ADULT UROLOGY

ELSEVIER

SYSTEMATIC FINE-NEEDLE ASPIRATION OF THE TESTIS:

CORRELATION TO BIOPSY AND RESULTS OF ORGAN
“MAPPING” FOR MATURE SPERM IN AZOOSPERMIC MEN
PAUL J. TUREK, IMOK CHA, AND BRITT-MARIE LJUNG

ABSTRACT
Objectives. This study compares fine-needle aspiration (FNA) and testis biopsy for the ability to detect
mature sperm in the testes of azoospermic men. In addition, we introduce the concept of testis “mapping”
with FNA and apply it to detect sperm in men with severe testis failure.
Methods. Sixteen patients were evaluated for azoospermia in a university-based infertility clinic. All men
had testis biopsies and FNAs from matched testicular sites to assess for the presence of spermatozoa.
Adequacy criteria for FNA specimens were strictly defined, and correlative analysis of the two techniques
was performed. In addition, a subset of 12 men with nonobstructive azoospermia (NOA) had systematic FNA
mapping (more than four FNA sites per testis) to detect mature sperm for potential clinical use.
Results. Adequate FNA specimens were obtained in 1 15 (91.3%) of 126 FNA attempts. Of 34 paired biopsy
FNA sites, FNA was seen to be more sensitive than, and equally specific as, testis biopsy for sperm detection.
When compared with the biopsy touch imprint, FNA was equally as sensitive and specific. Among men with
NOAwho underwent FNA mapping, 4 (33%) of 12 had localized “patches” of sperm detected in areas distant
from sperm-negative biopsy sites. In 1 case, a pregnancy was achieved with later biopsy and sperm extraction
“directed” by previous FNA.
Conclusions. For sperm detection, testis FNA provides equivalent or better information than a testis biopsy.
FNA can localize areas of sperm production within the testis and accurately guide sperm extraction proce-
dures in men with NOA. UROLOGY 49: 743-748, 1997. 0 1997, Elsevier Science Inc. All rights reserved.

A zoospermic men with obstruction

children with the use of testicular

or severe
testis failure are now able to father biological
sperm in con-
of men with NOA. First, there are no clinical or
laboratory features of men with NOA that are
clearly predictive of success with sperm extrac-
junction with in vitro fertilization (IVF) and in- tion procedures.3,4 Second, there is clinical evi-
tracytoplasmic sperm injection (ICSI).132 Al- dence to suggest that spermatogenesis in dam-
though it is not difficult to retrieve sperm from aged or failing testes may vary geographically,
obstructed testes, there is failure to obtain suf- resulting in focal areas or “patches” of sperm
ficient sperm for IVF and ICSI in 25% to 50% of production within an organ largely devoid of
men with severe testis failure, termed nonob- germ cells.4l5 This concept, in combination with
structive azoospermia (NOA).3,4 When testicular the fact that biopsy sites are usually randomly
sperm extraction attempts fail in cases of NOA, chosen for sperm extraction procedures, makes
IVF cycles are canceled at great emotional and it likely that these procedures fail simply because
financial cost to couples. There are several rea- of sampling error, or the inability to accurately
sons for failure to extract sperm from the testes find pockets of spermatogenesis in NOA testes.
To address these variables and to more fully in-
form infertile couples with NOA of the potential
From the Departments of Urology and Pathology, University of to retrieve sperm before IVF, we hypothesized that
California Sun Francisco, San Francisco, California sperm production could be systemically “mapped’
Reprint requests: PaulJ. Turek, M.D., Department of Urology, within the testis. Based on the concept of system-
U-575, University of California San Francisco, San Francisco,
CA 94143-0738
atic biopsy of the prostate in the detection of pros-
Submitted (Rapid Communication): November 25, 1996, ac- tate cancer, we used the established technique of
cepted (with revisions): December 17, 1996 fine-needle aspiration (FNAYj,’ to localize the

