Prognostic factors of success rate in microdissection testicular sperm extraction in male with non-obstructive azoospermia at Hanoi Medical University Hospital
Main Article Content
Abstract
Infertility affects 15% of couples, with 50% of the causes attributed to males. Non-obstructive azoospermia (NOA) is the most severe form; although micro-TESE can identify sperm, the causes of NOA are often undeterminedMicrodissection testicular sperm extraction (Micro-TESE) is an effective and safe method, but there is currently no consensus on the factors that predict its success. This study aimed to identify the associated factors and develop a predictive model for the success rate of Micro-TESE in patients with non-obstructive azoospermia (NOA) to improve treatment. 63 males with NOA underwent Micro-TESE. Results showed that the mean age of the patients was 31.76 ± 5.72 years old. High levels of LH and FSH were observed. The sperm retrieval rate was 30.16%. Sertoli cell-only syndrome was the most common lesion. Men with unretrievable sperm had higher FSH levels and more severe testicular histological lesions (p =0.023 and 0.004) +. Conclusion: FSH and testicular histology have prognostic value for sperm retrieval in Micro-TESE in NOA patients. Each unit increase in FSH reduces the sperm retrieval ability by 4.8% (p = 0.029), and each one-level increase in histological damage decreases the retrieval rate by approximately 51% (p = 0.049).
Article Details
Keywords
Non-obstructive azoospermia, micro-TESE
References
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2. Thonneau P, Marchand S, Tallec A, et al. Incidence and main causes of infertility in a resident population (1 850 000) of three French regions (1988–1989)*. Human Reproduction. 1991;6(6):811-816. doi:10.1093/oxfordjournals.humrep.a137433.
3. Chiba K, Enatsu N, Fujisawa M. Management of non-obstructive azoospermia. Reprod Med Biol. 2016; 15(3): 165-173. doi:10.1007/s12522-016-0234-z.
4. Jarow JP, Espeland MA, Lipshultz LI. Evaluation of the azoospermic patient. J Urol. 1989; 142(1): 62-65. doi:10.1016/s0022-5347(17)38662-7.
5. Schoor RA, Elhanbly S, Niederberger CS, Ross LS. The role of testicular biopsy in the modern management of male infertility. J Urol. 2002; 167(1):197-200.
6. Johnsen SG. Testicular Biopsy Score Count – A Method for Registration of Spermatogenesis in Human Testes: Normal Values and Results in 335 Hypogonadal Males. Hormones. 2008; 1(1): 2-25. doi:10.1159/000178170.
7. Schlegel PN, Su LM. Physiological consequences of testicular sperm extraction. Hum Reprod. 1997; 12(8): 1688-1692. doi:10.1093/humrep/12.8.1688.
8. Ezeh UI, Moore HD, Cooke ID. A prospective study of multiple needle biopsies versus a single open biopsy for testicular sperm extraction in men with non-obstructive azoospermia. Hum Reprod. 1998; 13(11): 3075-3080. doi:10.1093/humrep/13.11.3075.
9. Friedler S, Raziel A, Strassburger D, Soffer Y, Komarovsky D, Ron-El R. Testicular sperm retrieval by percutaneous fine needle sperm aspiration compared with testicular sperm extraction by open biopsy in men with non-obstructive azoospermia. Hum Reprod. 1997; 12(7): 1488-1493. doi:10.1093/humrep/12.7.1488.
10. Rosenlund B, Kvist U, Plöen L, Rozell BL, Sjöblom P, Hillensjö T. A comparison between open and percutaneous needle biopsies in men with azoospermia. Hum Reprod. 1998; 13(5): 1266-1271. doi:10.1093/humrep/13.5.1266.
11. Tournaye H. Surgical sperm recovery for intracytoplasmic sperm injection: which method is to be preferred? Hum Reprod. 1999;14 Suppl 1:71-81. doi:10.1093/humrep/14.suppl_1.71.
