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The Family Planning Scientific Research Institute in Chongqing China developed a painless and atraumatic technique for external spermatic sheath injection for vasal nerve block (the no-scalpel method) for vasectomy. As of early 1992 this technique has been used to perform 10 million vasectomies in China. Physicians at Cornell Medical Center and the Population Council in New York City have used it for >500 vasectomies. Physicians from both China and the US have not observed any complications from this method. The procedure involves 1st locating the middle-upper 3rds of the median raphe of the scrotum. Using the 3-finger technique the physician then needs to locate and secure the vas deferens under the skin and separate it from the internal spermatic vessels. After placing a 1.5 inch 25-27 gauge needle into a 1-1.5 cm skin wheal in the dermis over the vas deferens midway between the thumb and index finger the needle is advanced all the way in the direction of the external inguinal ring adjacent and parallel to the vas deferens. The syringe is lightly aspirated to verify that the needle is not in a blood vessel. 2-5 ml of 1-2% plain lidocaine is injected gently within the external spermatic fascial sheath. The same procedure is followed for the other vas deferens. After removal of the needle the skin wheal is pinched for several seconds to reduce swelling in the area over the vasectomy site. Lidocaine acts quickly (5 seconds) and works for up to 1 hour. It is safer than bupivacaine and procaine. Thus lidocaine should be the anesthesia of choice.

Measurements of tissue immunoassayable clusterin, a protein associated with programmed cell death and tissue reorganization, were performed in rats treated with nephrotoxic doses of gentamicin sulfate. Adult Lewis rats were treated with 100 mg/kg/day of gentamicin sulfate for 12 days. Urine, serum, and tissue levels of clusterin protein were measured, as were urinary N-acetyl beta-glucosaminidase (NAG) and serum creatinine levels. Induction of renal injury by gentamicin was detectable within 4 days by increased levels of urinary N-acetyl beta-glucosaminidase (from 280 +/- 66 (mean +/- SD) to 910 +/- 210 nmol/mg creatinine), and within 9 days of initiating gentamicin treatment by increased serum creatinine (from 0.5 +/- 0.1 to 1.2 +/- 0.4 mg/dl). Paralleling these changes, renal, urinary, and serum levels of clusterin increased 10-, 116-, and 3-fold (P less than 0.05). Treatment with gentamicin sulfate did not increase clusterin levels in the seminal vesicle, ventral prostate, testis, or epididymis. The measurement of urinary or serum clusterin may play a role in the early detection of renal injury.

We used a local anesthetic jet injection technique for adult male circumcision. This method eliminates needle use and may decrease the fear of local anesthetic injection used for male circumcision.We recruited 60 men seeking voluntary adult male circumcision into the study from June to September 2009. We used a MadaJet Medical Injector to deliver a high pressure spray of 0.1 ml 2% plain lidocaine solution directly through the penile skin circumferentially around the proximal third of the penis. All men underwent circumcision using the Shang Ring and were evaluated for anesthetic safety, efficacy and acceptability. Pain was measured on a visual analog scale.The average volume of 2% lidocaine anesthetic solution delivered by jet injection was 0.1 ml with a mean total of 0.9 ml per circumcision procedure. More than 85% of men did not require supplemental anesthesia. Anesthetic onset required approximately 45 seconds from the time that injections were completed. Mean pain scores for immediate postoperative, 24-hour postoperative, ring removal and post-ring removal events were 0.1, 6.8, 2.2 and 0.9, respectively. In 4 patients (6.67%) mild urethral bleeding resolved with pressure, resulting in technique modification.No-needle jet injection is safe and effective for adult MC. The technique efficiently delivers local anesthesia with rapid onset in men undergoing circumcision. This needle-free approach may enhance the popularity of adult male circumcision.

