I-3: New Advances in Surgical Sperm Retrievals for ICSI in NOA Patients

Background: Nonobstructive azoospermia (NOA) is due to different forms of spermatogenic failure and affects the majority of azoospermic patients. In many NOA cases spermatogenesis was shown to be focal with a “patchy distribution”. Different surgical sperm retrieval techniques have been developed to obtain gametes from the testicles of azoospermic men seeking fertility treatment. Nowadays, testicular sperm extraction (TESE) and microsurgical testicular sperm extraction (MicroTESE) are the most widely used. TESE is a standard open surgical biopsy: single or multiple specimens can be extracted from the same incision, or from different incisions (Multiple-TESE). In MicroTESE sperm extraction is done with the assistance of an operating microscope: testicular parenchyma is widely exposed and magnification can enable the search of seminiferous tubules that exhibit larger diameters (which are more likely to contain germ cells and eventually normal sperm production) in comparison to non-enlarged ones. A comprehensive review of the literature on this topic shows: a. overall Sperm Retrieval Rate (SRR) is reported to be significantly higher using Micro-TESE in comparison with conventional TESE, ranging from 16.7 to 45% in the TESE vs. 42.9 to 63% with the MicroTESE; b. MicroTESE is reported to be the better technique in men with Sertoli cell only syndrome (SSR variable from 22.5 to 41% vs 6.3 to 29% in TESE group), and hypospermatogenesis (SSR variable from 81 to 100% vs 50 to 84%in TESE group); c. in case of a failed conventional TESE, a salvage Micro-TESE can offers a positive SRR of 45%. The aim of our study was to define which is the more efficient sperm retrieval technique in NOA. Materials and Methods: Patients: 558 infertile patients with NOA, aged 18-63 years (mean 36.8 Y), with normal testosterone level, normal karyotype and no Y-chromosome microdeletions were assigned to either TESE (N=356) or MicroTESE (N=202) on the basis of their clinical picture Results: Testicular volume was comparable among groups, while FSH serum level was significantly higher in patients of MicroTESE group compared to TESE group (22.4 + 12.3 vs 19.64 + 14.8, p=0.025). Histology revealed that Sertoli cell only syndrome (SCO) was a more frequent finding in MicroTESE patients (79.2% vs 60.6%, p=0.00007), while hypospermatogenesis (HYPO) was a more common feature of TESE patients (23.87% vs 12.3%, p=0.01). SRR was comparable in both groups of patients (44.4% in TESE group and 39.6% in MicroTESE group, p=0.27), regardless of the histology findings. Binary logistic regression showed, however, that MicroTESE provided significantly higher SRR compared to TESE in a subgroup of patients with FSH level > 12 mIU/ml, testicular volume < 7.1 ml and histology different from HYPO. Conclusion: When looking at patients clinical characteristics, MicroTESE could provide better results in patients with higher FSH level and lower testicular volume.