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Editorial
. 2022 May-Jun;48(3):569-578.
doi: 10.1590/S1677-5538.IBJU.2022.99.14.

Microdissection TESE versus conventional TESE for men with nonobstructive azoospermia undergoing sperm retrieval

Sandro C Esteves  1   2   3
Affiliations
Editorial

Microdissection TESE versus conventional TESE for men with nonobstructive azoospermia undergoing sperm retrieval

Sandro C Esteves. Int Braz J Urol. 2022 May-Jun.
No abstract available

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Conflict of interest statement

None declared.

Figures

Figure 1
Figure 1. Step-by-step approach for the clinical management of men with nonobstructive azoospermia seeking fertility.
Figure 2
Figure 2. Microdissection Testicular Sperm Extraction Visual Map. The patient is brought shaved to the operating room, placed supine, prepped, and draped accordingly. Microdissection TESE is usually performed outpatient, under intravenously combined with local anesthesia (1). A transversal scrotal incision is fashioned (2), and the hemiscrotum is entered. The tunica vaginalis is opened, and the testis is delivered (3). An equatorial non-linear incision is fashioned in the tunica albuginea using a knife under operating microscopy at 6 to 8 times magnification (4). Microdissection is carried out through all areas of the superior and inferior poles of the testis. Magnification of 16 to 25-times is used when searching for the largest seminiferous tubules (5). Enlarged seminiferous tubules are identified (6 and 7), removed with micro-forceps, placed in a petri dish containing sperm culture medium (8), and sent to the IVF laboratory for examination (8). One or more specimens are taken for a histopathology examination. In general, the largest the tubule diameter, the greater the chance of finding active spermatogenesis (5). The extracted tubules are squeezed mechanically, and the cell suspension is examined under the inverted microscope in search of sperm (9). The surgeon is informed promptly if any sperm are found. Additional specimens can be taken to secure enough sperm for ICSI and freezing. The albuginea and vaginalis are closed, and the testicle is placed back to the hemiscrotum. Lastly, the dartos and skin layers are closed with absorbable sutures. The patient is discharged a few hours later.
Figure 3
Figure 3. Testicular sperm cryopreservation using Cell-sleepers. The Cell Sleeper (Nipro, Japan) consists of an outer vial, an inner tray, and a screw cap (A). The inner tray is placed onto the lid of a large culture dish, and a 2-μ L droplet of cryopreservation solution is pipetted into the tray, in a central position (B). Spermatozoa are aspirated and ejected into the droplet with the aid of a microinjection pipette (C). Immediately after that, the tray is returned to the vial, and the vial is closed with the screw cap. The vial is placed in a horizontal position 4-5 cm above the surface of liquid nitrogen (D). After 2 min, the vial is submerged in liquid nitrogen and secured into a cryopreservation cane for long-term storage (E).
Figure 4
Figure 4. Blastocyst euploidy probability per metaphase II oocyte. The plots show the probability of a metaphase II (MII) oocyte turning into a euploid blastocyst as a function of female age. The estimated probabilities (solid curves) and their 95% confidence interval (dotted curves) are presented according to sperm source to be used for IVF/ICSI, namely, ejaculated sperm (blue) and testicular sperm extracted from patients with non-obstructive azoospermia (NOA) (red). The relations are non-linear and characterized by a differential modulatory effect of sperm source across age. The effect size of female age on blastocyst euploidy probability per MII oocyte from the year (t) to year (t+1) was defined as the ratio p(t+1)/p(t) × 100. There was a significant decrease (p<0.001) in the probability of an MII oocyte becoming a euploid blastocyst with aging.
Figure 5
Figure 5. ART Calculator. Online calculator to estimate the minimum number of metaphase II oocytes required to obtain at least one euploid blastocyst for transfer in infertile patients undergoing IVF/ICSI cycles. The figure shows how the calculator is used in an office-based setting. (A) Pretreatment, clinicians input the patient's age and the sperm source for IVF/ICSI. If the option “Testicle” is marked, then the type of azoospermia (obstructive or nonobstructive) should also be defined. The user sets the probability of success for the estimation, which indicates the chance of having ≥1 euploid blastocyst when the predicted number of mature oocytes is achieved. Once the button “calculate” is pressed, a text box will pop up on the right side of the screen, indicating the predicted minimum number of metaphase II oocytes needed for obtaining at least one euploid blastocyst, with its 95% confidence interval. (B) Posttreatment, i.e., when fewer than the predicted number of metaphase II oocytes are obtained after one or more oocyte retrieval cycles. Clinicians input the pretreatment information and the actual number of metaphase II oocytes collected or accumulated. The user sets the probability of success; it reflects the chance of correct estimation according to the exact number of oocytes obtained. Once the button “calculate” is pressed, a text box will pop up on the right side of the screen, indicating the predicted probability of achieving ≥1 euploid blastocyst with the number of mature oocytes available. The ART calculator can be found online at http://www.members.groupposeidon.com/Calculator/.
See this image and copyright information in PMC

References

    1. Esteves SC, Miyaoka R, Agarwal A. Sperm retrieval techniques for assisted reproduction. Int Braz J Urol. 2011;37:570-83. - PubMed
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    1. Esteves SC. Clinical management of infertile men with nonobstructive azoospermia. Asian J Androl. 2015;17:459-70. - PMC - PubMed
    1. Esteves SC, Roque M, Bedoschi G, Haahr T, Humaidan P. Intracytoplasmic sperm injection for male infertility and consequences for offspring. Nat Rev Urol. 2018;15:535-62. - PubMed
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