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Micro TESE
Micro TESE is a surgical intervention performed in men with non-obstructive azoospermia (azoospermia) where there is damage to spermatogenesis in the testicle, with the aim of obtaining spermatozoa from the testicular tissue that will later be used for in vitro fertilization. With this method, spermatozoa are obtained from the testicles in about 50-60% of cases.
Otherwise, azoospermia is a pathological condition when there are no spermatozoa in the ejaculate and occurs in 1% of men. 15% of infertile men have azoospermia. The process of sperm development and maturation in the testis is called spermatogenesis.
Micro TESE is an abbreviation of the English term microsurgical testicular sperm extraction. It is done with the help of an operating microscope with a magnification of 6-24 times.
For the success of micro TESE, in addition to the surgical part, the work of the embryologist on finding and freezing the spermatozoa, as well as the subsequent fertilization with the ICSI method during the in vitro fertilization (IVF) process, is very important.
Indications for micro TESE
Micro TESE is performed:
- in patients with non-obstructive azoospermia when the cause is in the testicle (increased FSH and LH hormones, changes in the number of chromosomes or deletion on the Y chromosome);
- in patients in whom no spermatozoa were found on a classic testicular biopsy (TESA, TESE) or aspiration of the epididymis (PESA).
How is the micro TESE procedure performed?
Before micro TESE, it is necessary to perform the following analyses:
- hormones FSH, LH, TSH, prolactin, testosterone;
- genetic analyses: karyotype and Y chromosome deletions (AZF a, AZF b, AZF c). It is also necessary to examine the female partner before deciding on performing micro TESE.
- The patient fills out a detailed questionnaire about his state of health.
- Micro TESE can be performed under local or general anesthesia. It is often done under general anesthesia.
- When the work is done under general anesthesia, before the operation, there is a conversation with a doctor specializing in anesthesia and blood tests are done. If there is a disease or risk factor, it is necessary to perform additional analyses and an examination by a doctor of another specialty, most often an internist.
- The patient receives an antiseptic shampoo in the Clinic, which he will use to shower the night before and the morning before the intervention.
- 6-8 hours before micro TESE, the patient stops taking food and liquids. If the patient uses aspirin or other anticoagulant pills, it is necessary to stop the therapy 7 days before the operation.
- Upon arrival, the patient goes to the patient room where he is prepared to enter the operating room. A needle is inserted into the vein so that the patient can receive the necessary medication.
- Micro TESE is performed on the operating table. The patient receives an intravenous antibiotic immediately before surgery.
- The surgical field is treated with an antiseptic agent containing iodine or chlorine. After receiving local or general anesthesia, an incision of about 2-3 cm is made on the skin of the scrotum. Then an incision is made on the sheath of the testicle and the testicle is removed from the scrotum. In order to present the testicular tissue and the seminiferous tubules, where spermatozoa are produced, an incision is made in the "white coat" of the testicle (tunica albuginea).
- After opening the testicle, which "opens like a book", a visual analysis of the tissue, that is, the canal where spermatozoa are produced, is performed. All this is done under the control of an operating microscope that magnifies up to 24 times using micro -surgical instruments.
- The essence of micro TESE is that under high magnification it is possible to find tubules that are larger and of a different color than the surrounding area, since spermatozoa are much more likely to be found in these tubules.
- When such parts of the tissue are found, the tubules are taken with micro instruments, respecting the anatomy of the testicles in order to avoid bleeding and to minimize tissue damage. About 5-15 mg of tissue is removed.
- The obtained tissue is immediately given to embryologists who in the laboratory continue to work on the isolation of spermatozoa from the obtained samples. If embryologists can immediately isolate spermatozoa that are in sufficient numbers for IVF procedures, the intervention is stopped. The sheaths of the testicles are sutured with a thin suture and the testicle is returned to its anatomical place. If spermatozoa are not immediately found in one testicle, the procedure is repeated on the other testicle.
- Sometimes it takes several hours to find spermatozoa in the laboratory.
- The scrotum is closed with a self-resorbing suture, that is, the surgical suture does not have to be removed. One sample is taken both from one and the other testicle (if analyzed) for histopathological analysis to see if there is a process of spermatogenesis and to exclude possible malignant changes.
