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
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