Salvage Microdissection Testicular Sperm Extraction After Failed Conventional Testicular Sperm Extraction in Patients With Nonobstructive Azoospermia Akira Tsujimura,* Yasushi Miyagawa, Tetsuya Takao, Shingo Takada, Minoru Koga, Masami Takeyama, Kiyomi Matsumiya, Hideki Fujioka and Akihiko Okuyama From the Department of Urology, Osaka University Graduate School of Medicine (AT, YM, TT, ST, AO0, Suita and Department of Urology, Osaka Central Hospital (MK, MT) and Osaka Police Hospital (KM, HF), Osaka, Japan Purpose: TESE is considered the best procedure for identifying a tubule for spermatozoa retrieval. This technique improves the SRR to around 50%. However, it has been unclear whether it is useful in patients in whom conventional TESE has failed. We compared the outcome of microdissection TESE in patients in whom conventional TESE failed to that in patients who did not undergo conventional TESE. We also evaluated relations between the outcome of salvage microdissection TESE and the characteristics of previous conventional TESE. Materials and Methods: A total of 46 patients with nonobstructive azoospermia in whom salvage microdissection TESE was performed after failed conventional TESE were included. Patient characteristics and the SRR were compared between these patients and 134 in whom conventional TESE had not been performed previously. The previous TESE procedure, testicular histology and interval between TESEs were also evaluated. Results: Patient characteristics did not differ significantly between the groups. The microdissection TESE SRR also did not differ significantly between the groups (45.7% vs 44.0%). The possibility of successful spermatozoa retrieval by salvage microdissection TESE remained regardless of the previous failure of any other TESE procedure and regardless of testicular histology. The salvage microdissection TESE SRR was not related to the interval between TESEs. Conclusions: Because salvage microdissection TESE is effective in patients in whom conventional TESE has failed, this option should be made available to them with the understanding that extended followup after salvage microdissection TESE is necessary due to the risk of hypogonadism. Key Words: testis; spermatozoa; oligospermia; reproductive techniques, assisted; hypogonadism T esticular spermatozoa are retrieved successfully by the TESE procedure and used for ICSI in cases of NOA. Successful application of TESE depends on identifying a seminiferous tubule that contains spermatozoa because testicular tubules in patients with NOA are usually heterogeneous. 1,2 In general the absence of sperm in a single testicular biopsy specimen does not guarantee a complete lack of sperm in the testes. 3 A new microsurgical TESE procedure, that is microdissection TESE, has been reported. 4,5 Direct visualization with an operating micro- scope is advantageous because the large, whitish tubules of increased opacity that presumably contain the greatest number of spermatogenetically active germ cells can be identified. We had previously reported that the microdissec- tion TESE SRR is higher than the SRR of open biopsy, in which even multiple samples are obtained (conventional TESE). 6 Other studies have also shown a high SRR by microdissection TESE vs conventional TESE. 5,7,8 Currently microdissection TESE is an increasing popular technique for identifying a tubule for spermatozoa retrieval. This means that microdissection TESE may also be effective in patients with NOA in whom conventional TESE has failed. Indeed, the number of patients who request microdissection TESE after failed conventional TESE has been increasing. We compared the outcome of microdissection TESE in patients in whom previous conventional TESE had failed to that in patients in whom conventional TESE had not been performed. We also evaluated relations between the out- come of salvage microdissection TESE and several charac- teristics of the previous conventional TESE. MATERIALS AND METHODS A total of 46 patients with NOA in whom salvage microdis- section TESE was performed at one of our institutions after conventional TESE, that is an open procedure using local or lumbar anesthesia, failed elsewhere were included in this retrospective study. NOA was diagnosed based on a com- plete history, physical examination and endocrinological profile before TESE and sperm freezing were performed. The microdissection TESE procedure was performed as previously described. 6,9 Briefly, small samples (10 to 15 mg) were excised from the larger, more opaque tubules under a surgical microscope at 20 to 40 magnification. The pro- cedure was terminated when enough spermatozoa for at least 1 embryo transfer with in vitro fertilization were re- Submitted for publication June 10, 2005. * Correspondence: Department of Urology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565- 0871, Japan (telephone: +81-6-6879-3531; FAX: +81-6-6879-3539; e-mail: akitsuji@uro.med.osaka-u.ac.jp). Sexual Function/Infertility 0022-5347/06/1754-1446/0 Vol. 175, 1446-1449, April 2006 THE JOURNAL OF UROLOGY ® Printed in U.S.A. Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/S0022-5347(05)00678-6 1446