Microdissection testicular sperm extraction: effect of prior biopsy on success of sperm retrieval

Clinical predictors of successful outcomes for couples with nonobstructive azoospermic male partners undergoing micro-TESE

ABSTRACT

Nonobstructive azoospermia (NOA) is the most challenging and complex clinical scenario for infertile men. Besides circumstances such as hypogonadotropic hypogonadism, surgical sperm retrieval is typically necessary, and microdissection testicular sperm extraction (micro-TESE) is the procedure of choice for men with NOA desiring to father children with their own gametes. Micro-TESE results in the highest numbers of sperm cells retrieved for use with in vitro fertilization/intracytoplasmic sperm injection (ICSI) in comparison to all other techniques for surgical sperm retrieval in men with NOA. Several factors may affect sperm retrieval rate and ICSI outcomes, including the patient's age, testicular volume, histopathological and genetic profile, and serum hormone levels. This article aims to review the medical literature describing predictors of successful micro-TESE and the outcomes of ICSI in men with NOA.

Predictors of successful salvage microdissection testicular sperm extraction (mTESE) after failed initial TESE in patients with non-obstructive azoospermia: A systematic review and meta-analysis

BACKGROUND

There has been no systematic review and meta-analysis to analyze and summarize the predictive factors of successful sperm extraction in salvage microdissection testicular sperm extraction.

OBJECTIVES

We aimed to investigate the factors predicting the result of salvage microdissection testicular sperm extraction in patients with non-obstructive azoospermia who failed the initial microdissection testicular sperm extraction or conventional testicular sperm extraction.

MATERIALS AND METHODS

We conducted a systematic literature search in PubMed, Web of Science, EMBASE, and the Cochrane Library for literature that described the characteristics of patients with non-obstructive azoospermia who underwent salvage microdissection testicular sperm extraction after failing the initial microdissection testicular sperm extraction or conventional testicular sperm extraction published prior to June 2022.

RESULTS

This meta-analysis included four retrospective studies with 332 patients with non-obstructive azoospermia who underwent a failed initial microdissection testicular sperm extraction and three retrospective studies with 177 non-obstructive azoospermia patients who underwent a failed conventional testicular sperm extraction. The results were as follows: among non-obstructive azoospermia patients whose first surgery was microdissection testicular sperm extraction, younger patients (standard mean difference: -0.28, 95% confidence interval [CI]: -0.55 to -0.01) and those with smaller bilateral testicular volume (standard mean difference: -0.55, 95% CI: -0.95 to -0.15), lower levels of follicle-stimulating hormone (standard mean difference: -0.86, 95% CI: -1.18 to -0.54) and luteinizing hormone (standard mean difference: -0.68, 95% CI: -1.16 to -0.19), and whose testicular histological type was hypospermatogenesis (odds ratio: 3.52, 95% CI: 1.30-9.53) were more likely to retrieve spermatozoa successfully, while patients with Sertoli-cell-only syndrome (odds ratio: 0.41, 95% CI: 0.24-0.73) were more likely to fail again in salvage microdissection testicular sperm extraction. Additionally, in patients who underwent salvage microdissection testicular sperm extraction after a failed initial conventional testicular sperm extraction, those with testicular histological type of hypospermatogenesis (odds ratio: 30.35, 95% CI: 8.27-111.34) were more likely to be successful, while those with maturation arrest (odds ratio: 0.39, 95% CI: 0.18-0.83) rarely benefited.

CONCLUSION

We found that age, testicular volume, follicle-stimulating hormone, luteinizing hormone, hypospermatogenesis, Sertoli-cell-only syndrome, and maturation arrest were valuable predictors of salvage microdissection testicular sperm extraction, which will assist andrologists in clinical decision-making and minimize unnecessary injury to patients.

A Machine Learning Approach for the Prediction of Testicular Sperm Extraction in Nonobstructive Azoospermia: Algorithm Development and Validation Study

BACKGROUND

Testicular sperm extraction (TESE) is an essential therapeutic tool for the management of male infertility. However, it is an invasive procedure with a success rate up to 50%. To date, no model based on clinical and laboratory parameters is sufficiently powerful to accurately predict the success of sperm retrieval in TESE.

OBJECTIVE

The aim of this study is to compare a wide range of predictive models under similar conditions for TESE outcomes in patients with nonobstructive azoospermia (NOA) to identify the correct mathematical approach to apply, most appropriate study size, and relevance of the input biomarkers.

METHODS

We analyzed 201 patients who underwent TESE at Tenon Hospital (Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris), distributed in a retrospective training cohort of 175 patients (January 2012 to April 2021) and a prospective testing cohort (May 2021 to December 2021) of 26 patients. Preoperative data (according to the French standard exploration of male infertility, 16 variables) including urogenital history, hormonal data, genetic data, and TESE outcomes (representing the target variable) were collected. A TESE was considered positive if we obtained sufficient spermatozoa for intracytoplasmic sperm injection. After preprocessing the raw data, 8 machine learning (ML) models were trained and optimized on the retrospective training cohort data set: The hyperparameter tuning was performed by random search. Finally, the prospective testing cohort data set was used for the model evaluation. The metrics used to evaluate and compare the models were the following: sensitivity, specificity, area under the receiver operating characteristic curve (AUC-ROC), and accuracy. The importance of each variable in the model was assessed using the permutation feature importance technique, and the optimal number of patients to include in the study was assessed using the learning curve.

RESULTS

The ensemble models, based on decision trees, showed the best performance, especially the random forest model, which yielded the following results: AUC=0.90, sensitivity=100%, and specificity=69.2%. Furthermore, a study size of 120 patients seemed sufficient to properly exploit the preoperative data in the modeling process, since increasing the number of patients beyond 120 during model training did not bring any performance improvement. Furthermore, inhibin B and a history of varicoceles exhibited the highest predictive capacity.

CONCLUSIONS

An ML algorithm based on an appropriate approach can predict successful sperm retrieval in men with NOA undergoing TESE, with promising performance. However, although this study is consistent with the first step of this process, a subsequent formal prospective multicentric validation study should be undertaken before any clinical applications. As future work, we consider the use of recent and clinically relevant data sets (including seminal plasma biomarkers, especially noncoding RNAs, as markers of residual spermatogenesis in NOA patients) to improve our results even more.