12. Schlegel PN. Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Hum Reprod. 1999; 14(1): 131-135. doi:10.1093/humrep/14.1.131.
13. Amer M, Ateyah A, Hany R, Zohdy W. Prospective comparative study between microsurgical and conventional testicular sperm extraction in non-obstructive azoospermia: follow-up by serial ultrasound examinations. Hum Reprod. 2000; 15(3): 653-656. doi:10.1093/humrep/15.3.653.
14. Okada H, Dobashi M, Yamazaki T, et al. Conventional versus microdissection testicular sperm extraction for nonobstructive azoospermia. J Urol. 2002; 168(3): 1063-1067. doi:10.1016/S0022-5347(05)64575-2.
15. Ramasamy R, Yagan N, Schlegel PN. Structural and functional changes to the testis after conventional versus microdissection testicular sperm extraction. Urology. 2005; 65(6): 1190-1194. doi:10.1016/j.urology.2004.12.059.
16. Ghalayini IF, Al-Ghazo MA, Hani OB, et al. Clinical comparison of conventional testicular sperm extraction and microdissection techniques for non-obstructive azoospermia. J Clin Med Res. 2011; 3(3): 124-131. doi:10.4021/jocmr542w.
17. Okubo K, Ogura K, Ichioka K, et al. [Testicular sperm extraction for non-obstructive azoospermia: results with conventional and microsurgical techniques]. Hinyokika Kiyo. 2002; 48(5): 275-280.
18. Schlegel PN, Li PS. Microdissection TESE: sperm retrieval in non-obstructive azoospermia. Hum Reprod Update. 1998; 4(4): 439. doi:10.1093/humupd/4.4.439.
19. Li H, Chen LP, Yang J, et al. Predictive value of FSH, testicular volume, and histopathological findings for the sperm retrieval rate of microdissection TESE in nonobstructive azoospermia: a meta-analysis. Asian Journal of Andrology. 2018; 20(1): 30. doi:10.4103/aja.aja_5_17.
20. Rachman RI, Nurullah G, Atmoko W, Rasyid N, Cho SY, Birowo P. Clinical parameters as predictors for sperm retrieval success in azoospermia: experience from Indonesia. F1000Research. 2023; 12:1567. doi:10.12688/f1000research.141969.1.
21. Colpi GM, Colpi EM, Piediferro G, et al. Microsurgical TESE versus conventional TESE for ICSI in non-obstructive azoospermia: a randomized controlled study. Reprod Biomed Online. 2009; 18(3): 315-319. doi:10.1016/s1472-6483(10)60087-9.
22. Ramasamy R, Lin K, Gosden LV, Rosenwaks Z, Palermo GD, Schlegel PN. High serum FSH levels in men with nonobstructive azoospermia does not affect success of microdissection testicular sperm extraction. Fertil Steril. 2009; 92(2): 590-593. doi:10.1016/j.fertnstert.2008.07.1703.
23. Minhas S, Bettocchi C, Boeri L, et al. European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2021 Update on Male Infertility. Eur Urol. 2021; 80(5): 603-620. doi:10.1016/j.eururo.2021.08.014.
24. Dohle GR, Elzanaty S, van Casteren NJ. Testicular biopsy: clinical practice and interpretation. Asian J Androl. 2012; 14(1): 88-93. doi:10.1038/aja.2011.57.
25. Cerilli LA, Kuang W, Rogers D. A practical approach to testicular biopsy interpretation for male infertility. Arch Pathol Lab Med. 2010; 134(8): 1197-1204. doi:10.5858/2009-0379-RA.1
26. Owen A, Carlson K, Sparzak PB. Age-Related Fertility Decline. In: StatPearls. StatPearls Publishing; 2024. Accessed October 18, 2024. http://www.ncbi.nlm.nih.gov/books/NBK576440/.
