Effectiveness and Satisfaction with a Microsurgical Testicular Sperm Extraction Knowledge and Skills Masterclass for a World-Wide Audience

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Contributors: Luca Boeri, MD (Italy), and Rupin Shah, MD (India)

Luca Boeri, MD: Non-obstructive azoospermia (NOA) is the cause of infertility for about 10% of infertile couples. In these cases, testicular sperm extraction (TESE) associated with intracytoplasmic sperm injection (ICSI) represents a possibility to father a child. TESE is a simple procedure associated with minimal adverse events, however, the success rate is only about 40-60% according to published data. Microsurgical TESE (mTESE) was introduced in 1998 and emerging data have shown that sperm recovery was higher after this procedure compared to conventional TESE. Nonetheless, the rate of sperm recovery is still wide (20 to 60%) and related to several clinical and histopathologic parameters. To this aim, it is important to identify the best candidate for mTESE procedures. Successful mTESE requires a breadth of knowledge and skills for the appropriate evaluation of potential patients and successful execution of the mTESE procedure. For example, clinicians should have a great knowledge of the clinical history of the patient, a correct understanding of the hormonal parameters, genetic testing, and ultrasound findings. Moreover, proper training in the procedure is also crucial as the surgeon’s training and experience are key factors for successful sperm retrieval in mTESE. Accurate training in couple’s infertility management and mTESE procedures is rare and not standardized in several countries. Based on these consideration the GAF group organized an online mTESE masterclass tailored for the andrology workforce worldwide to improve their knowledge of this important topic.

The masterclass was organized by GAF in collaboration with the Turkish Urology Association (TUA) during the annual TUA Symposium (13–16 March 2023). Five didactic lectures were delivered followed by presentations of four varied and difficult NOA cases. These were used as a platform for in-depth discussions employing different case scenarios to debate the topics and deliberate the management of each case through interactive dialogues between moderators, panelists, and participants. A pre-quiz was distributed 10 days before the masterclass to all registered participants. This quiz was designed to assess the participants’ mTESE knowledge and skills. Moreover, the same quiz was delivered after attending the masterclass to gauge the acquisition of learning attributable to the masterclass. Participants' satisfaction was also assessed.

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A total of 1,025 participants initially registered, of which 163 completed both the pre- and post-quiz and the questionnaire and were considered for further analysis. Participants’ age ranged from 20 to 70 years old, with more male participants than females. Most of the attendees had clinical backgrounds and worked in public hospitals. Most participants never/occasionally performed mTESE. Likewise, most did not receive mTESE training. Nearly half the participants self-rated their mTESE skills as low, while only a minority (11%) rated themselves as very high. Whilst about 83% of the participants emphasized their need for mTESE training and guidance, roughly half the participants declared that good mTESE training was either unavailable or available with difficulty.

In terms of pre-post quiz scores, a significant improvement was seen after attending the masterclass. Clinicians had significantly higher scores in the pre-quiz, however, this difference became insignificant in the post-quiz. Importantly, participants with non-clinical backgrounds improved relatively more than those with clinical backgrounds. Of note, all participants enhanced their mTESE knowledge and skills after the masterclass regardless of their sex, professional background, experience, practice type, past mTESE training, and initial pre-masterclass self-rated skills in performing mTESE. Participants’ satisfaction with the webinar’s topics, quality, clinical relevance, and content was very high, ranging from 98% to above 99%.

In conclusion, the GAF masterclass on mTESE was extremely appreciated and useful for improvement in theoretical and practical skills. Such improvements were characterized by learning that was broad, deep, highly significant, inclusive, and differential. Participants who most needed mTESE knowledge and skills were the precise ones who improved the most, namely non-clinical practitioners with ≤5 years of experience serving in public practice, as well as clinical practitioners with low self-rated mTESE performance.

Rupin Shah: In March 2023 a unique, global, online workshop on the practical aspects of mTESE was presented by senior GAF members in a format that included lectures, operative videos, and multiple case discussions. The urgent need for such training was highlighted by the fact that there were over 1000 registrants for the symposium. The demographic data confirmed that the majority of those attending the symposium were the ones who most needed it, and that almost 100% of participants felt benefited from attending the symposium.

This paper provides details of the topics covered as well as a detailed analysis of the participants – their demographics, their pre and post symposium knowledge levels, and the various steps implemented to make the symposium optimally useful, and to document the resultant gain in knowledge. This paper will be a useful guide for anyone planning any educational activity related to this subject.

Take Home Message:

Mastering micro-TESE demands precise surgical skills due to its delicate nature, necessitating extensive training in microsurgical techniques. Surgeons often seek specialized training to work alongside experienced mentors to develop proficiency in this intricate procedure. However, such training is hard to come by in many countries and when available could be expensive. The surgery involves navigating tiny testicular structures under high-powered microscopes, identifying sperm-containing areas, and minimizing tissue damage risks. Even for skilled clinicians, micro-TESE doesn’t guarantee the retrieval of viable sperm in every case. The success rate can be affected by factors like the underlying cause of infertility, the quality of testicular tissue, and the expertise of the surgeon. Furthermore, the success of mTESE requires the services of laboratory specialists (and a state-of-the-art cryopreservation laboratory), with excellent skills in identifying, isolating, and freezing rare sperm. Ethical counseling for potential outcomes is crucial. Continuous learning and staying updated on microsurgical advancements are vital for excellence. Virtual masterclass training offers a viable solution due to limited availability of specialized training. (Contributor: Ashok Agarwal, USA)