Spermatogenesis in azoospermic, formerly cryptorchid men. Use of needle aspiration techniques

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.

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.

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.

Fine-needle aspiration of the testis in azoospermic men: the value of measuring serum follicle stimulating hormone and testicular size

Testicular fine-needle aspiration biopsy (FNAB) is used as a primary tool in assessing azoospermic infertile men in our institution. If the FNA is negative for sperm, a subsequent testicular biopsy specimen and wet preparation are obtained with possible immediate fertilization. To our knowledge, the value of these techniques in the context of testicular size and serum levels of follicle stimulating hormone (FSH) has not been explored. We reviewed 453 FNA biopsies of the testis performed for the identification of sperm in infertile azoospermic males between 1999 and 2000. We identified cases that had all three procedures (FNA, wet preparation and biopsy) performed. These were the patients that were compared for testicular size using Seager orchiometry and serum levels of FSH. Of the 453 FNAs reviewed, 128 (21%) had all three procedures performed. Seventy-two cases (56%) were negative in all three tests, 26 (20%) cases were positive in all tests, and 30 cases (23%) had different results. These 30 cases were excluded. The testicular size in the negative group ranged from 4 to 16 ml (median, 10 ml) and the positive group had testicular sizes ranging from 10 to 25 ml (median, 15 ml; P = 0.0001). The negative group had serum FSH levels ranging from 3 to 52 IU/l (median, 19 IU/l) whereas the positive group had serum levels ranging from 3 to 26 IU/l (median, 10 IU/l; P = 0.0001). Our findings suggest that in infertile azoospermic men, a testicular size of <10 ml combined with a serum FSH level of >19 IU/l, the chances of retrieving sperm are minimal using all three diagnostic modalities. The use of this cutoff point would lead to a 30-50% reduction in the number of procedures performed. This reduction would have a significant impact on the management of these patients with a significant decrease in cost, logistics, and patient anxiety.

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

OBJECTIVE

To assess by ultrasonography the safety of the association fine-needle aspiration (FNA) plus a new percutaneous large-needle aspiration biopsy technique (LNAB), and to compare the results obtained with the two techniques in the same testicle and with FNA in the two testicles of the same patient.

DESIGN

Retrospective analysis of clinical, ultrasonographic, and pathologic data.

SETTING

Clinical and academic research environment.

PATIENT(S)

Three hundred and eighty-seven testicles of 233 patients (ages 19 to 57 years) with nonobstructive azoospermia were consecutively examined with FNA (154) or FNA + LNAB (233); 54 patients (89 testicles) examined with FNA + LNAB underwent a second ultrasonography up to 63 days after.

INTERVENTION(S)

Ultrasonography, FNA, LNAB.

MAIN OUTCOME MEASURE(S)

Hypoechoic area at ultrasonography; cytologic picture at FNA or LNAB of only Sertoli cells (category 1), spermatogenetic cells different from elongated spermatids or spermatozoa (category 2), and elongated spermatids and/or spermatozoa (category 3).

RESULT(S)

Among the 54 patients monitored by ultrasonography 48 (88.9%) showed no difference and 6 (11.1%) showed an hypoechoic area < or =1 cm in the second image. Category 1 occurred at FNA or LNAB in a very similar number of testicles (36% vs. 36.9%). Categories 2 and 3 were more frequent at LNAB (29.9% vs. 9.8%) and at FNA (54.2% vs. 33.2%), respectively. One hundred and sixty-six patients had both testicles examined by FNA; 147 pair of testicles were concordant for the presence or the absence of spermatozoa or elongated spermatids. In the remaining 19 patients (11.4%), these spermatogenetic cells were shown only in the specimen from one of the two testicles. These 19 patients accounted for 20.0% of 93 patients with spermatogenetic cells in at least one of the two testicles.

CONCLUSION(S)

The combination of FNA and LNAB did not produce clinically or subclinically relevant complications. No important differences in the identification of category 1 with FNA or LNAB were found. Fine-needle aspiration was more adequate in identifying category 3, which was particularly relevant in 20% of the men who had these cells in at least one of the two testicles.