0 1997, ELSEVIER SCIENCE INC. 0090-4295/97/$17.00

ALL RIGHTS RESERVED PI1 s0090-4295(97)00154-4 743
presence or absence of mature sperm throughout
the testis. The comparative findings of FNA and
testis biopsy from obstructed and NOA testes as
well as preliminary results from testis “mapping”
are reported in this study.
MATERIAL AND METHODS
A consecutive series of 16 infertile patients were evaluated
for azoospermia by a single investigator (P.J.T.) in the Male
Infertility Clinic at the University of California San Francisco.
A history, physical examination and serum total testosterone
and follicle-stimulating hormone (FSH) levels were obtained
for all patients. Testis volume was estimated with a Prader
orchiometer (ASSI, Westbury, NY). In addition, a semen anal-
ysis, centrifuged pellet of ejaculate, and postejaculate urine
were examined to confirm true azoospermia. The presence of
either obstructive azoospermia or NOA was suspected before
testis biopsy. The diagnosis of obstructive azoospermia was
likely when the history or physical examination suggested a
blockage, serum testosterone and FSH levels were normal, the
centrifuged ejaculate contained no sperm, and the testes were
of normal size and consistency. If these general criteria were
not met, then a diagnosis of NOA was suspected.
All patients underwent a surgical testis biopsy and slide
touch imprint’ under local anesthesia to determine the state
of spermatogenesis and to confirm the suspected diagnosis.
FNA was performed immediately before biopsy (12 men) or
at a separate sitting if a previous biopsy had been performed
(4 men). We were interested in the ability of each technique
to determine the presence of sperm in the extracted tissue
obtained from site-matched areas of the testis. Approval by
the university committee on human research was obtained for
the study.
After written informed consent was obtained, the FNA pro-
cedure was performed as follows. With the patient recumbent,
the scrotal skin was prepared with 0.1% chlorhexidine. The
spermatic cord was infiltrated with 5 mL of 0.5% buvipicaine/
1% lidocaine (1:l mixture). To quicken the distribution of
the anesthetic, the region of the spermatic cord was gently
massaged after injection. After several minutes, the testis was
firmly palpated to ensure absence of pain. The testis was po-
sitioned with the epididymis and vas deferens directed pos-
teriorly, safe from injury. The scrotal skin was stretched taut
over the testis by elevating the testis and circumferentially
wrapping the scrotal skin behind the testis with a sponge or
small Penrose drain (Fig. 1). The “testicular wrap” served not
only as a convenient handle for manipulating the testis but
also fixed the scrotal skin over the testis for the procedure.
Using a sterile pen, the planned sites of aspiration were
marked on the scrotal skin overlying the testis. Depending on
testis size, four to nine systematically placed aspiration sites
were mapped. Using the local anesthetic, wheals of scrotal
skin were raised at the planned FNA sites.
FNA was performed with a sharp-beveled, 23-gauge fine
needle (Becton-Dickinson Co., Franklin Lakes, NJ) using the
established suction-cutting technique.g Briefly, the 23-gauge
needle, attached to a lo-mL syringe (Becton-Dickinson Co.)
and held with a Cameco syringe holder (Precision Dynamics
Corp., San Fernando, Calif), was percutaneously placed in the
testis at a planned site. Suction (1 to 2 mL) was then applied
and the syringe holder held steady as the needle was moved
