title: Combined trifocal and microsurgical testicular sperm extraction is the best technique for testicular sperm retrieval in "low-chance" nonobstructive azoospermia.
abstract: BACKGROUND
  There is no consensus for the best testicular sperm extraction (TESE) technique in patients with "low-chance" nonobstructive azoospermia (NOA).
  
  
  OBJECTIVE
  To determine sperm retrieval rates in an intraindividual comparison using three locations of the testicle with and without the assistance of a microscope (microsurgical TESE [M-TESE]).
  
  
  METHODS
  A series of 65 patients with low-chance NOA presenting with low testicular volume (<8 ml) and high serum follicle-stimulating hormone (FSH) (>12.4 IU/l) underwent trifocal-TESE plus M-TESE bilaterally (four biopsies per testis).
  
  
  METHODS
  Sperm retrieval was performed as trifocal-TESE (upper, middle, and lower testicular pole) with and without the assistance of a microscope in the middle incision.
  
  
  METHODS
  The number of evaluated tubules, the mean spermatogenetic scores, and the sperm retrieval rates were evaluated to determine retrieval locations and the use of the microscope. The Friedman and Cochrane Q tests were applied to determine statistical differences. Receiver operating characteristic curves were used for the analysis of serum FSH and testicular volume as preoperative prognostic factors.
  
  
  CONCLUSIONS
  The sperm retrieval success of 66.2% using the combined technique, meaning the percentage of patients with at least one tubule containing elongated spermatids, was the highest in the combination of trifocal- and M-TESE (p<0.01), indicating this technique as optimal for patients with low-chance NOA. M-TESE and trifocal-TESE alone were not significantly better. The mean spermatogenetic score giving the number of tubules with elongated spermatids in relation to all tubules was significantly higher in M-TESE versus conventional TESE (p<0.01), indicating the superior quality of the tissue harvested using the microscope. These results are limited by the definition of "success" using "one" spermatid/tubule. Preoperatively, high serum FSH and low testicular volumes did not exclude successful sperm retrieval.
  
  
  CONCLUSIONS
  The combination of trifocal- and M-TESE is the best technique to reach high sperm retrieval rates in patients with low-chance NOA.
authors.affiliation: Department of Urology, Paediatric Urology and Andrology, University of Giessen, Giessen, Germany.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Marconi
authors.forename: Andreas
authors.initials: A
authors.lastname: Keudel
authors.forename: Thorsten
authors.initials: T
authors.lastname: Diemer
authors.forename: Martin
authors.initials: M
authors.lastname: Bergmann
authors.forename: Klaus
authors.initials: K
authors.lastname: Steger
authors.forename: Hans-Christian
authors.initials: HC
authors.lastname: Schuppe
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Weidner
mesh_terms: D000328:Adult; D053713:Azoospermia / Q000601:surgery*; D001706:Biopsy / Q000379:methods; D005640:Follicle Stimulating Hormone / Q000097:blood; D006801:Humans; D008297:Male; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D012372:ROC Curve; D053625:Sperm Retrieval; D013087:Spermatids; D013737:Testis / Q000601:surgery*
chemical_list: D005640:Follicle Stimulating Hormone