Seminal plasma biomarkers for predicting successful sperm retrieval in patients with nonobstructive azoospermia: a narrative review of human studies

BACKGROUND

Non-obstructive azoospermia (NOA) is considered to be the most severe form of male infertility. Before the emergence of surgical testicular sperm extraction and assisted reproductive technology, NOA patients could hardly become biological fathers of their children. However, failure of the surgery could cause physical and psychological harm to patients such as testicular damage, pain, hopeless of fertility and additional cost. Therefore, predicting the successful sperm retrieval (SSR) is so important for NOA patients to make their choice whether to do the surgery or not. Because seminal plasma is secreted by the testes and accessory gonads, it can reflect the spermatogenic environment, making it a preferential choice for SSR valuation. The purpose of this paper is to summarize the available evidence and provide the reader with a broad overview of biomarkers in seminal plasma for SSR prediction.

RESULTS

A total of 15,390 studies were searched from PUBMED, EMBASE, CENTRAL and Web of Science, but only 6615 studies were evaluated after duplications were removed. The abstracts of 6513 articles were excluded because they were irrelevant to the topic. The full texts of 102 articles were obtained, with 21 of them being included in this review. The included studies range in quality from medium to high. In the included articles, surgical sperm extraction methods included conventional testicular sperm extraction (TESE) and microdissection testicular sperm extraction (micro-TESE). Currently, the biomarkers in seminal plasma used to predict SSR are primarily RNAs, metabolites, AMH, inhibin B, leptin, survivin, clusterin, LGALS3BP, ESX1, TEX101, TNP1, DAZ, PRM1 and PRM2.

CONCLUSION

The evidence does not conclusively indicate that AMH and INHB in seminal plasma are valuable to predict the SSR. It is worth noting that RNAs, metabolites and other biomarkers in seminal plasma have shown great potential in predicting SSR. However, existing evidence is insufficient to provide clinicians with adequate decision support, and more prospective, large sample size, and multicenter trials are urgently needed.

Germ cell-specific proteins AKAP4 and ASPX facilitate identification of rare spermatozoa in non-obstructive azoospermia

Non-obstructive azoospermia (NOA), the most severe form of male infertility, could be treated with intra-cytoplasmic sperm injection, providing spermatozoa were retrieved with the microdissection testicular sperm extraction (mTESE). We hypothesized that testis- and germ cell-specific proteins would facilitate flow cytometry-assisted identification of rare spermatozoa in semen cell pellets of NOA patients, thus enabling non-invasive diagnostics prior to mTESE. Data mining, targeted proteomics, and immunofluorescent microscopy identified and verified a panel of highly testis-specific proteins expressed at the continuum of germ cell differentiation. Late germ cell-specific proteins AKAP4_HUMAN and ASPX_HUMAN (ACRV1 gene) revealed exclusive localization in spermatozoa tails and acrosomes, respectively. A multiplex imaging flow cytometry assay facilitated fast and unambiguous identification of rare but morphologically intact AKAP4⁺/ASPX⁺/Hoechst⁺ spermatozoa within debris-laden semen pellets of NOA patients. While the previously suggested markers for spermatozoa retrieval suffered from low diagnostic specificity, the multi-step gating strategy and visualization of AKAP4⁺/ASPX⁺/Hoechst⁺ cells with elongated tails and acrosome-capped nuclei facilitated fast and unambiguous identification of the mature intact spermatozoa. AKAP4⁺/ASPX⁺/Hoechst⁺ assay may emerge as a non-invasive test to predict retrieval of morphologically intact spermatozoa by mTESE, thus improving diagnostics and treatment of severe forms of male infertility.

Feasibility of repeat microdissection testicular sperm extraction within 6 months for nonobstructive azoospermia

BACKGROUND

Microdissection testicular sperm extraction (mTESE) is the mainstay of sperm retrieval in men with nonobstructive azoospermia (NOA). Some experts believe that a resting period of ≥6 months is required between procedures to ensure better sperm retrieval rates and fewer complications. However, no scientific studies have investigated how long patients should wait before arranging a second mTESE procedure. This retrospective study aimed to evaluate whether good success rates are still achieved when a repeat mTESE procedure is performed within 6 months.

METHODS

Total 146 patients with NOA who underwent mTESE twice from the same testis between May 2012 and September 2019 were retrospectively collected. These patients were categorized into three groups according to the time interval between the two mTESE surgeries, with 44, 60, and 42 patients undergoing a repeat mTESE after <3 months (group I), between 3 and 6 months (group II), and >6 months (group III) after the first procedure, respectively.

RESULTS

No significant differences were observed between groups in terms of patient characteristics and preoperative hormone profiles. Overall sperm retrieval rates did not differ among the three groups (93.2%, 90.0%, and 88.1% in groups I, II, and III, respectively [ p = 0.719]), nor did fertility outcomes, including rates of fertilization, biochemical pregnancy, clinical pregnancy, and cumulative live births.

CONCLUSION

Sperm retrieval rates for repeat mTESE procedures were consistently high, even when the second procedure was performed within 6 months of the first. Repeat mTESE within 6 months is not a limitation for patients with NOA, if required clinically.

Histological and immunohistochemical outcomes after microdissection TESE in contrast with hormonal profile, testis volume and genetics in patients with azoospermia

A limited number of individuals with non-obstructive azoospermia (NOA) may recover spermatozoa through traditional testicular sperm extraction (TESE) techniques. There is an ongoing debate over the effectiveness of microdissection TESE compared to standard TESE methods. Microdissection TESE (micro-TESE) techniques enable the identification of spermatogenesis foci in non-obstructive forms of azoospermia. Only histological examination can provide an objective and definitive assessment of the testicular phenotype. This study aimed to evaluate the correlation between histopathological findings after microdissection TESE (micro-TESE) and the predictive role of various factors in determining the success of sperm retrieval. We evaluated 24 patients with azoospermia who underwent micro-TESE and considered the patient's hormonal profile, testis ultrasound, genetic evaluation, histology, and immunohistology (PLAP antibody) of collected testis biopsies. The preoperative blood FSH level, in conjunction with other parameters, may aid in the prediction of micro-TESE success. Sensitivity increases, and specificity decreases with higher FSH levels. Furthermore, testicular volume and FSH levels are typically normal in patients with maturation arrest. In conclusion, hormones, ultrasound evaluation of the testicles, testis volume, and available genetic tests have a predictive value in differentiating obstructive azoospermia (OA) from NOA with various sensitivity and specificity rates. Histological and immunohistochemical evaluation establishes the testicular phenotype accurately and guides patient management.

