Innovations in surgical management of nonobstructive azoospermia

Abstract

Testicular sperm extraction (TESE) technique and intra-cytoplasmic sperm injection are breakthrough fertility treatments for men with nonobstructive azoospermia (NOA). Newer advances such as the microdissection-TESE (micro-TESE) technique have continued to build upon past success by improving sperm retrieval and minimizing the postoperative complications compared to TESE. However, even with micro-TESE, sperm retrieval success has ranged from 40% to 60% due to the technique's dependence on surgeon and embryologist experience. While postoperative complications are minimal relative to the traditional TESE technique, testicular tissue must still be extracted without the knowledge of whether sperm are present in biopsies. In this review, we discuss the innovations in the surgical management of men with NOA and describe the novel experimental approaches that can improve sperm retrieval success.

Keywords: Micro-testicular sperm extraction; nonobstructive azoospermia; testicular sperm extraction; testicular sperm extraction technique.

Figure 1

Microdissection testicular sperm extraction involves wide incision of tunica albuginea to allow extensive visualization of testicular tubules. Permission for reproduction obtained from Elsevier Publishing[4]

Figure 2

Germ cell depleted, sertoli cell-only seminiferous tubule (a) and tubules with spermatogenesis (b). Low-power multiphoton microscopy (A). Reduced from ×4. High-power multiphoton microscopy (B). Reduced from ×25. H and E, reduced from ×25 (C). Permission for reproduction obtained from Elsevier Publishing[7]

Figure 3

Comparative full field optical coherence tomography and H and E-stained histology (a) Testis of a normal rat shows seminiferous tubules with relatively uniform size and shape (b) H and E histology stain of the same specimen. Arrows point to the sperm within the tubule lumen. (c) Seminiferous tubules in the testis of a rat treated with busulfan, showing thinner tubules and a greater degree of heterogeneity in size and shape with ~10% normal spermatogenesis. (d) H and E staining of the same specimen. Field of view in each panel: 1 mm² Permission granted under the creative commons attribution license[11]

Figure 4

(a) Mean processed spectra for sertoli cell-only (red curve) and active spermatogenesis (blue curve) with 1000 and 1690 cm⁻¹ discriminatory Raman peak intensity, respectively. (b) Representative testicular biopsy shows active spermatogenesis. (c) Representative testicular biopsy shows sertoli cell-only. (b and c), H and E, reduced from ×200. Permission for reproduction obtained from Elsevier Publishing[13]