Human Reproduction vol.12 no.7 pp.
1488–1493, 1997
Testicular sperm retrieval by percutaneous fine needle
sperm aspiration compared with testicular sperm
extraction by open biopsy in men with non-obstructive
azoospermia
S.Friedler1, A.Raziel, D.Strassburger, Y.Soffer,
D.Komarovsky and R.Ron-El
IVF and Infertility unit, Department of Obstetrics and Gynecology,
Assaf Harofeh Medical Center, Zerifin 70300, Israel
1To
whom correspondence should be addressed
The efficiency of testicular sperm retrieval by testicular
fine needle aspiration (TEFNA) was compared with open
biopsy and testicular sperm extraction (TESE), in 37
rigorously selected patients with non-obstructive azoo-
spermia. All patients underwent TEFNA and TESE consec-
utively. Thus, each patient served as his own control. The
case was regarded as successful if at least one testicular
spermatozoon was found allowing intracytoplasmic sperm
injection (ICSI) of at least one oocyte. The mean age of
the male patients was 32.7 years (range 24–47). Whereas
by TEFNA spermatozoa enabling performance of ICSI
were found in only four patients out of 37 (11%), open
biopsy and TESE yielded spermatozoa in 16 cases (43%).
The negative predictive value of high serum follicle stimu-
lating hormone (FSH) concentrations ( 10 IU/l) (predicting
failure to find spermatozoa for ICSI) was low (38.4%). The
positive predictive value (predicting the chance to find
spermatozoa for ICSI) of normal-sized testicle was not
different from that of small-sized (<15 ml) testicle (50%).
Complications included one case of testicular bleeding
following fine needle aspiration, treated locally, and two
cases of extratunical haematomata following TESE requir-
ing no intervention. In patients with non-obstructive azoo-
spermia, TEFNA has a significantly lower yield compared
to TESE. Performance of ICSI with testicular sperm in
these cases resulted in satisfactory fertilization and high
embryo transfer rates. The implantation and pregnancy
rates per embryo transfer were 13 and 29% respectively.
Neither serum FSH values nor testicular size were predict-
ive of the chances to find spermatozoa for ICSI. Some
complications may occur even following TEFNA.
Key words: ICSI/non-obstructive azoospermia/testicular fine
needle aspiration/testicular sperm extraction
Introduction
The ability to use only a few spermatozoa from the ejaculate
for intracytoplasmic sperm injection (ICSI) in order to achieve
high fertilization and pregnancy rates (Palermo et al., 1992)
along with the concept of using testicular sperm to achieve
fertilization and pregnancies (Schoysman et al., 1993) has
revolutionized the potential to treat patients suffering from
1488
azoospermia. The first to be treated were patients with obstruct-
ive azoospermia, where viable spermatozoa aspirated from the
epididymis (Tournaye et al., 1994) or testis (Craft et al., 1993),
permitted the achievement of high pregnancy rates following
ICSI (Silber et al., 1995a,b). The surgical sperm retrieval
methods introduced include open surgery aimed at the epididy-
mis, by micro-epididymal sperm aspiration (MESA) (Temple-
Smith et al., 1985; Tournaye et al., 1994; Silber et al., 1994)
or testicular biopsy with testicular sperm extraction (TESE)
(Schoysman et al., 1993; Devroey et al., 1994; Nagy et al.,
1995; Silber et al., 1995a,b,c; Abuzeid et al., 1995). Following
the remarkable results in patients with obstructive azoospermia,
success has been reported using a less invasive method of
sperm retrieval, the percutaneous aspiration by fine needle,
aiming at the epididymis (percutaneous epididymal sperm
aspiration, PESA) (Craft and Shrivastav, 1994; Shrivastav
et al., 1994; Craft et al., 1995a,b) or testis (testicular sperm
aspiration, TESA) (Tsirigotis and Craft, 1995; Craft and
Tsirigotis, 1995). Alternatively, in obstructive azoospermia,
efficient retrieval of testicular spermatozoa by closed percutan-
eous testicular biopsy was reported, using a modified 20-gauge
Menghini testicular biopsy needle (Bourne et al., 1995) or a
Biopty gun (Hovatta et al., 1995).