Intrasurgical Seminiferous Tubular Diameter Correlates with Total Motile Sperm Count in Azoospermia: a Prospective Cohort Study

We aimed to find a correlation between the intraoperative diameters of the seminiferous tubules evaluated at high magnification during micro-testicular sperm extraction (micro-TESE) and total motile sperm count (TMSC) in non-obstructive azoospermic (NOA) patients. Five hundred four consecutive NOA patients were included and underwent micro-TESE. The change in the mean TMSC and different seminiferous tubular diameters was of high statistical significance (p < 0.001). It should be noted that the highest mean TMSC was reported in the dilated tubules (DTs) group followed by the other study groups 941.72 ± 196.97, 487.37 ± 443.57, and 34.54 ± 60.79, respectively. Furthermore, 21 naïve cases had dilated tubules (DTs) and 18 (85.7%) of them had shown eventful micro-TESE. Conversely, 186 naïve cases had slightly dilated tubules (SDTs), and 101 (54.3%) of them had eventful micro-TESE. Only 8 (24.25%) cases of the 33 cases had non dilated tubules (NDTs) and showed eventful micro-TESE. The frequency of intrasurgical seminiferous tubular diameter and micro-TESE outcome among the naïve cases had demonstrated a highly statistical significance (p < 0.001). Interestingly, all salvaged cases (100%) with DTs and a previous eventful TESE had shown eventful TESE in the current study. The most dilated intrasurgical seminiferous tubular diameter is associated with the highest TMSC in NOA patients including SCO cases.

Micro-testicular sperm extraction outcomes for non-obstructive azoospermia in a single large clinic in Victoria

AIMS

To evaluate the results of microdissection testicular sperm extraction (micro-TESE) and intracytoplasmic sperm injection (ICSI) for treatment of non-obstructive azoospermia (NOA).

MATERIALS AND METHODS

We retrospectively analysed data of 88 consecutive patients with clinical NOA who were treated with micro-TESE by a single surgeon, between August 2014 and September 2020, in Melbourne, Victoria. Upon a successful sperm retrieval, sperm was either used fresh for ICSI, frozen for future use or both. The outcome measures were sperm retrieval rate (SRR), and in vitro fertilisation (IVF)/ICSI results. Furthermore, SRR was calculated for the predominant causes and histopathological patterns.

RESULTS

The overall SRR was 61.2%. It was significantly higher in patients with a history of cryptorchidism and other childhood diseases (100%) than in the other NOA groups (P < 0.05). Patients with Klinefelter syndrome had a 75% SRR. Among the different types of testicular histology, the highest SRR were noted in patients with complete hyalinisation (100%) and hypospermatogenesis (92.9%), and low with Sertoli cell-only syndrome (46.3%). The SRR has significantly increased from 33.3% in 2015-2016 to 73.6% in 2019-2020 (P = 0.009). Of the 52 patients with SSR, 47 underwent IVF/ICSI. Fertilisation rate was 42.4%. Twenty-nine couples achieved at least one good-quality embryo and had embryo transfer. Nineteen achieved pregnancy (40.4%), and in three patients a miscarriage resulted.

CONCLUSIONS

This is the first report from Australia showing that micro-TESE is an effective treatment for NOA with high SRR. The increasing success rates over several years indicate the importance of surgical skill and laboratory staff experience.

Repeated microdissection testicular sperm extraction in patients with non-obstructive azoospermia: Outcome and predictive factors

Objective

To assess the feasibility of repeated sperm recovery in patients with non-obstructive azoospermia (NOA), as little is known about the extraction rate in repeated microdissection testicular sperm extraction (microTESE) in these patients.

Patients and Methods

A total of 134 men with NOA had their first sperm recovery between January 2013 and February 2020. Repeated microTESE had been done mostly for patients with a successful initial retrieval.

Results

In the 323 procedures performed on the 134 men with NOA, sperm could be retrieved in 236 procedures (73.1%). A total of 88, 61 and 40 men underwent two, three and four sperm retrievals, respectively. In these cycles, sperm could be extracted in 65 (73.9%), 53 (86.9%) and 37 (92.5%) men, respectively. During the first microTESE procedure, sperm could be extracted in 81 (60.4%) men with NOA. In all, the success rate was significantly different between subgroups, showing highest rate in hypospermatogenesis cases (95.6%), followed by maturation arrest (58.5%), and Sertoli cell-only syndrome (56.0%). However, this difference was not significant at the third and fourth repeated microTESE. The FSH levels and testicular volume were among the noticeable factors affecting success of sperm retrieval. The duration between the first and second biopsies significantly increased the success rate by a factor of 1.3-fold/month; however, afterwards, the duration did not play any role in the success of microTESE. The success of previous trial significantly increased the probability of success by 10.1-fold in the second trial, 5.6-fold in the third trial, and 16.5 folds in the fourth.

Conclusion

Repeated MD -TESE ensures a high sperm recovery rate in patients with NOA. These data also show that when no spermatozoa can be obtained after thawing cryopreserved testicular sperm for ICSI in NOA patients, a repeat microTESE procedure can be planned.

Abbreviations

ICSI: intracytoplasmic sperm injection; IVF: in vitro fertilisation; MA: maturation arrest; (N)OA: (non-)obstructive azoospermia; OR: odds ratio; SCOS, Sertoli cell-only syndrome; SRR: spermatozoa retrieval rate; (micro)TESE: (microdissection) testicular sperm extraction

Intrasurgical parameters associated with successful sperm retrieval in patients with non-obstructive azoospermia undergoing salvage microdissection testicular sperm extraction

BACKGROUND

Patients with non-obstructive azoospermia with a previously failed conventional testicular sperm extraction may undergo a salvage microdissection testicular sperm extraction with the probability of successful sperm retrieval being almost dependent upon the number of previous surgical attempts and to different histopathologic categories.

OBJECTIVES

To determine whether the seminiferous tubules pattern and the histological categories could affect the sperm retrieval rate in patients with non-obstructive azoospermia undergoing salvage microdissection testicular sperm extraction after failed conventional testicular sperm extraction.

MATERIALS AND METHODS

Seventy-nine patients undergoing unilateral or bilateral salvage microdissection testicular sperm extraction were evaluated. During microdissection testicular sperm extraction, if present, dilated tubules were retrieved, otherwise, tubules with slightly larger caliber than that of the surroundings were removed. When no dilated tubule or tubule with slightly larger caliber was found, not dilated tubules were excised. A prediction model was built with seminiferous tubules pattern and testis histology as covariates.

