Microdissection testicular sperm extraction (micro-TESE) is
the gold standard surgical technique for non-obstructive azoospermia (NOA)
patients with variable sperm retrieval rates (SRRs) among centers. The
probability of successful sperm retrieval (SSR) is 1.5 times using micro-TESE compared
to conventional TESE. This higher SSR is due to the optical magnifcation of the
testicular parenchyma that helps the identification of dilated and sometimes
opaque tubules, which are presumed to contain mature germ cells. Detection of
the prevalent seminiferous tubule caliber pattern using high optical magnification
has attracted the attention of few authors in the past decade due to it’s
potential ability to explain the outcome of microTESE in NOA subjects. Medhat Amer
et al aimed in this prospective cohort study to fnd a correlation between the
intrasurgical diameter of the seminiferous tubules evaluated at high
magnifcation during micro-TESE and total motile sperms count (TMSC) in NOA
patients either naïve or salvaged cases.
A prospective cohort study was conducted where it included
504 consecutive patients attending Adam International Hospital. All
participants were males complaining of primary infertility diagnosed as NOA. Any
patient who was diagnosed as NOA by bringing at least 2 consecutive semen
analyses or who had proved spermatogenesis impairment from a previous
diagnostic testicular histopathology were included in the current study. Also,
there should be a time interval 6–12 months from the previous TESE.
Five hundred four consecutive NOA patients were included and
underwent micro-TESE. The change in the mean TMSC and different seminiferous
tubular diameters was of high statistical significance (p<0.001). The
highest mean TMSC was reported in the dilated tubules (DTs) group followed by
the other study groups.
Furthermore, 21 naïve cases had dilated tubules (DTs) and 18
(85.7%) of them had shown eventful micro-TESE. Conversely, 186 naïve cases had
slightly dilated tubules (SDTs), and 101 (54.3%) of them had eventful
micro-TESE.
Only 8 (24.25%) cases of the 33 cases had non dilated
tubules (NDTs) and showed eventful micro-TESE. The frequency of intrasurgical
seminiferous tubular diameter and micro-TESE outcome among the naïve cases had
demonstrated a highly statistical signifcance (p<0.001). Interestingly, all
salvaged cases (100%) with DTs and a previous eventful TESE had shown eventful
TESE in the current study. The most dilated intrasurgical seminiferous tubular
diameter is associated with the highest TMSC in NOA patients including SCO
cases.
The current study had demonstrated that 240 cases who were
either naïve or salvage had eventful micro-TESE, and their histopathology was
severe hypospermatogenesis that is defined by detecting an extremely low number
of mature sperm cells to only immotile spermatozoa, detecting sperm cells in
some (even in a single) of the testicular locations together with several hours
of careful processing of the samples by experienced embryologists to retrieve
sperm cells in the extracted testicular material.
It had asserted that intraoperative seminiferous tubular
diameter can ensure sperm retrieval with the highest TMSC especially in salvage
cases. Additionally, SCO cases can be salvaged from repeated micro-TESE by
using seminiferous tubular diameter as a predictive factor for sperm retrieval
and to ensure the highest TMSC. So, patients will be saved from the potential
complications such as temporary decrease in serum testosterone levels following
micro-TESE that may warrant subsequent androgen replacement in 5–10% of these
cases. In addition, hypo-echoic changes as early testicular ultrasound findings
following micro-TESE while focal echogenic lesions of fpbrosis and calcification
as late findings at 6 months can be detected as expected complications.
Admittedly, the target population in the current study is not large that could
be seen as major limitation of the current work.
Micro-TESE is still
the gold standard surgical procedure together with the most dilated
intra-operative seminiferous tubular diameter being essential for obtaining the
highest TMSC in NOA patients including SCO cases.
Source: Medhat Amer et al; Journal of Reproductive
Sciences March 2022
https://doi.org/10.1007/s43032-022-00927-w