Standardization of and training in adult male circumcision can significantly reduce its complication rate. Currently no such program exists for its standardization and training, making it difficult to guarantee the quality of male circumcision services. We therefore established a standardized surgical protocol for adult male circumcision in China using the Shang Ring, and applied it to a clinical study examining the performance of the Shang Ring in adult male circumcision.A total of 328 adult men aged 18-58 (mean 27.8) years, 25 with phimosis and 303 with redundant prepuce, underwent circumcision with the Shang Ring, and evaluation of the operation time, pain scores (using the visual analog scale), postoperative complications, time for wound healing, and their satisfaction with the postoperative appearance.The operation time was 4.7 +/- 1.3 minutes. The pain scores were 0. 2 +/- 0.6 during the surgery, 1.6 +/- 1.0 twenty hours postoperatively, 1.7 +/- 1.1 twenty hours prior to the ring removal, and 2.7 +/- 1.4 during the ring removal. Complications included infection in 2 (0.6%), bleeding in 2 (0.6%), and wound dehiscence in 2 (0.6%) of the patients. None of the patients with wound dehiscence required postoperative suturing and all were managed conservatively instead. Sixteen of the patients (4.9%) experienced penile edema. The time for complete wound healing after circumcision was 20.3 +/- 6.7 days. The rate of the patients'satisfaction was 99.7% (327/328).The standard protocol of adult male circumcision with the Shang Ring has the advantages of short operation time, slight pain, low rate of complications, and high satisfaction and acceptance of the patients. Strict standardization of the surgical protocol can maximize its clinical advantages for adult male circumcision.

Although HIV is a significant problem in Africa, HIV infection rates are rising rapidly in other regions such as Asia and South America. International health organizations have recognized the need to develop effective strategies to check the worldwide transmission of HIV. Studies have demonstrated the significant reduction of HIV, HPV, HSV-2 and other STD infection rates with male circumcision (MC). Although numerous MC techniques are available, there are no standardized protocols and surgical training programs. Studies have shown that the standardization of MC techniques coupled with training programs can significantly reduce complication rates. High complication rates have been a primary obstacle to the implementation of MC services. We recommend the establishment of surgical standards and training protocols prior to the promotion of MC services in China.

Recent randomized controlled clinical trials in Africa have demonstrated that adult male circumcision (MC) efficiently decreases the rate of HIV, HPV and HSV-2 infections. Many studies have clearly shown that MC is a simple, safe, and cost-effective method for the prevention of sexually transmitted diseases and urinary tract infection, and for improving genital hygiene. While a 30% MC prevalence exists worldwide, only 5% or less of the Chinese males have undergone circumcision. In this review, we report recent trends in international MC and HIV prevention efforts, as well as the potential benefits and importance of promoting MC in China. We appeal to medical and public health authorities to pay close attention to the international experience in MC and HIV prevention.

Objective To examine the economic impact of initial treatments for varicocele-associated nonobstructive azoospermia, specifically varicocelectomy versus microsurgical testicular sperm extraction (TESE) with IVF/intracytoplasmic sperm injection (ICSI). Design Decision analytic model based on 1) outcomes data from Society for Assisted Reproductive Technology (SART) database and peer-reviewed literature and 2) costing data from Medicare Resource-Based Relative Value Scale and sampling of high volume US IVF centers. Setting Academic medical center. Patient(s) Simulation with a decision analytic model. Intervention(s) Variation of successful spontaneous live delivery after varicocelectomy versus rate of successful live delivery after IVF/ICSI. Main Outcome Measure(s) Cost-effectiveness. Result(s) Microsurgical TESE was more cost effective than varicocelectomy. In 1999, initial treatment with microsurgical TESE was more cost effective ($65,515) than varicocelectomy ($76,878). Relative cost-effectiveness was unchanged in 2005: $69,731 versus $79,576. The cost-effectiveness of both treatments improved in relation to projections by inflation. Sensitivity analyses suggest that the relative cost-effectiveness of TESE versus varicocelectomy can only be changed with either substantial improvement in spontaneous live delivery rates after varicocelectomy or with deterioration in IVF success rates. Conclusion(s) Microsurgical TESE appears to be more cost effective than varicocelectomy for treatment of varicocele-associated nonobstructive azoospermia when indirect costs are considered. The cost-effectiveness of both treatments has improved with time. These results may be tailored with institution-specific data to allow more individualized results.