RESULTS

Sperm retrieval was successful in 30 out of 79 patients. The prediction model correctly classified 88.3% of cases, explained the 29.7% variability of the outcome, and significantly predicted the microdissection testicular sperm extraction outcome with a sensitivity of 67.7% and a specificity of 90.2%, Both tubules with slightly larger caliber and not dilated tubules were negatively associated with the chance of retrieving spermatozoa. Among the histological categories, only early maturation arrest was significant to the model (log(SSR) = 0.57 - 1.9SDT - 3.3NDT - 1.76EMA) (where SSR is sperm retrieval rate, SDT is tubule with slightly larger caliber, NDT is not dilated tubule, and EMA is early maturation arrest). The model had a clearly useful discrimination (area under the curve = 0.814), the estimated performance was 0.8105, and internal calibration was acceptable (p > 0.05).

DISCUSSION

Seminiferous tubules pattern and testis histology may reliably explain the salvage microdissection testicular sperm extraction outcome in all patients with non-obstructive azoospermia apart from those with early maturation arrest, where the homogeneous apparent seminiferous tubules pattern may be misleading.

CONCLUSION

The outcome of salvage microdissection testicular sperm extraction can be predicted by the same intrasurgical parameters that have been demonstrated to predict the outcome of microdissection testicular sperm extraction in naïve patients with non-obstructive azoospermia.

Pathogenesis of Brucella epididymoorchitis-game of Brucella death

Brucellosis is a worldwide zoonotic disease caused by Brucella spp. Human infection often results from direct contact with tissues from infected animals or by consumption of undercooked meat and unpasteurised dairy products, causing serious economic losses and public health problems. The male genitourinary system is a common involved system in patients with brucellosis. Among them, unilateral orchitis and epididymitis are the most common. Although the clinical and imaging aspect of orchi-epididymitis caused by brucellosis have been widely described, the cellular and molecular mechanisms involved in the damage and the immune response in testis and epididymis have not been fully elucidated. In this review, we first summarised the clinical characteristics of Brucella epididymo-orchitis and the composition of testicular and epididymal immune system. Secondly, with regard to the mechanism of Brucella epididymoorchitis, we mainly discussed the process of Brucella invading testis and epididymis in temporal and spatial order, including i) Brucella evades innate immune recognition of testicular PRRs；ii) Brucella overcomes the immune storm triggered by the invasion of testis through bacterial lipoproteins and virulence factors, and changes the secretion mode of cytokines; iii) Brucella breaks through the blood-testis barrier with the help of macrophages, and inflammatory cytokines promote the oxidative stress of Sertoli cells, damaging the integrity of BTB; iv) Brucella inhibits apoptosis of testicular phagocytes. Finally, we revealed the structure and sequence of testis invaded by Brucella at the tissue level. This review will enable us to better understand the pathogenesis of orchi-epididymitis caused by brucellosis and shed light on the development of new treatment strategies for the treatment of brucellosis and the prevention of transition to chronic form. Facing the testicle with immunity privilege, Brucella is like Bruce Lee in the movie Game of Death, winning is survival while losing is death.HIGHLIGHTSWe summarized the clinical features and pathological changes of Brucellaepididymoorchitis.Our research reveals the pathogenesis of Brucella epididymoorchitis, which mainly includes the subversion of testicular immune privilege by Brucella and a series of destructive reactions derived from it.As a basic framework and valuable resource, this study can promote the exploration of the pathogenesis of Brucella and provide reference for determining new therapeutic targets for brucellosis in the future.

Predictors of testicular sperm retrieval in patients with non-obstructive azoospermia: a review

Azoospermia is divided into two categories of obstructive azoospermia and non-obstructive azoospermia. Before 1995, couples with a male partner diagnosed with non-obstructive azoospermia had to choose sperm donation or adoption to have a child. Currently, testicular sperm aspiration or micro-dissection testicular sperm extraction combined with intracytoplasmic sperm injection allows patients with non-obstructive azoospermia to have biological offspring. The sperm retrieval rate is significantly higher in micro-dissection testicular sperm extraction compared with testicular sperm aspiration. Additionally, micro-dissection testicular sperm extraction has the advantages of minimal invasion, safety, limited disruption of testicular function, a low risk of postoperative intratesticular bleeding, and low serum testosterone concentrations. Failed micro-dissection testicular sperm extraction has significant emotional and financial implications on the involved couples. Testicular sperm aspiration and micro-dissection testicular sperm extraction have the possibility of failure. Therefore, predicting the sperm retrieval rate before surgery is important. This narrative review summarizes the existing data on testicular sperm aspiration and micro-dissection testicular sperm extraction to identify the possible factor(s) that can predict the presence of sperm to guide clinical practice. The predictors of surgical sperm retrieval in patients with non-obstructive azoospermia have been widely studied, but there is no consensus.

Omics in Seminal Plasma: An Effective Strategy for Predicting Sperm Retrieval Outcome in Non-obstructive Azoospermia

Non-obstructive azoospermia (NOA) is a severe form of male factor infertility resulting from the impairment of sperm production. Surgical sperm retrieval followed by intracytoplasmic sperm injection (ICSI) is the only alternative for NOA patients to have their own genetic children. Nevertheless, due to an approximately 50% chance of success, harvesting sperm from these patients remains challenging. Thus, discovering noninvasive biomarkers, which are able to reliably predict the probability of sperm acquisition, not only can eliminate the risk of surgery but also can lower the costs of NOA diagnosis and treatment. Seminal plasma is the non-cellular and liquid portion of the ejaculate that consists of the secretions originating from testes and male accessory glands. In past years, a wide range of biomolecules including DNAs, RNAs, proteins, and metabolic intermediates have been identified by omics techniques in human seminal plasma. The current review aimed to briefly describe genomic, transcriptomic, proteomic, and metabolomic profiles of human seminal plasma in an attempt to introduce potential candidate noninvasive biomarkers for sperm-retrieval success in men with NOA.

Prediction of sperm extraction in non-obstructive azoospermia patients: a machine-learning perspective

STUDY QUESTION

Can a machine-learning-based model trained in clinical and biological variables support the prediction of the presence or absence of sperm in testicular biopsy in non-obstructive azoospermia (NOA) patients?

SUMMARY ANSWER

Our machine-learning model was able to accurately predict (AUC of 0.8) the presence or absence of spermatozoa in patients with NOA.

