Conventional Testicular Sperm Extraction Research Articles

Duration of Microdissection Testicular Sperm Extraction Procedures: Relationship to Sperm Retrieval Success

We evaluated the operative time of microdissection testicular sperm extraction in successful and failed procedures to identify the chance of sperm retrieval during longer microsurgical procedures. A total of 793 men with nonobstructive azoospermia underwent a first attempt at microdissection testicular sperm extraction from January 2000 to September 2009. Clinical factors were analyzed, including age, testicular volume, endocrinological data and histology. Operative time was calculated from incision until the procedure was terminated. Testicular sperm were successfully retrieved in 57% of the men. Sperm were found within 2, 2 to 4 and 4 to 7 hours in 89%, 30% and 37% of the men, respectively. There were no differences in preoperative clinical characteristics, age, follicle-stimulating hormone, testicular volume, incidence of a Klinefelter's syndrome diagnosis and distribution of most advanced histopathology in patients in the 3 operative time groups. In men in whom sperm were retrieved the clinical pregnancy and live birth rates were 48%, 45% and 29%, and 37%, 30% and 29% for operative times up to 2, 2 to 4 and 4 to 7 hours, respectively (p >0.05). ROC curve analysis of the different operative times for detecting sperm showed that 125 minutes was the most accurate time (AUC 0.81) with 84% sensitivity and 95% specificity. The chance of sperm retrieval during microdissection testicular sperm extraction was best during the first 2 hours of the operation. However, sperm were still found in up to 37% of men who required greater than 4 hours of microdissection. Retrospective analysis of our data indicated no cutoff point after which sperm retrieval was uniformly unsuccessful.

The number of spermatozoa collected with testicular sperm extraction is a novel predictor of intracytoplasmic sperm injection outcome in non-obstructive azoospermic patients

The purpose of this study was to determine the relationships between monitors of spermatogenesis and predictors of the intracytoplasmic sperm injection (ICSI) outcome in patients with non-obstructive azoospermia (NOA) undergoing testicular sperm extraction (TESE). Seventy-nine patients with NOA (mean age: 43.6±5.2 years), each of whom yielded (97000±3040) spermatozoa with conventional TESE, were considered in our analysis. Their partners (mean age: 35.8±5.1 years) underwent a total of 184 ICSI cycles; 632 oocytes were collected, 221 oocytes were injected, 141 oocytes were fertilized, 121 embryos were obtained, 110 embryos were transferred, 14 clinical pregnancies were achieved and only one miscarriage occurred. Multivariate regression analysis indicated relationships between the percentage of fertilized oocytes, transferred embryos and clinical pregnancies with the following variable values: female partner's age, number of spermatozoa collected, testicular volume, male partner's levels of follicle stimulating hormone (FSH), number of oocytes collected, number of oocytes injected and number of ICSI cycles. A significant inverse relationship was found between female partner's age or male partner's FSH levels and biochemical pregnancies. A significant direct relationship emerged between the number of ICSI cycles and the percentage of oocytes fertilized, embryos transferred and biochemical pregnancies, and between the number of spermatozoa collected per testicular biopsy and biochemical pregnancies. The number of spermatozoa was positively linked to the number of clinical pregnancies, independent of the number of ICSI cycles and the number of oocytes collected/injected. The number of spermatozoa collected, FSH level and testicular volume are monitors of spermatogenesis linked to ICSI success.

Clinical Comparison of Conventional Testicular Sperm Extraction and Microdissection Techniques for Non-Obstructive Azoospermia