While in obstructive cases spermatozoa are abundant in the
epididymal or testicular tubuli, permitting a high rate of
retrieval success, in the non-obstructive cases the epididymis
is devoid of spermatozoa and only a few foci with spermato-
genesis may be found in the testicles. Publication of successful
sperm retrieval by testicular open biopsy in a case of partial
tubular atrophy and severely reduced spermatogenesis, but
normal gonadotrophins (Yemini et al., 1995), and another
case with Sertoli cell-only syndrome and markedly elevated
gonadotrophins (Gil-Salom et al., 1995), was complemented
almost simultaneously by a report on a series of successful
attempts in extraction of spermatozoa from testicular tissue by
multiple open biopsies in non-obstructive azoospermic patients
(Devroey et al., 1995). Since then, more experience has been
reported concerning the use of TESE and ICSI in non-
obstructive azoospermia (Tournaye et al., 1995, 1996;
Kahraman et al., 1996; Devroey et al., 1996; Silber et al.,
1996). Recently, the alternative sperm aspiration methodology
of testicular fine needle aspiration (TEFNA) performed in a
patient with maturation arrest and elevated gonadotrophins
has been published (Lewin et al., 1996). Still, experience in
applying fine needle aspiration in cases with non-obstructive
azoospermia is limited. To evaluate the possible clinical
advantages of TEFNA over open biopsy in non-obstructive
azoospermic patients, a prospective study was undertaken,
performing TEFNA prior to the open biopsies in all cases with
© European Society for Human Reproduction and Embryology

non-obstructive azoospermia. The predictive value of clinical
parameters such as serum follicle stimulating hormone (FSH)
concentration or the testicular volume, upon the chance to find
spermatozoa allowing performance of ICSI, was also analysed.
Materials and methods
Study population
The study population included 37 couples with non-obstructive
azoospermic male partners treated at Assaf Harofeh Medical Center’s
IVF unit, during the period of November 1995 to August 1996. The
mean age of the patients was 32.7 years (range 24–47). The patients
underwent physical examination of their genitalia, testicular and
transrectal sonography, assessment of their hormonal profile, cytogen-
etic consultation (including karyotyping and genetic family history)
and extensive work-up of several ejaculates prior to their surgical
sperm aspiration. No spermatozoa could be seen in any ejaculate
provided. Diagnosis of non-obstructive azoospermia based upon the
classification by Levin (1979) was made from the histological report,
taken previously or during the current procedure. The histological
findings according to Levin (1979) may include germ cell aplasia
(Sertoli cell-only syndrome), maturation arrest, germ cell hypoplasia
(severe hypospermatogenesis) or tubular sclerosis or even a combina-
tion of these histological findings. Chromosomal analysis was normal
in all patients.
All 37 consecutive patients were candidates for TESE, but consented
to undergo TEFNA prior to the open biopsy in order to compare in
the same patient the efficiency of the two procedures. The patients’
serum follicle stimulating hormone (FSH) values and testicular
volumes were recorded as well and correlated with the outcome of
the testicular sperm retrieval.
Sperm retrieval and preparation
TEFNA and TESE were performed under general anaesthesia. On
the day of the oocyte retrieval, the male partners were asked to
produce fresh ejaculates, and by extended sperm preparation (Ron-El
et al., 1996) the absence of spermatozoa in the specimen was verified.
Methodology of TEFNA procedure
All patients underwent TEFNA, using 21-gauge butterfly needles
attached to a 20 ml plastic syringe serving as an aspiration device.
The butterfly needle was passed directly through the scrotal skin, into
the testis, moved up and down at various sites, directing the needle
into the rete testis. While holding the testicle between the index
finger and the thumb, six different entries were made in each testicle,
sampling various locations. Before retrieving the needle from the
testis, a small artery forceps was used to clamp the butterfly’s
microtubing. Following each aspiration, the needle was flushed with
Earle’s balanced salt solution (EBSS) (Gibco BRL, Life Technologies,
Paisley, UK) with heparin (Sigma Chemical Co., St Louis, MO, USA)
into one well of a 4-well plate (Nunc, Copenhagen, Denmark). For
each puncture, a new butterfly needle was used. The aspirates were
immediately examined under an inverted microscope (Diaphot 300;
Nikon Corp., Tokyo, Japan) at 3200 and 3400 magnification to
detect presence the of any spermatozoa. The aspirate was then
collected and transferred to a 6 ml conical tube (Falcon; Becton
Dickinson Labware, NJ, USA) and centrifuged at 300 g for 10 min.
