

Surgical treatment of male infertility in the era of intracytoplasmic sperm injection - new insights

Assisted reproductive technology is an evolving area, and several adjuvant procedures have been created to increase a couple's chance of conceiving. For male infertility, the current challenges are to properly accommodate old and new techniques that are both cost-effective and evidence-based. In this context, urologists are expected to diagnose, counsel, provide medical or surgical treatment whenever possible and/or correctly refer male patients for assisted conception. Urologists are sometimes part of a multiprofessional team in an assisted reproduction unit and are responsible for the above-cited tasks as well as the surgical retrieval of sperm from either the epididymides or testicles. We present a comprehensive review of the surgical treatment options for infertile males, including the perioperative planning and prognostic aspects, with an emphasis on the role of microsurgery in the optimization of treatment results. This review also discusses current techniques for sperm retrieval that are used in association with assisted reproductive technology and includes sperm retrieval success rates according to the technique and the type of azoospermia. New insights are provided with regard to each surgical treatment option in view of the availability of assisted conception to overcome male infertility.

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.

Sperm acquisition in nonobstructive azoospermia: what are the options?

Approximately 10% of male-factor infertility is caused by azoospermia, and nearly two thirds of these patients have nonobstructive azoospermia (NOA). As experience has been gained, increasing numbers of men who have NOA are having sperm retrieved from their testes and used for intracytoplasmic sperm injection with vitro fertilization. This article reviews the various sperm retrieval techniques, discussing the advantages and disadvantages and the outcomes of each. Predictive factors for sperm retrieval are presented, as are some of the controversies that exist regarding sperm acquisition in NOA.

Fine needle aspiration cytology of the testis as the first-line diagnostic modality in azoospermia: a comparative study of cytology and histology

OBJECTIVES

Male factors are responsible for about half of all infertility cases. Until recently, testicular biopsy was the standard method to ascertain the aetiology of azoospermia. Fine needle aspiration cytology has gained increasing popularity as a simple and minimally invasive procedure that can help in assessing testicular function accurately. This study was aimed at addressing the question whether testicular fine needle aspiration (FNA) may be used as a first-line diagnostic modality in azoospermia and to assess its usefulness in the diagnostic protocol.

METHODS

The FNA was performed in 78 consecutive azoospermic patients. To obviate sampling errors both testes were aspirated, except when contraindicated. Routine haematoxylin and eosin as well as Romanowsky staining was performed on the smears.

RESULTS

The smears were categorized on cytological examination into normal spermatogenesis in 35 (50%) patients, Sertoli cells only syndrome in 22 (31.4%) and maturation arrest at the spermatocyte/spermatid level was seen in 13 (18.4%) patients. There were eight (10.2%) cases with scant smears where cytological diagnosis could not be made. A good correlation between cytological smears and histological sections was found in 54 of 58 testes (93.1%) in which histopathological confirmation was available.

CONCLUSIONS

Testicular FNA may be utilized as a first-line investigative modality in patients with azoospermia, provided the procedure is performed and interpreted by experts.

Current approaches for detection of carcinoma in situ testis

Testicular germ cell tumours have a favourable prognosis if detected early, but are potentially lethal in a subset of patients. Multi-modality treatment is often necessary, thus the preferable time of diagnosis is at the pre-invasive, but unfortunately often asymptomatic precursor stage of carcinoma in situ (CIS). This review describes current possible approaches for the detection of CIS. At present, an open testicular biopsy is the only definitive way of establishing the presence of CIS. The tissue section should be of an adequate size, be properly fixed, and evaluation be supported by at least one solid immunohistochemical marker, for example PLAP, OCT-3/4 or AP-2gamma. Determination of who should be offered testicular biopsies is based on clinical and ultrasonic examination along with the evaluation of risk factors. A surgical biopsy is an invasive procedure with potential complications, although rare. Therefore, a noninvasive and equally reliable method is needed. Testicular ultrasound is risk-free, painless and at present the only noninvasive method of aid for andrologists when CIS is suspected. The presence of testicular microlithiasis is, in some cases, indicative of pre-malignant changes, especially in males with additional risk factors. Promising results have recently been obtained with a novel noninvasive detection method based on immunocytological AP-2gamma-staining of CIS cells in semen. This method could be a supporting method in andrology centres where careful follow-up is possible. In conclusion, one difficulty is to determine in which males CIS should be suspected; secondly, there does not as yet exist an optimal noninvasive method of diagnosis that is more acceptable than an open surgical biopsy.

