Testicular sperm extraction

TESE is recommended to patients who do not have sperm present in their ejaculate, azoospermia, or who cannot ejaculate at all. In general, azoospermia can be divided into obstructive and non-obstructive subcategories.

TESE is primarily used for non-obstructive azoospermia, where patients do not have sperm present in the ejaculate but who may produce sperm in the testis. Azoospermia in these patients could be a result of Y chromosome microdeletions, cancer of the testicles or damage to the pituitary gland or hypothalamus, which regulate sperm production. Often in these cases, TESE is used as a second option, after prior efforts to treat the azoospermia through hormone therapy have failed.[3]

However, if azoospermia is related to a disorder of sexual development, such as Klinefelter syndrome, TESE is not currently used clinically; this is currently in the research phase.[4]

More rarely, TESE is used to extract sperm in cases of obstructive azoospermia. Obstructive azoospermia can be caused in a variety of ways:

• vasectomy
• trauma
• congenital absence of the vas deferens (CAVD)
• cystic fibrosis.[2][5]

TESE can also be used as a fertility preservation option for patients undergoing gender reassignment surgery and who cannot ejaculate sperm.[6]

Conventional TESE is usually performed under local, or sometimes spinal or general, anaesthesia.[7][8] An incision in the median raphe of the scrotum is made and continued through the dartos fibres and the tunica vaginalis. The testicle and epidydymis are then visible.[9] From here incision/s are through the outer covering of the testis to retrieve biopsies of seminiferous tubules, the structures which contain sperm. The incision is closed with sutures and each sample is assessed under a microscope to confirm the presence of sperm.[7]

Following extraction, sperm is often cryogenically preserved for future use, but can also be used fresh.[10]

Like all surgical operations, micro-TESE and TESE have risks of postoperative infection, bleeding and pain.[9] However, TESE can result in testicular abnormalities and scarring of the tissue. The procedure can also cause testicular fibrosis and inflammation, which can reduce testicular function and cause testicular atrophy.[14] Both procedures can alter the steroid function of the testes causing a decline in serum testosterone levels, which can result in testosterone deficiency.[11] This can cause side-effects including muscle weakness, decreased sexual function, anxiety, leading to sleep deficiency.[15] The blood supply to the testis can also be altered during this procedure, potentially reducing supply. Long-term follow-ups are often recommended to prevent these complications.[11]

Micro-TESE has limited postoperative complications compared with TESE. The use of the surgical microscope allows for small specific incisions to retrieve seminiferous tubules and evade damaging blood vessels by avoiding regions with no vasculature.[3][9]

If TESE needs to be repeated due to insufficient sperm recovery, patients are usually advised to wait 6–12 months in order to allow adequate healing of the testis before further surgery.[16]

• Azoospermia
• Intracytoplasmic sperm injection
• Semen cryopreservation