BackgroundWe compared the efficacy of microdissection testicular sperm extraction (microdissection TESE) and conventional TESE in patients with non-obstructive azoospermia (NOA) and related the positive sperm recovery to certain variables: follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels, testicular volume and histology.MethodsSperm retrieval rates (SRR) in patients with NOA who underwent microdissection TESE (n = 65) or conventional TESE (n = 68) were compared and related to the different variables.ResultsSRR by microdissection TESE (56.9%) was significantly higher than conventional TESE (38.2%). There was a positive relation between the SRR and increased testicular volume or decreased FSH levels. No effect of Testosterone or Prolactin levels on SRR by using either technique was observed. Sperm were recovered from those with hypospermatogenesis in 84% and 92.9% by conventional and microdissection TESE, respectively (P = 0.3). In cases of maturation arrest the SRR was 27.3% and 36.4%, respectively (P = 0.6). In cases of Sertoli-cell-only syndrome (SCOS) the SRR was 6.2% and 26.9%, respectively (P = 0.03). No major operative complications occurred in any patient in either group, and no patient required post-operative hormone replacement to treat hypogonadism.ConclusionsMicrodissection TESE significantly had twice better probability of success of SRR when compared to conventional TESE. No secure pre-operative prognostic elements of sperm recovery exist for NOA patients. Microdissection TESE appears to be recommendable in cases of atrophied testicles, high FSH concentration, or when SCOS with high FSH concentration can be predicted.KeywordsMicrodissection TESE; Sperm retrieval; Non-obstructive azoospermia; Histopathology; FSH concentration; Orchidometry

Conventional testicular sperm extraction combined with the microdissection technique in nonobstructive azoospermic patients: a prospective comparative study

To perform conventional and microdissection testicular sperm extraction (TESE) at the same session and compare their effectiveness. Prospective comparative study. University hospital setting. The study included 335 patients with nonobstructive azoospermia. Microdissection TESE was performed to 77 patient with atrophic testes. An additional 258 patients underwent conventional TESE using three incisions on three quadrants of the testis (upper, middle, and lower). Microdissection TESE was performed by enlarging the middle incision vertically when no spermatozoa could be detected using the conventional technique. Sperm retrieval, fertilization, clinical pregnancy rate (PR), and live birth rate were evaluated. The relation between sperm retrieval rate and FSH level and testis volume was also investigated. Spermatozoa was detected in 33.7% of patients using conventional TESE. The spermatozoa detected increased to 50.8% using microdissection TESE. The increase was statistically significant. In the primary microdissection TESE group, the surgical retrieval rate was 20.8%. The overall sperm retrieval rate was 43.9%. There was a significant relation between the sperm retrieval rate and testis volume, whereas there was no relation between sperm retrieval rate and FSH levels. The overall fertilization rate, clinical PR, and live birth rate were 57.1%, 50.4%, 36.4%, respectively. Conventional TESE combined with microdissection TESE can be used in selected patients. Sperm retrieval rate of TESE can be low in patients with atrophic testes.

Comparison between Conventional and Microsurgical Testicular Sperm Extraction in Non-obstructive Azoospermia

Purpose: Recovery of the testicular spermatozoa in non-obstructive azoospermic patients after intracytoplasmic sperm injection (ICSI) is a recent advance in the treatment of male infertility. In this study we compared sperm retrieval using microsurgical testicular sperm extraction (TESE) with retrieval by conventional TESE. Materials and Methods: A total of 450 men with non-obstructive azoospermia were included in the study. 277 of these 450 men underwent conventional TESE (Group 1), and the other 173 patients underwent microsurgical TESE (Group 2). Microsurgical TESE was performed by making multiple incisions in the tunica albuginea under surgical microscopy, with avoiding the underlying testicular artery. The seminiferous tubules that appeared dilated and opaque were harvested. The cases were categorized into three groups, that is, the germ cell aplasia group, the maturation arrest group and the hypospermatogenesis group. The sperm retrieval rates for the patients in the three histopathological categories were compared between the two groups. Results: The sperm retrieval rate by conventional TESE was 30.7% and it was 31.4% by microsurgical TESE (p=0.938). For the cases of histologically diagnosed germ cell aplasia the retrieval rate was 11.6% and 21.2%, respectively, for group 1 and group 2 (p=0.026). For the cases of maturation arrest the retrieval rate was 24.4% and 26.0%, respectively, for group 1 and group 2 (p=0.884). For the cases of hypospermatogenesis the retrieval rate was 83.0% and 91.3%, respectively, for group 1 and group 2 (p=0.339). Conclusions: For non-obstructive patients, and especially those with germ cell aplasia, microsurgical TESE can effectively retrieve spermatozoa and minimize the risk of complication. (Korean J Urol 2008;49:88-91) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