in and out, without changing direction and keeping the needle
tip within the substance of the testis. Twenty to 30 needle
excursions were performed, with a stroke size in the range of
8 to 12 mm to aspirate tissue fragments. The suction was
released before the needle was withdrawn from the testis.
With the needle disconnected from the syringe, air was drawn
744
FIGURE 1. Illustration of the circumferential “testis
wrap” with gauze and location of systematic, planned
aspiration sites.
into the syringe, the needle was reattached, and the tissue
fragments were expelled from the needle onto a slide. A por-
tion of the aspirated seminiferous tubules was gently smeared
onto a glass microscope slide and immediately immersed into
95% ethyl alcohol. A routine Papanicolaou stain was per-
formed on the slide. A second smear from each aspiration site
was air-dried and stained with May-Grunwald-Giemsa stain.
When performed together with FNA, surgical biopsies were
obtained with the “window” techniquea in areas of the testis
tunica albuginea with puncture marks corresponding to pre-
vious percutaneous FNA sites. Immediate touch imprints of
each biopsy were fixed in ethyl alcohol and stained with the
Papanicolaou stain. The biopsy tissue was placed in Bouin’s
solution and processed for routine histologic analysis. For
FNA procedures performed after surgical biopsy at separate
sittings, matched aspiration sites were carefully chosen to cor-
respond to the healed and scarred areas of earlier biopsies.
The goal of specimen interpretation was simply to deter-
mine the presence or absence of sperm in the extracted FNA
or surgical biopsy material. Surgical biopsies were interpreted
by pathologists for (1) established spermatogenic patterns
(normal, hypospermatogenesis, maturation arrest, Sertoli cell
only), and (2) whether complete spermatogenesis was pres-
ent. Because mature sperm with tails are difficult to see on
surgical biopsy, the finding of late spermatids in any portion
of the biopsy was interpreted as complete spermatogenesis
(sperm present). The stained biopsy touch imprints and FNA
smears were independently read by two cytologists (I.C., B.L.)
for (1) specimen adequacy and (2) the presence or absence of
mature sperm with tails. An adequate tissue smear from FNA
or touch imprint was defined as that which contained at least
12 clusters of testis cells or at least 2000 well-dispersed testis
cells. To correlate the findings from site-to-site matched sur-
gical biopsy and FNA specimens, 2 X 2 tables were con-
structed.
RESULTS
The clinical and laboratory characteristics of
the azoospermic men are shown in Table I. Kar-
UROLOGY 49 61, 1997
 TABLE I. Profile of azoospermic patients
Clinical FSH Level Testis Volume (mL)
Pt No. Diagnosis Histologic Diagnosis (2-17 IU/mL)* Left Right FNA Map
1 Idiopathic SC0 - 12 12 Yes
2 CAVD Normal 4.0 18 18 NO
3 Orchitis Maturation arrest 2.0 18 18 No
4 Varicocele Maturation arrest 4.4 18 15 Yes
5 Idiopathic SC0 52 8 8 Yes
6 Idiopathic Maturation arrest 27 10 12 Yes
7 Varicocele Maturation arrest&CO 30 12 12 Yes
8 Idiopathic SC0 23 8 10 Yes
9 Cryptorchid SC0 35 8 8 Yes
10 CAVD Normal - 20 20 No
11 Idiopathic SC0 18 8 8 Yes
12 Hx seminoma Hypospermatogenesis 34 16 None Yes
13 Hx seminoma Hypospermatogenesis 22 14 None No
14 Idiopathic Sclerosis 25 8 8 Yes
15 Cryptorchid Hypospermatogenesis 5.0 20 20 Yes
16 Varicocele SC0 27 16 14 Yes
KEY: Pt = patient; FSH = follicle-stimulating hormone; FNA = fine-needle aspiration; SC0 = Sertoli cell only; CAVD = congenital absence of vas d&ns; Hx = history oj
* Normal range.