27. Abdullah L, Bondagji N. Histopathological patterns of testicular biopsy in male infertility: A retrospective study from a tertiary care center in the western part of Saudi Arabia. Urol Ann. 2011; 3(1): 19-23. doi:10.4103/0974-7796.75867.
28. Siadati S, Shafi H, Ghorbani H. Testicular Biopsy in Males With Infertility: A Longitudinal Study. Iranian Journal of Pathology. 2017; 12(2): 177.
29. Mehmood S, Aldaweesh S, Junejo NN, Altaweel WM, Kattan SA, Alhathal N. Microdissection testicular sperm extraction: Overall results and impact of preoperative testosterone level on sperm retrieval rate in patients with nonobstructive azoospermia. Urology Annals. 2019; 11(3): 287. doi:10.4103/UA.UA_36_18.
30. Taitson PF, Filho AM, Radaelli MRM. Testicular sperm extraction in men with sertoli cell-only testicular histology - 1680 cases. JBRA Assisted Reproduction. 2019; 23(3): 246. doi:10.5935/1518-0557.20190023.
31. Liu G, Zhang J, Wang Z, Liang X. The predict value of seminiferous tubule hyalinization for the sperm retrieval rate of micro-dissection testicular sperm extraction in the non-obstructive azoospermia patients. Fertility and Sterility. 2016; 106(3): e300. doi:10.1016/j.fertnstert.2016.07.851.
32. Yu Y, Xi Q, Wang R, et al. Heterogenicity of testicular histopathology and tubules as a predictor of successful microdissection testicular sperm extraction in men with nonobstructive azoospermia. Medicine. 2018; 97(22): e10914. doi:10.1097/MD.0000000000010914.
33. Gashti NG, Gilani MAS, Abbasi M. Sertoli cell-only syndrome: etiology and clinical management. Journal of Assisted Reproduction and Genetics. 2021; 38(3): 559. doi:10.1007/s10815-021-02063-x.
34. Anniballo R, Ubaldi F, Cobellis L, et al. Criteria predicting the absence of spermatozoa in the Sertoli cell-only syndrome can be used to improve success rates of sperm retrieval. Human Reproduction. 2000; 15(11): 2269-2277. doi:10.1093/humrep/15.11.2269.
35. Bergmann M. [Spermatogenesis--physiology and pathophysiology]. Urologe A. 2005; 44(10): 1131-1132, 1134-1138. doi:10.1007/s00120-005-0909-2.
36. Suede SH, Malik A, Sapra A. Histology, Spermatogenesis. In: StatPearls. StatPearls Publishing; 2024. Accessed October 26, 2024. http://www.ncbi.nlm.nih.gov/books/NBK553142/.
37. Jeyendran RS. Interpretation of Semen Analysis Results: A Practical Guide. Cambridge University Press; 2000. doi:10.1017/CBO9780511759086.
38. Nguyễn Hoài Bắc, Trần Thị Hoa, Đinh Quang Hải. Đánh giá mối liên quan giữa thể tích với chức năng của tinh hoàn trên đối tượng nam giới đến khám tại Bệnh viện Đại học Y Hà Nội. Tạp chí Nghiên cứu Y học. 2023; 171:87-94. doi:10.52852/tcncyh.v171i10.2004.
39. D L, Y M, Dj K. Micro-testicular sperm extraction outcomes for non-obstructive azoospermia in a single large clinic in Victoria. The Australian & New Zealand journal of obstetrics & gynaecology. 2022; 62(2). doi:10.1111/ajo.13477.
40. Phạm Đức Minh, Đoàn Thị Hằng, Trịnh Thế Sơn. Nghiên cứu một số đặc điểm lâm sàng, cận lâm sàng và hiệu quả thu tinh trùng bằng phương pháp micro tese ở bệnh nhân klinefelter vô tinh. VMJ. 2023; 533(1). doi:10.51298/vmj.v533i1.7719.
