Step-by-step loupes-mTESE in non-obstructive azoospermic men, a retrospective study

Optimized Overview of Azoospermia and Testicular Sperm Extraction Techniques

Azoospermia, the complete absence of sperm in the ejaculate, is a primary contributor to male infertility, affecting approximately 1% of all men and 10-15% of infertile men. Among these cases, non-obstructive azoospermia (NOA) accounts for about 70%. NOA arises from a failure in spermatogenesis within the testes, presenting unique challenges in fertility treatment. Recent advances, such as testicular sperm extraction (TESE) techniques, have revolutionized the ability to retrieve viable sperm, offering hope to affected individuals.

Challenges in Treating Non-Obstructive Azoospermia

Men diagnosed with NOA often face complex fertility issues requiring innovative solutions. Conventional methods like fine needle aspiration (FNA) and traditional testicular biopsy often yield low sperm retrieval rates (SRRs). FNA, for example, retrieves sperm in only about 45% of NOA patients. Consequently, the demand for advanced techniques with higher success rates has driven the adoption of microdissection testicular sperm extraction (mTESE), now recognized as the gold standard for NOA patients.

The Emergence of mTESE

First introduced in the late 1990s, mTESE utilizes high-powered surgical microscopes to locate and extract sperm from isolated foci of spermatogenesis within the testes. Unlike random biopsies, mTESE focuses on identifying dilated seminiferous tubules, which are more likely to contain sperm. This targeted approach minimizes testicular tissue damage while achieving a higher SRR of up to 66% in some studies. Despite its efficacy, mTESE requires specialized training, equipment, and prolonged operative times, which may pose logistical and financial barriers for many centers.

Alternative Techniques: Loupe-Assisted TESE

To address these challenges, some institutions have developed alternative techniques using lower magnification tools, such as 6x magnifying loupes. This adaptation offers a cost-effective and accessible solution while achieving comparable SRRs. In a study spanning 14 years, a step-by-step loupe-assisted TESE procedure demonstrated an SRR of 51.8%, with sperm identified in the first testis in 61% of cases. By incorporating deep testicular dissection and real-time specimen assessment, this technique strikes a balance between efficacy and practicality.

Loupe-Assisted TESE: Step-by-Step Procedure

The loupe-assisted TESE technique emphasizes precision and minimizes tissue trauma. Here’s an overview of the procedural steps:

1. Incision and Exposure: A 2-3 cm transverse incision is made on the tunica albuginea. Careful irrigation with saline ensures clear visualization of the operating field, and bipolar electrocautery is used for hemostasis.
2. Superficial Tissue Assessment: Superficial seminiferous tubules are visually examined for signs of dilation. Tubules suspected of containing sperm are isolated and sent to the embryology lab for immediate analysis.
3. Bivalving the Testis: The testis is partially bivalved, allowing access to deeper parenchymal tissue. This technique ensures thorough exploration while sparing vascular structures.
4. Deep Dissection: The upper and lower poles of the testis are systematically dissected. Dilated tubules identified during this step are prioritized for extraction.
5. Real-Time Assessment: Retrieved specimens are immediately processed under high-power microscopy to determine the presence of viable sperm. If sufficient sperm are found, the procedure may conclude, reducing unnecessary dissection.
6. Closure and Recovery: The tunica albuginea and other tissue layers are meticulously sutured to minimize post-operative complications such as hematoma or testicular atrophy.

Factors Influencing Sperm Retrieval Rates

Several factors impact the SRR in patients undergoing TESE procedures:

• Testicular Pathology: Patients with hypospermatogenesis (HS) generally exhibit higher SRRs compared to those with Sertoli-cell-only (SCO) syndrome or maturation arrest (MA).
• Patient Age: Contrary to popular belief, older age does not necessarily reduce SRR in NOA patients. Instead, underlying histological patterns play a more significant role.
• Testicular Volume and Hormonal Levels: Smaller testicular volumes and elevated follicle-stimulating hormone (FSH) levels are not definitive predictors of poor outcomes. Small foci of spermatogenesis may still be present in such cases.

Optimizing Outcomes with Pre-Operative Preparation

Pre-operative optimization can enhance TESE success rates. Patients are often advised to:

1. Cease smoking and adopt healthier lifestyle habits.
2. Stop exogenous testosterone therapy at least six months prior to the procedure.
3. Undergo hormonal treatments, such as Clomiphene citrate or human chorionic gonadotropin (hCG), to boost endogenous testosterone levels.

In cases of palpable varicocele, subinguinal varicocelectomy may be performed six months before TESE to improve spermatogenic conditions.

Learning Curve and Practical Considerations

The success of loupe-assisted TESE hinges on both surgical expertise and effective collaboration with embryology teams. Surgeons must develop the skill to distinguish between dilated and non-dilated tubules, while embryologists play a crucial role in assessing retrieved specimens. In this study, a strong correlation (90%) was achieved between visual assessment and laboratory findings after a rigorous learning phase involving over 100 procedures.

Complications and Post-Operative Care

Post-operative complications are rare with loupe-assisted TESE. The most common issues include mild hematomas and transient scrotal pain. Testosterone levels generally normalize within one year post-surgery. In this study, no cases of testicular atrophy were reported, highlighting the safety of the technique when performed by experienced hands.

Cryptorchidism and Genetic Considerations

Special attention is required for NOA patients with a history of cryptorchidism or genetic abnormalities such as AZF microdeletions and Klinefelter syndrome. In cryptorchid patients, early orchidopexy significantly improves SRRs, emphasizing the importance of timely intervention. For men with AZFc microdeletions, SRRs are typically around 55%, but hormonal optimization and early biopsy are critical to success.

Conclusion

Azoospermia, particularly NOA, remains a formidable challenge in male infertility. However, advances in TESE techniques, including the use of magnifying loupes, have transformed the landscape of fertility treatment. Loupe-assisted TESE offers a practical and effective alternative to mTESE, especially in resource-limited settings. By combining meticulous surgical techniques with real-time specimen assessment and pre-operative optimization, this approach maximizes the chances of successful sperm retrieval while minimizing risks.

As research continues, the development of predictive markers and enhanced protocols will further refine azoospermia treatment, offering renewed hope to countless couples worldwide.

Referance: https://pmc.ncbi.nlm.nih.gov/articles/PMC6628476/pdf/12610_2019_Article_91.pdf