Comparison of microdissection testicular sperm extraction conventional testicular sperm extraction and testicular sperm aspiration for nonobstructive azoospermia A systematic review and meta analysis

Capsule:
Sperm retrieval was higher for microdissection compared with conventional testicular sperm extraction, and was also higher for conventional testicular sperm extraction compared with testicular sperm aspiration.

Authors:
Aaron M. Bernie, M.D., M.P.H., Douglas A. Mata, M.D., M.P.H., Ranjith Ramasamy, M.D., Peter N. Schlegel, M.D., F.A.C.S.

Volume 104, Issue 5, Pages 1099-1103

Abstract:

Objective:
To investigate the relative differences in outcomes among microdissection testicular sperm extraction (micro-TESE), conventional testicular sperm extraction (cTESE), and testicular sperm aspiration (TESA) in men with nonobstructive azoospermia.

Design:
Systematic review and meta-analysis.

Setting:
A variety of outpatient academic and private urology clinics.

Patients(s):
Men with nonobstructive azoospermia.

Intervention(s):
Micro-TESE, cTESE, or TESA.

Main Outcome Measure(s):
Sperm retrieval (SR).

Result(s):
Fifteen studies with a total of 1,890 patients were identified. The weighted average age of the patients was 34.4 years, the follicular stimulating hormone level was 20.5 mIU/mL, the T was 373 ng/dL, and the testicular volume was 13.5 mL. In a direct comparison, performance of micro-TESE was 1.5 times more likely (95% confidence interval 1.4–1.6) to result in successful SR as compared with cTESE. Similarly, in a direct comparison, performance of cTESE was 2.0 times more likely (95% confidence interval 1.8–2.2) to result in successful SR as compared with TESA. Because of inconsistent reporting, evaluation of other procedural characteristics and pregnancy outcomes was not possible.

Conclusion(s):
Sperm retrieval was higher for micro-TESE compared with cTESE and for cTESE compared with TESA. Standardization of reported outcomes as well as combining all available SR data would help to further elucidate the SRs of these procedures.

  • Kubilay Vicdan, MD, PhD

    Accumulated data in the literature within the last several years have alluded that
    micro-TESE provides the best SRR in men with NOA. Following similar
    retrospective reports, conventional TESE has been nearly abandoned. In a recent
    systematic review comparing the outcome of microdissection TESE with conventional TESE in non-obstructive azoospermia by Deruyver et al, 2014, including a total of seven studies among 61 articles, it was found that overall SRR was significantly higher in the microTESE group in five of these studies. Overall sperm retrieval ranged from 16.7 to 45% in the conventional TESE vs. 42.9 to 63% in the microTESE group. They stated that pseudo-randomized prospective data show more favorable sperm
    retrieval in NOA for microTESE, especially in histological patterns of patchy
    spermatogenesis such as Sertoli cell only syndrome and the outcome of
    microTESE seems less favourable in patients with uniform histological patterns such as maturation arrest. But their conclusion was that clinical randomized studies
    comparing microTESE with conventional TESE in NOA are still lacking and micro
    TESE may have some theoretical benefits over conventional TESE, but uncertainty
    exists about its superiority.
    In this systematic review and meta-analysis , 15 articles were found comparing SR techniques in men with NOA. It was found that sperm retrievals were higher in micro-TESE compared with cTESE and in cTESE compared with TESA and it was suggested that micro-TESE was 17% better than cTESE in studies which compared the two techniques. But it was interesting to find two different SR rates for cTESE (56% in the studies that compared it with TESA and 35% in those that compared
    it with micro-TESE). As a result, this meta-analysis has reported that the micro-TESE has a better outcome, but also have several limitations and although micro-TESE provided the highest SR in this analysis, it was not necessarily recommended that this be the only method of SR performed in men with NOA.

    I also agree with this conclusion because there are numerous limitations of the available studies to make a clear comment on the success for testicular sperm retrieval techniques. The most important of all is the lack of prospective, randomized
    controlled study comparing the conventional and micro-TESE techniques. The study design of the previous reports does not enable definitive conclusions since patients in the two TESE groups were not matched. According to the literature, there are many different variables suggested for or affecting successful sperm recovery and some of these are; age of the man, FSH and testosterone levels, the number of TESE trials, whether spermatozoa were positive or negative in a previous testicular biopsy or TESE attempt and the detected histopathology in a previous biopsy, underlying etiology of azoospermia, presence and type of previous medical treatments including CC,FSH, HCG, etc., whether spermatozoa were available just before TESE trial, the number and volume of tissue pieces taken in current TESE, duration of procedure, whether TESE was carried out unilaterally or bilaterally, current testicular histopathology (MA, or Sertoli Cell Only Syndrome, or hypospermtogenesis) in the testis which is unknown previously, experience of the embryologist, quality of laboratory, and techniques
    used to process tissue after SR, experience of the surgeon, the techniques used (TESA, c-TESE, m-TESE) and the most importantly the heterogeneity of the testis, etc. Furthermore a lack of standardization of conventional or micro-TESE procedure also makes it difficult to compare all these studies in favour of one of the techniques.

    In my opinion, the most important variables for successful sperm recovery are both the heterogeneity of the testis and the current testicular histopathology. Therefore, the best valuable indicator for the success of SR is still TESE procedure itself, regardless it is performed conventionally or by micro-TESE. Although there may be some advantages of micro-TESE in cases with a histopathology of Sertoli Cell Only Syndrome, it is still not clear that conventional-TESE technique is inferior to micro TESE in relation to sperm recovery in these cases.

  • Thanks for the comments Ed. It is interesting that several studies report similar improvements with micro-TESE compared to conventional biopsy.

  • This article comes from the source and authority of MicroTESE. The more work you put into the testicle in trying to retrieve sperm, the better the results and likelihood of getting sperm. This points out that if you want to give your NOA patients the best chance for conceiving a biological child together, don’t shortchange them by doing just an office aspiration. Leave the MicroTESE to those that do them and do them well.

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