MicroTESE vs. FNA Mapping: Medieval or Modern?

Put two experts in a room and give each of them the same problem to solve. What you’ll find is that they typically use similar
“knowledge structures” and “heuristic strategies” (i.e. organized and principled thinking) and then proceed to break the problem into smaller, more digestible ones to solve it. But, despite similar cognitive approaches, the solutions they derive may be worlds apart. And this is precisely what happened with the problem of
male infertility due to azoospermia.

Breaking it Down

Finding sperm in men with no ejaculated sperm due to testis failure is not easy. The first issue is that you need to look in the testicle itself to find sperm. To most men, infertile or not, this alone raises eyebrows. It’s also not a great way to make friends in life. Second, sperm may or may not be there. There may only be sperm precursor cells present, which are not clinically usable. Third, if you rifle around too much or too many times in testicles, they could lose the ability to supply the body with normal testosterone levels, and that’s a whole other problem. Fourth, many patients want to “know before they go” and spend mid-5 figures on assisted reproduction (IVF-ICSI) when they have no sperm available. So, now you see that this seemingly simple problem of no sperm is actually many problems, ranging from medical and physical to financial and psychological.

Crafting Solutions

One of us, the creator of microdissection testicular sperm extraction, hails from New York. Dr. Schlegel observed that if you look closely enough at the 700 ft. of tiny tubules that compromise the human testicle, tubules that contain sperm tend to be larger than those that don’t. So, starting with the testis biopsy, he made the incision much larger, and brought a microscope in to inspect all of the testicular tubules, often for hours. And, lo and behold, more sperm were found in more cases. Not bad, but a bit, well…medieval.
In California, where the sun shines more, we developed a different strategy. Although we agree that sampling intensity is critical to finding sperm, I stepped out of the urology thought-box and considered ways to do this non-surgically, without cutting the testicle. In fact, the inspiration for the approach came from my UCSF colleague Dr. Britt Marie Ljung, a Swedish clinician who told me: “I use fine needle aspiration all the time to diagnose tumors in children’s eyes.” Not sure about you, but to me procedures on eyes and testicles induce a similar gut reaction, so I was convinced this “less is more” approach might be worth investigating. In a series of papers, we described how fine needle aspiration (FNA) is as good as a biopsy for finding sperm and how it allowed for a whole lot more sampling of the testicle. And safely. Further, it delineates who is, and who is not, a candidate for surgical sperm retrieval. Even further, it allows us to craft” the sperm retrieval to fit the map and reduce the invasiveness, but maintain the success, of sperm retrievals. Now termed FNA “mapping,” or “sperm mapping,” this is a workhorse technique in the field and the ultimate “know before you go” procedure for azoospermia.
Which solution is better? That depends how you define “better.” Higher success? Safer? Cheaper? Fewer complications? The risk/reward combination? Patient-centeredness? This week, these issues will be revealed, in all of their glory, in public debate that we are having at our national fertility meeting. Bring it on, I say.

12 thoughts on “MicroTESE vs. FNA Mapping: Medieval or Modern?

  1. Dear doctor,
    I was diagnosed SCOS after TESA & Mtese, i decided to wait for stem cell therapy that hopefully solve azoospermic patients. Could you tell me how long should I wait for this treatment ???

    1. Dear Nameer, It will be a while, 5-10 yrs. Consider banking eggs in the meantime so that if the sperm technology comes around, you and your partner have young eggs to use it with.

  2. Hello Dr. Turek,
    How are you? I hope you are doing great! I recently found you online and I been reading a lot about you and it’s amazing everything you are doing for us men and Male Infertility. It’s something to admire. But anyways, a bit about me so far….
    I was diagnosed with non obstructive Azoospermia this Aug.2015. I’m 31 years old and been married for three years already. Between the time I was diagnosed and now, I have done the following tests:
    Testicular ultrasound: Normal testis sizes, with no hydroceles or bilaterally with the exception of a right epididymal cyst 6mm.
    Prolactin: 12.1 ng/mL
    Total Testosterone: 342 ng/dL
    Luteinizing Hormone 4.6 mIU/mL
    FSH: 12.80 MIU/ML
    Karyotype: Normal Male Karyotype
    Now I’m going for a Y Chromosome analysis test this up coming week. My older brother was also diagnosed with NOA with a Y Chromosome micro deletion in the AZF (b). So I’m wondering what is up for me, if is going to be the same result or what but who knows?
    But anyways to the main topic. I definitely want/try to be a biological father in the future and I would definitely would do the less invasive procedures first. It makes no sense doing the more invasive procedure (MicroTESE) when I can do Mapping to get a very accurate sign if is worth doing the more invasive procedure to find sperm. I think the majority, if not every man out there would want the less invasive procedure (Mapping) anytime of the week.
    And according to my research:::Mapping has a higher success rate, safer, and fewer complications. And the the risk/reward combination is better with mapping. And most important, is what makes sense to me the most.

