Objectives. Testicular sperm extraction (TESE) is an effective procedure to retrieve sperm from some men with nonobstructive azoospermia (NOA). To optimize treatment effectiveness, we have reviewed our experience with TESE for NOA to better understand technical factors needed for sperm retrieval and lead to an optimized approach to TESE.

Methods. Eighty-one men with confirmed NOA underwent attempted TESE using an open technique under optical magnification. Each testis sample was dispersed and examined in the operating room. Sequential biopsy attempts were made until sperm were visualized or until further biopsies were thought to jeopardize testicular blood flow. In 20 patients, standard biopsy and initial mechanical dispersion of the seminiferous tubules were compared with the passage of tissue through a 24-gauge angiocatheter after initial dispersion to quantitate spermatozoal yield.

Results. Overall, 47 (58%) of 81 patients who underwent TESE had direct intraoperative visualization of spermatozoa. The average number of biopsy attempts for all patients was 8.9 and for patients with sperm isolated 6.4 (P = 0.002). Passage of the testicular tissue suspension through a 24-gauge angiocatheter increased sperm retrieval in matched tissue specimens from 83,000 to 390,000 or 470% over that achieved with standard dispersion alone (P = 0.005). An initial, substantive tissue biopsy revealed sperm in only 23 (28%) of 81 patients. Using this approach with sequential biopsies under optical magnification, no patient had evidence of testis injury or devascularization.

Conclusions. Because multiple TESE procedures can cause transient and permanent alterations in testicular function, it is imperative to perform TESE as safely and as efficiently as possible. We suggest that open TESE with optical magnification provides a safe method of retrieving sperm. A single biopsy for extraction is inadequate to detect spermatozoa for men with NOA. Use of the needle dispersion technique with passage of testicular tissue through an angiocatheter enhances detection of sperm and could potentially reduce the need for subsequent biopsies. An algorithm to minimize biopsies and allow sperm retrieval is presented.