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

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

Seminal plasma inhibin‐B level is a useful predictor of the success of conventional testicular sperm extraction in patients with non‐obstructive azoospermia

The value of serum inhibin-B as a predictor of the presence of testicular spermatozoa is still controversial. The purpose of this study is to evaluate the predictive value of the seminal plasma inhibin-B level, which might more directly reflect the secretion by Sertoli cells, and to discriminate between successful and failed testicular sperm extraction (TESE) in non-obstructive azoospermia. Sixty-two patients with non-obstructive azoospermia were examined at the Department of Obstetrics and Gynecology at Niigata University Hospital, Niigata, Japan. The level of inhibin-B was measured using a two-site enzyme-linked immunoassay. Testicular sperm were successfully retrieved in 17 of 62 patients (27.4%). The serum levels of follicle-stimulating hormone (FSH) were significantly lower and the serum and seminal inhibin-B concentrations were significantly higher in the successful TESE group compared with the failed TESE group. According to the receiver operating characteristics (ROC) curve analysis, the best discriminating seminal plasma inhibin-B level was 27.0 pg/mL (sensitivity 88.2%, specificity 93.3%). The best discriminating serum inhibin-B level was 34.0 pg/mL (sensitivity 70.6%, specificity 95.6%). The area under the ROC curve for seminal plasma inhibin-B was significantly larger than that for FSH and testicular volume. Using multivariate logistic regression analysis, only seminal plasma inhibin-B was an independent predictor of the presence of spermatozoa on TESE. Seminal plasma inhibin-B level is a useful predictor of the presence of testicular sperm in men with non-obstructive azoospermia.

Enzymatic digestion plus mechanical searching improves testicular sperm retrieval in non-obstructive azoospermia cases

Background: In non-obstructive azoospermic patients (NOA) besides the mechanical treatment, vital spermatozoa from the tissue obtained from testes by biopsy can be enzymatically prepared. Objective: To increase the sperm recovery success of testicular sperm extraction (TESE), suitable for ICSI. Study design: Prospective, clinical study. In 177 consecutive men who presented with clinical and laboratory data indicating NOA, tissue samples were obtained by microdissection TESE method. Initially, mature spermatozoa were searched for by mechanical extraction technique shredding the biopsy fractions. In cases with no spermatozoa was observed after maximum 30 min of initial searching under the inverted microscope, the procedure was then followed by enzymatic digestion using DNAse and collagenase type IV. In cases of at least a mature spermatozoon could be obtained properly, ICSI was performed. Results: Of 177 cases with NOA, conventional mincing method extended with enzymatic treatment yielded successful sperm recovery for ICSI in 102 (57%). Overall in vitro tissue-processing time for patients with sperm recovery failure after 30 min of mechanical searching, was between 80 and 105 min (mean 96 ± 9). Cleavage, embryo transfer and clinical pregnancy rates in mechanical plus enzymatic TESE patients were not significantly different from those of only mechanically TESE performed patients ( p > 0.05). Conclusion: Combination of conventional TESE and enzymatic digestion is an effective method to recover spermatozoa suitable for ICSI. The benefit of the mincing combined with enzyme to sperm retrieval for NOA is firstly to shorten the mechanical searching time, thus minimizing further cellular damage as well as exposure to external conditions, and secondly to reduce the number of cases with sperm recovery failures.

