Patients with non-obstructive azoospermia ( NOA) can be very challenging to treat if they are not willing to accept the use of donor sperm. Since there is no test to differentiate between partial testicular failure and complete testicular failure, we need to explore their testes surgically, to see if they have pockets of sperm production. If they do have even a few patchy areas of normal spermatogenesis, we can recover testicular sperm from these tubules, and use them for ICSI.
For patients with obstructive azoospermia, we can pretty much stick a needle anywhere in the testes and recover lots of sperm. However , this is not true in patients with NOA, because even though there is no sperm production in the majority of the tubules, we may still be able to find some sperm ,if we are willing to be patient and to look long and hard.
There are many ways of recovering sperm from the testes, ranging from the simple, noninvasive needle biopsy (testicular sperm aspiration ) , to an open microsurgical testicular sperm extraction, where the surgeon cuts the scrotum, delivers the testes, and then examines the surface of the testes using high magnification with the help of an operating microscope, in a procedure called testicular mapping , in order to look for areas of normal sperm production.
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The truth is that if there is complete testicular failure, we will never be able to find testicular sperm, no matter what method we choose. Since we don’t know in advance whether the testicular failure is partial or complete, doctors basically take two diametrically opposite approaches .
There are some andrologists who are extremely aggressive , and will do an open surgical biopsy under the operating microscope for every man . They claim that this allows them to find sperm more reliably, and that this technique can work even in men where multiple needle biopsies may fail. I find this hard to believe .
The fact of the matter is that a closed needle biopsy allows us to sample testicular tubules from multiple sites just as effectively as an open biopsy can. Cutting open the skin doesn't help us to extract more testicular tubules; and examining the surface of the testes through an operating microscope does not allow us to identify where the normal seminiferous tubules are ( since these may be deep within the testes).
I can understand why andrologists prefer doing open testicular mapping . They can charge much more for using an operating microscope – and some doctors will charge over US $ 5000 for this procedure ! A closed needle biopsy is much quicker and simpler ( and kinder for the patient) , but some andrologists claim that it’s not as good as an open biopsy , because it’s hard for them to charge US $ 5000 for a simple needle biopsy, even though the truth is that it’s as effective in recovering sperm, if these are present !
I think we should remember the first rule in medicine – first, do no harm. It makes sense to prefer minimally invasive procedures, rather than doing extremely aggressive surgery. The doctor should start by first doing closed multiple needle biopsies when doing TESE. If he can recover enough testicular tissue from each of these sites, then there’s really no justification to cutting the scrotal skin and doing an open biopsy, because the chances of finding any sperm by doing an open biopsy in these patients is virtually zero. If the needle biopsy is technically easy ( which is usually the case if the doctor is experienced and the testes is firm), and the embryologist is happy with the amount of testicular tubules the doctors has retrieved, then there’s no point in being more aggressive.
More is not always better , and in fact going ahead and unnecessarily cutting open the scrotum and then the testis can actually cause harm, because this can disrupt the testicular blood flow and cause testicular atrophy. Especially in men with small testis , this kind of aggressive surgery can precipitate testicular failure because of the testicular damage the procedure itself causes .
A closed needle biopsy ( which is not the same as a fine needle aspiration !) is much kinder than an open biopsy ; does much less harm, and is much less expensive . However, in the very small minority of men who have small soft testes, where the tissue is jelly-like, we may not be able to extract enough testicular tissue using a needle. In these men, an open biopsy may allow us to retrieve testicular tubules more efficiently than a needle biopsy. However, this is such a small proportion , that it's hard to justify doing an open TESE for every man with NOA.
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