normal or possibly reconstructable reproductive

TESTIS BIOPSY tracts.

CORRELATIONOF FNA WITH TESTIS B~oPsYAND

TOUCHIMPRINT
A total of 126 FNAs were performed in 16 pa-
+ tients. Because fewer biopsies were performed
FNA than FNAs, site-to-site correlations of FNA and
testis biopsy findings were achieved for 34 sites.
I
Correlations between FNA findings and biopsy
touch imprints were available for 34 sites. Overall,
inadequate FNAs were obtained in 11 (8.7%) of
126 attempts. Inadequate touch imprints were ob-
+= sperm present tained in 1 (3%) of 34 biopsies. All testis biopsies
- = sperm absent provided adequate material for examination. The
histologic patterns obtained are presented in Table
FIGURE 2. Cot-relation between fine-needle aspiration
I. No carcinoma in situ (CIS) was observed.
(FNA) and testis biopsy in sperm detection (n = 34
sites). The ability of FNA to detect mature sperm is
compared with that of the testis biopsy in Figure
2. Of the 34 correlated sites, FNA detected sperm
in all cases in which sperm were present on his-
tologic analysis. In the majority of sites, FNA and
yotype analyses, performed in men with idio- biopsy findings agreed that sperm was absent.
pathic NOA, were negative. Patients with both Also, FNA showed sperm at all sites where biop-
obstruction (n = 2) and NOA (n = 14) were sies predicted sperm presence, but at three sites,
included in the correlative study of testis biopsy sperm was present on FNA that was not predicted
with FNA. Among the patients with NOA, 12 un- by the biopsy. This suggests that testis FNA is
derwent systematic FNA “mapping” of the testis, equal to, or more sensitive than, testis biopsy as a
defined as more than four FNA sites per testis. procedure to detect the presence of sperm in the
The 2 remaining patients with NOA were not testis.
truly mapped because fewer than four FNA sites A similar comparison of FNA with biopsy touch
per testis were obtained. Patients with a sus- imprints is shown in Figure 3. Of the 34 corre-
pected obstruction were not mapped with FNA sponding sites, there was complete agreement be-
to theoretically avoid the risk of needle injury to tween the two techniques with respect to the pres-

UROLOGY 49 6), 1997 745

 TOUCH-IMPRINT 8mL 8mL

+ -

+ 12 0
FNA
I
0 22
t

+= sperm present R L
- = sperm absent FIGURE 4. Testis sperm maps from both testes in a pa-
FIGURE 3. Correlation between fine-needle aspiration tient with idiopathic infertility. Previous biopsies from
(FNA) and touch-imprint in sperm detection (n = 34 the middle of each testis showed sclerosis and hyalini-
sites). zation. “X” signifies fine-needle aspiration sites from
which material was obtained, and shaded areas repre-
sent regions in which mature sperm were detected.
ence or absence of sperm. Thus, FNA appears to
be equally as sensitive and specific as touch-im-
print analysis in the detection of testicular sperm. with a superficial wound separation that healed
with supportive care.
RESULTSOF SYSTEMATIC FiVA MAPPING FOR SPERM
IN PATIENTS WITH NOA COMMENT
In 12 patients with NOA, testes were mapped by
obtaining at least four FNA sites per testis. Overall, The use of testicular sperm and IVF and ICSI is
117 FNAs were performed in 23 testes (mean, 5.1 now an established procedure for couples with se-
sites per testis). The mean testis volume in these vere male factor infertility to achieve biological
patients was 11.9 mL (range, 8 to 20). In eight pregnancies. l-4 In states of male reproductive tract
patients, the information obtained from multiple obstruction in which spermatogenesis is normal,
FNA mapping sites concurred with that found on sperm retrieval by either needle aspiration or bi-
one or two testis biopsies. However, in 4 (33%) of opsy is almost uniformly successfu1.2X’o However,
12 men, FNA mapping detected localized patches in men azoospermic because of severely low tes-
of mature sperm within testes that were presumed ticular sperm production, termed NOA, sperm re-
to have no sperm by biopsy. Figure 4 illustrates trieval for IVF and ICSI has a significant failure
the testis map from a man in whom sperm were rate.3’4 This is most likely due to a theoretic prob-
detected on FNA in geographic areas distinct from lem of heterogeneity of spermatogenesis in NOA
the sperm-negative biopsy sites. In one of these testes in conjunction with the use of inaccurate or
four men, sperm were subsequently extracted on “blind” sperm extraction procedures that are
the same day as oocyte retrieval with a repeat bi- highly susceptible to sampling error. There is ev-
opsy directed to the FNA site and a pregnancy idence to suggest that sampling error can be re-
achieved with IVF and ICSI. duced and the success of testis sperm retrieval en-
Initially, to assess testes for complications hanced with multiple testis biopsies in NOA testes.
from the FNA procedure, scrotal ultrasound In one study, up to 20 separate, simultaneous bi-
was performed in men 30 minutes after FNA opsies were performed in the testes of men with
was completed. This was discontinued because NOA to acquire sperm for IVF and ICSI.4 How-
no hematomas or hematoceles were detected. ever, these extended efforts are very laborious and
Subsequently, one patient was observed to have potentially place patients at higher risk of compli-
a small hematocele after the first of five planned cations and organ loss from devascularization.
aspirations in the testis. The hematocele was The present study attempts to solve the dilemma
diagnosed on aspiration at the third site. It was of how to find sperm in NOA testes through the
drained by FNA of the tunical space; pressure novel application of a well-recognized concept: or-
was then applied to the testis for 5 minutes, gan mapping. Although a familiar idea to urolo-
and normal recovery ensued. A second patient gists from experience with prostate cancer detec-
returned 7 days after a surgical biopsy and FNA tion, early hints that this approach may apply to