PREDICTION OF SUCCESSFUL OUTCOME OF MICRODISSECTION TESTICULAR SPERM EXTRACTION IN MEN WITH IDIOPATHIC NONOBSTRUCTIVE AZOOSPERMIA

Microsurgical techniques in testicular sperm extraction can improve sperm retrieval in patients with nonobstructive azoospermia (NOA). However, spermatozoa retrieval rates have still been reported to be around 50% for patients with NOA. Thus, a reliable prediction method for successful outcome is needed to avoid unnecessary surgery. In this retrospective study we determined the diagnostic and predictive values of noninvasive parameters used in the treatment of patients with NOA. We analyzed 9 preoperative factors including patient age, testicular volume and endocrinological data of 100 patients with NOA using multivariate logistic modeling. Testicular spermatozoa were retrieved successfully in 41 of the 100 patients (41%). We found that the concentrations of follicle-stimulating hormone (FSH), total testosterone (TT) and inhibin B were considered the most influential preoperative factors. We developed a formula to calculate the probability of successful outcome, P = [1 + exp(5.201 - 0.048 x FSH - 0.449 x TT - 0.021 x inhibin B)](-1). Association of predicted probabilities and observed responses was 0.77. A predicted probability of more than 15.7% was found to be the best cutoff. Sensitivity was 71.0% and specificity was 71.4% as determined by receiver operating characteristic analysis. We concluded that our formula should be useful for doctors considering microdissection testicular sperm extraction for patients with NOA because our equation uses noninvasive parameters without a preoperative testicular biopsy, which is a relatively invasive examination.

Selection of individual testicular tubules from biopsied testicular tissue with a stereomicroscope improves sperm retrieval rate.

The present study describes a new modification for testicular sperm extraction (TESE) with an intraoperative surgical loop, coupled with stereomicroscopic dissection in the laboratory, to identify sperm-containing tubules. The study included 116 consecutive patients with nonobstructive azoospermia (NOA) undergoing TESE and intracytoplasmic sperm injection. After dissection of testicular tissue under the stereomicroscope, patients were separated into 2 groups according to tubular diameter. In the first group (n = 72), all tubules were of the same diameter. In the second group (n = 44), tubules with variable diameters could be identified. In such cases, 1-2 of the most distended and opaque seminiferous tubules were selected and minced alone, then examined for the presence of spermatozoa. The rest of the testicular tissue suspension was minced and examined separately. In 11 (25%) cases, retrieved spermatozoa were found in the isolated distended tubules only. In 21 (47.7%) cases, spermatozoa were found in both the isolated distended tubules and the rest of the specimen. In 2 cases, spermatozoa were found only in the whole sample, not in the isolated tubules. In the remaining 10 cases, spermatozoa were not found in either the whole sample or the isolated tubules. The sperm recovery rate in the isolated tubules was significantly higher than that of the rest of the specimen (72.7% vs 52%, chi(2) = 3.93, P <.05), and larger numbers of spermatozoa could be easily retrieved in a shorter period of time. In conclusion, the selection and isolation of the most dilated and opaque seminiferous tubules by using the surgical loop, coupled with laboratory stereoscopic dissection, improves sperm retrieval for men with NOA. It is possible that surgical-loops TESE coupled with stereomicroscope may offer superior sperm retrieval when compared with conventional TESE and may also offer reduced operative time when compared with microdissection TESE.

Conventional Versus Microdissection Testicular Sperm Extraction for Nonobstructive Azoospermia

We established a practical and safe strategy for testicular sperm extraction (TESE) in patients with nonobstructive azoospermia and compared conventional with microdissection TESE. In a retrospective comparative study 46 patients, including 22 with obstructive and 24 with nonobstructive azoospermia, underwent conventional TESE. Another 100 patients, including 26 with obstructive and 74 with nonobstructive azoospermia, underwent microdissection TESE. Conventional TESE was performed via 3 small 5 mm. incisions in the tunica albuginea. Microdissection TESE was performed by making a 3 to 4 cm. incision in the tunica albuginea under operating microscopy, avoiding the underlying testicular artery. Seminiferous tubules that appeared dilated and opaque were harvested. Sperm recovery rates were compared, as were complication rates assessed by ultrasonographic and endocrinological evaluations. In obstructive azoospermia cases the sperm recovery rate was 100% for each procedure. In nonobstructive azoospermia cases sperm were recovered in 16.7% and 44.6% by conventional and microdissection TESE, respectively (p = 0.0271). In cases of histologically diagnosed maturation arrest the sperm recovery rate was 37.5% and 75%, respectively (p = 0.22585). In cases of the Sertoli-cell-only syndrome the sperm recovery rate was 6.3% and 33.9%, respectively (p = 0.0494). We identified dilated and opaque seminiferous tubules containing spermatozoa under operating microscopy in 22.2% of patients with maturation arrest and in 63.2% with the Sertoli-cell-only syndrome. The complication rate was significantly lower for microdissection than for conventional TESE. In nonobstructive cases, especially those of the Sertoli-cell-only syndrome, microdissection TESE can effectively retrieve spermatozoa and minimize the risk of complications.

