Know Before You Go: Sperm FNA Mapping

You know that the food is good when guests ask 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 it 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 nonobstructed 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)

Works for me! Here, have another serving; its good for you!

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53 thoughts on “Know Before You Go: Sperm FNA Mapping

  1. I ve learnt a lot sir and I wil continue reading your articles though we don’t ve such facilities were we can get help here in zambia.

  2. As a patient or Dr Turek I can confirm that it is minimally invasive. After the op you can get up and walk out. After a days rest and possibly some minor pain meds for a day ( only if required) you can be back to normal life within several short days.
    There is deep piece of mind for an azoospermic diagnosed male knowing that the little guys are in there , they just don’t wish to come out and play, this is part of the beauty of FNA mapping. The next time you go in it is a precise incision with no undue cutting and guessing as in a micro dissection. It is also worth noting that having The Turek Clinic dedicated lab looking and analysing the samples is part of the miracle of the FNA mapping procedure. The proof is in the pudding as they say and if TTC advise the FNA pudding is good then rest assured it is.

  3. My husband had a TESE in March 2010. They found no sperm. He hasn’t had a semen analysis in years. He’s given up hope. Do you think FNA Mapping would be worth a try & how much does this cost? We are emotionally & financially exhausted. Please Advise. Thank You

    1. Dear Mary, I know that you are tired, but consider starting this second trip with a FREE call on me. You never know. Depends alot on how hard they looked and how thoroughly they sampled…

  4. Dr Turek,
    I have submitted some questions for you previously but have yet to see my comments published. Anyway, My husband and I are interested in traveling from NC for FNA Mapping. He has a long history of Hogkins disease including a stem cell transplant 12 yrs ago. We do have two children ages 12 and 13. He has battled this disease since age 5. After 10 yrs of trying naturally we finally completed a SA which came back as a big fat zero. We were advised to try again in three months and then consider mTESE. My husband is very against such an invasive procedure due to numbing from previous biopsy sites secondary to his HD. With his history, do you think we should even bother with a second SA? We would rather try the mapping to see if it’s possible to do needle aspiration rather then the full mTESE. We are super confused and frustrated. Can we set up a call with you? Thank you.

    1. Dear Alexis, We have found sperm with mapping in men such as your husband. In fact, we have published cases of finding sperm in men who have gone through both autologous and allogeneic bone marrow transplants for HD and other lymphomas. I agree fully that Mapping would be a highly informative and far less invasive way than mTESE to learn about whether hubby can be a father. My big question is: are the two children you have now biological? Did someone already find sperm successfully? Consider going offline and setting up a free call to go to the next level.

      1. Thank you so much! I’m going to set up a free call. To answer your question, our two kids are biologically his. They were conceived when we were 18 &19 yrs old, after chemo and radiation but right before his autologous stem cell transplant. Hope to talk to you soon!

  5. When there is testicular failure confirmed by high fsh levels in non obstructive azoospermia, how can through FNA you can retrieve sperm when there is no production at all. r u fooling around.. i read your research no where it is saying clearly what exactly you are doing in FNA , and whether is there any evidence based study and whether its proved that in true azoospermia you can get sperms by FNA

    1. Dr Hameed, No, Dr Hameed, I am not fooling around with FNA mapping. It has 12 peer reviewed publications on it and has been a workhorse technique for me for 15 years. Not sure how you are applying the term “evidence based study” to describe a biological phenomenon. Do you really need a randomized, controlled study to identify sperm??

  6. what is mapping and how r u doing it, no where you have mentioned that, whats the special procedure you are doing in mapping and seeing whether there is any sperm or not ? testicualr failure with multiple semen analysis revealing azoospermia, how can u say that through mapping you can see whether there is any sperm inside the testis. technically how is mapping done .. am in to infertility treatment and i have done a lot of research. Am a ayurveda qualified doctor, and true non obstructive azoospermia i didnt find succes till today, what is your special procedure called Mapping.
    and yes today all major IVF clinics fools patients of non obstructive azoospermia that sperm be be extracted through MESA TESE ETC which i feel is a open fraud.
    i am really interested to know what and how u exactly do mapping with what medium or with what technology?
    thank you

    1. Dr. Hameed, you are welcome to learn the FNA mapping technique. I offer formal training to those interested. Simply contact the office at 415-392-3200.

