Microsurgical Testicular Sperm Extraction (TESE) & TESE


Non-obstructive azoospermia is a very common cause of male infertility. If a man has an adequate bioavailable testosterone on initial diagnostic testing or if he has had it corrected for at least four months and remains azoospermic, we typically recommend microsurgical testicular sperm extraction (microTESE)—if this was not already performed at the time of vasectomy reversal. Sperm is found approximately 70% of the time in the microTESE procedure.

For men with non-obstructive azoospermia, we typically do not recommend fine needle aspiration or biopsy prior to microTESE as many studies have shown that microTESE yields the highest sperm retrieval rate and causes the least amount of damage to the testis. If all of the sperm from the first microTESE are used in subsequent in vitro fertilization attempts, repeat microTESE procedures are possible. However, if the first microTESE is unsuccessful, repeat procedures result in only a 7-10% success rate.

Figure 1 Rationale for MicroTESE

why microtese

Figure 1 illustrates our rationale for not performing mapping biopsies prior to microTESE. The graph in this figure depicts the success of microTESE among men with non-obstructive azoospermia who have undergone 0, 1-2, or 3-4 prior testis biopsies to attempt to find sperm. Here we see that 56% of the men who have not had a prior biopsy have sperm found upon undergoing microTESE. This is in comparison to 51% of men who have had 1-2 biopsies and 23% of men who have had 3-4 biopsies. Put another way, if we performed a biopsy prior to microTESE and used it to determine whether or not to proceed with microTESE, we would fail to find sperm in half of the men where sperm could be obtained through microTESE.

The success of microTESE relies on two critical factors: the skill of the surgeon and the skill of the andrology technologist searching for sperm. Dr. Hotaling has a 72% successful sperm retrieval rate for microTESEh. Dr. Carrell, the andrology laboratory director and a world-renowned scientist with over 30-years experience, assigns an andrology technician to the operating room at the time of microTESE to analyze the seminiferous tubules for sperm at the time of surgery, which Carrell oversees. This combination will help to ensure that we maximize the chances of finding sperm during your procedure. If sperm are found during microTESE, they are extracted and frozen for future assisted reproductive technologies, such as in-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). Existing data demonstrate that frozen sperm may even perform better than fresh sperm for in-vitro fertilization. Please note that any sperm obtained during these procedures must be used for in-vitro fertilization as the sperm in the testis has not yet learned how to swim and, thus, cannot fertilize an egg if deposited in the uterus.

As Dr. Hotaling says: “the worst part of microTESE is the idea of the surgery.” The procedure is performed through a very small (3-4 cm) incision in the midline of the scrotum with the patient under general anesthesia. Thus, you will be completely asleep before we proceed with the surgery. We deliver each of the testis through this incision and then proceed to open the testicles and look for seminiferous tubules that are swollen and contain sperm at 30-40X magnification under a high power-operating microscope. We will examine the entire testis in this manner and will sample each section and pass off the tissue to an andrology technologist who will examine it under a standard microscope to assess for the presence of sperm.

Once we have obtained sufficient sperm from one side or after we have sampled all the tissue, we will stop, obtain meticulous hemostasis (stop any bleeding), and close the testis with very fine suture under the operating microscope. We will repeat the identical procedure on the opposite side. After we complete this, we will then close all the layers of tissue that we opened to enter the scrotum. The patient will be left with a suture that will eventually dissolve leaving little or no scar.

Most men are surprised by the minimal amount of pain they have after this surgery. The scrotum is one of the fastest healing parts of the body and the meticulous multi-layered closure helps to ensure that men do not have infections or bleeding after the surgery. Most men use an ice pack for the first 24 hours after the surgery and then forget to take the pain medications they are sent home with. We ask that men avoid sex, masturbation, or vigorous exercise for 10 days after the surgery. We will notify the patient by phone with the results of the procedure the day after the surgery. It typically takes 10–14 hours of searching for sperm under the microscope to determine if any sperm were found. Extracted sperm will be frozen in liquid nitrogen and can be used for in-vitro fertilization by your reproductive endocrinologist of choice.

TESE – Testicular Sperm Extraction

TESE or testicular sperm extraction is a simplified form of microTESE that is used in men who have obstructive azoospermia from a procedure such as a vasectomy. This procedure relies on the same principles as the microTESE procedure but can be performed in the office under local anesthesia. To perform this procedure, we initially use a very small needle to completely numb the testicle and overlying skin and then make a very small incision in the scrotum to extract a small amount of sperm from the testicle. We cannot use this procedure for men with non-obstructive azoospermia as it does not sample as much tissue as the microTESE procedure. We can also perform PESA (percutaneous epididymal sperm aspiration) or MESA (microsurgical epididymal sperm aspiration) upon request but use TESE as our standard technique as it does not disrupt the anatomy of the epididymis as these other techniques do.

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