Severe Testicular Atrophy does not Affect the Success of Microdissection Testicular Sperm Extraction

Abstract

Introduction and Objectives Men with azoospermia and severe testicular atrophy may be counseled to avoid sperm retrieval due to perceived limited success. We evaluated the outcomes of microdissection testicular sperm extraction (micro-TESE) in men with severe testicular atrophy (volume ≤ 2 mL). Methods We reviewed the records of 1127 men with nonobstructive azoospermia who underwent micro-TESE followed by intracytoplasmic sperm injection. The men were classified into three groups based on average testicular volume (mL), ≤2, >2–10, >10. Sperm retrieval, clinical pregnancy, and live birth rates were calculated. The clinical features evaluated included age, FSH level, history of cryptorchidism, Klinefelter syndrome, varicocele, and testicular histology from diagnostic biopsy. Result(s) Testicular sperm were successfully retrieved in 56% of the men. Sperm retrieval rates (SRR) in men with testicular volumes of ≤ 2, >2–10, and >10 mL was 55%, 56% and 55% respectively. Of those men who had sperm retrieved, clinical pregnancy and live birth rates were similar in the three groups (55.2%, 50.0%, and 47.0%; and 47.2%, 43.0% and 42.2% respectively). Of the 106 men with average testis volume ≤ 2 mL bilaterally, men who had sperm retrieved were younger (31.1 vs. 35.2 years), and were more likely to have a history of Klinefelter syndrome (82.2% vs 55.6%) compared to those in whom sperm was not found (p < 0.05). Men in this group had a higher prevalence of Klinefelter syndrome than men with testis >2 mL (72.6% vs 5.3%, p<0.0001). Men younger than 30 years with Klinefelter syndrome had a higher SRR (81.8%) compared to men older than 30 without Klinefelter syndrome (33%, p<0.01). There was no cut-point for age beyond which sperm could not be retrieved in men with small testes. On multivariable analysis, younger age was the only preoperative factor associated with successful sperm retrieval in men with small testes (<2mL). Conclusion(s) Testicular volume does not affect sperm retrieval rates at our center with micro-TESE. For men with the smallest volume testes, those younger men with Klinefelter syndrome had the highest sperm retrieval rates. Severe testicular atrophy should not be a contraindication for micro-TESE.

Anti-Mullerian hormone-to-testosterone ratio is predictive of positive sperm retrieval in men with idiopathic non-obstructive azoospermia

“…Similarly, regardless of sperm retrieval outcomes at microTESE, all iNOA men considered in our cohort showed reduced testicular volume. Despite testicular hypotrophy has been advocated to be associated with spermatogenic dysfunction 14 , current findings confirmed previous data showing that testis volume per se is not a reliable predictor of sperm retrieval outcomes at surgery 26 . To this must be added that primary hypogonadism in infertile men has been associated with low tT serum levels and high circulating FSH levels 27,28 .…”

Testicular histology may predict the successful sperm retrieval in patients with non-obstructive azoospermia undergoing conventional TESE: a diagnostic accuracy study

“…In order to avoid confounding factors, we excluded patients with hypotestosteronemia, given that studies demonstrated that optimizing testosterone level may improve spermatogenesis [16] and increase SRR [17]. We also excluded patients with Y microdeletions, given that this clinical condition has been found to be an independent predictor factor for SSR [11] Our data are consistent to those of studies evaluating large cohorts of patients demonstrating that serum FSH level and testicular volume are not predictive of SSR when evaluated as the unique independent predictive factor [6,18,19]. The poor relationship between FSH level and spermatogenesis can be explained because FSH secretion and release is controlled by too many endocrine and paracrine factors that ultimately contribute to its serum levels, without ignoring the contribution of the polymorphisms in FSHB genotype and FSHR genotype that may lead to higher than expected FSH levels in some patients [20], so that a linear relationship between FSH serum level and spermatogenesis cannot be expected in all patients.…”

“…The poor relationship between FSH level and spermatogenesis can be explained because FSH secretion and release is controlled by too many endocrine and paracrine factors that ultimately contribute to its serum levels, without ignoring the contribution of the polymorphisms in FSHB genotype and FSHR genotype that may lead to higher than expected FSH levels in some patients [20], so that a linear relationship between FSH serum level and spermatogenesis cannot be expected in all patients. On the other hand, the poor predictive role of testicular volume can be explained by the presence of focal area of intact spermatogenesis that may be found even in patients with testicular atrophy [18,21]. Our data demonstrate that if we would rely on testicular volume to obtain indication for selecting the optimal candidates to surgical sperm retrieval, we would wrongly include and exclude from attempting surgery 32 and 50 % of patients, respectively…”

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

“…(6, 14, 19) In addition, a recent report looking at microTESE for a large series of NOA patients has shown that testis volume has no effect on successful sperm retrieval. (20)…”