  7. Hi i have non obstructive azoospermia and also did biopsy before 5 days only and no sperms found all damaged so is FNA mapping is advisable?and in mumbai(india)where yhis technique availabale?whether i can have biological child too

  8. I got the FNA done by Dr Turek a few weeks back, and it was an absolutely seamless experience. No pain, no discomfort, nothing. I got it done in the afternoon, at night I was out and enjoying some of SF’s finest sushi. Within four days, i was horse back riding in the caribbean. I didn’t need any pain killers.
    If you’re in two minds about whether to get this done vs go straight for a tese/mtese, forget it – this really is a no brainer. Go with FNA – far less invasive and statistically more likely to give you a successful outcome. If you’re still not convinced, do what I did – spend 15 seconds watching an mTESE video on youtube. Then spend 15 seconds watching an FNA video. You’ll never think twice about your decision again.

  9. Hi Dr.Turek,
    I really have hope now that I’ve learned about your technique. My husband has no sperm and we are waiting for the rest of his results. We are very tight on budget. We are both students. My insurance told me it will be covered, it really made my day. Later contacting your office, I was told that it has to be out of pocket. Any chance in the near future will you be accepting health insurance?
    Thank you

    1. Sarah, It very well be “covered” by insurance. We can submit the procedure for approval to the insurance company and an enlightened insurer could reimburse your expenses.

  10. Hello Prof. Dr. Paul Turek
    I have a problem with man infertility (azospermy) so I will be very thankful to you if you help me. In meen time:
    sperm bacteriological: Clean – no bactery (method: CUL, MIC)
    Blood analyze, y microdeletion and aneuploidy on sex chromosomes: The result is OK
    Karyotype 46 xy: The result is OK
    Last Hormonal profiling (24.08.2016):
    FSH=16.3 mlU/ml
    Testesteron=216 ng/mL
    I never took some steroid and i never have a very high temperature. I dont know why i have azoospermia when everything is ok.
    Till now I have done:Last year Tese (no sperm found, Diagnose: maturation arrest at secondary spermatocyte),after that i have another – Surgery – varikocela,after that result was same azoospermia and this year i had Micro Surgery Tese (was taken 25 pieces and no sperm found).Because i have 3 operation doctor say that i dont need to make another operation because no sense any more. After first tese my fsh go up from 12 to 16 and testosteron goes a little down,after micro tese i stil dont know what will be with my hormone.
    Because im from Europe and FNA mapping(maybe and micro tese ) will be a very expensive for me, i really want to know what you think for all this.Is any change to find some sperm from your experience? Because i had 3 operation already will be this dangerous for my health (testosterone,fsh)?
    Thank you!

    1. Dear Has, you have been through a lot. However, from a sperm retrieval point of view, you have been through a TESE and an mTESE procedure. You started with a low normal T level and it is likely that your post mTESE T level will remain low or be lower. So you are now at risk for needing T replacement which is information you might use to guide what you do next. FNA Mapping can find sperm in 29% of mTESE failures and shouldn’t significantly alter T levels (non surgical technique). FNA mapping works best in failed mTESE cases when the biopsy histology is maturation arrest.

  11. Hello Dr Turek,
    My husband had his TESA done and no sperm found. The histology says Non Obstructive azoospermia with Sertoli Cell only Syndorme. Can going for FNA mapping would result in any sperm or is it just the end of the road. We are devastated and live in UK. Are there anybody here who can do FNA mapping?

