I Get We Want to Lower Costs, But I Think What’s Most Important Is to Do the Best For Our Patients

I Understand We Want to Lower Costs, But I Think What’s Most Important Is to Do the Best For Our Patients: Maximize Chances of Success While Minimizing Complications and The Number of Procedures .  A Critique of a Recent Article by Patel, Park, Reddy, fisher Mirabal and Lipshultz in the March 2023 Journal: Urology.  


An article entitled: “Testicular Core Extraction: Important Technique for Determining Sperm Retrieval Method in Non-obstructive Azoospermia” reports on the value of pre-surgical sperm retrieval performance of a “Testicular Core Extraction” (TCE).    The report advocates for this approach.  I do not.

Surgical sperm retrieval is an operation performed in the setting of, most commonly, azoospermia  (no sperm in the ejaculate) and less commonly anejaculation (the inability or a man to produce an ejaculation), within the rubric of a couple experiencing infertility.   Surgically retrieved sperm can be used in an In Vitro Fertilization (IVF) setting to initiate a pregnancy.   

Azoospermia can be considered in most cases to be either “obstructive”  or “non-obstructive”.     In obstructive azoospermia (OA)  sperm production is normal but sperm release into the ejaculate is blocked;  the two most common examples of this are vasectomy and congenital absence of the vas deferens.     In non-obstructive azoospermia (NOA)  sperm production is either absent altogether or diminished to the point that sperm cannot escape the testis into the ejaculate.  The actual technique of surgical sperm retrieval in cases of NOA is most commonly approached with a “Micro-dissection”  (MTESE) technique in which the testis is micro-surgically explored lobule by lobule for the presence of sperm production.

Drs Patel et al advocate for an office base TCE under local as a pre-procedure before moving on to either CTESE  (open testis biopsy with 2cm incision, performed in the office under local anesthesia) vs. MTESE in an OR.   The results were reported to show that of 82 NOA patients, 51 TCE procedures were positive for sperm.    The rate of finding sperm in subsequent office based TESE (Not micro) was then 97%.  MTESE success for the remaining patients was 75%.

Why I don’t like this:


IVF cycles in my area now routinely cost more than $20,000.00.    In my opinion, most azoospermic patients should be treated with the technique which offers the best chance of success and the best yield for sperm which also minimizes the need for additional procedures as well as the chance of complications.   For most patients that is MTESE.

Eric K. Seaman MD Dr. Seaman is a urologist specializing in the field of Male Reproductive Medicine and Surgery. Dr. Seaman Completed his Male Infertility Fellowship under the direction of Larry I. Lipshultz MD at Baylor College of Medicine Houston in 1996. Since that time he has focused his practice on the sub-subspecialty focus area of Male fertility and infertility.

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