Know Before You Go: Sperm FNA Mapping

You know you’re on to something when the audience asks for more. That’s why I am absolutely delighted at the invitation from my urological colleagues to lecture about sperm FNA mapping at the annual meeting of the Society for the Study of Male Reproduction (SSMR) in Orlando, Florida this week.

“GPS” of the Testicle

Since I first published on the subject in 1997, using FNA mapping to find sperm in infertile men with azoospermia has matured beautifully as a valuable workhorse tool in the field. Over the years, the technique has evolved to include more sites, found more sperm, and has remained extremely safe. Although constantly compared to microdissection testicular sperm extraction (mTESE), sperm mapping represents a more refined and elegant solution to a very difficult problem. Here is why:

Characteristic               FNA Mapping             mTESE
Accuracy                       Excellent                      Excellent
Concept                       Targeted                       Blind
Invasiveness                 Minimal                         Maximal
Testis sparing               Yes                                 No
Relative recovery         Short                             Long
Pain pills                         Few                             Many
Testosterone impact     Small                           Large

Optimized Outlook

Appropriately, my SSMR lecture topic is “Optimizing Sperm Retrieval,” something that I think about with each and every azoospermic patient I see. Because, mind you, testicles don’t just make sperm for having kids; they also provide testosterone for life. As I listen to patients, I ask myself: “What can I do to maximize sperm retrieval and minimize invasiveness, pain, recovery and impact on testosterone levels?” In other words, how do I personalize his care for optimal results?

Ok, so I’m a bit of a planner, but I’ve always believed in 2 timeless surgical principles: “know before you go” (a variation of “measure twice and cut once”) and “less is more.” So, for this lecture, I put my principles to the test and examined my results.

A Better Mousetrap

Looking at almost 100 of my sperm retrieval procedures over the last year, I evaluated exactly how sperm mapping simplified or optimized them in non-obstructed azoospermic men. Here’s what I found:

  • When “mapping” is performed in advance of sperm retrieval, only 50% of patients will need the fully loaded mTESE for sperm retrieval. Fully half of them need far less invasive procedures such as needle aspiration (TESA) or simpler biopsies (TESE).
  • When “mapping” is performed before mTESE and used to guide it, the ability to find sperm increases by 74% (53% sperm retrieval with blind mTESE vs. 92% with map-guided mTESE).
  • When “mapping” is performed before mTESE and used to guide it, the likelihood of needing to operate on both testicles to retrieve sufficient sperm is decreased 6-fold (Fewer testicles get the knife: 14% bilateral procedures with mapping vs. 84% bilateral procedures without it).