    1. Dear JCesar, Fascinating that you AND your brother are both azoospermic and that he has a Y chromosome deletion and yours is getting tested. Typically, we believe that Y deletions ARE NEW TO EACH GENERATION (de novo) and not typically inherited. However, your test will be quite compelling to see. The most important feature of the Y deletion test here is whether this is a COMPLETE or INCOMPLETE/PARTIAL deletion. Finding sperm with a complete AZFb deletion is rare, but finding sperm with a partial deletion is possible. Thank you for your support of FNA Mapping, too!

      1. Dr. Turek,
        Thanks for your respond. My brother’s deletion is a non continuous partial. But he went to a second opinion at NYC aND that doctor told him he wanted to do a more detailed you chromosome test to see the severity of the Micro deletion with more markers something of that nature. He said that the test he previously got wasn’t that clear. I’m doing my test at the same location at NYC. I will definitely share my results with you once I have them. I will keep you updated. Thanks again for taking the time.

        1. Hello Dr. Turek
          How are you? I hope are you doing great! As I promise that I would keep you updated on our situations as brothers….
          This is an updated on my brother’s results. As I had told you he did his Y chromosome analysis with Labcorp for the first time and it came out as a AZFb partial deletion. He went to see another doctor at Cornell NYC and that doctor told him he wanted to do his own Y chromosome Analysis……forward a month later…., NOW he just go his results from Cornell at NYC and his Y chromosome analysis came out as a complete AZFb deletion, and he was told that the only option he had was to wait for science to have a shot a biological child.
          Two questions…
          1.What would you suggest for my brother to do?
          2. Can a lab do an error on this test because it’s clear one lab did an error. Labcorp or the lab at Cornell NYC. This is when expertise on this field is really needed. My brother doesn’t know if he should seek a second opinion about all this? His situation was already complex but now with two different results results for the same test makes even more complex and frustrating.
          ****My Y chromosome analysis still pending at Cornell NYC***** so I will keep you updated on my results.
          Hope to hear from you. Thanks for your help.

  3. Are there other doctors in the US, specifically Eastern states, who are trained and currently practice FNA mapping?
    I am hopeful my internet research led to this blog post and your website with possibilities we had not heard of. My husband was diagnosed with azoospermia through testis biopsy 4 years ago. The urologist said he had no germ cells but he does have sertoli cells. The doctor suspects it was caused by my husband’s cancer treatment with the drug cyclophosophamide at age 14-15. He is now 31. He also has a vericocele, but the urologist said that was not the cause of the infertility so it did not need to be corrected. We were told “there is nothing I can do. Consider using a sperm donor or adopting.”
    We would prefer to find someone more local as the mapping technique may provide us with a more accurate diagnosis.

    1. Michelle, I like your logic of looking harder than a simple biopsy for sperm in the case of chemotherapy induced azoospermia. FNA mapping would likely double the chance of finding sperm. Currently there is no one fully trained and certified (by me) to do FNA mapping on the east coast of US.

      1. Dr Turek
        thanks for this valuable blog.
        I have a question for you:
        I am 46yo male no hx of cancer or chemotherapy was recently diagnosed as SCOS with FNA mapping done in NY after taking 3 months of clomid 50mg every other day.
        I do have a bilateral varicocele which was not repaired first seen when I was 19.
        my FSH was high and my testosterone was low little over 300.
        my karyotype was normal and no genetic abnormalies were detected in the Y chromosome.
        Do you think TESE procedure is indicated based on my FNA mapping results? What is the percentages of patient going through TESE after negative sperm detection in FNA mapping? I heard Dr Silber indicate cases like mine from 25 to 60% of finding sperm using his approach to micro-TESE.
        Do you recommend fixing my varicoceles and I heard the most effective way is to fix bilaterally based on literature not unilateral repair.
        I would appreciate if you can answer this questions.

  4. Dr Turek
    How are you doing?
    I hope you are well.
    Thanks for this Blog.
    I have a very important matter to ask you.
    I was recently diagnosed with sertoli cells only syndrome with testicular mapping done in NY (this is same procedure invented by you) after three months of taking clomid 50mg every other day.
    I am 46 and had two sperm analysis indicated zero sperms.
    My FSH was elevated
    my testosterone was slightly above 300
    my genetic studies were all normal
    They did detected large bilateral varicoceles which was discovered when i was 19 but no repair was done.
    Do you think there is a way for me to have a biological child of my own and also Do you think I would benefit from micro TESE procedure Dr Silber style.
    And is there any use of doing varicocele surgery considering my SCOS diagnosis.
    I would appreciate if you can help.

  5. Hello Dr. Turek,
    I want to know your opinion on using the FNA mapping procedure for slightly small testes with stippled bilateral calcifications for a male with no varicocele and azoospermia.

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