Micro-dissection testicular sperm extraction as an alternative for sperm acquisition in the most difficult cases of Azoospermia: Technique and preliminary results in India

Abstract

CONTEXT:Non-obstructive azoospermia (NOA) is an unfavorable prognostic condition for male infertility since spermatogenesis is disrupted. Sperm retrieval (SR) coupled with intracytoplasmic sperm injection (ICSI) is the only option for men with NOA who seek fertility. Among the SR techniques, microdissection testicular sperm extraction (micro-TESE) has been applied with encouraging results.AIMS:We describe how we implemented the micro-TESE procedure and present initial micro-TESE experience in a group of men with NOA and poor prognosis for SR.SETTINGS AND DESIGN:Case series of men with NOA treated in a tertiary healthcare center.MATERIALS AND METHODS:An Assisted Reproductive Technology (ART) facility was setup to perform SR using microsurgery. Fourteen men with NOA and previous failed retrievals or unfavorable histologic results underwent micro-TESE while their female partners received ovarian stimulation for oocyte pickup (OCP). Micro-TESE was performed the day prior to OCP and testicular sperm were used for sperm injections. We assessed retrieval rates and ICSI outcomes.STATISTICAL ANALYSIS:Outcomes of SR and ICSI were analyzed descriptively. Mann-Whitney and Fisher exact test were used to compare characteristics of men with successful and failed SR.RESULTS:The success of micro-TESE was 50.0% with no major complications. A clear microscopic distinction between enlarged and collapsed seminiferous tubules was seen in 35.7% of the cases, and sperm were retrieved in all but one of these cases. Patients with successful and failed retrieval did not differ with respect to baseline characteristics, use of medical therapy, presence of varicocele, and testicular histology. Sperm injections resulted in normal fertilization and embryo cleavage of 64% and 75%, respectively. A total of five transfers with an average of 1.5 embryos resulted in a cumulative clinical pregnancy rate per ICSI cycle of 28.6%, with an implantation rate of 33.3%.CONCLUSIONS:We were successful in integrating the micro-TESE procedures to the in vitro fertilization (IVF) laboratory. Our initial experience with micro-TESE applied to the most difficult cases of azoospermia is reassuring.

Clinical management of infertile men with nonobstructive azoospermia

“… 107 Micro-TESE has been shown to rescue approximately one-third of the cases that had failed in the previous retrieval attempts with conventional TESE or percutaneous testicular aspiration (TESA), and is particularly helpful for men with NOA presenting the worst-case scenarios. 100 107 108 A new micro-TESE after an initially successful procedure can be carried out, but should be delayed for at least 6 months due to inflammatory changes. SR success is markedly lower (25% vs 80%) if repeat micro-TESE is performed within 6 months of the first operation.…”

“…Micro-TESE is, therefore, helpful to increase laboratory process efficiency in addition to minimizing testicular damage and increasing SR success. 38 42 108 …”

Re: Sperm retrieval rates and intracytoplasmic sperm injection outcomes for men with non-obstructive azoospermia and the health of resulting offspring

“…An advanced site of sperm production can be found even in the worst case scenario of SCO. 2 3 Moreover, removal of testicular tissue with the sole purpose of histopathological evaluation could potentially remove foci of sperm production and thus jeopardize the chances of future successful retrieval attempts. 4 Our routine is to take a small testicular biopsy specimen during sperm retrieval for histologic confirmation of NOA.…”