Micro-TESE and male infertility

The male factor plays a more important role in fertility than it is acknowledged, being involved in more than half of the cases in which conception is delayed. Also, a percentage of 5-10% of infertile men face the total absence of sperm due to reduced production (non-obstructive azoospermia). Until recently, they were considered sterile and intrauterine insemination was recommended, with donated sperm. But a number of scientific observations have led to a change in this approach, with direct evaluation of testicular biopsy specimens revealing the presence of sperm in men with non-obstructive azoospermia. Although these sperm have poor functionality and mobility, they are not particularly effective for in vitro insemination or fertilization, with the help of intracytoplasmic sperm injection (ICSI), the eggs can be fertilized with them, the sperm being introduced into the egg cytoplasm.

The micro-TESE procedure allows the extraction of a small amount of testicular tissue from the regions where sperm production takes place, increasing the efficiency of the sampling process, compared to standard biopsy techniques. It was first described in 1999 and represents an evolution from conventional TESE, with an advanced success rate of 60% to find viable sperm. It involves a surgery with general anesthesia, performed through a small incision in the scrotum, which allows the visualization of the testicles. Sperm are collected from one or both testicles.

Studies on micro-TESE

According to a study published in February 2018 in the Kaohsiung Journal of Medical Sciences, micro-TESE is a safe procedure when performed by an experienced surgeon and it offers to the infertile men experiencing non-obstructive azoospermia the chance to have children. The aim of this study was to evaluate the predictive value of the preoperative hormone levels and pathology, as well as the result of the microsurgical extraction of sperm from the testis under a microscope. In this regard, the records of a number of 145 men who underwent micro-TESE between March 2013 and November 2016 were evaluated. The patient’s age, the testicular volume, the hormonal profile for follicle-stimulating hormone (FSH), the luteinizing hormone (LH) and the testosterone level were taken into consideration, being recorded the testicular pathology. Conclusion: the sample rate of sperm from the testicle reached 65.5%. There were no side effects after the procedure, except for a local infection in a patient.

According to a study published in 2015, designed to investigate the differences in results between microsurgical testicular sperm extraction (micro-TESE), conventional testicular sperm extraction and testicular sperm aspiration (TESA) in men with non-obstructive azoospermia, the sperm sampling rate was higher for micro-TESE compared to conventional extraction and for conventional extraction higher than TESA, in which 15 studies with a total of 1890 patients were considered. At 34.4 years, the level of follicle-stimulating hormone was 20.5 mIU / mL, T was 373 ng / dL, and the testicular volume was 13.5 mL. Within a direct comparison, micro-TESE performance was 1.5 times more likely to lead to successful sperm sampling compared to conventional extraction. Similarly, the performance of conventional extraction had 2.0 more chances of leading to successful sperm sampling compared to TESA.

Micro-TESE surgery

In the case of men with non-obstructive azoospermia, fine needle aspiration or classic biopsy is not recommended, micro-TESE representing the procedure with the highest sampling rate and the fewest testicular lesions. Statistically, it has a double chance of sampling viable sperm compared to standard biopsies.  With its help  the most favorable regions of the testicles can be directly biopsied. Random biopsies are inaccurate, making it impossible for a surgeon to discover pockets of sperm just by looking outside.

The procedure involves the following steps:

  • A small incision is made in the middle of the scrotum, usually under general anesthesia
  • The surgeon will open the testicles by incision and will look for the seminiferous tubules (in which sperm are produced and transported) with the help of an extremely powerful microscope (magnification power 30-40X)
  • A testicle sample is collected, the bleeding is stopped, and the testicles closed with resorbable sutures
  • The procedure is repeated for the second testicle

The whole operation lasts up to an hour and the patient can be discharged on the same day. After collecting the testicular tissue sample, this is examined under a microscope to identify viable sperm. The patient is informed if the biologist finds sperm, usually within 10-12 hours. If sperm are found, they are extracted and frozen in liquid nitrogen for use in assisted reproduction techniques, such as in vitro fertilization with intracytoplasmic sperm injection (ICSI). When sperm are used fresh (the preferred option of most clinics specialized in in vitro fertilization), micro-TESE is performed the day before the egg is taken from the partner, so the partners can support each other in interventions.

Preoperative recommendations:

  • Before the micro-TESE operation, the patient must have an EKG and blood tests, such as a coagulation test, a complete blood count, a test for hepatitis, HIV and syphilis.
  • It is important for the man to be in good health, and if he knows of any pre-existing conditions, to inform the doctor before the operation.
  • Aspirin and its products, as well as anticoagulants, should be avoided by the patient for one week before surgery.
  • If the urologist prescribes medication before the micro-TESE operation, this should be administered according to the recommendations. Any questions / concerns should be discussed with your doctor

Postoperative information

Because it is a surgical procedure, there are several risks associated with the micro-TESE procedure:

  • Bleeding
  • Infection of the skin or testicle
  • Inability to find viable sperm
  • Transmission of a potential cause of genetic infertility to a descendant as a result of the sperm used
  • Testicular lesions (occur extremely rarely)
  • Risks associated with general anesthesia (allergic reactions etc.)

Because the scrotum has a fast healing, the convalescence period will be quick and the pain will be minor after the operation. In any case, the patient is recommended analgesic medication. As a result of the technique used to close the incision, infections are avoided and bleeding is minimal. It is recommended to apply an ice pack in the first 24 hours after surgery to reduce the discomfort or pain felt. Also, sex, masturbation and intense exercise should be avoided by the patient for 10 days after surgery.