Study on the effectiveness of sperm retrieval and relationship between a number of factors and sperm retrieval ability of microdissection testicular spem extraction technique on non

Journal of military pharmaco-medicine no9-2019

STUDY ON THE EFFECTIVENESS OF SPERM RETRIEVAL AND
RELATIONSHIP BETWEEN A NUMBER OF FACTORS AND
SPERM RETRIEVAL ABILITY OF MICRODISSECTION
TESTICULAR SPEM EXTRACTION TECHNIQUE ON
NON-OBSTRUCTIVE AZOOSPERMIA PATIENTS
Vu Thi Thu Trang1; Quach Thi Yen2; Nguyen Dinh Tao3; Trinh The Son3
SUMMARY
Objectives: Microdissection testicular spem extraction is currently the optimal sperm retrieval
method for non-obstructive azoospermia patients. Research and development of this technique
will help clinicians have more tools to collect sperm effectively for non-obstructive azoospermia
patients, enabling these patients to have children of their own. Subjects and methods: 100
patients with non-obstructive azoospermia who underwent micro TESE from August 2016 to
October 2018 at Military Institute of Clinical Embryology and Histology, Vietnam Military Medical
University. Results: The average age of patients was 32.21 ± 4.55; the average duration of
infertility was 4.77 ± 3.37 years; 93% of patients were primary infertility; testicular volume 6.57 ±
2.77 mL; the average concentration of FSH, LH, and testosterone were 20.30 ± 12.63 mIU/mL,
10.83 ± 6.26 mIU/mL amd 4.24 ± 2.40 ng/mL, respectively. 19 patients (19%) had gene
abnormalities in AZF region; Sertoli cell-only syndrome accounted for the highest proportion in
the histopathological subgroup (50%); the rate of sperm collection was 37%. Surgical testicular
volume, endocrine concentration, AZF gene abnormalities and histopathological lesions related
to sperm collection possibility. There was no short complications after surgery. Conclusions:
Microdissection testicular spem extraction was a safe sperm retrieval method with a sperm
retrieval rate of 37%. Surgical testicular volume, endocrine concentration, AZF gene
abnormalities and histopathological lesions related to sperm retrieval capacity.
* Keywords: Non-obstructive azoospermia; Sperm retrieval; Micro-dissection testicular
sperm extraction.

INTRODUCTION
The appearence of intra cytoplasmic

sperm injection (ICSI) method in 1992 and
the success of the ICSI case with sperm
obtained from the epididymis aspiration of
azoospermia patients of Tournaye in 1994

has opened a revolution in the treatment
of male infertility especially with the
azoospermia case. Since then, there have
been many different methods of retrieving
sperm, each method has its own
advantages and disadvantages,but for
non-obstructive azoospermia patients,

1. Hung Yen Obstetrics and Pediatric Hospital
2. Vietnam University of Traditional Medicine
3. Vietnam Military Medical University
Corresponding author: Vu Thi Thu Trang ()
Date received: 15/10/2019
Date accepted: 06/12/2019

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Journal of military pharmaco-medicine no9-2019
micro-dissection testicular sperm extraction
(micro TESE) is the best method for
sperm retrieval. As the first to implement
this technique, Schlege N.P (1999) showed
that the ability to collect sperm was from
42 to 63% [2]. This method reduces

damages, reduces the effect of testicular
function by micro-surgical microscopy that
helps to see the sperm ducts and avoid
blood vessels. This is a new technique
applied in Vietnam, so the objectives of
the topic were: Determine the sperm
retrieval ability and explore some factors
related to the sperm retrieval ability of
micro TESE method in non-obstructive
azoospermia patients.
SUBJECTS AND METHODS
1. Subjects.
100 patients with non-obstructive
azoospermia were conducted micro TESE
at Military Institute of Clinical Embryology
and Histology, Vietnam Military Medical
University from August 2016 to October
2018.
* Selection criteria: Patients without
sperm in the semen according to WHO
(2010) [3], not retrograde ejaculation;
underwent percutaneuos epididymal sperm
aspiration (PESA) or microsurgical epidymal
sperm aspiration (MESA - Microsurgical
Epidymal Sperm Aspiration) to eliminate
the obstructive azoospermia cases.
* Exclusion criteria: Cases of secondary
hypogonadism; cases of acute diseases,
social diseases, endocrine diseases,
taking drugs and chemicals affecting

sperm production.

