Azoospermia : Azoospermia, seen in approximately 10–15% of male infertility cases, is the condition in which no mature sperm cells, either live or dead, are present in the ejaculate (semen).

The diagnosis of azoospermia should be made at least twice through the detailed examination of a centrifuged semen sample. Otherwise, if the semen sample is not carefully evaluated and is examined by inexperienced individuals, patients who do not actually have azoospermia may be misdiagnosed. This may lead to unnecessary microTESE procedures.

Causes of Azoospermia:

  • Pretesticular: Usually due to endocrine causes. It is most commonly seen as hypogonadotropic hypogonadism. These patients benefit from long-term medical treatment, and sperm may begin to appear in the semen from the sixth month onward.
  • Testicular: Pathologies related to the testes, meaning disorders in sperm production due to primary testicular failure. (Chromosomal abnormalities are also included in this group.)
  • Posttesticular: Causes related to obstruction in the sperm ducts. They account for approximately 40% of azoospermia cases.

Patients presenting with azoospermia are evaluated with physical examination, hormonal tests, and genetic analyses for differential diagnosis. Those who require medical treatment are treated and followed accordingly. Patients diagnosed with non-obstructive azoospermia (NOA), characterized by impaired sperm production, are prepared for microTESE. Patients with obstructive azoospermia, where there is no production problem but rather a blockage, are prepared for one of the methods such as TESE, PESA, MESA, or TESA.

Before microTESE, in addition to hormone tests (FSH-LH-TT-E2), chromosomal analysis (karyotype) and Y chromosome microdeletion tests should be performed.

The most common chromosomal abnormality encountered is Klinefelter syndrome (47XXY). In these patients, the sperm retrieval rate with microTESE is approximately 60–70%.

Nowadays, diagnostic testicular biopsy should not be performed. In addition, testosterone preparations should not be used for empirical medical treatment.

Patients diagnosed with non-obstructive azoospermia who do not require medical treatment should be scheduled for microTESE.

MICROTESE : It is the gold standard surgical method for NOA. The operation can be performed under epidural or general anesthesia. In microTESE, seminiferous tubules can be visualized under a microscope, and the more dilated and opaque tubules that are likely to contain sperm are selectively extracted. Therefore, the use of a microscope increases the likelihood of sperm retrieval. MicroTESE not only increases the chance of finding sperm but also allows for less tissue removal. The sperm retrieval rate with microTESE is approximately 40–70%, depending on different clinical and histopathological conditions. The duration of sperm search in microTESE should be at least one and a half to two hours. Patients are discharged 3–5 hours after the operation and can return to work within 4–5 days.

The main complications of sperm retrieval procedures include bleeding, infection, low testosterone levels, and testicular atrophy. With the use of a microscope, these complications have been reduced but not completely eliminated.

In conclusion, patients should be carefully prepared for microTESE. Despite all advancements, there is currently no test that can definitively predict the presence of sperm in the testes before the procedure. At least six months should pass before performing a second microTESE.

For patients in whom no mature sperm is found with microTESE, stem cell studies that have not yet entered clinical practice are ongoing.