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Center for Male Reproductive Medicine and Microsurgery

"State-of-the-Art Compassionate Care for the Infertile Couple"

AUA News (November 2001)
TESTICULAR BIOPSY: INDICATIONS AND IMPLICATIONS

Carin V. Hopps, M.D. & Marc Goldstein, M.D.

TESTICULAR BIOPSY: INDICATIONS AND IMPLICATIONS
Summary
References



Indications for testicular biopsy have changed over the past decade, reflecting advances in the diagnosis and treatment of infertility. The novel finding of motile sperm in human testis biopsy specimens presented the possibility for use of these sperm for in vitro fertilization utilizing intracytoplasmic sperm injection (ICSI).1

Fig 1. Injection of human cadaveric testicle reveals tunical perforating arteries entering at poles and coursing under tunica albuginea. (Courtesy of Jonathan P. Jarrow)
Thus, in select cases, testicular biopsy is beneficial not only for diagnosis, but the tissue may at the same time be processed and the sperm cryopreserved, a process which requires an andrology laboratory skilled in performance of these techniques. We perform open microsurgical testis biopsy in which a small incision is made within an avascular region of the tunica albuginea. Blood vessels are readily visualized utilizing the operating microscope (fig. 1), and bleeding is easily controlled with a bipolar electrocautery. A small piece of protruding testicular tissue is excised with iris scissors (fig. 2) and is preserved in Bouin’s solution.


Fig 2. Testis biopsy is performed using iris scissors under 10-power magnification provided by an operating microscope. Note that testicular blood vessels can be easily seen and readily avoided.

A touch prep is performed by touching a glass slide to the cut surface of seminiferous tubules (fig. 3), adding a drop of human tubal fluid media and a coverslip. If no spermatozoa are found, wet prep cytological examination may be done by excising an adjacent, smaller piece of tissue through the same tunical incision. The tissue is placed on a slide with a drop of media, teased apart with two 25-gauge needles and compressed with a coverslip. Human tubal fluid media enhances sperm motility. The slide is then examined intraoperatively for the presence of sperm (fig. 4), and motility or twitching is assessed.


Fig 3. A touch prep is made by applying a glass slide to the cut surface of seminiferous tubules.

The primary reason to consider testicular biopsy is to determine if men with either azoospermia or severe oligospermia have an absence or deficiency of sperm production or if obstruction is present at some point along the pathway from seminiferous tubule to ejaculatory duct. Men with azoospermia, normal testicular size, bilateral palpable vasa deferentia and normal FSH benefit from testicular biopsy to differentiate between obstructive azoospermia and primary seminiferous tubule failure. The presence of motile sperm on wet preparation is an excellent predictor for normal spermatogenesis and obstruction.1 Patients likely to have obstruction may undergo immediate exploration and microsurgical reconstruction and/or sperm retrieval for immediate use in an IVF/ICSI cycle or cryopreservation. Any sperm found at the time of diagnostic biopsy and not immediately used are cryopreserved.


Fig 4. Intraoperative wet prep cytological examination reveals sperm with tails.

In the past, testicular biopsy for men with azoospermia, small/soft testes and elevated FSH has been thought unnecessary, as patients with this profile clearly have primary testicular failure and therefore, irreversible infertility. The evolution of ICSI, however, has prompted thorough investigation of men with non-obstructive azoospermia, as the finding of a solitary sperm could significantly alter fertility potential. Tournaye et al recovered sperm utilizing wet preparation in 50% of patients with non-obstructive azoospermia.2 Chen et al discovered motile spermatozoa in 10.7% and spermatids in 50% of patients with Sertoli cell-only syndrome and motile spermatozoa in 17.1% and spermatids in 51.2% of patients with non-obstructive azoospermia overall.3 These findings suggest that spermatogenesis often occurs focally even within the testes of patients with severe spermatogenic disorders. Chen additionally reported that, although FSH < 30 mIU/ml correlated with higher likelihood of finding motile spermatozoa and spermatids within the testes of patients with non-obstructive azoospermia, one patient with Sertoli cell-only syndrome and FSH 50.3 mIU/ml was found to have spermatids on biopsy.3 Tournaye et al likewise found FSH concentration to be a poor predictor for recovery of sperm in azoospermic patients.2 An additional study demonstrated that 30% of men with non-obstructive azoospermia and FSH levels 3 times normal had mature spermatozoa on touch preparation cytology or testicular biopsy, and several of these patients also exhibited testicular atrophy, again stressing lack of correlation between serum FSH and testicular size with the presence of spermatozoa within the testis.4 Su et al showed that testis histopathology is the best predictor of testicular sperm retrieval in men with non-obstructive azoospermia, whereas FSH and testicular volume are not predictive (see table 1).5