Purification of the cell suspensions was executed by lysis of erythro-
cytes (by a 5 min suspension in erythrocyte-lysing buffer, containing
155 mM NH4Cl, 10 mM KHCO3, 2 mM EDTA, pH 7.2). Cell
separation after red cell lysis, by discontinuous Percoll gradient, was
not performed in all cases. However, occasionally, when a lot of cell
TEFNA versus TESE for non-obstructive azoospermia
debris was seen, the resuspended pellet was layered on a mini-Percoll
gradient (90–45%) (Sigma) and centrifuged at 300 g for 20 min. The
original pellet after red cell lysis or the sperm-containing fraction
following Percoll separation (90% Percoll) was washed twice, by
addition of 6 ml of human tubal fluid (HTF)–HEPES–albumin medium
supplemented with 7.5% synthetic serum (Irvine Scientific, Santa
Ana, CA, USA) and centrifuged at 250 g for 5 min. The final pellet
was incubated until the sperm injection (between 3 and 6 h). Prior to
the injection, the final pellet was examined under the inverted
microscope for the presence of spermatozoa using a Petri dish
containing multiple droplets (up to 50) of 10 µl each. If spermatozoa
were identified, they were transferred to drops of 10% polyvinyl-
pyrrolidone (Irvine) covered by pre-equilibrated embryo-tested
paraffin oil (Sigma).
Methodology of TESE procedure
In all cases, irrespective of the result of TEFNA, up to three open
biopsies were performed in each testicle yielding tissue upon which
sperm extraction was executed. TESE was performed according to
the technique published by Silber et al. (1996). After stabilization of
the testicle, a small incision in the testicle’s mid-portion was per-
formed, cutting through the scrotal skin, tunica vaginalis and the
tunica albuginea. A substantial piece of the extruding testicular tissue
was cut with small scissors, washed by medium to remove blood
traces and placed in a Petri dish containing ~1–3 ml EBSS with
heparin (Gibco). In the laboratory, a wet preparation was carried out
(Jow et al., 1993) for examination. Testicular tissue was vigorously
fragmented and minced using two glass slides and immediately
examined under the inverted microscope for the presence of spermato-
zoa. Once spermatozoa were found the surgical procedure was
terminated. If spermatozoa were not observed, up to three biopsies
were taken, from different areas of the same testicle and also from
the contralateral testicle. The testicle was closed by layers using 3-0
vicryl or plane stitches. Part of the testicular specimen was sent for
histological analysis. Following vigorous tissue shredding, HTF–
HEPES–albumin medium supplemented with 7.5% synthetic serum
was added to the suspension obtained and incubated in 6 ml Falcon
tubes, for 2 h (5% CO2 in air) at 37°C. The overlying pellet was then
collected and centrifuged (300 g for 10 min). The remaining pellet
was isolated, processed and finally examined in multiple droplets
under oil, according to the procedures described above. Also, the
remains of the underlying pellet were processed and examined in
multiple droplets, as described above.
Ovulation induction and oocyte retrieval was performed as
described elsewhere (Ron-El et al., 1991), using a protocol of gonad-
otrophin releasing hormone agonist (DTRP6, Decapeptyl 3.75 mg
i.m.; Ferring, Malmö, Sweden) suppression with human menopausal
gonadotrophins (HMG) (Pergonal; Teva, Petah Tikva, Israel) for
ovarian stimulation. Oocytes were retrieved 36 h after administration
of 10 000 IU of human chorionic gonadotrophin (HCG) (Chorigon;
Teva), by vaginal ultrasound-guided follicular puncture.
Sperm collection and ICSI procedure
When spermatozoa could be identified and isolated, ICSI was per-
formed as described by Van Steirteghem et al. (1993). Following
removal of the oocyte’s surrounding cumulus and corona cells, nuclear
maturation assessment was performed using an inverted microscope,
to ensure injection of metaphase II oocytes only. Fertilization was
assessed on the following day, 16–18 h post sperm injection, and
confirmed if two distinct pronuclei could be observed.
Embryo transfer, luteal support and pregnancy evaluation
After assessment of fertilization, embryonic cleavage and morpholo-
gical quality ~24 h later, embryo transfer was performed, using a
1489
S.Friedler et al.

