Combined Trifocal and Microsurgical Testicular Sperm Extraction Is the Best Technique for Testicular Sperm Retrieval in “Low-Chance” Nonobstructive Azoospermia

Abstract

BackgroundThere is no consensus for the best testicular sperm extraction (TESE) technique in patients with “low-chance” nonobstructive azoospermia (NOA). ObjectiveTo determine sperm retrieval rates in an intraindividual comparison using three locations of the testicle with and without the assistance of a microscope (microsurgical TESE [M-TESE]). Design, setting, and participantsA series of 65 patients with low-chance NOA presenting with low testicular volume (<8ml) and high serum follicle-stimulating hormone (FSH) (>12.4 IU/l) underwent trifocal-TESE plus M-TESE bilaterally (four biopsies per testis). InterventionSperm retrieval was performed as trifocal-TESE (upper, middle, and lower testicular pole) with and without the assistance of a microscope in the middle incision. Outcome measurements and statistical analysisThe number of evaluated tubules, the mean spermatogenetic scores, and the sperm retrieval rates were evaluated to determine retrieval locations and the use of the microscope. The Friedman and Cochrane Q tests were applied to determine statistical differences. Receiver operating characteristic curves were used for the analysis of serum FSH and testicular volume as preoperative prognostic factors. Results and limitationsThe sperm retrieval success of 66.2% using the combined technique, meaning the percentage of patients with at least one tubule containing elongated spermatids, was the highest in the combination of trifocal- and M-TESE (p<0.01), indicating this technique as optimal for patients with low-chance NOA. M-TESE and trifocal-TESE alone were not significantly better. The mean spermatogenetic score giving the number of tubules with elongated spermatids in relation to all tubules was significantly higher in M-TESE versus conventional TESE (p<0.01), indicating the superior quality of the tissue harvested using the microscope. These results are limited by the definition of “success” using “one” spermatid/tubule. Preoperatively, high serum FSH and low testicular volumes did not exclude successful sperm retrieval. ConclusionsThe combination of trifocal- and M-TESE is the best technique to reach high sperm retrieval rates in patients with low-chance NOA.