    1. Dear Seeta, Generally TESA procedures are not as comprehensive as either FNA Mapping or mTESE for finding sperm, so the short answer is Yes, there is still a chance of sperm. Consider a visit with Dr Jonathan Ramsay in London UK, a certified FNA Mapping expert.

      1. Thank you for you suggestion Dr Turek. My only concern is Sertoli Cell only Sydrome. Are there any success in finding sperm with this condition?

  12. Dear Dr Turek,
    I am facing the azoospermia. I had all recommended tests and checking (hormones -> Testosterone, FSH and others , all results are OK . No carrier deletion in Y-Chromosome. Normal size testis). A lot of other blood tests and others which done in Jordan. Most of doctors advised me to go for mtese but still worried about it. After I read what you wrote about FNA mapping, one doctor called Dr. Rami advised me to do FNA mapping but don’t know if he is certified FNA mapping. Kindly advise me.

    1. Dear Alqudrah, No this doctor is not certified in FNA mapping. Best thing to do is to frankly ask him what his success rates are in finding sperm by FNA Mapping as he performs it.

  13. Hi found out my husband has a zero sperm count in May after seman anaylsis. Had another in June to confirm. Referred to urologist from our RE. He did blood work, genetic testing, and physical exam. All tests were good except testosterone very low at 172 and he said FSH slightly elevated at 12. Urologist put my husband on clomid to improve testosterone and he said possibly start sperm production. Recommended we come back in about 2 1/2 months to recheck testosterone and repeat seman anaylsis. Although T went up to 889 still zero count. Urologist still wants us to get a scrotal ultrasound to rule out any varicoceles that he said he might not have felt by hand. After ultrasound wants to do a testicular biopsy before doing TESA. Is a biopsy before TESA a good idea or will it just cause damage and reduce our chances of finding sperm through harvesting? I’ve done research and some say a biopsy is not helpful and may reduce chances of finding sperm. What is your professional option on a biopsy before TESA?

    1. Dear Stephanie, Great question (and sorry about your state of affairs with fertility). I published a paper in the Asian Journal of Andrology (Beliveau and Turek, 2011) that reviewed the literature on sample size and the chance of finding sperm in men with non obstructive azoospermia. A single testis biopsy has a 30% chance of finding sperm. A simple TESA procedure is similar. an 18 site, FNA Mapping procedure is 60%. Microdissection is similar to mapping. So, there is “some” value in having a biopsy, but it is certainly not the whole story. Based on this data, I stopped doing biopsies, as FNA mapping is less invasive and more informative (by 2x).

  14. Hi my husband had a zero sperm count and recently had a vericocele surgery (grade 3) on both testes. During the surgery the biopsy showed no sperm. He’s been on clomid for months now and labs show he’s responding well. He had the kerotype lab drawn and came back normal. If that is normal and we know he’s producing sperm will sperm be found in the TESA?

    1. Dear Brittany, you are trying hard to have hubby make sperm. This is what’s called “maximal medical therapy” (clomid and varicocele repair). Although he may not have ejaculated sperm, there is a 30-40% chance that he develops it after the varicocele repair. Give it 9 mos or so. If no sperm then, consider biopsy or TESA or FNA Mapping. FNA mapping has a 63% chance of finding testicular sperm in this setting.

  15. Hi Dr.
    After 4 years of stress and our results being lost (nhs) UK. I final got told that my blood showed I have a genetic problem,azoospermia and fhs levels is at 35 . I had 2 sperm test done resent for freezing but no sperm was found in both results,and my chances are very slim as my testies are also small. ( on sperm test done 3 Year’s ago sperm was found at very low level.) But they can retrieve sperm with an operation. Lucky for me I read your notes, and seen mapping YouTube video, and my fertility consultant had to google it when I ask about mapping first.
    Any thoughts Dr.?