Table I. Correlation between testicular histology and sperm presence for Table II. Correlation between testicular size and sperm presence, following
intracytoplasmic sperm injection, following testicular sperm extraction testicular sperm extraction
(TESE) and testicular fine needle aspiration (TEFNA)
Testicular n Spermatozoa PPV NPV Sensitivity Specificity
Testicular n No Spermatozoa Spermatozoa volume
histology spermatozoa found by found by Not found Found
found TESE (%) TEFNA
ù15 ml 23 15 8 57% 65% 50% 71%
Germ cell aplasia 11 6 5 (45.4%) 1 (small)
Maturation arrest 14 10 4 (28.5%) 1 .15 ml 14 6 8
Germ cell hypoplasia 7 3 4 (57.2%) 2 (normal)
Not availablea 5 2 3 (60.0%)
PPV 5 positive predictive value; NPV 5 negative predictive value.
aIn five cases histology was not performed due to patients’ objections on
religious grounds.

Table III. Correlation between serum follicle stimulating hormone (FSH)

Wallace catheter. Luteal support included i.m injections of HCG,
2500 IU, on days of embryo transfer 13, 16, 19 or of progesterone
in oil (50 mg/day, Gestone; Paines and Byrne, Surrey, UK), from day
11 until serum βHCG measurement 14 days following embryo
transfer. Only clinical pregnancies indicated by sonographic demon-
stration of a gestational sac were counted.
Results
Of the 37 patients with non-obstructive azoospermia, testicular
spermatozoa were retrieved in 16 (43%), to enable the perform-
ance of ICSI. A significant difference (P 5 0.02, Fisher’s
exact test) was found using the two methodologies of sperm
retrieval. Whereas TEFNA yielded spermatozoa in 11%
(4/37) of the patients or 25% (4/16) of the patients in whom
testicular spermatozoa were available, with TESE, testicular
spermatozoa were found in 16 out of the 37 patients (43%).
No significant difference was observed in the mean 6 SD age
(years) between the males in whom testicular spermatozoa
were available (32.5 6 5.9, range 24–43) or where sperm
retrieval failed (33.4 6 5.8, range 24–47), nor between those
with successful retrieval by TEFNA (32.5 6 7.4, range 24–
42) or TESE (32.5 6 6.0, range 24–43) (P . 0.05, Fisher’s
exact test).
The distribution of the variable histological entities among
the patients in our study group was correlated with presence
of spermatozoa following sperm retrieval, according to the
two methodologies used (Table I). Five patients refused transfer
of any piece of tissue from the testicular biopsy for histological
examination, on religious grounds. Testicular spermatozoa
were found in half of the males with germ cell aplasia
(45%, 5/11) or hypoplasia (57%, 4/7). The chances of finding
spermatozoa in cases of maturation arrest were almost half
that of the previous pathologies (28%, 4/14). As shown in
Table I, spermatozoa could be aspirated by TEFNA in any of
the three histological categories.
Regarding the total number of testicular spermatozoa har-
vested with the two methods, although not having quantitative
data, our experience is that only few spermatozoa were
available following TEFNA. Consequently, no spermatozoa
were left for freezing following TEFNA, whereas in six
patients following TESE, spermatozoa were available for
freezing from the remaining testicular tissue.
The mean 6 SD values of serum FSH values in the
TEFNA1 group and TESE1 group were 25 6 13.8 and 17
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levels and sperm presence, following testicular sperm extraction
n Spermatozoa PPV NPV Sensitivity Specificity
Not found Found
Mean 6 SD 22 6 0.8a 19 6 10.9a
FSH (IU/l)
ø10 6 2 4 66% 61% 25% 90%
.10 31 19 12
ø20 18 11 7 39% 53% 44% 48%
,20 19 10 9
PPV 5 positive predictive value; NPV 5 negative predictive value.
aNo significant difference, Student’s t-test.
6 9.6 IU/l respectively (P . 0.5, Student’s t-test). Three of
the four TEFNA1 patients had testicular volume of ø15 ml
compared with five (42%) of the 12 TESE1 patients (P 5
0.28, Fisher’s exact test).
Correlation between testicular volume and the presence of
spermatozoa for ICSI following TESE is presented in Table II.
No statistically significant difference was found in the number
of patients with small testicles between patients with successful
or unsuccessful TESE. The positive predictive value (PPV) of
normal testicular volume (.15 ml), predicting the chance of
finding spermatozoa, was 57%, disappointingly similar to the
negative predictive value (NPV) of small testicles (ø15 ml),
predicting failure to find spermatozoa, in 65% of the cases.
That means that even in men with small testicles, in eight out
of 23 (35%) spermatozoa could be identified. The calculated
sensitivity of small testicular volume was 50% and specifi-
city 71%.
