显微镜下睾丸切开取精术在非梗阻性无精子症助孕治疗中的应用

Application of microdissection testicular sperm extraction for patients with non-obstructive azoospermia

目的 评估显微镜下睾丸切开取精术(microdissection testicular sperm extraction, MD-TESE)在非梗阻性无精子症(non-obstructive azoospermia, NOA)助孕治疗中的价值及其安全性。方法 回顾性分析2017年7月1日至2022年3月15日在我中心确诊为NOA的患者,共176例,根据选择取精方式的不同分为MD-TESE和睾丸穿刺取精术(testicular sperm aspiration, TESA)。比较两种取精方式的手术时间、术中出血量、血肿形成等并发症、精子获得率(sperm retrieval rate, SRR)以及体外受精的临床结局。结果 两组患者的年龄、体质量指数(body mass index, BMI)、睾丸体积、睾酮(testosterone, T)、促黄体生成素(luteinizing hormone, LH)、抗苗勒管激素(anti-Müllerian hormone, AMH)、促卵泡生成素(follicle-stimulating hormone, FSH)等无明显差异(P>0.05);MD-TESE组的手术时间明显长于TESA组(P<0.001);MD-TESE组术后睾丸血肿发生率为2.4%(1/42),略低于TESA组7.5%(10/134);两组均无术后感染。MD-TESE组的SRR为38.1%(16/42),显著高于TESA组的9.0%(12/134,P<0.001)。两组获得的精子用于卵胞浆内单精子显微注射技术(intracytoplasmic sperm infecting, ICSI)助孕治疗,MD-TESE组受精率、卵裂率、临床妊娠率分别为65.1%、93.9%和50.0%,TESA组受精率、卵裂率、临床妊娠率分别为58.3%、71.4%和50.0%,两组平均疗效无明显差别。结论 MD-TESE安全有效,尤其适合于隐睾、病毒性睾丸炎以及Y染色体AZFc缺失等有迫切希望生育自身遗传背景的子代的无精子症患者。

Objective To investigate the value and safety of microdissection testicular sperm extraction(MD-TESE) for patients with non-obstructive azoospermia(NOA). Methods A retrospective analysis study of 176 NOA patients diagnosed in our center from July 1, 2017 to March 15, 2022. According to sperm retrieval methods, they were divided into MD-TESE group and testicular sperm aspiration(TESA) group. The time of procedure, intra-operative bleeding, surgical complications(such as hematoma), sperm retrieval rate(SRR) and clinical outcome of in vitro fertilization were compared between the 2 groups. Results There were no significant differences between the 2 groups in age, body mass index(BMI), testicular volume, and levels of testosterone(T), luteinizing hormone(LH), anti-Müllerian hormone(AMH) and follicle-stimulating hormone(FSH)(P>0.05). The MD-TESE group had obviously longer operation time(P<0.001) and lower incidence of testicular hematoma rate[2.4%(1/42) vs 7.5%(10/134)] than the TESA group. No infections were observed in either group. SRR was significantly higher in MD-TESE group than the TESA group[38.1%(16/42) vs 9.0%(12/134), P<0.001]. When the obtained sperms were used in intracytoplasmic sperm injection(ICSI), no obvious differences were seen in the fertilization rate, cleavage rate, and clinical pregnancy rate between the MD-TESE group and TESA group(65.1% vs 58.3%, 93.9% vs 71.4%, 50.0% vs 50.0%). Conclusion MD-TESE is a safe and effective method for sperm retrieval in NOA patients, especially in those with cryptorchidism, viral orchitis and Y-chromosome AZFc microdeletions.