andrology service - “san paolo” hospital - university of ... · - single biopsy (uni- or...
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Andrology Service - “San Paolo” Hospital - University of Milan
ITALY
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TESE is presently the most used procedure to retrieve spermatozoa in cases of non-obstructive azoospermia
(NOA).
TeFNA allows to recover sperms in 93-100% of Obstructive Azoospermia
patients. However, as reported in the literature, experience has actually shown that the positive sperm retrieval rate by TeFNA in NOA patients is excessively
low.
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TeFNA & NOA
TeFNA gives less chances thanTESE to recover spermatozoa
Positive Sperm Retrieval Rate:mean 34.2%, median 14.2 %, range 7.1-58.5%
Friedler et al., 1997; Ezeh et al., 1998; Tournaye, 1999; Lewin et al., 1999; Westlander et al., 1999
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Extraction of fragment(s) of testicular tissue by:
TEsticular Sperm Extraction (TESE) (Silber et al., 1995)
- Single Biopsy (Uni- or Bi-lateral)(reduced invasivity and risks; usually performed on the better testis).(Friedler et al., 1997;Schlegel et al., 1997 Hauser et al., 1998; Ostad et al., 1998; Ezeh et al., 1998; Colpi et al., 1998)
- Multiple Biopsies (Uni- or Bi-lateral)(higher invasivity and risks: the loss of parenchima in hypogonadic patients may cause transient or irreversibledamage to gonadal trophism and to testosterone levels !)(Gil-Salom et al., 1998; Hauser et al., 1998)
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TESE & NOA
Retrievals Spz +
TESE (single biopsy) 296 121(Positive: 40.8%)(Friedler et al., 1997;Schlegel et al., 1997Hauser et al., 1998; Ostad et al., 1998Ezeh et al., 1998; Colpi et al., 1998)
TESE (multiple biopsies) 154 81 (Positive: 52.6%)(Gil-Salom et al., 1998; Hauser et al., 1998)
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From the need for a higher retrieval rate arises the …..
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Microsurgical TESE (Schlegel et al., 1998)
- Selective Microdissectionof the Tubuli Seminiferi
(Micro-TESE)
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Microsurgical TESE (Schlegel et al., 1998)
•Removal of <10mg tubuli seminiferi (usually those withgreater diameter and those closer to the arteries)•Extraction of a larger number of spermatozoa (mean: 160,000 vs 64,000 by conventional TESE = 720 mg). •Respect of the vascular supply of the testis.•More expensive technique, due to microsurgery.
Sperm retrieval rate : 58-60%(Su and Schlegel, 1999; Schlegel, 2000)
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Microsurgical TESE (Schlegel et al., 1998)
Under general anesthesia, the testicular albugineais equatorially incised under the control of an
operative microscope (8-15x) (to prevent lesions of the subalbugineous vessels).
A microdissection of the testicular tissue is performed at 15-25x, thus obtaining multiple tiny
extractions (<10mg, totally) where the microscopicalcharacteristics of the parenchyma seem to secure
foci of spermatogenesis.
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Equatorial incision along 3/4
of the circumference, in
a relatively avascular portion of the testicular albuginea, and
careful hemostasis with bipolar thermal
cautery
1
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2
Holding the edges of the opened albuginea with tiny hooks, the
testicular lobuli are gently separated, accurately respecting the vessels. The
procedure is deepened towards the testis hylum.
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3Disentangling of the testicular lobuli by
sequential dissection of single
tubuli.
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According to Schlegel, tubuli with foci of spermatogenesis appear larger and opaque.
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During our experience we did not find, except for very few cases, tubuli clearly having different
diameters, perhaps because during the disentangling process they are
stretched and do not show differences in calibre.
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We perform usually thirty micro-extractions, all of them not far from the vessels, all from different
areas. A sort of mapping of the testicular tissue is carried out, with a chance to go deeper and
approach the hylum. This allows to make deep extractions too, unlike
TESE where extractions are made more superficially.
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4Careful haemostasis with bipolar thermal cauteryand albugineorraphy with 3-4 separate approaching stitches (Vicryl 4/0) and continous
suture (Vicryl 6/0)
Closing of the vaginal tunica in and instillation of local anesthetic(Marcainehydrocele)
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1Microextraction tissue must be put inside Petri dishes in HTF medium and minced to obtain
a homogeneous mush where tissue particles are no more visible to the naked eye.
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2Extraction of spermatozoa from seminiferi tubuli
- The suspension so obtained is passed through a24G vascular catheter several times.
Crabbe et al. (1998) suggested to make use of the enzymatic digestion of the testicular tissue withtype IV collagenasis for cases in which themechanical procedure of sperm retrieval does notprove successful.To the present time, however, we have not yet applied thismethod.
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According to Schlegel & Li (1998), the spermatozoaextraction should be performed in an IVF laboratory close to the operating theatre, thus making possible additional retrievals in case offailed sperm finding.
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TESE vs mTESE & NOA
Retrievals Spz +
Microsurgical TESE (58 -TESE (single biopsy)(40.8%)TESE (multiple biopsies) (52.6%)
81 4760 %)
296 121
154 81
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Testicular sperm retrievals in NOA patients : our experience
cases sperm +Single TESE (Uni- or Bi-lateral) 84 42 (50.0%)Multiple TESE (Uni- or Bi-lateral) 21 12 (57.1%)Micro-TESE * 42 17 (40.5%)
Tot. 147 71 (48.3%)
*prevalently performed in patients with worseprognosis according to testis volume and/or high FSH
Colpi, september 2001
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17
25
0
5
10
15
20
25
N° pazienti
Recuperi + Recuperi -
Micro-TESE
R i
No. patients
Positive Retrievals Negative Retrievals
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However, to compare the true effectiveness of the micro-TESE
versus TESE, we studied a group of non selected NOA patients by
performing firstly a conventional TESE, which was immediately
followed by an equatorial incision of the albuginea for a micro-TESE
procedure.
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Testicular sperm retrievals in NOA patients
TESE vs microTESE
Spermatozoa Retrievals•TESE + & microTESE + 9 (40.9%)•TESE - & micro-TESE + 5 (22.7%) •TESE + & micro-TESE - 0 -•TESE - & micro-TESE - 8 (36,4%)
Tot. 22 (100%)
Colpi, september 2001
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9
13
13
9
0
5
10
15
20
25
No.patients
TESE mTESE
TESE vs mTESE in NOA
NegativoPositivo
September 2001
FSH </= N 6 cases FSH >N 10 cases FSH >2N 6 cases
Fisher's Exact Test P = 0.0055
Retr. -
Retr. +
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In conclusion, to perform an ICSI procedure only very few sperms are
required.
At least according to our very preliminary data, in NOA patients microTESE seems able to assure a
higher positive sperm finding compared to conventional TESE,
thus confirming Schlegel’s reports.