Navigating male infertility through testicular biopsy: outcomes, predictive parameters, and surgical innovation

Advancements in the management of male infertility, particularly azoospermia, have significantly improved with the evolution of testicular biopsy techniques. This review explores the clinical applications and outcomes of three primary methods: testicular sperm aspiration (TESA), testicular sperm extraction (TESE), and microdissection TESE (mTESE). TESA remains a practical, minimally invasive solution for obstructive azoospermia, offering high success rates. However, its limited effectiveness in non-obstructive azoospermia (NOA) highlights the need for more refined approaches. mTESE has emerged as the preferred method in NOA cases due to its microsurgical precision, higher sperm retrieval rates, and reduced damage to testicular tissue. Multiple factors influence the success of these procedures, including patient age, testicular volume, hormone levels, and underlying histopathology. The identification of reliable predictive biomarkers such as follicle-stimulating hormone (FSH), inhibin B, anti-Müllerian hormone (AMH), and TEX101 has enhanced patient selection and procedural planning. Additionally, imaging techniques and metabolite profiling are emerging as valuable non-invasive tools for predicting outcomes. The integration of AI and machine learning into clinical practice further supports individualized treatment strategies by improving predictive accuracy and intraoperative decision-making. Despite clinical success, ethical and psychosocial considerations remain central to the comprehensive care of affected individuals. Financial constraints and unequal access to specialized reproductive services also pose challenges. Future efforts should prioritize the development of validated predictive models, the expansion of biomarker research, and the implementation of standardized clinical protocols. A multidisciplinary, patient-centered approach will be essential in optimizing outcomes for men facing infertility due to azoospermia.