Semen evaluation is the most important laboratory test for assessing male fertility. However, lack of strict quality control (QC) for semen analyses in hospital andrology laboratories makes it difficult and meaningless to compare semen data between different laboratories. This paper reports a comparative study on the accuracy of the Hemacytometer (Qiujing Inc., Shanghai, China), Makler (Sefi-Medical Instrument, Haifa, Israel), and Cell-VU (Millennium Sciences Inc., New York, USA) chambers for sperm counting.Both low [(18 +/- 2.5) x 10(6)/ml] and high [(35 +/- 5) x 10(6)/ml] pre-calibrated standard latex bead solutions (Hamilton Thorne Biosciences, USA) were used as the quality control solution to perform counts on the three different counting chambers. Bead counts for the three different chambers were compared, and variability within the chambers determined for standard solutions at low and high concentrations of latex beads, respectively.Mean bead concentrations for the Cell-VU, Hemacytometer and Makler chambers were (37.63 +/- 4.89), (42.74 +/- 4.98) and (53.52 +/- 6.67) x 10(6)/ml respectively for a standard solution containing (35 +/- 5) x 10(6) beads/ml, and (18.22 +/- 1.77), (20.48 +/- 1.56), (24.97 +/- 4.75) x 10(6)/ml respectively for a standard solution containing (18 +/- 2.5) x 10(6) beads/ml. Mean bead concentrations for the Cell-VU chamber were consistently similar and close to the standard pre-calibrated bead solutions, while those for both the Hemacytometer and the Makler chambers were significantly overestimated (P0.001). The average coefficients of variation for the Cell-VU chamber were 7.51% for a higher concentration of the standard solution containing (36 +/- 5) x 10(6) beads/ml and 1.22% for a lower concentration of the standard solution containing (18 +/- 2.5) x 10(6) beads/ml, while the mean variation rates of the Hemacytometer and Makler chambers were 22.11% and 13.78% for a standard solution containing (36 +/- 5) x 10(6) beads/ml, and 52.91% and 38.72% for a standard solution containing (18 +/- 2.5) x 10(6) beads/ ml, respectively.Semen analysis is one of the most important tests for male fertility evaluation, but the data obtained from commercially available counting chambers may differ markedly in accuracy and reliability. Results from this comparative study demonstrated that the Cell-VU chamber exhibits significantly more accurate and less variable results than those of the Hemacytometer and Makler chambers. To ensure the best possible evaluations and accurate diagnoses, we therefore recommend that Cell-VU be used as the standard counting chamber for routine semen analyses in andrology laboratories.

In the past 5 to 10 years, very few fields in modern medicine have changed so dramatically as reproductive medicine, especially for the treatment of male infertility. Advances have been made in intracytoplasmic sperm injection (ICSI), refined microsurgical reconstructive techniques (vasovasostomy and vasoepididymostomy), and microsurgical techniques of surgical sperm retrieval from the epididymis and testis. All men with epididymal obstruction (obstructive azoospermia) now have the opportunity to father their own biological children. In this article, the authors reviewed the most updated microsurgical vasovasostomy, vasoepididymostomy techniques and surgical indications as well as the key factors for successful microsurgical treatment. They also predicted the future directions and discussed the advantages of microsurgical techniques, emphasized the significant roles of microsurgical training for urological doctors to treat male infertility.

Microsurgical vasovasostomy and vasoepididymostomy remain technically challenging procedures. Refinements in technique have continually improved patency and pregnancy rates for the 2 procedures in experienced hands. Advances in surgical robotics produced the Da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, California) with motion reduction and no tremor, features that may improve outcomes in microsurgery. We report a randomized prospective study of vasoepididymostomy and vasovasostomy using the Da Vinci robot in rats.A total of 24 adult male Wistar rats underwent vasectomy through a midline abdominal incision. Two weeks later the animals were randomized to microsurgical multilayer vasovasostomy, longitudinal vasoepididymostomy or robotic vasovasostomy and vasoepididymostomy groups. Outcomes measured included surgical time, complications, patency and sperm granuloma formation at 9 weeks.Animals were sacrificed 9 weeks after microsurgery. There were no significant differences in complications among the groups. Robotic vasovasostomy was significantly faster than the conventional microsurgical technique (68.5 vs 102.5 minutes, p = 0.002). The robotic and microsurgical vasoepididymostomy groups did not differ significantly in time. Patency rates were 100% for the robotic vasovasostomy and vasoepididymostomy groups, and 90% in the microsurgical vasovasostomy and vasoepididymostomy groups. These differences were not significant. Sperm granulomas were found in 70% of microsurgical vasovasostomy anastomoses and 27% of robotic vasovasostomy anastomoses (p = 0.001). No significant difference in the sperm granuloma rate was found between the robotic or microsurgical vasoepididymostomy groups (42% and 50%, respectively, p = 0.37).To our knowledge we report the first randomized prospective study using the Da Vinci robot for microsurgery. We believe that the improved stability and motion reduction during microsurgical suturing with the robot helped achieve excellent patency rates for vasovasostomy and vasoepididymostomy. The robot may also allow experienced microsurgeons to perform microsurgical procedures in patients at remote locations where no experienced microsurgeons are available.

