Taking on the Challenge of Revising Azoospermia Treatment Guidelines through FNA Mapping!
It has already been 22 years since micro-TESE was first introduced in eastern Japan (2004), and since pregnancy rates achieved through micro-TESE for azoospermia were first reported in Japan (2006).
In 2016, our clinic introduced FNA Mapping in Asia. Since the introduction of FNA Mapping, the treatment of azoospermia has undergone a major transformation, and a proven track record has steadily been built.
Recently, in cases where micro-TESE had been unsuccessful at other clinics, we performed a new salvage therapy based on the results of FNA Mapping. As a result, motile sperm appeared in the ejaculate, and some patients have been able to proceed with intracytoplasmic sperm injection, or ICSI. Even in fresh cases, based on FNA Mapping results, some patients have been able to have children while avoiding surgical procedures. We plan to present these data at this year’s Annual Meeting of the Japan Society for Reproductive Medicine.
My older brother, a pediatric surgeon who was introduced as a renowned physician on Gaia no Yoake, used to say that the better the surgeon, the less eager they are to operate. I believe this means that highly accomplished physicians are stoic about surgical indications, while doctors who seek to improve their own surgical skills, build their track record, or pursue profit tend to be more lenient with surgical indications and more inclined to recommend surgery. This also applies to microscopic low ligation for varicocele, which has recently become more widespread since gaining insurance coverage.
Patients have now begun coming to our clinic for FNA Mapping from all over the world, including from the United States, and from countries that are in political conflict with the United States. We are proud that our medical practice can have a positive impact on patients in places truly all over the world.
In May, our FNA Mapping task force members—consisting of our clinic director and three staff members—will travel for training to The Turek Clinic in San Francisco, USA, which likewise accepts patients from around the world. Since micro-TESE became covered by insurance in Japan, there has been a significant gap in attitudes toward surgery. We would like to discuss how FNA Mapping can be scaled up without compromising quality. If results can be achieved across multiple institutions, the evidence base will become stronger, and we should be able to revise the description in the azoospermia guidelines of the already published Male Infertility Treatment Manual, where micro-TESE was rated “A” due to political and commercial factors.
Below is what has changed in azoospermia treatment through FNA Mapping.
- Unnecessary surgery has been avoided for the majority of patients whose testes contain no sperm, and as a result, the aftereffect of decreased male hormone levels has almost disappeared.
- The risk of missing sperm through micro-TESE has been drastically reduced. Moreover, because only a localized incision is made in one testis, postoperative pain and the risk of complications have also been greatly reduced.
- Through FNA Mapping, in cases where spermatogenesis has stopped just one step before completion, salvage therapy has made it possible to perform ICSI using ejaculated sperm without surgical intervention.
People undergoing fertility treatment naturally want to begin effective treatment as soon as possible. However, I hope that many people will read this blog and refrain from proceeding too readily with micro-TESE simply because it has been recommended by their attending physician, who may not have first-hand experience with FNA Mapping.