746 UROLOGY 49 (3, 1997

testicular sperm detection have only recently sur-
faced from work with FNA techniques.‘l Because
it is a cytologic and not histologic technique, FNA
is inferior to testis biopsy in the evaluation of sem-
iniferous tubule and interstitial architecture; it is
an imperfect reporter of the classic histologic pat-
terns of spermatogenesis, such as maturation
rest or hypospermatogenesis.7 However, as the
present study demonstrates, FNA correlates ex-
tremely well with the findings on both testis bi-
opsy and touch-imprint analysis if the objective is
to determine whether sperm are present within the
testis. In fact, this preliminary series suggests that
FNA may be more sensitive than a routinely pre-
pared testis biopsy for sperm detection. In 3 (9%)
of 34 matched sites, FNA detected sperm when the
biopsy did not. Also, in 4 of 12 patients, pockets
of sperm were detected by FNA in areas distant
from sperm-negative biopsy sites. These data also
provide direct clinical confirmation of the fact that
there is heterogeneity of spermatogenesis in the
testes of men with NOA.
One limitation of the study includes the fact that
it represents an early experience in a small series
of consecutive patients that must be confirmed
with further work. The success of FNA at procur-
ing testis tissue should also be addressed. We ap-
plied a strict definition of what constitutes an ade-
quate FNA specimen; using this definition,
aspiration success rates equivalent to those re-
ported in the literature were obtained.6’7 In this
respect, it should be emphasized that the FNA pro-
cedure is a technical one that requires formal train-
ing and, as such, has a brief but real learning curve
associated with it. Also, although information
about testicular malignancies can be acquired with
FNA,l’ it is not clear whether this is also true for
testis CIS. Finally, it is crucial that men with NOA
who are candidates for sperm retrieval be properly
counseled on, and tested for, specific Y-chromo-
some deletions that a small proportion of them
may possess. I3 Infertility-associated gene deletions
are heritable and therefore potentially transmissi-
ble to male offspring.
The present investigation suggests that FNA
mapping may become a very powerful tool in the
evaluation and treatment of infertility. It has re-
cently become an established technique
sperm procurement in patients with obstructed
testes.” With the potential to be more sensitive
for sperm detection than the more invasive testis
biopsy, it certainly holds diagnostic promise. In
addition, it can allow clinicians to direct testis
biopsies to prelocalized areas of sperm produc-
tion for simplified sperm retrieval in difficult
cases of NOA. Likewise, it may save couples with
NOA and no mature sperm on testis mapping the
unnecessary expense and effort that they may
UROLOGY 49 (5), 1997
otherwise invest in IVF cycles destined for fail-
ure.
CONCLUSIONS
For the purpose of spermatozoa identification
within the testes of infertile men, we conclude
ar- from the present study of 16 azoospermic men and
34 site-matched procedures that testis FNA may
be more sensitive and specific than routine testis
biopsy. In addition, the FNA technique can be
safely performed systematically to geographically
map the the testis for spermatozoa in men with
NOA. FNA mapping data reveal that there is het-
erogeneity of spermatogenesis within the failing,
atrophic testis. Indeed, “patches” of sperm pro-
duction may be localized within the testis with this
technique; sperm from these areas can potentially