The reproductive system of the male dog is unusual in that the seminal vesicles and bulbourethral glands are absent. Therefore, we chose the dog as a model to evaluate the effect of seminal vesicles on clearance of spermatozoa from the male reproductive tract after vasal occlusion. Thirty adult male beagle dogs with ejaculates containing at least 500 x 10(6) sperm with greater than 90% motility were used for this study. The dogs' vasa were occluded percutaneously using a Vasocclude clip-applying device through a small scrotal puncture site. Dogs were ejaculated and semen analysis was performed before and after vas occlusion. The first 24 dogs were completely azoospermic 1 week following vas occlusion. In order to explain these unanticipated results, an additional 6 dogs were evaluated to determine the specific time course of sperm disappearance from the ejaculate at 1, 3, 5, and 7 days after vas occlusion. The results revealed that spermatozoa were almost completely absent within 1 day after vas occlusion (99.9% reduction, X = 1.0 + 1.1 x 10(6) sperm per milliliter at 1 day, P

Vasoepididymostomy is a technically challenging and complex microsurgical procedure. Recently a new triangulation end-to-side microsurgical technique was reported that allows intussusception of the epididymal tubule into the vasal lumen, resulting in a higher clinical patency rate of 92% with shorter operative time in preliminary clinical studies. We performed a prospective controlled randomized study comparing the patency rate, postoperative sperm granuloma rate and operating time of conventional and intussusception end-to-side vasoepididymostomy in previously vasectomized rats.We randomized 42, 6-week-old male Wistar rats into 4 groups, including 6 into the sham operation, and 12 each into the control, conventional end-to-side and intussusception end-to-side vasoepididymostomy groups. Bilateral 2-clip vasectomy was performed in all animals except those in the sham operation group. Bilateral intussusception or conventional end-to-side vasoepididymostomy was performed in the assigned animals 2 weeks after vasectomy. Animals in the control group underwent vasectomy only. In the sham operation group the testes were mobilized out of the scrotum and then returned. Rats were sacrificed at 8, 12, 16 and 24 weeks, respectively. The anastomosis and vasectomy sites were inspected for sperm granuloma. To assess patency the abdominal end of the vas was transected and intraluminal fluid was examined microscopically at 400x magnification for the presence of motile sperm. Patency was further confirmed by performing retrograde indigo carmine vasography through the anastomoses.In the intussusception and conventional groups the patency rate was 91.7% and 54.2% (p = 0.004), the sperm granuloma rate was 20.8% and 58.4% (p = 0.035), and average operative time was 65.8 and 67.7 minutes (p = 0.197), respectively.Intussusception end-to-side vasoepididymostomy is superior to conventional end-to-side vasoepididymostomy with respect to the patency and postoperative sperm granuloma rates. Further investigations are required to confirm such findings clinically in humans.

Objective To evaluate the potential clinical application of Raman spectroscopy (RS) as a tool that may identify spermatogenesis within human seminiferous tubules. Design RS scanning of human testicular tissue at different maturational stages; immunohistochemistry study and metabolomic analysis of nonobstructive azoospermic/obstructive azoospermic testes. Setting State-owned hospital. Patient(s) Fifty-two patients with clinical indications of nonobstructive azoospermia (NOA) and obstructive azoospermia (OA) who underwent infertility evaluation and treatment. Intervention(s) None. Main Outcome Measurement(s) Raman spectra of seminiferous tubules, thickness of lamina propria (LP), immunohistochemistry of type I, III, and IV collagens and laminin, metabolites of human testes. Result(s) Tubules of OA patients had spectral intensities below 2,000 (au), while tubules of NOA patients had higher intensities, depending on the degree of spermatogenesis. RS was able to separate samples of NOA and OA testicular tissue with a sensitivity of 90% and specificity of 85.71%. The LP of NOA tubules were thickened and had increased deposition of type I and type III collagens. Gas chromatography-mass spectrometer (GC-MS) detected 12 metabolites that showed significant differences between NOA and OA testes. Conclusion(s) RS can noninvasively distinguish seminiferous tubules with complete and incomplete spermatogenesis and may serve as a novel and potentially useful tool to guide surgeons performing micro-testicular sperm extraction to improve sperm retrieval.