WHAT IS KNOWN ALREADY

Patients with NOA can conceive with their own biological gametes using ICSI in combination with successful testicular sperm extraction (TESE). Testicular sperm retrieval is successful in up to 50% of men with NOA. However, to the best of our knowledge, there is no existing model that can accurately predict the success of sperm retrieval in TESE. Moreover, machine-learning has never been used for this purpose.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study of 119 patients who underwent TESE in a single IVF unit between 1995 and 2017 was conducted. All patients with NOA who underwent TESE during their fertility treatments were included. The development of gradient-boosted trees (GBTs) aimed to predict the presence or absence of spermatozoa in patients with NOA. The accuracy of these GBTs was then compared to a similar multivariate logistic regression model (MvLRM).

PARTICIPANTS/MATERIALS, SETTING, METHODS

We employed univariate and multivariate binary logistic regression models to predict the probability of successful TESE using a dataset from a retrospective cohort. In addition, we examined various ensemble machine-learning models (GBT and random forest) and evaluated their predictive performance using the leave-one-out cross-validation procedure. A cutoff value for successful/unsuccessful TESE was calculated with receiver operating characteristic (ROC) curve analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

ROC analysis resulted in an AUC of 0.807 ± 0.032 (95% CI 0.743–0.871) for the proposed GBTs and 0.75 ± 0.052 (95% CI 0.65–0.85) for the MvLRM for the prediction of presence or absence of spermatozoa in patients with NOA. The GBT approach and the MvLRM yielded a sensitivity of 91% vs. 97%, respectively, but the GBT approach has a specificity of 51% compared with 25% for the MvLRM. A total of 78 (65.3%) men with NOA experienced successful TESE. FSH, LH, testosterone, semen volume, age, BMI, ethnicity and testicular size on clinical evaluation were included in these models.

LIMITATIONS, REASONS FOR CAUTION

This study is a retrospective cohort study, with all the associated inherent biases of such studies. This model was used only for TESE, since micro-TESE is not performed at our center.

WIDER IMPLICATIONS OF THE FINDINGS

Machine-learning models may lay the foundation for a decision support system for clinicians together with their NOA patients concerning TESE. The findings of this study should be confirmed with further larger and prospective studies.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Division of Obstetrics and Gynecology, Soroka University Medical Center, there are no potential conflicts of interest for all authors.

Predictors of surgical sperm retrieval in non-obstructive azoospermia: summary of current literature

Intracytoplasmic sperm injection (ICSI), combined with surgical sperm retrieval (SR) techniques, is the sole option for patients with non-obstructive azoospermia to achieve fertility; however, with suboptimal results. Given the variability in clinical presentation, the potential role of factors that can predict the likelihood of successful testicular SR needs to be clarified. This article summarizes the current evidence concerning the variables predicting SR success in non-obstructive azoospermic patients with spermatogenic failure. For this, we used 60 articles, including 46 original papers and six meta-analyses. Clinical and laboratory factors, as well as adjuvant therapies and surgical retrieval methods, were the factors most commonly investigated. We found that Klinefelter syndrome, Y chromosome microdeletions in regions AZFa/b, and Sertoli cell-only histopathology were associated with reduced SR success. By contrast, testis volume > 12.5 ml, history of cryptorchidism, use of micro-TESE as the sperm retrieval method, and adjuvant therapy were associated with improved SR success. None of the predictors, alone or combined, provide definitive information about the chances of harvesting sperm in men with non-obstructive azoospermia, except for Y chromosome microdeletions in regions AZFa/b. In the latter, SR success is virtually nil. We conclude that SR outcomes in men with non-obstructive azoospermia are difficult to predict based on the existing variables. Although several predictors can be used for patient counseling, their clinical value is limited to either ensure SR success or discourage reproductive urologists from recommending SR to men with non-obstructive azoospermia seeking fertility. A notable exception includes the deletions involving the regions AZFa and/or AZFb of the Y chromosome; the affected patients should be counseled against undergoing SR.

Testicular sperm extraction in men with sertoli cell-only testicular histology - 1680 cases

Objective:

To study the outcomes of testicular sperm extraction (TESE) among men with pure Sertoli cell-only histology identified during diagnostic testicular biopsy.

Methods:

This retrospective cohort study involved 1680 cases of patients with nonobstructive azoospermia (NOA) diagnosed with pure Sertoli cell-only histology who underwent testicular biopsy with TESE in a reference center in Brazil by a single surgeon. Sperm retrieval rates (SSR) were the main outcome measure.

Results:

Overall, 14.83% of patients with Sertoli cell-only had sperm retrieved with TESE in quantity that allowed the performance of ICSI. No differences were observed in SSR based on testis volume (<15 mL vs. <15 mL) or serum FSH level.

Conclusions:

Patients with Sertoli cell-only histology can be counseled that they have some likelihood of sperm retrieval with TESE. Based on the findings, patients to be submitted to testicular biopsy for histologic analysis may be concomitantly prepared for ICSI with TESE in case sperm is available.

Predictive value of FSH, testicular volume, and histopathological findings for the sperm retrieval rate of microdissection TESE in nonobstructive azoospermia: a meta-analysis

We performed this meta-analysis to evaluate the predictive value of different parameters in the sperm retrieval rate (SRR) of microdissection testicular sperm extraction (TESE) in patients with nonobstructive azoospermia (NOA). All relevant studies were searched in PubMed, Web of Science, EMBASE, Cochrane Library, and EBSCO. We chose three parameters to perform the meta-analysis: follicle-stimulating hormone (FSH), testicular volume, and testicular histopathological findings which included three patterns: hypospermatogenesis (HS), maturation arrest (MA), and Sertoli-cell-only syndrome (SCOS). If there was a threshold effect, only the area under the summary receiver operating characteristic curve (AUSROC) was calculated. Otherwise, the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and the diagnostic odds ratio (DOR) were also calculated. Twenty-one articles were included in our study finally. There was a threshold effect among studies investigating FSH and SCOS. The AUSROCs of FSH, testicular volume, HS, MA, and SCOS were 0.6119, 0.6389, 0.6758, 0.5535, and 0.2763, respectively. The DORs of testicular volume, HS, and MA were 1.98, 16.49, and 1.26, respectively. The sensitivities of them were 0.80, 0.30, and 0.27, while the specificities of them were 0.35, 0.98, and 0.76, respectively. The PLRs of them were 1.49, 10.63, and 1.15, respectively. And NLRs were 0.73, 0.72, and 0.95, respectively. All the investigated factors in our study had limited predictive value. However, the histopathological findings were helpful to some extent. Most patients with HS could get sperm by microdissection TESE.

