Prof. Dr. Ates Kadıoglu

Submitted by bahadır on Wed, 03/23/2022 - 12:21
Azospermi, Microtese

Azoospermia is a condition in which there are no sperm in the ejaculate (semen). About 1% all of men, 10-15% of those who apply for infertility do not have sperm in the semen analysis. There are two main types of azoospermia:

  • Poor or no sperm production (nonobstructive azoospermia). (60%)
  • There is normal sperm production but no sperm in the ejaculate due to obstruction in the reproductive tract (obstructive azoospermia). (40%)

Causes of obstructive azoospermia:

  • Infection
  • Trauma
  • Cystic fibrosis gene mutation
  • Vasectomy
  • Previous surgeries in the pelvic area.

Causes of nonobstructive azoospermia:

  • Genetic causes
    • Kallmann syndrome
    • Klinefelter’s syndrome
    • Y chromosome deletion
  • Hormone imbalances (hypogonadotropic hypogonadism)
  • Radiation and toxins
  • Medications
  • Cryptorchidism
  • Testicular cancer

It is important to distinguish between obstructive azoospermia and non-obstructive azoospermia in patients with azoospermia. Patients' medical history, physical examination, 2 semen analyzes and hormone profile (FSH, Testosterone) should be evaluated. With these findings, the type of azoospermia can be determined in 90% of the patients. While most of the patients with obstructive azoospermia have correctable pathologies, pregnancy in cases with non-obstructive azoospermia is only possible with assisted reproductive methods. For patients whose sperm production is insufficient in the testicles and therefore there is no sperm in the semen analysis  (non-obstructive azoospermia), the method of obtaining sperm from the testis by surgery (TESE) should be tried.

TESE, which is the most important development in infertility treatment, is a method of searching sperm from testicular tissue by open surgery. With this method, small foci of sperm production in the testicles were shown and sperm in these foci were obtained, and it was shown that it was possible to have children by trying the in vitro fertilization or intra-cytoplasmic sperm injection (ICSI) methods with the sperm obtained (Palermo-1992). While TESE was previously performed with the method of taking more pieces from the testis, later with the microdissection (micro-TESE) method using a microscope, less samples were taken and higher success was achieved (Schlegel-1999).

Micro-TESE is a surgical intervention. It can be done with general, spinal or spermatic cord and local anesthesia of the skin. Both testicles can be reached with a small incision made in the midline of the scrotum. Samples are taken from one testicle or both. Under the operating microscope, under 15-25x magnification, sufficient samples are taken from especially full, opaque and large tissues that have a high probability of finding sperm in the testis. The operation is terminated after sperm is found or when it is concluded that sufficient sampling is done. In vitro fertilization can be tried with the sperm obtained in this process, or the sperm can be frozen and used in the future.

While the probability of finding sperm is 35% with the method of taking many pieces of testicular tissue with the naked eye, called conventional TESE, the success of finding sperm under the microscope with micro-TESE has increased to 55%. In cases where sperm is obtained from the testis, the pregnancy rate is around 30-40%.

Micro-TESE is a reproducible method. If sperm are found in the first micro-TESE, sperm retrieval rates are also high in recurrent micro-TESEs. When it is planned to repeat TESE, 6 months should be waited. After unsuccessful macro TESE, if the second micro-TESE is performed, sperm can be detected at a rate of 25-44%. If micro-TESE is performed for the second time after unsuccessful micro-TESE, sperm retrieval rates are quite low (6-10%).

Micro-TESE and genetics:

Anomaly rate increases in genetic tests (karyotype and Y chromosome microdeletion) in azoospermia patients. Therefore, these genetic tests should be performed before using assisted reproductive techniques (in vitro fertilization/vaccination). On the short arm of the Y chromosome, there are 3 regions called AZFa, AZFb and AZFc related to sperm production. Anomaly in any of these regions affects sperm production to varying degrees. In patients without sperm production, AZFa anomaly is seen the least with 5%, while AZFc is seen most frequently with 65-70%.

In the anomaly in the AZFc region, sperm can be found in the semen (38%). In addition, 50-75% of sperm can be obtained after micro-TESE in patients with anomaly in the AZFc region. In complete deficiency in the AZFa and AZFb regions, sperm cannot be found both in the semen and with the TESE procedure. No phenotypic (appearance) anomalies have been reported except for abnormal sperm production in men with Y chromosome microdeletion. Boys with a mutation in the AZF region are also likely to have this mutation more commonly in boys who will be in vitro fertilization. Therefore, genetic examination is recommended for boys from these patients. However, since the AZF region is carried on the Y chromosome, there is no risk factor for girls.

Klinefelter syndrome is diagnosed in 3% of infertile patients and approximately 11% of patients who do not have sperm in their semen. It is usually characterized by severe sperm deficiency or no sperm found in semen analysis. In these patients, the genetics is generally 47 XXY and with the micro-TESE procedure, sperm can be obtained in the testis at a rate of 55%. In addition, it has been shown that if testosterone levels are increased before micro-TESE in Klinefelter patients with low testosterone levels, the rate of sperm finding in the testis can reach up to 77%.

The most important advantage of micro-TESE sperm retrieval method compared to other sperm retrieval methods is that the sperm retrieval rate and the amount of sperm obtained increase due to the use of a microscope during the surgery. At the same time, even minimal bleeding during the surgery can be noticed and intervened with the microscope. Thus, blood accumulations called hematomas are prevented after the surgery. In addition, fewer parts are taken during the procedure, so that the hormone production of the testicles is affected as little as possible.

It was previously known that there are many factors that affect the success rate of the micro-TESE procedure. In particular, studies have shown that the patient's hormone (FSH, inhibin b) level and testicular volume are not a predictor of sperm retrieval rate. The most important parameters affecting the success of the procedure are the status of the patient's genetic tests and the pathology result of the testicular tissue taken. Especially in some genetic disorders (AZFa,b), sperm retrieval rate decreases. In addition, a learning curve is required for a high sperm retrieval rate. After 50 patients, there was a significant increase in sperm retrieval rate.

Another important factor in the success of Micro-TESE is the experience of the embryology laboratory, which searches for sperm in testicular tissue.

The patient is discharged on the same day.

As a result of the detailed laboratory examination, it is reported on the same day (2-3 hours) whether sperm is found at the end of the surgery.

The stitches do not need to be removed as they will dissolve on their own.

It is recommended that the patient wears suspension panties for a week.

Physical activity and heavy lifting are not allowed for two weeks.

After a week, sexual intercourse is allowed.