Endocrine stimulation in men with non-obstructive azoospermia and low serum testosterone prior to micro-TESE: hormonal response as a predictor of sperm retrieval

Shlomi Barak¹, Netanel Waldenberg¹, Aharon Peretz², Reut Bartoov¹, Guy Bar¹, Snir Dekalo^3,*
1 Obstetrics and Gynecology, Assuta Ashdod University Hospital, Faculty of Health Sciences, Ben-Gurion University of the Negev, Ashdod, 7747629, Israel
2 Obstetrics and Gynecology, Shaare Zedek Medical Center, The Hebrew University Hadassah Medical School, Jerusalem, 9103102, Israel
3 Urology Department, Tel Aviv Sourasky Medical Center, The Gray School of Medical Sciences, Tel Aviv University, Tel Aviv, 6423906, Israel
* Corresponding Author: Snir Dekalo. Email: email

Canadian Journal of Urology https://doi.org/10.32604/cju.2025.066936

Received 21 April 2025; Accepted 27 October 2025; Published online 03 December 2025

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Abstract

Background: Hormonal treatment and response as a predictor of sperm retrieval prior to microdissection testicular sperm extraction (micro-TESE) are not well established in the current literature. This study aimed to investigate the hormonal response as a predictor of sperm retrieval among men with nonobstructive azoospermia (NOA). Methods: Seventy-seven consecutive patients who had testosterone levels ≤ 14 nmol/L were treated medically with an aromatase inhibitor or recombinant human chorionic gonadotropin (rec-hCG) prior to micro-TESE and were included. Thirty-four (44.2%) had unexplained NOA (UNEX), 25 (32.5%) had Klinefelter syndrome (KS), 8 (10.4%) had a history of cryptorchidism (UDT), 4 (5.2%) had microdeletion of the Azoospermia factor C (AZFc), and 6 (7.8%) were treated previously with chemotherapy. Baseline and post-treatment serum hormonal levels were documented. Pre-op testosterone levels were entered into binary logistic regressions with age, Follicle-stimulating hormone (FSH), and Luteinizing hormone (LH) levels to test for significance with sperm retrieval. We then built logistic regression models to identify predictors of successful surgical sperm retrieval (SSR). Results: Forty-five patients (58%) had successful retrieval. In 32 patients (42%), no sperm was retrieved. Both the mean pre-op testosterone and the mean testosterone change between the two groups were significant (p = 0.02 and p = 0.011, respectively). Receiver operating characteristic (ROC) analysis demonstrated an area under the curve (AUC) of 0.785 (95%CI = 0.685–0.886, p < 0.001). The Youden index coefficient was calculated for KS and UNEX. The cut-off point for KS was established at 0.764 (sensitivity = 0.875, false positive rate [FPR] = 0.111), and 0.215 for UNEX (sensitivity = 0.438, FPR = 0.222). We also observed a correlation between age and SSR (p = 0.05). In KS patients, SSR was determined by pre-op testosterone levels irrespective of age. Conclusion: Pre-operative hormonal response is a predictor for SSR in NOA patients who were treated medically. This data may help during pre-operative counselling.