Non-obstructive azoospermia (or abnormal sperm production) is a very common cause of male infertility. We usually recommend microsurgical testicular sperm extraction (microTESE) for non-obstructive azoospermia for these reasons:
- If a man has an adequate level of testosterone in sperm test results*
- If he has had testosterone levels corrected for at least four months and remains azoospermic
Sperm is found approximately 70% of the time in the microTESE procedure.
MicroTESE Instead of Biopsy
For men with non-obstructive azoospermia, we do not recommend fine needle aspiration or biopsy before to microTESE because 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 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.
This chart illustrates our reasoning for not performing mapping biopsies prior to microTESE. The graph in this figure shows the success of microTESE in men with non-obstructive azoospermia who have undergone 0, 1–2, or 3–4 prior testis biopsies attempting to find sperm. Here we see that 56% of the men who have not had a prior biopsy have sperm found after having 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 before microTESE and used it to determine whether or not to choose microTESE, we would not find sperm in half of the men where sperm could be obtained through microTESE.
What Makes MicroTESE Successful
For microTESE to be successful, you need to have a skillful surgeon and an excellent andrology technologist searching for sperm. At the time of the microTESE procedure, an andrology lab technician is assigned to the operating room to analyze the seminiferous tubules for sperm. If sperm are found during microTESE, they are extracted and frozen for future reproductive treatment, such as in-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). (Existing data demonstrate that frozen sperm may perform even better than fresh sperm for in-vitro fertilization.)**
The worst part of microTESE is really the idea of the surgery. The procedure is performed through a very small (3–4 cm) incision in the midline of the scrotum. The patient is under general anesthesia (completely asleep) before we start the surgery. We open the testicles through this incision and look under a high power, operating microscope (at 30–40X magnification) for seminiferous tubules that are swollen and contain sperm.
Once we have taken a sample of sperm from one side’s tubules or after we have sampled all the tissue, we will 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 collecting the samples, we 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. The sample tissue is then passed to an andrology technologist who will examine it under a standard microscope to look for the presence of sperm.
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 multi-layered closure technique we use 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 uses the same principles as the microTESE procedure but can be performed in the office under local anesthesia.
To perform this procedure, we use a very small needle to completely numb the testicle and overlying skin. We 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.
*Note: this is very different from the total testosterone that many labs check
**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.
|Utah Center for Reproductive Medicine||675 Arapeen Dr. Suite 201
Salt Lake City, UT 84108
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South Jordan, UT 84009