The power of the map: testicular mapping to guide surgical sperm retrieval in patients with non-obstructive azoospermia

Background: For male infertility patients with suspected non-obstructive azoospermia, fine needle aspiration mapping (FNAM) of the testis identifies and locates sperm and guides surgical sperm retrieval (SSR), offering an alternative approach to microsurgical testicular sperm extraction (mTESE). Our objectives were to (I) identify success rates with less invasive methods of SSR guided by FNAM, (II) understand how hormone levels influence sperm presence on FNAM, and (III) describe surgical complications in a contemporary cohort of individuals undergoing FNAM of the testis. Methods: We completed an institutional review board (IRB) approved retrospective medical records review of men with azoospermia or cryptozoospermia who underwent a 12-point systematic sampling of each testicle between May 2009 and May 2023 including results of subsequent SSR. Possible cytopathologic diagnoses included germ cell aplasia (GCA), maturation arrest (MA), hypospermatogenesis (HS) and normal spermatogenesis (NS). Hormone levels and detection of sperm on FNAM were compared utilizing analysis of variance (ANOVA) and subsequent unpaired t-tests. Results: Of the 220 men who underwent FNAM, 84 (38%) were found to have sperm. Of those 84, 52 subsequently underwent SSR based on their FNAM. Of these, 4 (8%) underwent testicular sperm extraction (TESE), 30 (59%) underwent testicular sperm aspiration (TESA), and 18 (33%) underwent mTESE. SSR successfully obtained sperm in all 52 (100%) patients. Average follicle stimulating hormone (FSH) levels were 13.9 +/- 11.3 and 19.6 +/- 10.7 mU/mL in those with and without sperm on FNAM, respectively (P<0.001). When patients were stratified by detailed cytopathologic FNAM diagnosis, no difference was noted between FSH levels in those with HS from those with GCA or MA, however a difference was noted between HS and NS (P<0.001). In men with FSH levels between 7.7 and 14.9 mU/mL, 36% were found to have sperm and in men with FSH exceeding 15 mU/mL, 28% were found to have sperm on FNAM. Of those patients with FSH levels exceeding 7.6 mU/mL, 47% had successful office-based sperm extraction based on their FNAM. Conclusions: FNAM allows for de-escalation of sperm extraction technique, even in patients with poor clinical predictors of sperm presence, such as those with significantly elevated FSH levels.