2. Method
Prospective, cohort study.
RESULTS
1. Some characteristics of research
subjects.
* Age, infertility type, infertility period of
the study subjects:
- The average age of the patient was
32.21 ± 4.55. The highest was 47 years
old, the lowest was 21 years old. Most in
age group of > 30 - 40 years old (57%).
- Primary infertility accounted for 93%.
Only 7% were secondary infertility.
- The average infertility period was
4.77 ± 3.37 years. Patients with the
longest infertility period were 19 years
and the shortest were 1 year. Infertility
group from 2 - < 5 years was seen the
most (52%), followed by group 5 - < 10
years (31%), the lowest was infertility
group under 2 years (7%).
* The surgical testicular volume:
The average surgical testicular volume
was 6.57 ± 2.77 mL. The biggest
testicular volume undergoing surgery was
16 mL, the smallest was 2 mL. There
were 59% testicles with volume from 5 < 10 mL; group with volume < 5 mL
accounted for 27%; the lowest was the

group with volume over 15 mL (1%).
* Concentrations of some hormones of
study patients:
The average concentration of FSH, LH
and testosterone of the study subjects
were 20.30 ± 12.63 mIU/mL, 10.83 ±
6.26 mIU/mL and 4.24 ± 2.40 ng/mL.
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Journal of military pharmaco-medicine no9-2019
* Results of AZF genetic testing:
Table 1:
Results of AZF genetic testing
Normal AZF genes
Types of AZF gene
abnormalities
Abnormal AZF genes

n

%

81

81

19

19

100

100

The amount and
proportion/abnormality AZF gene

AZFa abnormality

1 (5,3)

AZFb abnormality

3 (15,8)

AZFc abnormality

7 (36,8)

Associated lesions

8 (42,1)

Total

19% of patients had AZF gene damage. Associated lesions were the most common
(42.1%), followed by AZFc gene abnormality (36.8%), the lowest was AZFa gene
abnormality (5.3%).
2. Results of retrieving sperm by micro TESE method in study patients.

* Percentage of patients retrieving sperm:
Of the 100 patients participating in the study, 37 patients (37%) obtained sperm and
63 patients (63%) did not obtaine sperm.
Table 2: Percentage of patients with AZF gene abnormality obtained sperm.
Obtaining sperm
(n = 7)

Not obtaining sperm
(n = 12)

(n; %)

(n; %)

AZFa abnormality

0 (0)

1 (1)

AZFb abnormality

2 (66,7)

1 (33,3)

AZFc abnormality

5 (71,4)

2 (28,6)

Associated lesions

0 (0)

8 (100)

Abnormal AZF genes
(n = 19)

Among19 cases with abnormal AZF genes, abnormality in AZFc gene had the
highest sperm retrieval rate (71.4%). The group with abnormality in AZF genes and
associated lesions were unable to find sperm.
3. Relationship of some factors with the ability to collecting sperm from
micro TESE.
* Relationship between age, type of infertility, time/period of infertility, and ability of
retrieving sperm:
The test results did not find the relationship between age, type of infertility, time of
infertility and the ability of retrieving sperm of the micro TESE method in the study
patient (p > 0.05).
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Journal of military pharmaco-medicine no9-2019
* Relationship between surgical testicular volume and the ability to retrieve sperm:
Table 3:
Obtaining sperm
(n = 37)

Not obtaining sperm
(n = 63)

(n; %)

(n; %)

≥7

21 (48.8)

22 (51.2)

<7

16 (28.1)

41 (71.9)

Surgical testicular volume
(mL)

p
OR (95%CI)
0.033
2.45 (1.06 - 5.62)

(*: χ2 test)
There was a relationship between testicular volume of ≥ 7 mL with surgery to see
sperm. Subjects with testicular volume of ≥ 7 mL were more likely to find sperm

2.45 times higher than those with a testicular volume of less than 7 mL (p < 0.05).
* Relationship between several tests and the ability to obtain sperm:
Table 4: Relationship between FSH, LH, and testosterone concentrations and sperm
retrieval ability.
Obtaining sperm
(n = 37)

Not obtaining sperm
(n = 63)

(n; %)

(n; %)

FSH normal (2 - 10 mIU/mL)

13 (59.1)

9 (40.9)

FSH outside the normal value

24 (30.8)

54 (69.2)

0.015*
3.25 (1.22 - 8.63)

LH normal (1.5 - 20)

36 (40.0)

54 (60.0)

0.086**

LH outside the normal value

1 (10.0)

9 (90.0)

χ2 = 3.48

Testosterone normal (2.2 - 8.0 ng/mL)

35 (43.8)

45 (56.2)

0.005**

Testosterone outside the normal value

2 (10.0)

18 (90.0)

χ2 = 7.82

Hormone level

p
OR (95%CI)

(*: χ2 test; **: Fisher’s exact test)
There was a relationship between FSH concentration in the normal range and
testosterone level in the normal range with the surgery to see sperm (p < 0.05). We did
not find the relationship between normal LH concentration and the surgery to see
sperm (p > 0.05).
Table 5: Relationship between histopathological results and sperm retrieval ability.
Obtaining sperm

