Algorithm for azoospermic men with normal follicle stimulating hormone (FSH) levels and an unclear clinical diagnosis...

In men with azoospermia, it is critical to differentiate between obstructive azoospermia (OA) and non-obstructive azoospermia (NOA). Clinical and laboratory cues such as testicular volumes, dilatation of the epididymides, semen volumes, historical or physical examination clues of etiologies of azoospermia, and the serum follicle stimulating hormone (FSH) level can help differentiate between OA and NOA. However, in some cases there are mixed findings making the differentiation more challenging. The American Urologic Association/American Society for Reproductive Medicine (AUA/ASRM) guidelines recommend that in men with normal semen volume, normal testicular volume, no epididymal dilatation, and FSH ≤7.6, a diagnostic testicular biopsy differentiates between OA and NOA. Although this is diagnostic, it is invasive, an additional procedure, additional recovery and cost, violates testicular parenchyma that may disrupt vasculature to downstream areas of spermatogenesis, and may delay time to in vitro fertilization (IVF). The AUA/ASRM guidelines recommend attempting sperm cryopreservation at the time of biopsy if present for IVF, but his is a conventional testicular sperm extraction (cTESE) which has a lower sperm retrieval rate in men with NOA. The objective of this study is to explore a novel algorithm for men in this situation.

A retrospective chart review of the electronic health records was performed of men presenting for fertility evaluations diagnosed with azoospermia with testicular volume, epididymal exam, semen volume, and serum FSH levels not allowing for a definitive diagnosis of NOA versus OA who underwent cTESE progressing to microdissection testicular sperm extraction (microTESE) when indicated with intraoperative diagnostic testicular biopsies. Histopathologic patterns diagnostic of NOA versus OA in men with normal FSH levels and uncertain preoperative diagnoses of NOA versus OA were assessed.

Over two-thirds of men in this cohort with serum FSH levels <7.6 IU/L with unclear preoperative clinical indicators of NOA versus OA had histopathological diagnoses consistent with NOA.

cTESE under anesthesia progressing to microTESE when indicated is an appropriate algorithm minimizing morbidity and numbers of interventions in men with normal serum FSH levels and an unclear preoperative diagnosis of NOA versus OA.