Controversy exists in most areas of life, work, sports and of course, medicine. In the very focused area of how best to manage men who have no sperm in the ejaculate, there is controversy about which approach is best. Options for men who have Non Obstructive Azoospermia (very low or absent sperm production), include the option of a multiple pass Testis aspiration technique (TESA), This has the advantage of technically offering an option of local anesthesia, and, possibly, a slightly lower risk of complications. However, the alternative option is MTESE which is literally opening the testis and looking at all the seminiferous tubules under an operating microscope in order to select the most promising tubules.
The question as to which is the best approach has seemingly been answered in a study by Jensen et al in article from the May 19 2022 European Urology. The results of sperm retrieval performed on 100 patients were reviewed. 49 of the men underwent mTESE and 51 underwent TESE. The results speak for themselves: Sperm were retrieved in 21/49 (43%) men after mTESE and in 11/51 (22%) men after multiple needle-pass TESA, a success rate of almost double for the open surgical approach.
In addition, the authors note that none of the TESA patients but 6% (3) of the mTESE patients had complication requiring an intervention.
There is some logic to these results: with MTESE, the surgeon is literally looking at the tubules that make the sperm in order to find the most promising ones. Sometimes the difference between a tubule making sperm vs. one that is not, is obvious; however, sometimes the difference is subtle, particularly in cases where some of the tubules have sperm precursors only (also known as maturation arrest). But being able to directly visualize the tubules clearly offers an advantage.
Multiple needle pass TESE is done blindly. One cannot see the tubules. There are advocates for “fine needle aspiration testicular mapping”. This is an approach where by an aspiration of the testis is performed in multiple areas ahead of sperm retrieval in order to find out where in the testis the sperm are located. The efficacy and value of this technique also remains controversial with advocates like Paul Turek who originally described the technique stating it is the right way to go but others who perform micro TESE stating that if the whole testis is surveyed anyway, what is the additional value?
I learned how to perform mTESE from Dr. Peter Schlegel who originally described the technique and have been performing mTESE for the overwhelming majority of my surgical sperm retrievals for almost twenty-five years. Preoperative evaluation generally requires hormonal and genetic testing through bloodwork, a scrotal ultrasound and an in person office visit. Procedures are accomplished on an outpatient basis.