Techniques for Sperm Harvesting TESE and micro-TESE

TESE and micro-TESE (performed with a microscope) are more advanced techniques used to extract sperm in man who does not have sperm in his semen (azoospermia).

TESE (Testicular Sperm Extraction) and micro-TESE

What is TESE and micro-TESE procedures?

TESE and micro-TESE are methods that sperms are directly retrieved from the testicular germinal epithelium. Tissue samples that are taken from the outer testicular layer by small incisions are referred to the embryology laboratory.

The fresh sperm that is retrieved are immediately used for oocyte fertilization with ICSI method at the same day of oocyte retrieval in an IVF cycle and the spare sperm is cryopreserved to avoid the need to repeat the procedure. If sperm will not be used for ICSI it can be frozen for use at a later time.

The procedures are performed on the outpatient basis in a short general anesthesia or spinal anesthesia and requires an incision on the scrotum to gain access to the testicles.

Who can benefit from TESE and micro-TESE?

TESE or micro-TESE is very successful in cases of obstructive azoospermia (Obstruction in the ejaculatory system-epididymis, vas deferens, or ejaculatory channels, conducting the sperm thus, sperm creation in the testis is normal).

TESE can also be very useful in patients with non-obstructive azoospermia (NOA).  There are several genetic, infection-related and hormonal conditions that lead to very low levels of sperm production that can be uncovered through surgery.

How TESE procedure is performed?

For TESE, a standard open surgical biopsy technique is used to remove the testicular parenchyma without the aid of optical magnification. A 2-cm transverse incision is made through the anterior scrotal skin and tunica vaginalis. A 1-cm incision is made in the albuginea, and gentle pressure is applied to the testis to aid the extrusion of the testicular parenchyma. A fragment of approximately 5x5 mm is excised with sharp scissors and placed in sperm culture media. Single or multiple specimens can be extracted from the same incision.

Depending on the underlying medical condition, albuginea incisions can be made for the sampling of different areas. Several testicular samples are taken and immediately.sent to the laboratory for processing and immediate microscopic examination. Any sperm found can be used immediately to fertilize an egg (ICSI) or they can be frozen for later use.

The tunica albuginea is closed with sutures. The testicle is then repaired and placed back into the scrotum. The testicle is generally able to function normally after the procedure and continue to produce testosterone.

What are the advantages of TESE procedure?

  • No microsurgical expertise is required,
  • No operating microscopeis required,
  • Fast and repeatable.

What are the disadvantages of TESE procedure?

  • Relatively low success rate in non obstructive azoospermia (NOA),
  • Relatively few sperm is retrieved in non obstructive azoospermia (NOA),
  • Risk of testicular atrophy (with multiple biopsies),
  • Postoperative discomfort.

How micro-TESE procedure is performed?

The micro-TESE method is a technique that requires microsurgery. Micro-TESE is a TESE procedure that is performed with the use of an operating microscope that allows the surgeon to observe regions of seminiferous tubules of the testes those have more chance of containing spermatozoa. Similarly to TESE, an incision is made in the scrotum and surface of the testicle to expose seminiferous tubules. However, this exposure is much more wide in micro-TESE. This allows exploration of the incision under the microscope to identify areas of tubules more likely to contain more sperm.

Taking advantage of the 30-fold magnification of the microscope, the thin tubules called tubulus, where sperm production is carried out, are enlarged under the operating microscope and large opaque whitish tubules are distinguished.

These tubules contain more spermatogenically active germ cells. These tubules are examined by the embryologist, the sperm inside the tubule is retrieved and the sperm is searched under a microscope with a larger magnification (200-400) times.

If no sperm can be identified, biopsies are taken at random from a wide range of locations. The incision is closed with sutures. Samples are re-examined post-surgery to locate and then purify sperm.

What are the advantages of Micro TESE procedure?

