What Is MicroTESE?
Microsurgical testicular sperm extraction (microTESE) is a surgical procedure used to retrieve sperm from the seminiferous tubules of a male’s testes. It’s used for men with non-obstructive azoospermia, which is when a man cannot produce enough sperm to have a detectable amount in his semen — a common cause of male infertility. Doctors will usually recommend microTESE in these cases:
- If a man has an adequate level of testosterone in his blood after a hormone test and has other exams indicating that his testicles are not making normal amounts of sperm.
- If a man remains azoospermic even though he has received treatment and his testosterone levels have been normal for at least four months.
The microTESE success rate is quite favorable for men. In fact, doctors are able to find sperm approximately 60 percent of the time during microTESE procedures.
Why Is MicroTESE Better Than a Biopsy?
For men with non-obstructive azoospermia, we do not recommend having fine needle aspiration or biopsy before microTESE. Many studies have shown that microTESE yields the highest sperm retrieval rate and causes the least amount of damage to the testis.*
If you plan on using all of your sperm for IVF, you may need to have more than one microTESE procedure. In some cases, a doctor can’t find or extract sperm during the microTESE procedure. If this happens and you choose to have microTESE again, the chances of your doctor successfully finding sperm are only seven to ten percent.
* Outcome of microdissection TESE compared with conventional TESE in non-obstructive azoospermia: a systematic review. Deruyver Y, Vanderschueren D, Van der Aa F. Andrology. 2014 Jan;2(1):20-4.
* Comparison of microdissection testicular sperm extraction, conventional testicular sperm extraction, and testicular sperm aspiration for nonobstructive azoospermia: a systematic review and meta-analysis. Bernie AM, Mata DA, Ramasamy R, Schlegel PN. Fertil Steril. 2015 Nov;104(5):1099-103.e1-3.
MicroTESE: Effect of Prior Biopsy on Sperm Retrieval
This chart shows why we don’t recommend performing mapping biopsies before 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. During microTESE procedures, doctors are able to find sperm in 56 percent of men who haven’t had a prior biopsy. Doctors find sperm in only 51 percent of men who’ve had 1–2 biopsies. For men who’ve had three to four biopsies, doctors find sperm in only 23 percent of men.
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.
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What Makes MicroTESE Successful?
For microTESE to be successful, you need to have a skillful surgeon and an excellent andrology technologist searching for sperm. During your microTESE procedure, an andrology lab technician will be in the operating room to analyze your seminiferous tubules for sperm.
If the technician finds sperm during your microTESE, your sperm will be extracted and frozen so they can be used in future reproductive treatments, like in-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI).
Current data shows that frozen sperm may perform even better than fresh sperm during IVF (in-vitro fertilization).
Please note that any sperm we find during this procedure must be used for IVF (in-vitro fertilization). This is because sperm inside your testis hasn’t learned how to swim yet, so it can’t fertilize an egg if it’s placed inside the uterus.
For most patients, the worst part of microTESE is the idea of having surgery. To perform the procedure, your doctor will make a very small (2-3 cm) incision (or cut) in the midline of the scrotum. You will be under general anesthesia (completely asleep) before we start the surgery. The doctor will open your testicles through this incision and look under a high-power operating microscope (at 30–40X magnification) for seminiferous tubules that are swollen and may contain sperm.
Next, we’ll take a tissue sample from one testicle’s tubules. Then, we’ll stop any bleeding and close the testis with very fine stitches. We’ll repeat this procedure on the other testicle.
After collecting tissue samples, we close all the layers of tissue that we opened in order to enter your scrotum. You will have a suture that will eventually dissolve on its own and will leave little or no scarring. We will then give your tissue sample to our andrology technologist who will examine it under a standard microscope to look and see if it has any sperm.
We will call you the day after your surgery to let you know if we found any sperm. It usually takes 10-14 hours of searching under the microscope to determine if any sperm were found. If our technologist did find sperm in your tissues, he or she will extract the sperm and freeze it in liquid nitrogen. You can then use your sperm for IVF (in-vitro fertilization).
The possible risks for undergoing microTESE include:
- skin or testicle infections,
- inability to find sperm,
- transmission of a potential genetic cause of infertility to any offspring resulting from use of the sperm,
- testicle damage (which is rare) and
- risks of general anesthesia
If microTESE isn’t a viable option, there are other alternatives such as sperm donation and adoption.
The scrotum is one of the fastest healing parts of the body so most men recover quickly and have very little pain after surgery. But your doctor will prescribe you pain medication just in case. The multi-layered closure technique we use helps to ensure that men don't have infections or bleeding after the surgery.
A majority of patients will use an ice pack for the first 24 hours after the surgery. For the first three days, we recommend taking 800 mg of Ibuprofen every eight hours and 650 mg of Tylenol every six hours to keep any pain or discomfort at bay. You can also take the prescribed narcotics if needed. We ask men to avoid sex, masturbation, or vigorous exercise for 10 days after the surgery.
What Is Testicular Sperm Aspiration (TESA)?
Testicular sperm aspiration (TESA) is a simple procedure used to obtain sperm in men with obstructive azoospermia. Men with this condition produce sperm at a normal rate, but a blockage prevents the sperm from reaching the semen. It commonly occurs in men who have had a vasectomy, who are missing the vas deferens (the tubes that carry sperm out of the testes), or other functional abnormalities.
What Happens During the TESA procedure?
The surgery is minimally invasive and can be done in your doctor’s office. We will use a local anesthesia to numb your testicle and the skin around it. A larger needle is then inserted into the testicle and tubules where sperm are aspirated (suctioned out) through a syringe. You will not need stitches because no incisions are made during the procedure. If we cannot get any sperm using the TESA technique, we will move forward with the next step in treatment: testicular sperm extraction (TESE).
What Is Testicular Sperm Extractions (TESE)?
TESE is a simpler type of microTESE surgery that also removes testicular tissue to find sperm in men. It can be performed in your doctor’s office under local anesthesia much like TESA. This surgery cannot be used on men with non-obstructive azoospermia because TESE is not able to sample all the areas of the testicle to find rare areas that are producing sperm.
The TESE Procedure
This procedure can be performed in your doctor’s office under local anesthesia, moderate sedation, or general anesthesia (completely asleep). A small needle is used to completely numb your testicle and the skin around it. Then we make a tiny incision (cut) inside your scrotum so we can extract a small amount of sperm from your testicle. It’s impossible for doctors to predict how much sperm will be found, but in many cases one TESE procedure could fill several vials of sperm to be stored and frozen for later use.
Like any surgery, there are health risks associated with TESE and TESA such as bleeding, hematoma formation, skin or testicle infection, and the risks of general anesthesia.
After Surgery Care
For the most part, men do very well after both of these procedures with only mild discomfort, but we will prescribe pain medication. Doctors recommend taking 800 mg of Ibuprofen every eight hours and Tylenol 650 mg every six hours for the first three days. Sex, masturbation, strenuous exercise and heavy lifting are also prohibited for one week.