Not obtaining sperm

(n; %)

(n; %)

1 (9.1)

10 (90.9)

Sertoli-cell-only syndrome

12 (24.0)

38 (76.0)

Maturation arrest

5 (41.7)

7 (58.3)

Hypospermatogenesis

19 (70.4)

8 (29.6)

Histopathological results
Seminiferous tubule hyalinization

p

< 0.001**

χ2 = 20.31

(**: Fisher’s exact test)
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Journal of military pharmaco-medicine no9-2019
The group with impaired spermatogenesis
was most likely to obtain sperm at the
highest rate (70.4%), followed by the
halfway spermatogenesis group (41.7%)

and the lowest was the hyalinization
spermatomy tube group with the rate of
obtaining sperm of 9.1%.
4. Accidents and complications
after surgery.
There were no complications after surgery
such as: bleeding, hematoma, infection.
DISCUSSION
Through the study results, we realized
that micro TESE method was an effective
method of collecting sperm for nonobstructive azoospermia patients. The
percentage of sperm obtained from nonobstructive azoospermia patients by this
method reached 37%. Micro TESE was
also a safe method, with small volume of
testicle tissue removed, each time only
from 5 to 10 mg of testicular tissue, thus
less affecting the testicular function after
surgery. In the study, after the testicular
tissue sample was obtained under a
micro-surgical microscope, a sample of
collagenase type IA was added at a
concentration of 0.8 mg/mL, so that the
sperm cell line was separated from the
wall of the spermatogenesis tube. This is
the first procedure implemented in
Vietnam instead of studying testicular
tissue with two prism or two obtuse
needles. Dabaja A.A et al (2013)
recommended the use of enzymes to
process testicular tissue samples to

increase the chances of sperm retrieval
from tissue samples obtained [4].
220

However, compared to results published
by some authors in the world, our success
rate was still lower. Schlege N.P (1999)
announced that the percentage of sperm
collection by micro TESE method was
about 42 - 63%; Bryon F.C (2014)
showed that this rate reached 50 - 60%
[2, 5]. This difference may be due to
patient selection criteria, the sample size,
and it also depends on the surgical base
and surgeon's experience.
Compared with the sperm collection
rate from testicles of non-obstructive
azoospermia patients by TESE in Vietnam
published by Trinh The Son et al (2015),
the micro TESE method was the method
of collecting sperm from testicles much
more effective than other methods (37%
compared to 23.3%) [1]. Thus, with the
success of the micro-TESE, it has
contributed to improving the quality and
effectiveness of infertility treatment in
general and male infertility in particular
and providing opportunities for nonobstructive azoospermia patients to have
their own baby.
In the study, the AZFc gene abnormality

group had a higher sperm collection rate
than the other AZF gene abnormalities
that contributed to the counseling and
prognosis for patients.
The average FSH concentration of the
study patients was 20.30 ± 12.63 mIU/m,
much higher than the normal index of
about 2 - 10 mIU/mL. In this study, FSH
and testosterone levels were correlated
with sperm retrieval ability (table 4). However,
some other authors, such as Kalsi J et al
(2012) found that FSH concentrations did
not have a prognostic value of sperm


Journal of military pharmaco-medicine no9-2019
retrieval ability of micro TESE method [6];
Bermie M.A (2013), Bryson F.C (2014)
supposed that there was no single factor
that can assess the sperm retrieval ability
of micro TESE, so it is necessary to
combine all factors/elements to predict
[5, 7]. This difference may be due to
differences in sample size and subjects.
Among the histopathologic lesions, the
group with impaired spermatogenesis was
most likely to obtain sperm at the highest
rate (70.4%), followed by the halfway
spermatogenesis group (41.7%) and the
lowest was the hyalinization spermatomy

tube group with the rate of obtaining sperm
of 9.1% (table 5). Thus, histopathology
was a valuable factor in the prognosis of
sperm retrieval ability of micro TESE.
CONCLUSION
Micro TESE is a method to collect
sperm from the testicle safely, effectively
in patients with non-obstructive azoospermia,
the sperm collection rate reacheed 37%.
Testicular volumes, FSH concentration,
testosterone, AZF gene abnormalities,
histopathological lesions had a prognostic
value of sperm retrieval ability in nonobstructive azoospermia patients by micro
TESE method.

REFERENCES
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aspiration (PESA) and testicular spem
extraction (TESE) on azoospermia patients in
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Journal of Military Medicine. 2015.
2. Schlegel P.N. Testicular sperm extraction:
Micro-dissection improves sperm yield with
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14, (1), pp.131-135.
3. WHO. WHO laboratory manual for the
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Fifth edition. Switzerland. 2010.
4. Dabaja A.A, Schlegel N.P Micro-dissection

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