Publication of NOA Medical Review

At the request of the Japan Society of Reproductive Medicine, a review of over 100 papers summarizing the historical transition of azoospermia treatment along with the latest findings was accepted and finally made public. Before the introduction of FNA Mapping, micro TESE was performed at a rate of 100 cases per year from 2004 to 2016. In fact, in 2014, a review paper was published that absolutely supported micro TESE. Since then, there has been a blind bias toward micro TESE for the treatment of azoospermia, especially in Japan, and there has been a problem of premature surgery being performed without understanding the pathology of azoospermia, and with insufficient training.

In this paper, we emphasized that the true value of micro TESE can only be obtained through FNA Mapping, and concluded that it is important for doctors to be skilled in both surgical procedures.

Occasionally, there are specialists who post about FNA Mapping without a solid understanding of it, so I would like to address a few of the common misconceptions here.

1: “Sperm collected during FNA Mapping are wasted.” → Only a very small number of sperm are collected during FNA Mapping. Considering that FNA Mapping can avoid unnecessary bilateral testicular incision and avoid sequelae in more than two-thirds of patients with non-obstructive azoospermia in which sperm are not present, and that if sperm are present, a small incision or puncture aspiration of one testicle is sufficient, the argument that sperm collected during FNA Mapping are wasted is meaningless. Patients in whom no sperm was found during micro TESE, which accounts for more than two-thirds of non-obstructive azoospermia, will suffer psychological damage as well as postoperative pain and sequelae. On the other hand, if sperm are confirmed during FNA Mapping, sufficient sperm for pregnancy can be collected with directed micro TESE in almost 100% of cases, and the average time from the start of surgery to sperm collection is 23 minutes.

2: “FNA Mapping is expensive due to the rights of the developer.” → In the United States, average micro TESE costs are around $20,000 and FNA Mapping is around $6,000. In Japan, prices are lower but the comparative difference remains: if micro TESE is performed at a university hospital for 2 nights and 3 days under general anesthesia, it will cost about 840,000 yen, which is more expensive than FNA Mapping. The actual sperm search time for micro TESE is about 2 hours, but in FNA Mapping, the search is usually performed for a total of about 36 hours by specialized trained staff. Certainly, it takes a considerable amount of time and money to obtain a license for FNA Mapping, but this is not to protect the rights of the developer, Dr. Turek, but to maintain the quality of the procedure.

Our paper also points out the current situation in Japan where the quality of micro TESE is uneven.