41. Chen X, Ma Y, Zou S, et al. Comparison and outcomes of nonobstructive azoospermia patients with different etiology undergoing MicroTESE and ICSI treatments. Translational Andrology and Urology. 2019; 8(4): 36673-36373. doi:10.21037/tau.2019.04.08.
42. Pavan-Jukic D, Starc A, Stubljar D, Jukic T. Obesity with High Body Mass Index Does Not Influence Sperm Retrieval in Males with Azoospermia. Med Sci Monit. 2020; 26:e923060-1-e923060-6. doi:10.12659/MSM.923060.
43. Schubert M, Pérez Lanuza L, Gromoll J. Pharmacogenetics of FSH Action in the Male. Front Endocrinol (Lausanne). 2019; 10:47. doi:10.3389/fendo.2019.00047.
44. Meachem S, Nieschlag E, Simoni M. Inhibin B in male reproduction: Pathophysiology and clinical relevance. European journal of endocrinology / European Federation of Endocrine Societies. 2001; 145: 561-571. doi:10.1530/eje.0.1450561.
45. Colpi GM, Colpi EM, Piediferro G, et al. Microsurgical TESE versus conventional TESE for ICSI in non-obstructive azoospermia: a randomized controlled study. Reproductive BioMedicine Online. 2009; 18(3): 315-319. doi:10.1016/S1472-6483(10)60087-9.
46. Eken A, Gulec F. Microdissection testicular sperm extraction (micro-TESE): Predictive value of preoperative hormonal levels and pathology in non-obstructive azoospermia. The Kaohsiung Journal of Medical Sciences. 2018; 34(2): 103-108. doi:10.1016/j.kjms.2017.08.010.
47. Flannigan R, Bach PV, Schlegel PN. Microdissection testicular sperm extraction. Transl Androl Urol. 2017; 6(4): 745-752. doi:10.21037/tau.2017.07.07.
48. Chen X, Ma Y, Zou S, et al. Comparison and outcomes of nonobstructive azoospermia patients with different etiology undergoing MicroTESE and ICSI treatments. Translational Andrology and Urology. 2019; 8(4): 366. doi:10.21037/tau.2019.04.08.
49. Zhang HL, Zhao LM, Mao JM, et al. Sperm retrieval rates and clinical outcomes for patients with different causes of azoospermia who undergo microdissection testicular sperm extraction-intracytoplasmic sperm injection. Asian Journal of Andrology. 2020; 23(1): 59. doi:10.4103/aja.aja_12_20.
50. Colaco S, Modi D. Azoospermia factor c microdeletions and outcomes of assisted reproductive technology: a systematic review and meta-analysis. Fertility and Sterility. 2024; 121(1): 63-71. doi:10.1016/j.fertnstert.2023.10.029.
2. Thonneau P, Marchand S, Tallec A, et al. Incidence and main causes of infertility in a resident population (1 850 000) of three French regions (1988–1989)*. Human Reproduction. 1991;6(6):811-816. doi:10.1093/oxfordjournals.humrep.a137433.
3. Chiba K, Enatsu N, Fujisawa M. Management of non-obstructive azoospermia. Reprod Med Biol. 2016; 15(3): 165-173. doi:10.1007/s12522-016-0234-z.
4. Jarow JP, Espeland MA, Lipshultz LI. Evaluation of the azoospermic patient. J Urol. 1989; 142(1): 62-65. doi:10.1016/s0022-5347(17)38662-7.
5. Schoor RA, Elhanbly S, Niederberger CS, Ross LS. The role of testicular biopsy in the modern management of male infertility. J Urol. 2002; 167(1):197-200.
6. Johnsen SG. Testicular Biopsy Score Count – A Method for Registration of Spermatogenesis in Human Testes: Normal Values and Results in 335 Hypogonadal Males. Hormones. 2008; 1(1): 2-25. doi:10.1159/000178170.
7. Schlegel PN, Su LM. Physiological consequences of testicular sperm extraction. Hum Reprod. 1997; 12(8): 1688-1692. doi:10.1093/humrep/12.8.1688.