    1. Dear Hubert, You are likely to be an excellent candidate for testicular sperm retrieval, especially with a history of having ejaculated sperm several years ago. Which way you go is really the decision. In the setting of normal baseline testosterone levels, microTESE or FNA mapping are good choices. In the setting of low normal testosterone levels, microTESE is far more likely to lower testosterone levels than FNA mapping or even map-directed sperm retrievals.

  16. Hello Dr. Turek,
    My friend was diagnosed with NOA. He had a varicocele repair in 2009 and biopsy in 2010 which showed no sperm. His current blood work shows normal testosterone levels, slightly elevated FSH (20). He was given a 35-40% chance of sperm retrieval using MicroTese. However, he is currently divorced and would like to know if there is a chance of finding sperm before proceeding with such an invasive surgery. He researched sperm mapping and read great things, however some professionals have informed him that sperm mapping may cause damage to the inflicted areas. Is this true? What are the risks of sperm mapping?

    1. Dear Sandra. Great Question! How can something so good at finding sperm like FNA mapping actually be far safer than micro dissection, which essentially bivalves the testis under anesthesia to find sperm? Well, the fact of the matter is that it is the safest thing you can do to a testicle compared to anything else out there. I have done 2000 cases and here are my complications:
      1. No infections, bleeding.
      2. Occasionally scrotum can have patches of black and blue that resolve in a week
      3. Mean pain pill use after procedure is two (2) pills
      4. No chronic pain
      5. Two (2) spermatic cord hematomas (followed and resolved)
      5. Five (5) men feel like having sex within 3 days of the procedure and noted spots of blood in the ejaculate (painless, resolved)
      That it it!
      As far as internal damage, there are not good animal studies published that show it is entirely safe from every imaginable angle (hormones, ultrasound etc). And probably the most convincing point of safety is the fact that if I do an FNA map and find a single site of sperm in one testicle, there is a 92% chance of finding sufficient sperm after that with a targeted sperm retrieval. Honestly, if FNA mapping “damaged” testicles, we would never be finding these small numbers of sperm after FNA mapping.

  17. Hi Doctor,
    My husband was diagnosed with azoospermia non-obstructive, all his hormone levels are normal according to the urologist. The doctor recommended a sperm retrieval and we went ahead and did the procedure, however nothing was found. May I add, before the procedure he has a testicular ultrasound and came out normal as well. The doctor dismissed our case and said its most likely genetic, however it doesn’t run in his family so it has kept us confused and very discourage and finical drained. What do you think we should do next?

    1. Dear Annie, What you should do next will be much clearer when your options are understood. Genetic infertility can be tested by checking Y chromosome deletions and chromosomes (karyotype). You might consider this, but it typically doesn’t predict the presence or absence of sperm.
      Whether or not small pockets of usable testicular sperm are still present in your partner’s testicles depends on how hard the doctor looked for sperm. For example, FNA mapping can find sperm in up to 40% of men who only had a testis biopsy and in 29% of men who previously had a microdissection that failed.
      If you want to learn more, set up a call with us!

    1. Dear AR, there is a chance that a repeat mTESE in the setting of a prior failed mTESE could find sperm. The literature is small on this topic and the number of patients few. Overall it might be 20% in the best hands. However, the risk is that testosterone levels may take a hit from such large procedures and be permanently lowered. This is all part of the discussion with your doctor. We have reported finding sperm in 29% of men after failed mTESE procedures using the far less invasive FNA Mapping technique that has a MUCH lower chance of affection testosterone levels.

  18. I have seen many of whom that have shared with you Dr. TurekMD regarding of infertility case and the process which are taken during those passed period of time, but I have similar problem which may related to one of those cases. I have low testosterone levels and extra Y chromsome, due to your experience, do I have a chance to try any of your experience treatment. The problem is that, my testicles are small and when enrection began, it is happening but in the end there is white crystal coming out of my penis out of my attention. But from the beginning of my maturity, there was nothing like that but as I remember, there was a time viene on front of left groin was kept paint and I went to Dr. Once he gave me to fills only, I swallow one at that night and in the morning when I wake up, my underwear was fun sticky liquid and don’t know what really happened.