Large needle percutaneous aspiration biopsy of the testicle in men with nonobstructive azoospermia: technical performance

The aim of this study was to relate retrospectively in 215 percutaneous large needle aspiration biopsy (LNAB) of the testicles the number of seminiferous tubules (ST) per testicular biopsy, from differently sized testicles, to the size of the needle used in order to obtain information useful for selecting the needle size according to the testicular size. Clinical, ultrasonographic and pathologic data of 134 patients with nonobstructive azoospermia examined with LNAB were retrospectively analyzed. One hundred and sixty-three testicles with volume>or=10 ml, 39<10 ml and>or=6 ml, 13<6 ml underwent 215 LNABs. In the larger testicle group the prevalence of adequate biopsies (ST>/=20) varied from 83% to 50% with a statistically significant difference among the needle groups (P=0.028) and being 83% in the biopsies with the 18 gauge (g.) needle. The mean number of ST obtained with the 18 g. needle was significantly higher than that obtained with the other needles (P=0.000). In the medium volume testicle group the adequate biopsy incidence varied from 20% to 83.3% with statistical significance among the various needle groups (P=0.042) being 83.3% in the biopsies with the 22 g. needle. In the smaller testicle group the mean number of ST obtained with the 22 g. needle was significantly higher than with the 20 g. needle (71 versus 25, P=0.011). In the patients with nonobstructive azoospermia, the 18 g. needle seemed to offer the best performance in the larger testicles, while in the medium and lower sized testicles the smaller 22 g. needle gave results comparable to or slightly better than the other larger needles.

Control and Performance Characteristics of Eight Different Suction Biopsy Devices

PURPOSE

To determine the control and performance characteristics of eight different suction biopsy devices.

MATERIALS AND METHODS

Physician control of the syringe and needle was measured precisely with the validated linear displacement method during the aspiration phase and during five biopsy passes. The visual analog scale was used to measure operator difficulty in the following domains: (i) attachment to the needle, (ii) generation of vacuum, (iii) detection of loss of vacuum, (iv) release of the vacuum, and (v) clearing of the sample from the needle.

RESULTS

Performance in various phases of the biopsy procedure varied widely among the biopsy devices tested. Unintended forward penetration (ie, loss of control in the forward direction) was significant with the reverse aspiration syringe (31.5 +/- 1.7 mm), three-ringed control syringe (25.4 +/- 4.1 mm), BioSuc-C7 syringe (28.3 +/- 1.9 mm), conventional syringe with a plunger lock (6.1 +/- 1.5 mm), syringe pistol (9.2 +/- 2.4 mm), and conventional syringe (3.8 +/- 2.9 mm) but was significantly less for the reciprocating procedure device (RPD; 0.7 +/- 0.7 mm; P </= .001) and RPD syringe holder (0.6 +/- 0.6 mm; P </= .001). The mean performance rankings were the best for the RPD (3.42 +/- 2.57) and RPD syringe holder (4.29 +/- 2.50) and worst for the conventional syringe (6.14 +/- 2.67; P </= .001) and conventional syringe with a plunger lock (6.86 +/- 3.80; P </= .001).

CONCLUSIONS

Each of the suction biopsy devices has unique advantages and disadvantages. Suction biopsy devices with the least favorable overall performance were the conventional syringe and the conventional syringe with a plunger lock. The highest overall performance was seen with the RPD and RPD syringe holder.

Large-needle percutaneous aspiration biopsy of the testicle in men with nonobstructive azoospermia

Two hundred thirteen testicular specimens of men with nonobstructive azoospermia were obtained by large-needle percutaneous aspiration biopsy. The mean values of the number of seminiferous tubules per histologic section, dimension, weight, and the fraction of biopsies with spermatogenetic cells (53, 0.2 x 0.3 x 0.62 cm, 385 mg, and 63%, respectively) were similar to those obtained by open or other surgical biopsy techniques that were used for assisted fertilization in the same type of patients.