be retrieved with “directed” biopsies for clinical
use.
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1. Schoysman R, Vanderzwalmen P, Nijs M, Segal L, Se-
gal-Bertin G, Geerts L, van Roosendaal E, and Schoysman D:
Pregnancy after fertilisation with human testicular spermat-
ozoa (Letter). Lancet 342: 1237, 1993.
2. Silber SJ, Van Steirteghem AC, Liu J, Nagy Z, Tournaye
H, and Devroey P: High fertilization and pregnancy rate after
intracytoplasmic sperm injection with spermatozoa obtained
from testicle biopsy. Hum Reprod 10: 148-152, 1995.
3. Kahraman S, Ozgur S, Alatas C, Aksoy S, Tasdemir M,
Nuhoglu A, Tasdemir I, Balaban B, Biberoglu K, Schoysman
R, et al: Fertility with testicular sperm extraction and intra-
cytoplasmic sperm injection in non-obstructive azoospermic
men. Hum Reprod 11: 756-760, 1996.
4. Tournaye H, Liu J, Nagy PZ, Camus M, Goossens A,
Silber S, Van Steirteghem AC, and Devroey P: Correlation be-
tween testicular histology and outcome after intracytoplasmic
sperm injection using testicular spermatozoa. Hum Reprod
11: 127-132, 1996.
5. Skakkebaek NE, Hammen R, Philip J, and Rebbe H:
Quantification of human seminiferous epithelium. III. Histo-
logical studies in 44 men and controls with normal chromo-
some complements. Acta Path01 Microbial Immunol Stand
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6. Piaton E, Fendler JP, Berger N, Perrin P, and Devonec
M: Clinical value of fine needle aspiration cytology and biopsy
in the evaluation of male infertility. Arch Path01 Lab Med 119:
722-726,1995.
7. Gottschalk-Sabag S, Glick T, and Weiss DB: Fine nee-
dle aspiration of the testis and correlation with testicular open
biopsy. Acta Cytol 37: 67-72, 1993.
8. Coburn M, and Wheeler TM: Testicular biopsy in male
for infertility evaluation, in Lipshultz LI, and Howards SS (Eds):
infertility in the Male, 2nd ed. Philadelphia, Mosby-Year Book,
1991, pp 223-253.
9. Ljung B-M: Techniques of aspiration and smear prep-
aration, in Koss LG, Woyke S, and Olszewski W (Eds): As-
piration Biopsy: Cytologic Interpretation and Histologic Bases,
2nd ed. New York, Igaku-Shoin, 1992, pp 12-34.
10. Bourne H, Watkins W, Speirs A, and Baker HWG: Preg-
nancies after intracytoplasmic injection of sperm collected by
fine needle biopsy of the testis. Fertil Steril 64: 433-436,
1995.
11. Gottschalk-Sabag S, Weiss DB, Folb-Zacharow N, and
Zukerman Z: Is one testicular specimen sufficient for quan-
747
titative evaluation of spermatogenesis? Fertil Steril 64: 399-
402, 1995.
12. Verma K, Ram T, and Kapila K: Value of fine needle
aspiration cytology in the diagnosis of testicular neoplasms.
Acta Cytol 33: 631-634, 1989.
13. Reijo R, Lee TY, Salo P, Alagappan R, Brown LG, Ro-
senberg M, Rozen 5, Jaffe T, Straus D, Hovatta 0, et al: Diverse
spermatogenic defects in humans caused by Y chromosome
deletions encompassing a novel RNA-binding protein gene.
Nat Genet 10: 383-393, 1995.
EDITORIAL COMMENT
With the development of intracytoplasmic sperm injection
(ICSI), the potential for procreation in men with previously
untreatable infertility has drastically changed. Even men with
severely abnormal semen analyses now have a mechanism to
allow fertilization of the egg, and pregnancy. The frontier was
advanced even further with reports of ICSI success in men
with nonobstructive azoospermia, by testicular biopsy and
subsequent microinjection of sperm extracted from testicular
tissue.‘,’ Even in men with absolutely no evidence of sperm
production in the testicular biopsy examination (Sertoli cell-