8. Ezeh UI, Moore HD, Cooke ID. A prospective study of multiple needle biopsies versus a single open biopsy for testicular sperm extraction in men with non-obstructive azoospermia. Hum Reprod. 1998; 13(11): 3075-3080. doi:10.1093/humrep/13.11.3075.
9. Friedler S, Raziel A, Strassburger D, Soffer Y, Komarovsky D, Ron-El R. Testicular sperm retrieval by percutaneous fine needle sperm aspiration compared with testicular sperm extraction by open biopsy in men with non-obstructive azoospermia. Hum Reprod. 1997; 12(7): 1488-1493. doi:10.1093/humrep/12.7.1488.
10. Rosenlund B, Kvist U, Plöen L, Rozell BL, Sjöblom P, Hillensjö T. A comparison between open and percutaneous needle biopsies in men with azoospermia. Hum Reprod. 1998; 13(5): 1266-1271. doi:10.1093/humrep/13.5.1266.
11. Tournaye H. Surgical sperm recovery for intracytoplasmic sperm injection: which method is to be preferred? Hum Reprod. 1999;14 Suppl 1:71-81. doi:10.1093/humrep/14.suppl_1.71.
12. Schlegel PN. Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Hum Reprod. 1999; 14(1): 131-135. doi:10.1093/humrep/14.1.131.
13. Amer M, Ateyah A, Hany R, Zohdy W. Prospective comparative study between microsurgical and conventional testicular sperm extraction in non-obstructive azoospermia: follow-up by serial ultrasound examinations. Hum Reprod. 2000; 15(3): 653-656. doi:10.1093/humrep/15.3.653.
14. Okada H, Dobashi M, Yamazaki T, et al. Conventional versus microdissection testicular sperm extraction for nonobstructive azoospermia. J Urol. 2002; 168(3): 1063-1067. doi:10.1016/S0022-5347(05)64575-2.
15. Ramasamy R, Yagan N, Schlegel PN. Structural and functional changes to the testis after conventional versus microdissection testicular sperm extraction. Urology. 2005; 65(6): 1190-1194. doi:10.1016/j.urology.2004.12.059.
16. Ghalayini IF, Al-Ghazo MA, Hani OB, et al. Clinical comparison of conventional testicular sperm extraction and microdissection techniques for non-obstructive azoospermia. J Clin Med Res. 2011; 3(3): 124-131. doi:10.4021/jocmr542w.
17. Okubo K, Ogura K, Ichioka K, et al. [Testicular sperm extraction for non-obstructive azoospermia: results with conventional and microsurgical techniques]. Hinyokika Kiyo. 2002; 48(5): 275-280.
18. Schlegel PN, Li PS. Microdissection TESE: sperm retrieval in non-obstructive azoospermia. Hum Reprod Update. 1998; 4(4): 439. doi:10.1093/humupd/4.4.439.
19. Li H, Chen LP, Yang J, et al. Predictive value of FSH, testicular volume, and histopathological findings for the sperm retrieval rate of microdissection TESE in nonobstructive azoospermia: a meta-analysis. Asian Journal of Andrology. 2018; 20(1): 30. doi:10.4103/aja.aja_5_17.
20. Rachman RI, Nurullah G, Atmoko W, Rasyid N, Cho SY, Birowo P. Clinical parameters as predictors for sperm retrieval success in azoospermia: experience from Indonesia. F1000Research. 2023; 12:1567. doi:10.12688/f1000research.141969.1.
21. Colpi GM, Colpi EM, Piediferro G, et al. Microsurgical TESE versus conventional TESE for ICSI in non-obstructive azoospermia: a randomized controlled study. Reprod Biomed Online. 2009; 18(3): 315-319. doi:10.1016/s1472-6483(10)60087-9.