There was no statistically significant difference in the
mean serum FSH values comparing patients yielding testicular
spermatozoa for ICSI following TESE (22 6 10.8 IU/l), and
those in whom no testicular spermatozoa were found (19 6
10.9 IU/l) (Table III). Positive and negative predictive values
were calculated, classifying the patients for cut-off points of
10 and 20 IU/l FSH. The NPV of obviously elevated serum
FSH values, predicting failure to find spermatozoa for ICSI,
was insufficient (for a limit of ø10 IU/l, 61%; for a limit of
ø20 IU/l, 53%). The PPV of normal serum FSH values (ø10
IU/l), predicting the chance of finding spermatozoa for ICSI,
was also disappointing (67%). The specificity and sensitivity
of FSH are listed in Table III.
Complications following TEFNA included one case of
bleeding, necessitating haemostatic suturing. Otherwise, bluish

Table IV. Outcome of testicular sperm extraction 1 intracytoplasmic sperm
injection (ICSI) in patients with non-obstructive azoospermia
No. of cycles with sperm for ICSI 16
No. of injected oocytes 125
No. of oocytes fertilized 61 (49 %)
No. of embryos cleaved 57 (93 %)
No. of embryos transferred 45
No. of embryos cryopreserved 3 Only in one of the latter groups were spermatozoa found on
Implantation rate 6/45 (13%)
No. of embryo transfers 14/16 (91 %)
Pregnancy rate/transfer 4/14 (29 %)
spots indicating small focal bleeding on the tunica and in the
testis were observed once the testicles were opened following
TEFNA. Following the biopsies, two cases of small haemat-
omata outside the tunica albuginea were observed. In one
patient the testis reached a volume of 30 ml, and resided
spontaneously after 4 weeks following the procedure. In the
second patient the haematoma was of 20–25 ml and absorbed
spontaneously within 10 days.
The outcomes of the cycles performing ICSI with testicular
spermatozoa from patients with non-obstructive azoospermia
in our study are presented in Table IV. The 2-pronuclear
fertilization rate was 49%, leading to an embryo transfer in
91% of the cycles. The implantation rate was 13% and the
clinical pregnancy rate per embryo transfer 29.0%.
Discussion
The patients included in our study group were diagnosed as
non-obstructive azoospermic males with testicular failure. This
diagnosis was not based on their hypergonadotrophic status or
size of testicles but on the histology of their testicular biopsies
performed during the same procedure in which spermatozoa
were retrieved for ICSI. Therefore testicular sperm retrieval
success or failure correlated in our study with the actual
histopathological evaluation of the same piece of testicular
tissue. Furthermore, ‘pseudo-azoospermia’ was also excluded,
as all patients underwent extensive examination of their ejacu-
lates for existence of any spermatozoa, prior to any surgical
intervention (Ron-El et al., 1996). Considering that in non-
obstructive azoospermia eventual foci of normal spermato-
genesis may exist in the testicles (Silber, 1995; Silber et al.,
1995c; Devroey et al., 1995; Tournaye et al., 1995), it is
natural to assume a positive correlation between the amount
of testicular tissue retrieved and the chance of finding spermato-
zoa for ICSI. Use of TEFNA for assessment of testicular
cytology has been reported (Foresta et al., 1992; Mallidis and
Baker, 1994) but being efficient mainly in showing evidence
of complete spermatogenesis. The use of this technique for
diagnosis of testicular failure (Gottschalk-Sabbag et al., 1995)
has yet to be proven. In the original series implementing TESE
for non-obstructive azoospermia (Devroey et al., 1995; Silber
et al., 1996) up to four or five testicular biopsies were taken
per testicle to maximize the chances of finding spermatozoa.
Therefore, our methodology included up to six fine needle
punctures in each testicle, allowing sampling of several regions
of the testicle.
TEFNA versus TESE for non-obstructive azoospermia
Our results show that sperm retrieval by TEFNA is a
less efficient method for sperm retrieval in non-obstructive
azoospermia, compared with TESE. Hovatta et al. (1995), in
her report focusing on obstructive azoospermia, included six
patients in whom no spermatozoa could be retrieved by
testicular needle biopsy, whose histology showed spermatog-
enic arrest (one case) and hypospermatogenesis (five cases).
the open biopsy.