Objectives. At least 12% of initially patent vasovasostomies (VVs) shut down. Currently, only nonabsorbable sutures are used for VV. A synthetic, slowly absorbing, monofilament polyglactin suture has been developed that retains tensile strength for up to 6 months. We performed a prospective controlled randomized study comparing absorbable and nonabsorbable sutures for rat VVs. Methods. Bilateral microsurgical VV was performed in three groups of 36 Wistar male rats, with 10-0 nylon, 10-0 polypropylene, and 10-0 polyglactin sutures. Twelve control rats underwent sham operations. Three rats in each group were killed at 2, 6, 12, and 24 weeks. The abdominal end of the vas deferens was transected and the intraluminal fluid examined microscopically for presence of sperm. The segment of the vas deferens containing the anastomosis was excised. Fluid from the testicular end was examined for sperm to confirm spermatogenesis. Patency was confirmed by an antegrade indigo carmine vasogram of the anastomotic segment. Segments were randomly sent for histologic or tensile strength evaluation. Results. The mean tensile strength of the anastomoses performed with nylon was slightly higher than in polypropylene and polyglactin sutures, although the difference was not statistically significant. Polyglactin consistently maintained tensile strength throughout 6 months without significant fluctuations. The mean patency rate in the polyglactin group was 96%, in nylon 81%, and in polypropylene 61%. Although polyglactin had a consistently higher patency rate compared with nonabsorbable sutures, the difference was not statistically significant ( P = 0.11) but indicated a strong trend. The occurrence of microscopic sperm granuloma, muscle layer injuries, intimal fibrosis, and adventitial fibrosis of the vas deferens was not significantly different between suture types. Conclusions. The three suture materials appear equivalent with respect to overall tensile strength of anastomosis; with histologic evaluation, the trend was toward better patency with polyglactin. Polyglactin 10-0 microsurgical suture is a viable alternative to nonabsorbable sutures in microsurgical VVs, although further studies are indicated to assess long-term results.

To evaluate the effect of commonly used intraoperative vasography and tissue staining agents, indigo carmine, methylene blue, and Renografin, on sperm motility.Semen from 20 healthy men was obtained after 2 to 4 days of abstinence. Sperm motility was initially evaluated in each specimen. Standard solutions of indigo carmine, methylene blue, and Renografin-60 were diluted 2x and 4x with lactated Ringer's solution. Equal aliquots of sperm were mixed with undiluted and diluted drugs, and sperm motility was assessed.Initial mean sperm motility was 70.3%+/-3.0%. Undiluted methylene blue and Renografin severely depressed sperm motility to 1.1%+/-0.5% and 2.3%+/-0.7%, respectively (P0.05). Diluted methylene blue depressed motility to 4.9%+/-1.8% and 11.2%+/-3.0% (P0.05). Diluted Renografin depressed motility to 25.1%+/-4.1% and 55.3%+/-3.3% (P0.05). Although undiluted and 2x-diluted indigo carmine moderately decreased sperm motility (48.9%+/-3.2% and 61.7%+/-3.0%, P0.05), 4x-diluted indigo carmine had minimal effect on sperm motility (67.3%+/-2.8%, P0.05). Lactated Ringer's solution had no effect on sperm motility.We found a severe, immediate reduction in sperm motility after exposure to undiluted standard solutions of methylene blue and Renografin. Dilution of Renografin significantly decreased its negative impact on the sperm motility, whereas the adverse effect of methylene blue remained fairly constant even with increasing dilution. Sperm motility should be assessed prior to application of these agents. Sperm should be aspirated for immediate use and/or cryopreservation prior to the use of these agents. Indigo carmine may be safely used as a tissue stain or vasography agent with a minimal effect on sperm motility in dilutions of 4x and higher.

Intracytoplasmic sperm injection (ICSI) has allowed improved sperm fertilization and pregnancy rates for men with sperm in the ejaculate despite severely defective sperm production (1). Sperm retrieval in conjunction with ICSI was initially performed for men with normal sperm production and reproductive tract obstruction (2,3). Preliminary studies demonstrated that rare sperm may be present within the testicles of men with nonobstructive azoospermia-despite severely defective sperm production (4). Using extensive testicular biopsies, spermatozoa can be retrieved for ICSI from at least some men with non-obstructive azoospermia (5–7). Unlike standard diagnostic biopsies, testicular sperm extraction (TESE) is a noninvasive procedure that may involve multiple sites of biopsy from one or both testes to find the very few spermatozoa that are present only within the testis of these men with severely defective sperm production.