  • Higher success rates in non obstructive azoospermia (NOA): When compared with conventional TESE, micro-TESE generally has higher success in extracting sperm; as such, micro-TESE is preferable in cases of NOA, where infertility is caused by a lack of sperm production rather than a blockage. In these cases, micro-TESE is more likely to yield sufficient sperm for use in ICSI.
  • Larger number of sperm retrieved: Micro-TESE method provides the opportunity to obtain much more and better quality sperm compared to the previous multiple biopsy method.
    Performing the procedure under microscope increases the chance of finding sperm from 30 percent to 50-60 percent.
  • Relatively higher chance of sperm freezing.
  • Testis is a gonad that produces the testosterone hormone. Therefore, this method minimizes tissue loss by reducing the amount of tissue taken from the testis. The tissue loss of the patient is less in this method compared to the multiple biopsy method.
  • As micro-TESE it is performed under a microscope the risk of damaging the vessels of the testicle is minimized.

What are the disadvantages of micro-TESE procedure?

  • The procedure is more invasive than clasical TESE, requiring general anaesthetic, and generally used only in patients with non-obstructive azoospermia.
  • The cost of micro-TESE is higher than TESE procedure.
  • Operation time is longer.
  • Microsurgical instruments and expertise is required.
  • An operating microscope is required.

How Many Hours Does Micro TESE Surgery Take?

Micro TESE is an operation performed under operating room conditions and general anesthesia and takes approximately 1-2 hours.

The duration of the surgery depends on whether the sperm can be found or not. This period can sometimes exceed two hours. However, if healthy sperm is found, the process can be terminated in a very short time.

What should be done after Micro TESE Surgery?

  • After the micro-TESE surgery, the patient is kept under observation for 2-3 hours.
  • Home rest for 3-4 days is recommended after discharge.
  • After the Micro-TESE surgery driving home is not advised.
  • After the operation bed rest is not recommended. The patient should stay away from heavy physical activity and sexual intercourse for 10 days.
  • He can take a shower 2 days after the micro-TESE surgery.
  • After the operation, patients are recommended to wear tight underwear or a suspender for 10-15 days.
  • Since the stitches will dissolve automatically in about a week, there is no need to take stitches.

How Many Times can Micro TESE be repeated?

There is no definite answer to the question. First of all, the clinical findings of the patient and the results of the TESE procedures they have undergone should be evaluated. After this evaluation, it is decided whether there is a need to repeat the TESE process. Micro-TESE surgery can be performed more than once if deemed necessary.

What Should Be Done If no Sperm is retrieved by Micro TESE?

If no sperm is found after micro-TESE surgery, the tissues taken must be sent for pathological examination. The pathological diagnosis to be obtained as a result of this examination is a guide in terms of the possibility of finding sperm in the future TESE procedures that the patient will have. If a positive pathological diagnosis is obtained and sperm precursor cells are found, TESE can be performed again.

Is TESE and micro-TESE surgery risky?

TESE and micro-TESE surgery mostly does not adversely affect the quality of life of patients. Complication rates are also low, as the patient is relatively more comfortable compared to other surgeries. However, negative side effects such as infection, swelling, redness, testicular inflammation, bleeding, hematoma (blood clot accumulation),decrease in testicular volume may occur at the wound site. The likelihood of these side effects is much lower in good centers and experienced hands.

Can those who have babies with TESE and Micro-TESE use frozen sperm for a second baby?

Those who have babies with TESE and Micro-TESE can have the second baby when they request, if the sperm obtained during the procedure is frozen.

If no sperm is found in TESE or Micro-TESE surgery, when can the second one be performed at the earliest?

The most important decisive factor here is the pathology result of the sample taken in the first surgery and how long the treatment to be started afterwards will be continued. Generally, it is recommended to wait at least 6 months for the second surgery after the first surgery.

Is the right testis or the left testicle used when searching for sperm with TESE or micro-TESE surgery?

There are no specific selection criteria for micro TESE surgery. If sperm cannot be found, sperm search should be performed by intervening in both testicles. When both testicles are present, the physician decides which one to start first, according to the patient's current medical characteristics.

Can Micro TESE be performed bilaterally?

The sperm is first searched on one side of the testis, if necessary, micro-TESE is applied to the testis on the other side.

Can Micro-TESE be performed on patients with Klinefelter Syndrome?

Micro-TESE surgery is a method for sperm retrieval azoospermia patients so it is also an operation performed to search for sperm for patients with Klinefelter Syndrome.

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