For patients with non-obstructive azoospermia, multiple biopsies done bilaterally are warranted to localize spermatozoa, as spermatogenesis may occur focally; these sperm may then be utilized for ICSI. A microsurgical approach is recommended,6-8 as tubules in which spermatogenesis occurs typically appear somewhat larger and more full when compared to those tubules in which spermatogenesis is deficient, these appearing thin and stringy.7

Patients with oligospermia do not routinely require testicular biopsy, as the assessment of testicular tissue will not change the course of treatment. However, in the case of severe oligospermia, biopsy may be considered to rule out partial ductal obstruction, in which case spermatogenesis is normal.

For those men with bilateral congenital absence of the vas deferens, testicular biopsy for diagnostic purposes only is unnecessary, as spermatogenesis is routinely present.9 Spermatozoa may be aspirated for use in ICSI.


In summary:

  1. Testis biopsy is indicated for virtually all azoospermic men with palpable vasa deferentia.
  2. Intraoperative microscopic examination of fresh testicular tissue is indicated for all testis biopsies.
  3. Diagnostic biopsies should always be considered potentially therapeutic, and cryopreservation of sperm-bearing testicular tissue is always recommended.
  4. The use of an operating microscope allows avoidance of injury to testicular blood supply, minimizing complications, and may enhance the ability to identify sperm-bearing tubules.


References:

  1. Jow, W.W., Steckel, J., Schlegel, P.N., Magid, M.S., Goldstein, M.: Motile sperm in human testis biopsy specimens. J Androl, 14:194-198, 1993
  2. Tournaye, H., Verheyen, G., Nagy, P., Ubaldi, F., Goossens, A., Silber, S., Van Steirteghem, A.C., Devroey, P.: Are there any predictive factors for successful testicular sperm recovery in azoospermic patients? Hum Reprod, 12(1): 80-6, 1997
  3. Chen, C.S., Chu, S.H., Lai, Y.M., Wang, M.L., Chan, P.R.: Reconsideration of testicular biopsy and follicle-stimulating hormone measurement in the era of intracytoplasmic sperm injection for non-obstructive azoospermia? Hum Reprod, 11(10): 2176-9, 1996
  4. Kim, E.D., Gilbaugh, J.H., Patel, V.R., Turek, P.J., Lipschultz, L.I.: Testis biopsies frequently demonstrate sperm in men with azoospermia and significantly elevated follicle-stimulating hormone levels. J Urol, 157: 144-6, 1997
  5. Su, L.M., Palermo, G.D., Goldstein, M., Veeck, L.L., Rosenwaks, Z., Schlegel, P.N.: Testicular sperm extraction with intracytoplasmic sperm injection for nonobstructive azoospermia: testicular histology can predict success of sperm retrieval. J Urol, 161(1):112-6, 1999
  6. Goldstein, M.: Surgery of Male Infertility and Other Scrotal Disorders. In: Campbell’s Urology, 7th ed. Edited by P.C. Walsh, A.B. Retik, E.D. Vaughn and A.J. Wein. Philadelphia: W.B. Saunders, chapt 44, pp. 1331-1377, 1998
  7. Schlegel, P.N.: Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Hum Reprod, 14(1):131-5, 1999
  8. Dardashti, K., Williams, R.H., Goldstein, M.: Microsurgical testis biopsy: a novel technique for retrieval of testicular tissue. J Urol, 163: 1206-7, 2000
  9. Goldstein, M. and Schlossberg, S.: Men with congenital absence of the vas deferens often have seminal vesicles. J Urol, 140:85-6, 1988


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