I Get We Want to Lower Costs, But I Think What’s Most Important Is to Do the Best For Our Patients

I Understand We Want to Lower Costs, But I Think What’s Most Important Is to Do the Best For Our Patients: Maximize Chances of Success While Minimizing Complications and The Number of Procedures .  A Critique of a Recent Article by Patel, Park, Reddy, fisher Mirabal and Lipshultz in the March 2023 Journal: Urology.  

An article entitled: “Testicular Core Extraction: Important Technique for Determining Sperm Retrieval Method in Non-obstructive Azoospermia” reports on the value of pre-surgical sperm retrieval performance of a “Testicular Core Extraction” (TCE).    The report advocates for this approach.  I do not.

Surgical sperm retrieval is an operation performed in the setting of, most commonly, azoospermia  (no sperm in the ejaculate) and less commonly anejaculation (the inability or a man to produce an ejaculation), within the rubric of a couple experiencing infertility.   Surgically retrieved sperm can be used in an In Vitro Fertilization (IVF) setting to initiate a pregnancy.   

Azoospermia can be considered in most cases to be either “obstructive”  or “non-obstructive”.     In obstructive azoospermia (OA)  sperm production is normal but sperm release into the ejaculate is blocked;  the two most common examples of this are vasectomy and congenital absence of the vas deferens.     In non-obstructive azoospermia (NOA)  sperm production is either absent altogether or diminished to the point that sperm cannot escape the testis into the ejaculate.  The actual technique of surgical sperm retrieval in cases of NOA is most commonly approached with a “Micro-dissection”  (MTESE) technique in which the testis is micro-surgically explored lobule by lobule for the presence of sperm production.

Drs Patel et al advocate for an office base TCE under local as a pre-procedure before moving on to either CTESE  (open testis biopsy with 2cm incision, performed in the office under local anesthesia) vs. MTESE in an OR.   The results were reported to show that of 82 NOA patients, 51 TCE procedures were positive for sperm.    The rate of finding sperm in subsequent office based TESE (Not micro) was then 97%.  MTESE success for the remaining patients was 75%.

Why I don’t like this:

• Patient population: Testis volume reported ranged from 10-20 ml.   NOA patients most commonly have testis volume less than 10 ml. Therefore, the population of patients in this study was biased to favor positive results.
• Would the quality of sperm have been better if an MTESE approach was used?  A small CTESE window into the testis only allows one to access a small portion of the testis.  Might better quality sperm have been retrieved using more of an exploration?   IVF outcomes were not reported in this study.
• Freezing additional sperm for future cycles: Small window techniques often yield less tissue and less freeze-ability of tissue for additional cycles.  I had one patient with absence of the vas who asked me to do an office based procedure for his sperm retrieval.   Each time we did his procedure he swore it would be his last procedure.   But insufficient sperm were retrieved to be frozen for additional future use so we did his last procedure five times!  If we had done one operating room procedure we could have retrieved enough tissue for multiple cycles.
• Percutaneous procedures into the testis have complications: Risks include hematoma of the spermatic cord,  scrotal hematoma and infection. 
• 2 procedures instead of one: For patients who want an office procedure due to cost, why not simply use testicular size and Serum FSH as a guide to predicting sperm presence and then do that procedure?  Data from this study appear to show that the overwhelming majority patients with normal testis size and FSH had sperm found on TCE.   In cases of failure, MTESE can be pursued.  That approach would have removed the majority of unnecessary TCE’s in this study. 
• The point is moot: Finally, most offices are not equipped with electrocautery which I would assume is necessary to perform an open office based procedure with a 2 cm incision as these authors describe. 

IVF cycles in my area now routinely cost more than $20,000.00.    In my opinion, most azoospermic patients should be treated with the technique which offers the best chance of success and the best yield for sperm which also minimizes the need for additional procedures as well as the chance of complications.   For most patients that is MTESE.

Author

Eric K. Seaman MD Dr. Seaman is a urologist specializing in the field of Male Reproductive Medicine and Surgery. Dr. Seaman Completed his Male Infertility Fellowship under the direction of Larry I. Lipshultz MD at Baylor College of Medicine Houston in 1996. Since that time he has focused his practice on the sub-subspecialty focus area of Male fertility and infertility.