Jow et al. (1993) reported finding motile spermatozoa in
wet testicular tissue preparations. Their failure rates to find
spermatozoa in cases of germ cell aplasia, maturation arrest
or germ cell hypoplasia were 100, 77 and 36%, respectively
(overall 20/29 5 68.9%). Our failure rates, according to the
respective histologies, were 55, 75 and 50% (overall 57%). In
the series reported by Tournaye et al. (1996), concerning 54
TESE procedures performed in non-obstructive azoospermic
patients, only in 10 patients (18.5%) were spermatozoa not
found for ICSI. However, 27 of these patients had ‘virtual
azoospermia’, meaning that they had had at least one sperm
cell present in a previous ejaculate, indicating some foci of
spermatogenesis. In contrast, our group included patients with
absolute azoospermia, with absence of spermatozoa previously
verified in many ejaculates. Therefore, the observed lower
success rate may be partially explained by the difference in
the patient population and our rigorous inclusion criteria in
this study. According to Tournaye et al. (1996), patients with
germ cell aplasia or maturation arrest needed significantly
more (up to 20) biopsies to be taken in order to find spermato-
zoa. Patients with germ cell hypoplasia, similarly to those with
normal histology, required significantly fewer biopsies to be
taken (up to three) and had significantly more spermatozoa
recovered. Our failure rate of 56% may express not only the
difference in the patient population and the rigorous inclusion
criteria but also the fact that, after taking three substantial
pieces of tissue, the testicular biopsy procedure was concluded
to avoid extensive irreversable testicular damage. For the time
being, it seems that these patients should be offered open
testicular biopsy as the optimal testicular sperm retrieval
procedure, allowing examination of a relatively large amount
of tissue in order to recruit sufficient number of spermatozoa
for ICSI. In many testicles, variable histological pictures may
coexist, including areas of Sertoli cell only, maturation arrest
and normal focal spermatogenesis (Silber et al., 1995c), all
different expressions of the same genetic disturbance involving
deletions in specific regions of the Y chromosome (Reijo et al.,
1995, 1996). Therefore, evaluation of the results by histological
finding has questionable biological meaning in our opinion.
Neither serum FSH values nor testicular size were predictive
of the chances of finding spermatozoa for ICSI, supporting
previous reports (Tournaye et al., 1995). In fact, testicular
failure may exist in conjunction with fairly normal testicles
and normal serum FSH values (De Kretser et al., 1995).
Testicular parenchymal damage may perpetuate elevation of
FSH, without necessarily presenting in all patients as total
damage in the germinal epithelium (Martin-du-Pan and
Bischof, 1995). Therefore, the serum value of FSH cannot be
used as an indicator for absolute absence of spermatogenesis.
1491
S.Friedler et al.
In fact, the inability of FSH concentrations to predict the
presence of spermatozoa available for ICSI emphasizes the
need to find efficient prospective parameters that can predict
the chances for success in finding spermatozoa in the testicles
of patients suffering from non-obstructive azoospermia and
save an unnecessary and hopeless procedure for half of the
patients. Furthermore, a prospective follow-up of the possible
complications after testicular sperm retrieval should be recom-
mended, to investigate whether fewer complications follow
TEFNA compared to open biopsies.
Previous experience showed that, by using testicular sperma-
tozoa for ICSI, in comparison to ejaculated spermatozoa,
lower rates of fertilizaton were achieved (Nagy et al., 1995).
Following ICSI with testicular spermatozoa, the fertilization
rate of 49% in our group is comparable with the fertilization
rates of 34, 45.2 and 58% in cases with non-obstructive
azoospermia published previously [Kahraman et al., 1996;
Tournaye et al., 1996 (normal histology excluded); and
Devroey et al., 1996, respectively].
However, the implantation rate of 13% in our group of
patients was lower than the 26.6, 18.4 and 19% reported by
others [Kahraman et al., 1996, Tournaye et al., 1996 (normal
histology excluded); and Devroey et al., 1996, respectively].
The low implantation rate and pregnancy rate of 29% per
embryo transfer may be best explained by the rigorous preselec-
tion of these cases, probably reflecting their genetic potential.
In conclusion, azoospermic men suffering from non-
obstructive testicular failure should be offered testicular sperm
retrieval by TESE, rather than by TEFNA. TESE seems to be
a significantly more efficient method to obtain testicular
spermatozoa in these cases, allowing not only successful ICSI,
but also freezing of testicular spermatozoa for later use in
subsequent cycles.
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Received on December 30, 1996; accepted on April 21, 1997

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