Analysis of factors affecting repeat microdissection testicular sperm extraction outcomes in infertile men

OBJECTIVE

There is no clear consensus on which patients and how many of microscopic testicular sperm extraction (mTESE) procedures will be successful. In this study, we aimed to evaluate the sperm retrieval rates and factors affecting these rates in men who underwent repeat mTESEs.

MATERIAL AND METHODS

A total of 346 patients who underwent mTESE for sperm retrieval were included in the study. Patients were divided into groups according to the number of mTESE operations. Patients' karyotype, follicle-stimulating hormone (FSH) and testosterone levels, varicocele presence, and testis volumes were recorded from patient files. The sperm retrieval rates were compared between groups, and predicting factors for successful sperm retrieval were evaluated.

RESULTS

Microscopic TESE was applied for the first time in 244 patients, 1-2 times in 73 patients, and 3-4 times in 29 patients. There was a significant difference between groups in preoperative FSH values and postoperative testicular histopathology (p=0.004 and p<0.001). The sperm retrieval rate in the group of patients who had not undergone previous TESE was higher than the group of patients that had undergone TESE for 1-2 times and 3-4 times (p=0.028). In addition, testicular volume, histology, karyotype, and Y-chromosome microdeletion were predicting factors for successful sperm retrieval (p=0.011, p=0.039, p=0.002, and p<0.001, respectively).

CONCLUSION

Our results confirm the necessity for repeat mTESE operations to be performed by experienced surgeons in reference centers to optimize the chance of reduced sperm retrieval rates with recurrent biopsies.

Sperm fine-needle aspiration (FNA) mapping after failed microdissection testicular sperm extraction (TESE): location and patterns of found sperm

We sought to evaluate the ability of fine-needle aspiration (FNA) mapping to find sperm and to guide sperm retrieval after failed microdissection testicular sperm extraction (micro-TESE) in nonobstructive azoospermic men. In this study of consecutive male infertility cases, interventions included testicular FNA mapping and subsequent sperm retrieval. Outcomes included the frequency and location of found sperm on FNA maps after failed micro-TESE and the salvage sperm retrieval success. Among 548 patients undergoing FNA mapping from 2010 to 2016, 82 men with previous micro-TESE procedures were identified. The mean time between micro-TESE and FNA mapping was 2.2 years. A total of 2825 (1424 on right and 1401 on left) sites were mapped. At least one site revealed mature sperm in 24 (29.3%) of 82 men with prior failed micro-TESE procedures. There was an equal likelihood of detecting sperm in either testis (6.1% right; 5.7% left; P = 0.58). Digital "heat maps" revealed differences in sperm findings within the testis with mature sperm more likely found in the testis periphery rather than centrally. Fifteen (62.5%) patients subsequently underwent sperm retrieval procedures guided by FNA maps. Sufficient sperm were retrieved in all cases, and in 10 (66.7%) of 15 cases, extra sperm were frozen for future use. In a significant proportion of failed micro-TESE procedures representing the largest study to date, sperm were detected by FNA mapping and could be reliably retrieved through FNA map-guided surgical sperm retrieval. When present, sperm were more likely to be found in the testis periphery rather than centrally with FNA mapping.

New insights into the morphological and hormonal characteristics of spermatogenic arrest

The reported sperm retrieval rate (SRR) in patients with nonobstructive azoospermia (NOA) due to spermatogenic arrest (SA) is highly variable in the literature. This discrepancy could be explained by the heterogeneity of testicular tissues. Surprisingly, even though inhibin B levels reflect directly Sertoli cell function; no studies have evaluated this parameter in SA. We aimed to clarify the morphological and biological profile in 158 men with SA. From the total population, patients whose seminiferous tubules diameter was below 165 µm have higher SRR (46.9% vs. 27.4%, p < 0.05), lower inhibin levels and a higher frequency of nonuniform SA (71.9% vs. 38.7%, p < 0.001). On multivariate analysis, patients with late SA and a history of cryptorchidism were positively associated with successful sperm extraction. Patients with successful SRR and uniform SA exhibited inhibin levels twofold lower than those with failed TESE (45 pg/ml vs. 95 pg/ml, p < 0.05), whereas FSH levels were similar in the two groups. In this study, we showed for the first time that the mean diameter of the seminiferous tubules may be of value in the diagnosis of SA. Our results suggest that inhibin levels could be useful in the management of NOA with SA, along with FSH levels and testicular volume.

Testicular histopathology, semen analysis and FSH, predictive value of sperm retrieval: supportive counseling in case of reoperation after testicular sperm extraction (TESE)

Background

To provide indicators for the likelihood of sperm retrieval in patients undergoing testicular sperm extraction is a major issue in the management of male infertility by TESE. The aim of our study was to determine the impact of different parameters, including testicular histopathology, on sperm retrieval in case of reoperation in patients undergoing testicular sperm extraction.

Methods

We retrospectively analyzed 486 patients who underwent sperm extraction for intracytoplasmic sperm injection and testicular biopsy. Histology was classified into: normal spermatogenesis; hypospermatogenesis (reduction in the number of normal spermatogenetic cells); maturation arrest (absence of the later stages of spermatogenesis); and Sertoli cell only (absence of germ cells). Semen analysis and serum FSH, LH and testosterone were measured.

Results

Four hundred thirty patients had non obstructive azoospermia, 53 severe oligozoospermia and 3 necrozoospermia. There were 307 (63%) successful sperm retrieval. Higher testicular volume, lower levels of FSH, and better histological features were predictive for sperm retrieval. The same parameters and younger age were predictive factors for shorter time for sperm recovery. After multivariable analysis, younger age, better semen parameters, better histological features and lower values of FSH remained predictive for shorter time for sperm retrieval while better semen and histology remained predictive factors for successful sperm retrieval. The predictive capacity of a score obtained by summing the points assigned for selected predictors (1 point for Sertoli cell only, 0.33 points for azoospermia, 0.004 points for each FSH mIU/ml) gave an area under the ROC curve of 0.843.

Conclusions

This model can help the practitioner with counseling infertile men by reliably predicting the chance of obtaining spermatozoa with testicular sperm extraction when a repeat attempt is planned.

