Microdissection is the best way to perform sperm retrieval in men with non-obstructive azoospermy? | Opinion: No, there are other options

This is the authors' abstract. We don't add key points for this paper.

In the last 23 years, Intracitoplasmic Sperm Injection (ICSI) has given non-obstructive azoospermic man the opportunity to become biological fathers, if sperm could be found in their testicles.These men present the biggest challenge in the routine of infertility clinics around the World, since there are no positive, clinical or laboratory, prognostic factors for sperm recovery.Once testicular sperm has been regularly used for ICSI, discussion about which technique for testicular sperm retrieval has been done.Sperm can be harvest from testicular parenchyma by: open biopsy (Testicular Sperm Extraction-TESE), percutaneous aspiration (Testicular Sperm Aspiration), open guided biopsy by previous cytology (Testicular fine-needle Aspiration) and open biopsy using microsurgery technique (Testicular Microdissection).The proposed techniques have the same objective, to find sperm with minimal testicular damage and in a reproducible way (1).TESE can be done by a large longitudinal incision on the testicular albuginea and excision of a representative large testicular fragment where multiple tubule samples can be examined for sperm presence.A variation is a multiple biopsy approach by incision of multiple sites and searching for sperm in each fragment.Both techniques have similar results once spermatogenesis is diffusely distributed, but sometimes very sparse, making it difficult to find sperm by random biopsies (2).Testicular fine needle aspiration (TFNA) had been defined for histologic testis examination, and brought to infertility use as a tool to identify spermatogenesis foci and guide sperm retrieval for ICSI.A simple procedure done under local anesthesia that correlates almost 90% with histology, although it is necessary a second intervention for sperm retrieval (3).Testicular Microdissection described by Schlegel brought a new concept for sperm retrieval by using optical magnification to identify spermatogenesis foci based on the morphological testicular tubules characteristics and initial better results with minimum parenchyma amount excised (4).The key questions are: what sperm recovery rate (SRR) is considered good and how to find spermatogenesis foci with minimal testicular damage?Multiple sampling, fine needle citology or magnification?The present techniques have positive and negatives aspects, but the debate about those aspects was interrupted after testicular microdissection, despite different experiences.