22. Ramasamy R, Lin K, Gosden LV, Rosenwaks Z, Palermo GD, Schlegel PN. High serum FSH levels in men with nonobstructive azoospermia does not affect success of microdissection testicular sperm extraction. Fertil Steril. 2009; 92(2): 590-593. doi:10.1016/j.fertnstert.2008.07.1703.
23. Minhas S, Bettocchi C, Boeri L, et al. European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2021 Update on Male Infertility. Eur Urol. 2021; 80(5): 603-620. doi:10.1016/j.eururo.2021.08.014.
24. Dohle GR, Elzanaty S, van Casteren NJ. Testicular biopsy: clinical practice and interpretation. Asian J Androl. 2012; 14(1): 88-93. doi:10.1038/aja.2011.57.
25. Cerilli LA, Kuang W, Rogers D. A practical approach to testicular biopsy interpretation for male infertility. Arch Pathol Lab Med. 2010; 134(8): 1197-1204. doi:10.5858/2009-0379-RA.1
26. Owen A, Carlson K, Sparzak PB. Age-Related Fertility Decline. In: StatPearls. StatPearls Publishing; 2024. Accessed October 18, 2024. http://www.ncbi.nlm.nih.gov/books/NBK576440/.
27. Abdullah L, Bondagji N. Histopathological patterns of testicular biopsy in male infertility: A retrospective study from a tertiary care center in the western part of Saudi Arabia. Urol Ann. 2011; 3(1): 19-23. doi:10.4103/0974-7796.75867.
28. Siadati S, Shafi H, Ghorbani H. Testicular Biopsy in Males With Infertility: A Longitudinal Study. Iranian Journal of Pathology. 2017; 12(2): 177.
29. Mehmood S, Aldaweesh S, Junejo NN, Altaweel WM, Kattan SA, Alhathal N. Microdissection testicular sperm extraction: Overall results and impact of preoperative testosterone level on sperm retrieval rate in patients with nonobstructive azoospermia. Urology Annals. 2019; 11(3): 287. doi:10.4103/UA.UA_36_18.
30. Taitson PF, Filho AM, Radaelli MRM. Testicular sperm extraction in men with sertoli cell-only testicular histology - 1680 cases. JBRA Assisted Reproduction. 2019; 23(3): 246. doi:10.5935/1518-0557.20190023.
31. Liu G, Zhang J, Wang Z, Liang X. The predict value of seminiferous tubule hyalinization for the sperm retrieval rate of micro-dissection testicular sperm extraction in the non-obstructive azoospermia patients. Fertility and Sterility. 2016; 106(3): e300. doi:10.1016/j.fertnstert.2016.07.851.
32. Yu Y, Xi Q, Wang R, et al. Heterogenicity of testicular histopathology and tubules as a predictor of successful microdissection testicular sperm extraction in men with nonobstructive azoospermia. Medicine. 2018; 97(22): e10914. doi:10.1097/MD.0000000000010914.
33. Gashti NG, Gilani MAS, Abbasi M. Sertoli cell-only syndrome: etiology and clinical management. Journal of Assisted Reproduction and Genetics. 2021; 38(3): 559. doi:10.1007/s10815-021-02063-x.
34. Anniballo R, Ubaldi F, Cobellis L, et al. Criteria predicting the absence of spermatozoa in the Sertoli cell-only syndrome can be used to improve success rates of sperm retrieval. Human Reproduction. 2000; 15(11): 2269-2277. doi:10.1093/humrep/15.11.2269.
35. Bergmann M. [Spermatogenesis--physiology and pathophysiology]. Urologe A. 2005; 44(10): 1131-1132, 1134-1138. doi:10.1007/s00120-005-0909-2.
36. Suede SH, Malik A, Sapra A. Histology, Spermatogenesis. In: StatPearls. StatPearls Publishing; 2024. Accessed October 26, 2024. http://www.ncbi.nlm.nih.gov/books/NBK553142/.