Microdissection testicular sperm extraction (micro-TESE): Predictive value of preoperative hormonal levels and pathology in non-obstructive azoospermia

The aim of this study was to evaluate the predictive value of preoperative hormonal levels and pathology, as well as the outcome of microsurgical testicular sperm extraction in patients with non-obstructive azoospermia (NOA), presenting to our clinic for treatment of infertility. The records of 145 men with NOA who underwent microdissection testicular sperm extraction (micro-TESE) between March 2013 and November 2016 were studied. The patient's age, testicular volume, hormonal profile for follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone (TT), and testicular pathology were recorded. The sperm retrieval, the clinical pregnancy and live birth delivery rates were noted. Our testicular sperm retrieval rate was 65.5%. There was no statistical difference in age, testicular volume, or hormonal levels in the TESE-positive and negative groups. Hypospermatogenesis was found in testicular histopathology in 57 of 117 patients (48.7%) who underwent testicular biopsy. Sertoli Cell-Only (SCO) syndrome was seen in 20.5%, Germ Cell Maturation Arrest (MA) in 16.3%, and Atrophy-hyalinization in 14.5%. Seven men had Klinefelter's syndrome (KS), four of whom were TESE-positive. There were no adverse effects of the procedure except for infection at the incision site in one patient. Single intracytoplasmic sperm injection (ICSI) cycles were performed in 92 couples leading to 41 clinical pregnancies and 26 live birth deliveries. Micro-TESE is a safe procedure in experienced hands and provides infertile men with NOA an opportunity to father children. However unselected candidates with NOA should be counselled at the outset that only 17.9% will eventually become biological fathers.

Long-term clinical outcomes of testicular sperm extraction and intracytoplasmic sperm injection for infertile men

Purpose

To find the best methods to achieve the highest pregnancy and birth rates for couples needing testicular sperm extraction (TESE)‐intracytoplasmic sperm injection (ICSI).

Methods

Retrospectively studied were 801 patients with male factor infertility who had undergone TESE‐ICSI between April, 1996 and July, 2016 and who had been categorized into four groups: obstructive azoospermia (OA); non‐obstructive azoospermia (NOA); Klinefelter syndrome (KS); and cryptozoospermia (Crypt). The sperm retrieval rate, hormone levels, fertilization rate (FR), pregnancy rate (PR), and birth rate (BR) after ICSI among three groups were compared: fresh testicular sperm (FS)‐fresh oocytes (FO) (Group I); frozen‐thawed testicular sperm‐FO (Group II); and FS‐vitrified‐warmed oocytes (Group III).

Results

The testicular sperm recovery rate was 57.8% (463/801): 89.6% in the Crypt, 97.1% in the OA, 28.9% in the NOA, and 42.2% in the KS groups. The follicle‐stimulating hormone levels were significantly higher in the NOA and KS groups and the testosterone levels were significantly lower in the KS group. The FR, PR, and BR were: 65.2%, 43.2%, and 28.5% in group I; 59.2%, 33.4%, and 18.7% in group II; and 56.4%, 33.8%, and 22.1% in group III.

Conclusion

Intracytoplasmic sperm injection with FS‐FO achieved the best PR and BR. It should be considered what to do in cases with no testicular sperm by TESE. The authors hope that ICSI with donor sperm will be allowed in Japan in the near future.

Microdissection testicular sperm extraction

Microdissection testicular sperm extraction (microTESE) is considered the gold standard method for surgical sperm retrieval among patients with non-obstructive azoospermia (NOA). In this review, we will discuss the optimal evaluation of NOA patients and strategies to medically optimize NOA patients prior to microTESE. In addition, we will also discuss technical principles and pearls to maximize the chances of successful sperm retrieval, sperm retrieval rates (SRR) based upon testicular histology, predictors of successful sperm retrieval, gonadal recovery following microTESE, and potential complications.

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.

Does detection of DDX4 mRNA in cell-free seminal plasma represents a reliable noninvasive germ cell marker in patients with nonobstructive azoospermia?

This study aimed to investigate the potential application of DDX4 gene expression in cell-free seminal mRNA as a noninvasive biomarker for the identification of the presence of germ cells in men with nonobstructive azoospermia and to correlate this factor with testicular biopsy. Male reproductive organ-specific genes were chosen: DDX4, which is a germ cell-specific gene and transglutaminase 4, which is a prostate-specific gene that was used as a control gene. Thirty-nine azoospermic males and twenty-eight normospermic fertile males (serving as a control group) participated in the study. Histopathological examination of testicular biopsies categorised azoospermic males into 20.5% with maturation arrest, 17.9% with incomplete Sertoli cell-only syndrome and 61.5% with complete Sertoli cell-only syndrome. Using real-time polymerase chain reaction, positivity for DDX4 gene was detected in 17 of 39 males with NOA which was due to maturation arrest in 35.3% (n = 6/17) of cases, due to incomplete Sertoli cell only in 23.5% (n = 4/17) and due to complete Sertoli cell only in 41.2% (n = 7/17). The study recommends joint utilisation of molecular transcripts as noninvasive biomarkers and histopathological examination of testicular biopsies in management of cases with azoospermia of the nonobstructive type.

Salvage micro-dissection testicular sperm extraction; outcome in men with non-obstructive azoospermia with previous failed sperm retrievals

OBJECTIVE

To assess the outcome of micro-dissection testicular exploration sperm extraction (m-TESE) as a salvage treatment in men with non-obstructive azoospermia (NOA) in whom no sperm was previously found on single/multiple TESE or testicular sperm aspiration (TESA).

PATIENTS AND METHODS

In all, 58 men with NOA underwent m-TESE. All the patients had previously undergone either single/multiple TESE or TESA with no sperm found. All the patients underwent an m-TESE using a standard technique. Serum follicle-stimulating hormone (FSH), testosterone and histopathological diagnosis were examined as predictive factors for sperm recovery. All patients underwent preoperative genetic screening. One patient was found to have an azoospermic factor c (AZFc) micro-deletion and five were diagnosed with Kleinfelter's syndrome.

RESULTS

The mean (range) patient age was 39.0 (26-57) years. Spermatozoa were successfully retrieved in 27 men by m-TESE (46.5%). The mean (range) FSH level was 19.4 (1.6-58.5) IU/L. There was no correlation in age (mean age retrieved 38.1 years, not retrieved 39.7 years, P = 0.38), FSH levels (mean FSH retrieved 21.4 IU/L, not retrieved 17.7 IU/L, P = 0.3) and the ability to find sperm by m-TESE. However, there was a significant difference in testosterone levels and sperm retrieval (mean testosterone retrieved 14.99 nmol/L, not retrieved 11.39 nmol/L, P < 0.05). Patients with a diagnosis of Sertoli-cell-only (SCO) syndrome [14/35 (40%)] and maturation arrest [four of 11 (36%)] had lower sperm retrieval rates than those in the hypospermatogenesis group [nine of 12 (75.0%)] (P < 0.05). There were no significant complications after m-TESE.