    1. Dear J.Jok, having an extra Y chromosome does not mean that you don’t have sperm, even in the setting of a low testosterone. FNA Mapping can detect sperm in the testis that is simply too low in production to make it out naturally. Would love to talk more! Don’t give up!

    1. Dear Khurram Khalid, Although there may be individuals saying that they perform FNA mapping in India, I have not formally trained anyone in that country in the technique…

  19. My husband is diagnosed with Azoospermia we have done 4 semen analysis in past 15 months each reported zero sperm count, doctor has advised testicular biopsy to see if its obstructive or non-obstructive
    serum LH 5.20
    serum FSH 7.92
    serum testosterone 442.9
    I am from Pakistan can you tell me any doctor who can perform sperm mapping here or anywhere else where we can travel easily.

    1. Dear Khushi, An FSH of 7.92 is pretty close to 8.0 which implies non obstructive azoospermia. A testis biopsy has a 30% chance of showing sperm. FNA mapping, at its lowest is 60%. I have not trained anyone in Pakistan in FNA mapping however.

  20. Hi dr turek
    i had investigation on 2014
    My fsh has show a raised value 37.9,an LH of12.2, testosterone of 10 and prolactin of 254.and has normal 46 xy chromosomes and is nagative for cystic fibrosis gene mutation.the scrotal ultrasound also confirm small testicular volume my dr said it’s primary testicular failed
    I had test done again may 2918 karyotype 46 XY; CF gene mutation test nagative;FSH 42.2 IU/L (which is high,previously it was 37 IU/L in 2014 ),LH 17.5 IU/L; prolactin 247 my/L; TSH 2.0 my/L; testosterone 10.7 nmol/L and SHBG 40 nmol/L the both testicular ultrasound showed both test small, but have normal echotexture and appears comparable from the previous ultrasound which occurred in 2014 in Nov 2018 I had procedure surgical sperm retrieval but they have not found any sperms
    Can you please give my your advice as I am living in U.K. If there is and specialist ivf dr in U.K.
    Thank you very much take your to read my letter

    1. Dear Kan, You have been through a lot of testing and procedures over 4 years. Classic nonobstructive azoospermia. Depending on how complex your sperm retrieval procedure was (microTESE vs TESE vs TESA) the chance of finding sperm using FNA Mapping is in the range of 29-40%. One concern I have is what your testosterone balance is like AFTER the sperm retrieval as the T was borderline low BEFORE the retrieval in 2018.

  21. Hi dr turek
    I like to thank you for you reply on 23.nov2018
    When I find out my testosterone level I let you know
    Can you plz let me know that how many moths after I can have anothe procedure and if you know any good dr who can do sperm mapping in the U.K.
    I like to thank you again

    1. Dear Kan, you should wait at least 6 mos after having a testicular procedure (TESE or microTESE) before considering FNA mapping to find sperm. Even after failed mTESE procedures, we are finding sperm in 29% of men with FNA Mapping and I have been able to then retrieve sperm for IVF-ICSI in all cases of found sperm.

  22. Hello Dr Turek
    Do you know any Dr in UAE, who has learned FNA techniques from you ?
    My husband has SCOS. We did mtese in 2013 with no success.

  23. Hi Dr Turek,
    I have been diagnosed with NOA. Cause is unknown.already did mtese but did not find any sperms in any of the three samples. I find myself perfectly healthy. Despite my testosterone levels showing low in my test. My sex drive and mood all seems to be good. I m at my wit’s end. Will FNA mapping will help me? I m in Singapore and financially not capable to travel to us at the moment for treatment. Infertility treatment cost a bomb in Singapore. Any advice is greatly appreciated.

    1. Dear Muhamed, There is still hope. We recently published that 29% of men who failed mTESE procedures will have sperm upon FNA mapping. My gut feeling is that this rate of finding sperm is higher among mTESE failures in Asia.

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