Microsurgical TESE and the distribution of spermatogenesis in non-obstructive azoospermia

We wished to map the distribution of spermatogenesis in different regions of the testis in 58 men with non-obstructive azoospermia, and to develop a rational microsurgical strategy for the testicular sperm extraction (TESE) procedure. One goal was to maximize the chances for retrieving spermatozoa from such men, to minimize tissue loss and pain, and to preserve the chance for successful future procedures. Another goal was to expand upon the previously reported quantitative histological analysis of testicular tissue in 45 azoospermic men undergoing conventional TESE, this time using microsurgical as well as histological mapping. Tubular fullness observed at microsurgery and the presence of spermatozoa in the TESE specimen was compared with the quantitative histological analysis of spermatogenesis. Thus, our conclusions about the distribution of spermatogenesis are based on our experience with TESE in 103 consecutive cases of non-obstructive azoospermia. It was confirmed that men with non-obstructive azoospermia caused by germinal failure have a mean of 0 to 3 mature spermatids per seminiferous tubule in contrast to 17-35 mature spermatids per tubule in men with normal spermatogenesis and obstructive azoospermia. The former represented the threshold of quantitative spermatogenesis which must be exceeded in order for spermatozoa to 'spill over' into the ejaculate. Both testicular 'mapping' by multiple biopsy (n = 15) and microsurgical removal of contiguous strips of testicular tissue (n = 43) revealed a diffuse, rather than regional, quantitative distribution of spermatogenesis. A microsurgical approach resulted in the minimal amount of tissue loss and minimal-to-no pain (compared with the original 45 cases already reported). By this means it is often possible to immediately locate the few tubules with spermatogenesis at microsurgery, under local anaesthesia. But even in cases where greater amounts of tissue must be removed in order to find spermatozoa, the microsurgical TESE procedure prevents secondary testicular damage by protecting blood supply and preventing pain and atrophy from increased testicular pressure. Thus, future attempts at TESE-ICSI need not be compromised.

Prospective comparative study between microsurgical and conventional testicular sperm extraction in non-obstructive azoospermia: follow-up by serial ultrasound examinations

The value of testicular sperm extraction (TESE) by microdissection was evaluated according to its physiological consequences compared with open, classic surgical biopsy in the same patient. A total of 100 patients with non-obstructive azoospermia and bilateral identical testicular histology underwent bilateral diagnostic TESE via the conventional method on one side and the microsurgical method on the other side. The spermatozoa recovery rate by microdissection TESE was significantly higher than by conventional TESE (47 and 30% respectively; P < 0.05). In order to assess the safety of this new procedure, 60 patients were followed-up ultrasonographically for 1, 3 and 6 months. Acute and chronic complications were significantly lower in the microsurgical side compared with the conventional side (15 and 58.3% respectively and 3 and 30% respectively; P < 0.05). Segmental devascularization was detected in seven testes operated on conventionally, and in two testes operated on microsurgically. However, permanent devascularization could not be detected in any patient after 6 months. These findings suggest that microdissection TESE is not devoid of complications, but that it is relatively safer than the conventional technique and improves sperm yield significantly in patients with non-obstructive azoospermia.