Micro TESE takes about 60-180 minutes. The patient receives a local anesthetic to relieve pain after surgery.
- Micro TESE is performed as day surgery. The patient moves from the operating room to the patient room where he stays for up to 4 hours after the operation. First, he gets water, and then a light meal.
- Pain is treated with painkillers, most often paracetamol, ibuprofen and diclofenac. Nausea and tiredness are sometimes felt during the day as a result of anesthesia.
- Swelling and often blue color of the skin are present several days after the operation, as well as discomfort, which can be described as a condition after a ball hit the testicles.
- The patient is not advised to drive a car on the day and several days after the intervention.
- Showering is allowed, but not sitting in the tub and swimming until the skin wound is completely healed.
- For the protective patch, it is removed from the wound after 5 days, and in the meantime, it is changed as needed.
- The patient can return to normal activities 4-5 days after the operation, depending on the work performed
- The wound is washed at home exclusively with saline solution.
The patient receives information about the result, that is, whether spermatozoa were found, before going home. The obtained spermatozoa are frozen for the later procedure of in vitro fertilization. In vitro fertilization can also be done with "freshly" obtained spermatozoa, but then the aspiration of the egg cells must be done on the same day as the micro TESE. The results of histopathological findings are obtained 7-10 days after micro TESE.
When can micro TESE not be applied?
Micro TESE is not performed:
- when there is a deletion of the Y chromosome AZF a and AZF b;
- after the failed first micro TESE.
Complications during and after micro TESE
Complications during and after micro TESE are rare and can be:
- wound infection;
- infection of the epididymis;
- bleeding during and after surgery. Bleeding after surgery leads to the formation of a hematoma (clotted blood), more often in the scrotum than in the testicle itself;
- permanent drop in testosterone (very rare).
Expert advice: frequently asked questions
Answers by: Milan Milenković MD, PhD.
What is the difference between TESE/TESA and micro TESE?
Micro TESE is an operation that is performed under the control of an operating microscope with a magnification of up to 24 times. The testicle is completely opened (like a book) and then the tissue that meets the criteria for spermatogenesis is isolated with micro-instruments.
Spermatozoa are isolated during micro TESE in about 50-60% of patients with non-obstructive azoospermia.
TESE and TESA are "blind" testicular biopsies. In these methods, a random sample of tissue is taken and then analyzed in the IVF laboratory. TESE is an abbreviation of testicular sperm extraction when the biopsy is taken with a special instrument or the testicle is "removed" from the scrotum and several small cuts of 3-4 mm are made from which the testicle tissue is removed.
TESA is short for testicular sperm aspiration, when the seminal ducts are removed from the testicles with a needle and analyzed in the IVF laboratory. The term "fine needle aspiration (FNA)" is also used. The success rate of TESE/TESA is about 20-30% in non-obstructive azoospermia.
How successful is micro TESE?
In about 50-60% of patients with non-obstructive azoospermia, spermatozoa are found during micro TESE. Non-obstructive azoospermia is a condition when there is a disorder of sperm production in the testicle itself. In this case, the pituitary hormones, FSH and LH, are elevated, or there are genetic changes ("Klinefelter's syndrome, syndrome or deletion of the Y chromosome).
In patients with obstructive azoospermia, that is, a condition where there is spermatogenesis in the testicle, but due to blockage or lack of ducts there are no spermatozoa in the ejaculate, PESA (aspiration of the epididymis) and conventional TESE/TESA (testicular biopsy) are performed first. If no spermatozoa are found with these methods, micro TESE is performed, where the success rate is around 80%.
What is the advantage of micro TESE compared to TESE/TESA?
The advantages of micro TESE compared to TESE/TESA in non-obstructive azoospermia are:
- success rate of micro TESE is around 50-60% compared to 20-30% of conventional TESE/TESA;
- tissue trauma with micro TESE is less since it is done under the control of an operating microscope;
- with micro TESE, around 5-15 mg of tissue is removed, while with conventional TESE, around 40-50 mg of tissue is removed;
- bleeding during and after surgery is less with micro TESE.
Is micro TESE a painful intervention?
Micro TESE is most often performed under general anesthesia so that the patient does not feel pain during the operation.
When it is done under local anesthesia, the patient may have an unpleasant feeling, that he feels that something is being done, but he does not feel pain. Local anesthesia is added during the operation, and the patient also receives intravenous pain medication.