only syndrome or complete maturation arrest), Toumaye et
al3 were able to find enough sperm for ICSI in the majority
of cases.
For those of us who perform testicular biopsy in men with
nonobstructive azoospermia for use in ICSI cycles, a persis-
tent, frustrating problem has been the failure to retrieve ade-
quate numbers of sperm from the biopsy specimen. In their
report, Turek et al. propose a method for limiting this occur-
rence by systematically “mapping” testicular areas for the
presence or absence of sperm production.
Several important messages should be underscored: (1) The
authors verify that in men with nonobstructive azoospermia,
spermatogenesis may be present in some areas of the testis
and not in others. Testicular mapping should allow identifi-
cation of the crucial areas. (2) The possible increased sensi-
tivity with fine-needle aspiration over histologic examination
of testicular tissue in identifying spermatozoa demonstrates
inherent problems with utilizing histologic examination alone
in defining whether a patient may be suitable for testicular
extraction (TESE)/ICSI. (3) Conversely, the agreement be-
tween touch imprint and fine-needle aspiration underscores
the need for touch imprint remaining an integral step in men
undergoing testicular biopsy.
There are potential problems with the proposed testicular
mapping procedure: (1) Although no significant complica-
tions were seen in this series, there is the potential for injury
74%
to testicular tissue from multiple needle passes; and (2) al-
though the presence or absence of morphologically normal
spermatozoa can be determined by this technique, the viabil-
ity of the sperm (and therefore the suitability for ICSI) is not
known. The latter problem could perhaps be circumvented by
a procedure that we have adopted at the University of Mich-
igan. During the diagnostic evaluation of men considered for
ICSI, a portion of the extracted tissue is sent to the gamete
laboratory for direct examination by the embryologists who
perform the ICSI procedures, who then render an opinion of
the suitability of the material in a future ICSI cycle, either
examining for sperm motility, cell membrane integrity by the
eosin-nigrosin method, or by the presence of hypo-osmotic
swelling.
Dana Ohl, M.D.
University of Michigan Medical Center
Section of Urology
Ann Arbor, Michigan
REFERENCES
1. Silber SJ, Van Steirteghem AC, Liu J, Nagy Z, Tournaye
H, and Devroey P: High fertilization and pregnancy rate after
intracytoplasmic sperm injection with spermatozoa obtained
from testicle biopsy. Hum Reprod 10: 148-152, 1995.
2. Kahraman S, Ozgur S, Alatas C, Aksoy S, Tasdemir M,
Huhoglu A, Tasdemir I, Balaban B, Biberoglu K, Schoysman
R, et al: Fertility with testicular sperm extraction and intra-
cytoplasmic sperm injection in non-obstructive azoospermic
men. Hum Reprod 11: 756-760,1996.
3. Toumaye H, Liu J, Nagy PZ, Camus M, Goossens A,
Silber S, Van Steirteghem AC, and Devroey P: Correlation be-
tween testicular histology and outcome after intracytoplasmic
sperm injection using testicular spermatozoa. Hum Reprod
11: 127-132, 1996.
REPLY BY THE AUTHORS
Because we are concerned about the small (but real) poten-
tial for testis injury with FNA, we do not perform FNA “map-
ping” on patients in whom we suspect an obstructive process
that may be reconstructable. The recommendation to perform
a “trial run” of sperm extraction during the diagnostic biopsy
for infertility is a wise one; this is routinely done in our pro-
gram but the results were not reported in this study.
Paul j. Turek
UROLOGY 49 (51, 1997