37. Jeyendran RS. Interpretation of Semen Analysis Results: A Practical Guide. Cambridge University Press; 2000. doi:10.1017/CBO9780511759086.
38. Nguyễn Hoài Bắc, Trần Thị Hoa, Đinh Quang Hải. Đánh giá mối liên quan giữa thể tích với chức năng của tinh hoàn trên đối tượng nam giới đến khám tại Bệnh viện Đại học Y Hà Nội. Tạp chí Nghiên cứu Y học. 2023; 171:87-94. doi:10.52852/tcncyh.v171i10.2004.
39. D L, Y M, Dj K. Micro-testicular sperm extraction outcomes for non-obstructive azoospermia in a single large clinic in Victoria. The Australian & New Zealand journal of obstetrics & gynaecology. 2022; 62(2). doi:10.1111/ajo.13477.
40. Phạm Đức Minh, Đoàn Thị Hằng, Trịnh Thế Sơn. Nghiên cứu một số đặc điểm lâm sàng, cận lâm sàng và hiệu quả thu tinh trùng bằng phương pháp micro tese ở bệnh nhân klinefelter vô tinh. VMJ. 2023; 533(1). doi:10.51298/vmj.v533i1.7719.
41. Chen X, Ma Y, Zou S, et al. Comparison and outcomes of nonobstructive azoospermia patients with different etiology undergoing MicroTESE and ICSI treatments. Translational Andrology and Urology. 2019; 8(4): 36673-36373. doi:10.21037/tau.2019.04.08.
42. Pavan-Jukic D, Starc A, Stubljar D, Jukic T. Obesity with High Body Mass Index Does Not Influence Sperm Retrieval in Males with Azoospermia. Med Sci Monit. 2020; 26:e923060-1-e923060-6. doi:10.12659/MSM.923060.
43. Schubert M, Pérez Lanuza L, Gromoll J. Pharmacogenetics of FSH Action in the Male. Front Endocrinol (Lausanne). 2019; 10:47. doi:10.3389/fendo.2019.00047.
44. Meachem S, Nieschlag E, Simoni M. Inhibin B in male reproduction: Pathophysiology and clinical relevance. European journal of endocrinology / European Federation of Endocrine Societies. 2001; 145: 561-571. doi:10.1530/eje.0.1450561.
45. Colpi GM, Colpi EM, Piediferro G, et al. Microsurgical TESE versus conventional TESE for ICSI in non-obstructive azoospermia: a randomized controlled study. Reproductive BioMedicine Online. 2009; 18(3): 315-319. doi:10.1016/S1472-6483(10)60087-9.
46. Eken A, Gulec F. Microdissection testicular sperm extraction (micro-TESE): Predictive value of preoperative hormonal levels and pathology in non-obstructive azoospermia. The Kaohsiung Journal of Medical Sciences. 2018; 34(2): 103-108. doi:10.1016/j.kjms.2017.08.010.
47. Flannigan R, Bach PV, Schlegel PN. Microdissection testicular sperm extraction. Transl Androl Urol. 2017; 6(4): 745-752. doi:10.21037/tau.2017.07.07.
48. Chen X, Ma Y, Zou S, et al. Comparison and outcomes of nonobstructive azoospermia patients with different etiology undergoing MicroTESE and ICSI treatments. Translational Andrology and Urology. 2019; 8(4): 366. doi:10.21037/tau.2019.04.08.
49. Zhang HL, Zhao LM, Mao JM, et al. Sperm retrieval rates and clinical outcomes for patients with different causes of azoospermia who undergo microdissection testicular sperm extraction-intracytoplasmic sperm injection. Asian Journal of Andrology. 2020; 23(1): 59. doi:10.4103/aja.aja_12_20.
50. Colaco S, Modi D. Azoospermia factor c microdeletions and outcomes of assisted reproductive technology: a systematic review and meta-analysis. Fertility and Sterility. 2024; 121(1): 63-71. doi:10.1016/j.fertnstert.2023.10.029.