A local anesthetic is injected into the skin of the scrotum and after intervention under general anesthesia to reduce pain in the first post-operative hours.
Mild pain may occur after micro TESE. Pain after surgery responds well to paracetamol, ibuprofen and diclofenac. Patients are advised to take Paracetamol, tablets 500 mg, 2 tablets up to 4 times a day for the first 3-4 days after surgery.
Can the micro TESE be repeated?
Micro TESE can be repeated if spermatozoa were isolated at the first operation. It is important to note that micro TESE is an operation that is performed exclusively under the control of an operating microscope using micro-instruments. An intervention performed with the help of a magnifying glass that magnifies 2-3 times is not classified as micro TESE.
What is the cost of the micro TESE procedure?
For all the prices of examinations and interventions in the Milenković Clinic, see our price list which is updated regularly.
When can in vitro fertilization (IVF) be done after micro TESE?
If the spermatozoa isolated during micro TESE are frozen, stimulation of the female partner for IVF can be started after the first menstrual cycle or later in agreement with the couple. When "fresh" spermatozoa are used, egg cells aspiration is performed on the same day as micro TESE.
Is it better to do in vitro fertilization (IVF) with frozen or "fresh" spermatozoa?
The percentage of pregnancies after IVF is similar when using frozen and "fresh" spermatozoa. The advantage of IVF with frozen spermatozoa is that there is no hormonal stimulation of the female partner unless the spermatozoa are isolated. If the woman already has frozen eggs, IVF is done with "fresh" spermatozoa, and spermatozoa that are not used are frozen.
When can I shower after micro TESE?
You can take a shower the same day after micro TESA, but it is not recommended to take a bath or swim until the wound on the skin has healed. It needs to be changed for a protective patch if it gets wet. It is not recommended to use soap or shampoo in the wound area until the skin wound has healed.
When can I train after micro TESE?
You can start training when you feel that you can train. It is most common 7-10 days after micro TESE.
When can I have sexual intercourse after micro TESE?
You can have sexual intercourses when you feel you can. It is most common 7-10 days after micro TESE.
When is the first check-up after micro TESE?
The check-up after micro TESE is most often after 3-4 weeks or as needed. The patient is advised to first contact the surgery at 069 50 22222 or info@drmilenkovic.com for everything related to the operation.
In which acute situations should the Clinic be contacted?
In case of pain, high fever, swelling that increases and has a blue color, you should call 069 50 22222, send a message to info@drmilenkovic.com.
Will there be pain after the micro TESE procedure?
After micro TESE, the most common discomfort in the area of the testicles is accompanied by mild pain. Sometimes pain in the lower abdomen may also occur. Pain after the intervention is most often treated with analgesics and non-steroidal anti-inflammatory drugs.
Do hormone therapy and supplements increase the success of micro TESE?
There is no therapy before micro TESE that can increase the success of the intervention. Since FSH and LH are already elevated, there is no point in taking these hormones. Damage in the testicle itself and testicular tissue does not respond even to the already elevated level of internal hormones. Drugs such as letrozole and clomiphene citrate aim to raise FSH and LH levels, so these drugs also have no effect in non-obstructive azoospermia of the testicular type.
Supplements and vitamins have no effect on spermatogenesis and are not advised before micro TESE, as well as in the treatment of azoospermia and disorders of spermatogenesis.
When can micro TESE be done after failed TESA /TESE?
Micro TESE as well as TESE/TESA can be done 3 months after the previous procedure.
Does varicocele surgery increase the success rate of micro TESE?
Varicocele, that is, dilated veins around the testicles, occurs in 5-10% of patients with non-obstructive azoospermia. About 10% of patients have spermatozoa in the ejaculate after varicocele surgery that can be used for in vitro fertilization.
Are there factors that can predict the success of micro TESE?
There are no parameters that can predict the success of micro TESE. Hormone values and testicular size before micro TESE cannot predict the outcome of micro TESE.
How long does micro TESE last?
Micro TESE takes about 60-180 minutes.
What is azoospermia?
Azoospermia is a pathological condition when there are no spermatozoa in the ejaculate and occurs in 1% of men. 15% of infertile men have azoospermia.
