Micro-TESE, Success Rates, and Current Approaches

When discussing IVF treatment, the focus is often thought to be primarily on the woman. However, when it comes to infertility, the picture is much more balanced. In couples who wish to have a child, male factors play a role in approximately 50% of infertility cases. Azoospermia accounts for about 10–15% of male factor infertility.

So, what is azoospermia? Are we truly making progress in treatment? Is Micro-TESE still the gold standard? Do newer approaches such as stem cell therapy or PRP offer real hope? In this article, we address all the frequently asked questions about azoospermia within a scientific framework.

What Is Azoospermia?

Azoospermia is the condition in which no sperm cells are found in a man’s ejaculate (semen). This diagnosis can be quite distressing for a couple. However, it is important to clearly state: Receiving a diagnosis of azoospermia does not mean that having a child is impossible.

Azoospermia is divided into two main groups:

1. Obstructive Azoospermia

In this condition, sperm production in the testes is present, but due to a blockage in the sperm ducts, sperm cannot be ejaculated. This group generally has a better prognosis. The likelihood of finding sperm with Micro-TESE is quite high.

2. Non-Obstructive (Production Failure) Azoospermia

In this case, the problem is not in the sperm ducts but in the sperm-producing capacity of the testes. Sperm production is either very low or absent. In this type, sperm retrieval rates are lower, and the process must be planned more carefully.

The Gold Standard in Azoospermia Treatment: Micro-TESE

Today, the gold standard method in the treatment of azoospermia is still Micro-TESE.

Micro-TESE (Microsurgical Testicular Sperm Extraction) is a procedure in which testicular tissue is examined under an operating microscope to identify areas with active sperm production, and sperm is retrieved from those areas.

Compared to conventional TESE, this is a much more delicate surgical technique and offers several advantages:

• More targeted tissue sampling
• Less damage to the testis
• Increased likelihood of finding sperm

The generally accepted sperm retrieval rate, considering all factors, is approximately 55–60%. However, this rate varies depending on the type of azoospermia, genetic factors, and the experience of the center.

Is Micro-TESE a One-Time Procedure?

There is a common misconception in society: “If sperm were not found during the first Micro-TESE, there is no hope anymore.”

This is not true.

If no sperm are found during the first Micro-TESE, a second or even a third attempt may be considered. However, the critical question is:

• Should the procedure be performed at the same center?
• Should it be evaluated by a different andrologist and team?

One of the most important factors affecting success in Micro-TESE is the experience of the team performing the procedure.

In experienced centers:

• Longer and more meticulous microscopic examination
• More extensive tubule sampling
• Detailed microscopic search by the embryologist can significantly influence the likelihood of sperm retrieval.

In patients in whom sperm were not found at other centers, repeat Micro-TESE performed under appropriate conditions can result in sperm retrieval in approximately 15–20% of cases.

Fresh Sperm or Frozen Sperm?

There is an important strategic decision in the treatment of azoospermia: When should Micro-TESE be performed?

Our approach is generally as follows:

• First, the woman is prepared.
• On the day of egg retrieval, the man undergoes Micro-TESE surgery.
• Goal: To use fresh sperm.

Why fresh sperm?

Because using sperm fresh, rather than freezing and thawing mature sperm cells:

• In terms of fertilization rates
• It may be more advantageous in terms of embryo quality.

However, it is necessary to clarify a common misunderstanding: Fresh sperm is used in the first procedure. If excess sperm is obtained during Micro-TESE, it is frozen. This way, if in the future there is a need for IVF again, the patient does not have to undergo surgery again.

Genetic Factors and Success Rates

One of the most important factors affecting the success of Micro-TESE is the genetic condition.

Especially:

• Chromosome analysis (karyotype)
• Klinefelter Syndrome
• Conditions such as Y chromosome microdeletions directly affect the likelihood of finding sperm.

For example:

• The sperm retrieval rate in Klinefelter Syndrome is lower compared to the general population.
• In certain regions of Y chromosome microdeletions, the chance of finding sperm is very low.

Therefore, when a diagnosis of azoospermia is made, a detailed genetic evaluation must be conducted.

Testosterone Level and Metabolic Status

In the treatment of azoospermia, testicular surgery alone is not discussed. The man’s overall metabolic condition is also important.

For example:

• If diabetes is present, blood sugar regulation should be ensured.
• HbA1c levels should be within the ideal range.
• Testosterone levels should be evaluated.

The topic of testosterone is still debated. Some experts advocate hormonal regulation first in patients with levels below a certain threshold (for example, above 3 ng/mL). The decision on this is generally made by the andrology specialist based on an individual evaluation.

Stem Cell, PRP, and Plasma Treatments – Are They Really Promising?

In recent years, stem cell, PRP, and plasma applications have come into focus in the treatment of azoospermia.

Theoretically, these methods:

• Stimulating testicular tissue
• It is applied with the aim of increasing sperm production.

However, it should be clearly stated that:

These methods have not yet been included in international guidelines or become routine treatments. Most are still at the study level, and their results are not yet conclusive.

Unfortunately, this field is also prone to exploitation. Therefore, patients should be cautious of experimental methods presented with promises of a "definite solution."

Currently, the scientifically accepted and gold standard method is Micro-TESE.

Factors Affecting Micro-TESE Success

Success in Micro-TESE does not depend solely on the patient. There are many factors that influence the process:

1. Type of azoospermia (obstructive vs non-obstructive)
2. Genetic condition
3. Hormonal profil
4. Metabolic diseases
5. Experience of the andrologist performing the procedure
6. Time allocated for the surgery
7. Number of tubules collected
8. Quality of the embryologist’s microscopic evaluation

Therefore, the treatment of azoospermia is a team effort. It should be approached not only surgically but also with a multidisciplinary approach.

Conclusion: Are We at the Same Point in Azoospermia Treatment?

There has not been a major revolution in azoospermia treatment. However, current methods have become more systematic, safer, and experience-focused.

Micro-TESE is still the gold standard.

Success rates are high in experienced centers.

The use of fresh sperm provides an important strategic advantage.

Genetic and metabolic evaluation is an integral part of the process.

Methods such as stem cells and PRP are still in the experimental stage.

Most importantly: A diagnosis of azoospermia does not mean hopelessness.

With the right evaluation, the right center, and proper timing, many couples can achieve healthy embryos and pregnancies.