Microdissection testicular sperm extraction in men with Sertoli cell only testicular histology

Capsule:
Diagnostic testis biopsy in nonobstructive azoospermia has little value, even when uniform Sertoli cell–only pattern is seen. When both testis volume and follicle-stimulating hormone are considered, sperm retrieval rates are 7%–45%.

Authors:
Boback M. Berookhim, M.D., M.B.A., Gianpiero D Palermo, M.D., Ph.D., Nikica Zaninovic, Ph.D., Zev Rosenwaks, M.D., Peter N. Schlegel, M.D.

Volume 102, Issue 5, Pages 1282-1286

Abstract:

Objective:
To study the outcomes of microdissection testicular sperm extraction (microTESE) among men with pure Sertoli cell–only histology on diagnostic testicular biopsy.

Design:
Retrospective cohort study.

Setting:
Tertiary referral center.

Patient(s):
Six hundred forty patients with pure Sertoli cell–only histology on testicular biopsy who underwent microTESE by a single surgeon.

Intervention(s):
MicroTESE.

Main Outcome Measure(s):
Sperm retrieval rates.

Result(s):
Overall, 44.5% of patients with Sertoli cell only had sperm retrieved with microTESE. No difference was noted in sperm retrieval rates based on testis volume (≥15 mL vs. <15 mL, 35.3% vs. 46.1%, respectively). Patients with ≥15 mL testicular volume and FSH 10–15 mU/mL had the worst prognosis, with a sperm retrieval rate of 6.7%. Conclusion(s):
Patients with previous testicular biopsy demonstrating Sertoli cell–only histology can be counseled that they have a reasonable likelihood of sperm retrieval with the contemporary delivery of microTESE. Given this finding, the utility of testicular biopsy before microTESE is further questioned.

  • Peter Schlegel

    The results (differences) are significant, but there is no subset of patients with zero chance of success. In addition, the measurement of testicular volume can vary somewhat from examiner to examiner, with most experts believing that ultrasound provides the most reliable measure of testicular volume

  • Helen

    Dr Schlegel, this study is interesting. In regards to the subset of men with FSH between 10 and 15 and normal size testicles having a particularly poor prognosis: do we know that the results are significant? Seems to be a low number of men in the group who fit this category.

    I’m asking because my husband fits in this box. FSH is 12, unilateral biopsy showed sertoli cell only and testicles seem to be normal size. We’ve yet to attempt micro-tese.

  • Peter Schlegel

    We have recently presented data on the results of sperm retrieval for men who had a most advanced pattern of maturation arrest on biopsy (ASRM, 2014.) Those results indicated that men with later maturation arrest had a better sperm retrieval rate. The current publication refers to men with Sertoli cell-only (i.e., 100% of biopsied sample had no germ cells). Of course, other foci of the testis may have germ cells or full spermatogenesis even when a diagnostic biopsy shows Sertoli-only.

  • ranjithrama

    “Men with an FSH level of 10–15 mU/mL and normal-volume testes had a uniquely poor prognosis, with an SRR of only 6.7%”. This is an important subset of patients that are often counseled with much higher chances of successful sperm retrieval due to “normal” findings. It would be interesting to know whether these men had early vs. late maturation arrest on histology.

  • Peter Schlegel

    We have been interested in the opportunities that new imaging techniques can provide to identify and isolate regions of sperm production within the dysfunctional testes of men with non-obstructive azoospermia. We have applied techniques of OCT (optical coherence tomorgraphy), power Doppler, Raman spectroscopy, and multiphoton microscopy (MPM), among others. We have published results with the two latter techniques that are promising. OCT provides good analysis of the size of tubules, but penetrates little more than what is exposed during surgery (depth of penetration for images ~ 500 microns.) MPM appears to have the greatest promise, as it can identify sperm, but it is also limited by penetration into tissue (as well as transportability into the OR. We continue to seek optimized ways to identify sites of sperm production. It is interesting that microsurgical identification of functional tubules remains so effective throughout our experience.

  • Very large single surgeon review (N = 640 patients) of the Cornell experience with microTESE in Sertoli cell only infertile men. Sperm retrieval was 44.5% in the hands of one of the most experienced surgeons performing this procedure. It is reassuring that men with this diagnosis can reasonably expect that sperm can be found if they undergo this procedure. However, the couple must be counseled that the success rates may not reflect the published value in less experienced hands. Important negative prognostic factors found in this population: FSH between 10-15 and testicular volume >15 mL.

    Would be interesting to see if utilizing full field optical coherence tomography can improve the retrieval rates.

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