This is a technique [15] for obtaining multiple micro-biopsies from all over the testis without having to bivalve it as in microdissection TESE. It is much simpler, and less traumatic than microdissection TESE. It can be performed using loops making it more readily available in oncology centers where an operating microscope may not be available.

The scrotum is incised and the testis is exposed. The testis is squeezed gently and the tunica is punctured in an avascular area with a 21G needle. A loop of seminiferous tubule will pop out through the puncture hole. If it does not then the tunical opening is dilated gently with a single prong of a microsurgical forceps. Under magnification the protruding tubule is grasped with a microsurgical forceps and pulled out of the testis. Usually it is possible to pull out a long strand of seminiferous tubule through the puncture hole (Fig. 3.2). The final tissue recovered can equal an open biopsy. However, since this is only a tiny puncture hole it does not need stitching and does not harm the testicular vessels. Hence, it can be repeated over the entire surface of the testis at 1-cm intervals taking 20–30 biopsies with minimal trauma and no subsequent pain [16]. The noninvasiveness of this method, as compared to microdissection TESE, makes it very attractive in this group of seriously ill patients.

This invasive technique allows for a comprehensive search of the entire testis. The testis is exposed and the tunica is incised along the transverse equator. The cut edges are grasped and slowly pulled apart, thus bivalving the testis all the way to the hilum. Vessels will be seen radiating from the hilum to the periphery, separating the lobules. The tissue is gently separated along these planes so that the parenchyma gets spread out (Fig. 3.3). The entire tissue is inspected under an operating microscope, looking for tubules that are larger than the surroundings. All these are biopsied and sent to the IVF laboratory for sperm retrieval. After careful hemostasis the parenchyma is replaced in the testis and the tunica is sutured with 5-0 prolene. This technique allows visual identification and biopsy of pockets of spermatogenesis in a poorly functioning testis.

Needle aspiration biopsy is the simplest and quickest method and avoids an incision. It is useful in those cases where a few random biopsies can be expected to yield adequate sperm. Thus, it is suitable for men who are unable to give a semen sample and in preadolescent boys. It can also be tried as the first step in men with azoospermia due to testicular failure before proceeding to more invasive sperm retrieval procedures. If the needle biopsies retrieve sufficient sperm then the open surgical procedure can be avoided.

SST testicular mapping and microdissection TESE are used in men with azoospermia or extreme oligozoospermia due to testicular failure (NOA). Since the SST mapping technique is much simpler and less traumatic than microdissection TESE it is tried first. Thus, in men with testicular failure the sperm retrieval is started by performing three needle biopsies and sending these to the laboratory to check for sperm. If no sperm are found in the initial screening then we proceed with open SST mapping on one side. The tissue is screened for sperm as the biopsies are being taken. If no sperm are found after 20–30 mapping biopsies (as per size of testis) then the testis is bivalved and microdissection TESE is performed. If no sperm are found during initial screening the opposite testis is similarly explored. If sperm are not seen during initial evaluation the tissue is further minced, incubated, and spread into microdroplets that are examined over several hours.

Once chemotherapy is initiated sperm quality will decline and there are concerns about genetic damage in the remaining sperm that are available [17]. Hence, when testicular sperm retrieval is indicated it should be done before or during the first hospital visit for chemotherapy.

Further, in testicular cancer patients scheduled for orchiectomy, cryopreservation is advisable before orchiectomy as studies have shown that after orchiectomy semen parameters are worse than those before orchiectomy [18]. Similarly, if the semen is found to be azoospermic, the surgical sperm retrieval should be performed before or at the time of orchiectomy.

Potential complications of any testicular sperm retrieval procedure include hematoma, pain, or infection. Microdissection TESE, being more invasive, carries additional risks of intratesticular hematoma, prolonged testicular tenderness, partial testicular atrophy or reduction in testis size (due to devascularization), and fall in testosterone levels [19–21].

Cryopreservation of normal testicular tissue is highly successful with very good sperm retrieval and pregnancy [22]. Even in men with NOA, cryopreservation of testicular tissue can be done with good success in subsequent IVF [23].

However, in some men with NOA very few sperm may be recovered and then there is a possibility that the sperm may not survive freezing-thawing. Hence, in such cases the cryopreservation must be done by an IVF laboratory well accustomed to special techniques for handling testicular tissue from men with NOA [24]. Further, such patients should be counseled for the small possibility of not finding sperm when the tissue is thawed.