CONCLUSIONS

In men with NOA who have undergone previous attempts at sperm retrieval with negative results, a salvage m-TESE offers a significant chance of finding sperm even in SCO syndrome. There does seem to be a correlation between preoperative testosterone levels and the ability to successfully find sperm.

Predictive factors of successful microdissection testicular sperm extraction in patients with presumed sertoli cell-only syndrome

BACKGROUND

To evaluate predictive factors of successful microdissection-testicular sperm extraction (MD-TESE) in patients with presumed Sertoli cell-only syndrome (SCOS).

MATERIALS AND METHODS

In this retrospective analysis, 874 men with non-obstructive azoospermia (NOA), among whom 148 individuals with diagnosis of SCOS in prior biopsy, underwent MD-TESE at Department of Andrology, Royan Institute, Tehran, Iran. The predictive values of follicle stimulating hormone (FSH), luteinizing hormone (LH), and testosterone (T) levels, testicular volume, as well as male age for retrieving testicular sperm by MD-TESE were analyzed by multiple logistic regression analysis.

RESULTS

Testicular sperm were successfully retrieved in 23.6% men with presumed SCOS. Using receiver operating characteristic (ROC) curve analysis, it was shown that sperm retrieval rate in the group of men with FSH values >15.25% was 28.9%. This was higher than the group of men with FSH ≤15.25 (11.8%).

CONCLUSION

Sperm retrieval rate (SRR) was 23.6% in men with presumed SCOS and FSH level can be a fair predictor for SPR at MD-TESE. MD-TESE appears to be recommendable in such cases (SCOS with high FSH concentration) with reasonable results.

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.

Testis sperm extraction

The last 20 years have produced developments in the treatment for patients with non-obstructive azoospermia (NOA) who were once considered to be infertile. The combination of intracytoplasmic sperm injection together with various testicular sperm retrieval techniques, including conventional testicular sperm extraction (TESE), microdissection TESE (micro-TESE) and fine needle aspiration (FNA), have revolutionized treatment for these men. In men with NOA, isolated regions of spermatogenesis within the testis are common. The goal for all types of sperm retrieval procedures is locating the focal region(s) of spermatogenesis, and harvesting the sperm for assisted reproduction. This review article explores the surgical management of men with NOA and describes all techniques that can be used for testicular sperm retrieval. A PubMed search was conducted using the key words: “sperm extraction”, “NOA”, “testicular FNA”, “testicular mapping”, “TESE”, and “testicular biopsy”. All articles were reviewed. Articles were included if they provided data on sperm retrieval rates. The methods for performing sperm retrieval rates and outcomes of the various techniques are outlined. Micro-TESE has a higher sperm retrieval rates with fewer postoperative complications and negative effects on testicular function compared with conventional TESE.

Microdissection testicular sperm extraction in men with Sertoli cell-only testicular histology

OBJECTIVE

To study the outcomes of microdissection testicular sperm extraction (microTESE) among men with pure Sertoli cell-only histology on diagnostic testicular biopsy.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral center.

PATIENT(S)

Six hundred forty patients with pure Sertoli cell-only histology on testicular biopsy who underwent microTESE by a single surgeon.

INTERVENTION(S)

MicroTESE.

MAIN OUTCOME MEASURE(S)

Sperm retrieval rates.

RESULT(S)

Overall, 44.5% of patients with Sertoli cell only had sperm retrieved with microTESE. No difference was noted in sperm retrieval rates based on testis volume (≥15 mL vs. <15 mL, 35.3% vs. 46.1%, respectively). Patients with ≥15 mL testicular volume and FSH 10-15 mU/mL had the worst prognosis, with a sperm retrieval rate of 6.7%.

CONCLUSION(S)

Patients with previous testicular biopsy demonstrating Sertoli cell-only histology can be counseled that they have a reasonable likelihood of sperm retrieval with the contemporary delivery of microTESE. Given this finding, the utility of testicular biopsy before microTESE is further questioned.

Progressing management of non-obstructive azoospermia in the era of microdissection testicular sperm extraction

Previously, it was absolutely impossible for azoospermic men to reproduce except in some obstructive azoospermic cases for whom reconstruction of the seminal pathway was successful. However, nowadays, intracytoplasmic sperm injection and microdissection testicular sperm extraction have brought about chances of biological paternity in some non-obstructive azoospermic men. It is almost 15 years since the first trials of testicular sperm retrieval using surgical microscopy for non-obstructive azoospermia were reported. In this manuscript, the progress and outcomes of these novel techniques since then are reviewed, the controversial points are discussed and the latest research to achieve pregnancies in tough non-obstructive azoospermic couples are introduced. Not only the bright side of the renovations, but the underlying concerns are also discussed.

Updates on sperm retrieval techniques

In the most extreme form of male infertility, the male partner is azoospermic. The advent of in vitro fertilization (IVF)-intracytoplasmic sperm injection (ICSI) has revolutionized our ability to treat azoospermia in both obstructive and non-obstructive cases. In obstructive azoospermia, it allows paternity without microsurgical reproductive tract reconstruction and also in cases where the reproductive tract is unreconstructable. In men with non-obstructive azoospermia, microdissection testicular sperm extraction (mTESE) has allowed us to retrieve sperm in men with exceedingly low sperm production. The introduction of microsurgery in sperm retrieval improves sperm yields and quality while minimizing the chance of surgical morbidity.

Update in the evaluation of the azoospermic male

Approximately 1% of all men in the general population suffer from azoospermia, and azoospermic men constitute approximately 10 to 15% of all infertile men. Thus, this group of patients represents a significant population in the field of male infertility. A thorough medical history, physical examination and hormonal profile are essential in the evaluation of azoospermic males. Imaging studies, a genetic workup and a testicular biopsy (with cryopreservation) may augment the workup and evaluation. Men with nonobstructive azoospermia should be offered genetic counseling before their spermatozoa are used for assisted reproductive techniques. This article provides a contemporary review of the evaluation of the azoospermic male.