With 500,000 to 800,000 vasectomies performed annually and a reversal rate of 3% to 8% vasectomy reversal has become a commonly performed procedure. Two-layer microsurgical vasovasostomy remains the gold standard for surgical reconstruction of the vas. However, this procedure is technically demanding and time-consuming. We determined the ability of biomaterials and surgical sealants to decrease the number of sutures used, enhance anastomosis watertightness and decrease operative time.Adult male Wistar rats underwent vasectomy 2 weeks prior to vasovasostomy. Standard 2-layer microsurgical repair was performed in control animals. Experimental groups underwent 3-suture mucosal approximation and then completion of the anastomosis with a biomaterial membrane and/or synthetic sealant. The rats were sacrificed 9 weeks after vasovasostomy. Anastomotic patency was assessed functionally by the presence of motile sperm in the vas distal to the testes and anastomosis, and mechanically by methylene blue vasogram. The presence and size of sperm granulomas were also recorded.Microsurgical vasovasostomy required significantly less time when biomaterial (42.7 minutes) or sealant (40 minutes) was used compared to the standard sutured group (102.5 minutes, each p0.001). There was no difference in patency between the standard sutured and biomaterial groups (90% vs 92%). Patency was significantly lower in the sealant groups, that is 70% in the suture, biomaterial and sealant group, and 75% in the suture and sealant group. The biomaterial group had only 1 sperm granuloma in 12 procedures, which was significantly better than the 7 in the control group (p0.001).Using a biomaterial wrap during vasovasostomy resulted in significantly decreased operative time and fewer sperm granulomas than in the control group. Sealants were not effective. Biomaterial wrap may support vasovasostomy and by decreasing leakage improve the outcome.

Many men with non-obstructive azoospermia will have fully formed spermatozoa within their testes that can be extracted using biopsy or aspirations. Recent studies suggest that sperm extraction by open biopsy will find spermatozoa for more men with non-obstructive azoospermia than that obtained with percutaneous aspiration (Friedler et al., 1997). However, open biopsies carry potential risks of injury to the testis (Schlegel and Su, 1997), and often remove unnecessarily large volumes of testicular parenchyma. In this video, we demonstrate a technique of testicular microdissection that minimizes the amount of tissue removed during testicular sperm extraction (TESE), while optimizing the chance of finding spermatozoa for use with assisted reproduction. In the video, intraoperative views of sperm extraction are provided during two operative cases. The view is through an operating microscope. The testis in the first case is measured directly at 1.5 cm in maximum length. The subtunical vessels are identified under the operating microscope and avoided. A stay suture of 6‐0 polypropylene is placed into the tunica albuginea. A linear incision across the surface of the testis is transversely made using an ophthalmic ‘ultrasharp’ knife, with care taken to avoid subtunical vessels. The testis is initially opened and dissection bluntly performed between the septae of the testis to expose multiple areas of the testicle. Irrigation with Ringer’s lactate solution is copiously used to prevent blood from obscuring the view of the testicular parenchyma. In the first case, most of the testis is composed of immature stromal elements, and random biopsies would likely yield no spermatozoa. However, in one corner of the incision, seminiferous tubules are seen. These tubules are dissected under the microscope to isolate the larger tubules that are then excised. A second procedure on another patient reveals the ability of the microdissection technique to identify blood vessels within the testicular parenchyma. This dissection helps to prevent injury to the vascular integrity of the testis. Bipolar diathermy is used to limit bleeding, but its application should be minimized to avoid creating excessive local heat that may destroy spermatozoa. Despite a large volume of tubules with sclerotic features suggestive of a histological Sertoli cell-only pattern, an individual clump of tubules is identified with normal spermatogenesis. These tubules alone are excised, providing the embryologist with less tissue to dissect to find spermatozoa. In addition, the patient is left with an optimally preserved testis. Despite the larger incision in the tunica albuginea, our microdissection approach allows excellent preservation of the testicular blood supply and testicular tissue, with optimized sperm retrieval. This technique has now been attempted during over 30 TESE attempts for non-obstructive azoospermia at our institution. For one-third of the cases with spermatozoa found, the spermatozoa were only present in microdissected samples, not in adjacent large random biopsies. Microdissection during TESE limits the need to remove testicular tissue and maximizes the chance of finding spermatozoa for assisted reproduction.