IN-SITU MINI-INCISION MICROTESE (Microsurgical Testicular Sperm Extraction)
Microsurgical testicular sperm extraction (microTESE, testicular microdissection) is a major advancement in the treatment of the most challenging cases of male infertility. The procedure offers very good success rates for men, who just thirty years ago, would not have been able to father a child. Unfortunately, there are a number of risks and drawbacks to this procedure that rightly concern patients. These include the graphic on-line descriptions by some surgeons who cut the testicle open and turn it inside out to find a few sperm, and the notion that the procedure will permanently damage the testicle, necessitating lifelong testosterone replacement therapy. It all sounds “cringe-worthy,” not to mention the anticipation of pain and swelling and having the testicles get smaller. The good news is that there are different ways of performing a microTESE even though the procedures are called by the same name. This summary article offers a brief history of microTESE and the description of a minimally invasive technique developed by Dr. Philip Werthman to obtain sperm in men with non-obstructive azoospermia (The Werthman Technique).
Since the development of In Vitro Fertilization (IVF) and Intra-Cytoplasmic Sperm Injection (ICSI) in the 1980’s and 1990’s, the ability to treat male infertility has greatly expanded. The technology of injecting a single sperm into an egg has reduced the number of sperm necessary to achieve a pregnancy down from millions to just a few, or even one single live sperm. ICSI has been a great tool for men who have very low sperm counts, but it has been even more miraculous for the men who have no sperm in the ejaculate, a condition known as azoospermia. Absence of sperm is either secondary to a blockage in the reproductive plumbing in someone with normal sperm production (obstructive azoospermia) or may be a sign poor sperm production (non-obstructive azoospermia NOA). Most men with NOA produce very small amounts of sperm within the testicles at levels so low, they do not rise above a minimal threshold amount to be released into the ejaculate fluid and be detected on a semen analysis. Some men produce no sperm at all.
The challenge for doctors treating men with NOA is to find sperm within the testicle for injection with IVF/ICSI to achieve a pregnancy. From studying past testicular biopsy specimens from the 1980’s that were performed on men for purely diagnostic purposes, urologists came to understand that small levels of sperm production occurred in varying amounts and locations within the testicle and it was shown that these sperm were viable, healthy and safe to use for baby-making purposes. In the 1990’s male fertility specialists developed sperm extraction procedures to harvest sperm for therapeutic purposes (not diagnostic) in an effort to treat a couple’s infertility, allowing them to conceive when it was previously deemed impossible.
Early on, urologists used the same biopsy techniques they had been using in the past for diagnostic purposes and applied them to sperm harvesting. One of two surgical procedures are still used by many, if not most urologists; the open random biopsy technique now called testicular sperm extraction (TESE) or the needle biopsy known as testicular sperm aspiration (TESA) or needle TESE. What was discovered was that in the abnormal testicle, small amounts of sperm were made in microscopic tubules that appeared visually different than areas of the testicle that didn’t produce sperm or were scarred. Large random biopsies were typically taken with the TESE procedure to increase chances of finding sperm but caused lots of damage; or very small biopsies could be taken blindly with the needle and many times, the areas that produced sperm were missed.
In 1999, Dr. Schlegel in New York started using an operating microscope during TESE surgery to magnify the tubules of the testicle and help select the ones for removal that were most likely to produce sperm fir use in the IVF lab. The operation is performed using a generous incision in the scrotal wall and the testicle is taken out of the sac for examination. A horizontal or equatorial incision is then made along the center of the testicle and it is opened in two like a clamshell. Widely opening the testicle allows for a comprehensive microscopic examination of the tubules inside to select the best ones to remove. This technique has led to a 1.5-2 times higher chance of finding sperm than the non-microsurgical TESE and an even higher success rate over the needle biopsy. Current sperm retrieval rates are in the order of 50-70% depending on the underlying condition. While this is a phenomenal success unfortunately the operation performed this way can be fairly painful, the recovery time prolonged and carries a real risk of damaging the testicle permanently. Removing many testicular tubules can cause a significant drop in the male hormone Testosterone, necessitating replacement.
Over ten years ago I noticed that in most of the patients that had sperm found during micro-TESE, I could identify the good tubules without having to open the whole testicle. We discovered that a small incision in the cover of the testicle would usually suffice to allow enough visualization to pick the tubules that contained sperm and called this modification mini-incision micro-TESE. Since it was no longer always necessary to make a wide cut in the testicle, it was no longer necessary to make a large skin incision to remove the testicle from the sac. By leaving the testicle in the scrotum the procedure really became minimally invasive and I perform it with a less than 1 inch cut that is so small a Band-Aid is used to cover it. In my experience, pain, recovery time and complications such as massive swelling or bleeding are reduced from the standard micro-TESE and the odds of severely injuring the testicle are almost nil. Much less damage is being done to the testicle via this approach so the chances of lowering testosterone is negligible compared with the standard microTESE or large biopsy TESE done by general urologists.
Another significant advance we developed is the ability to widen the incision in the testicle to expose more tubules while still keeping the testicle within the scrotal sac using the same small skin incision. This is accomplished with tiny “stay sutures” placed in the cover of the testicle to control the rotation of the testicle. This combines the microTESE’s success in regards to finding sperm with the small skin incision but without the disadvantages of the aggressive testicular micro-dissection in terms of damage and complications. Some surgeons will literally almost turn the testicle inside out and spend hours picking at tubules with little if any additional benefit to finding sperm for that cost and effort. There are really two critical components in the advanced search for sperm; the first is to identify and remove the best tubules, the second is the quality of the lab and embryologist spending the needed time examining the processed specimen. In rare cases, it can take the embryologist several hours or more to find enough sperm to inject the eggs during IVF.
The take-away message is that there can be multiple ways to perform the microTESE procedure and not all surgeons perform it in the same way, nor get the same results. We are always working on refining procedures to bring patients the highest chances of success with the fewest risks and complication. This has been my mission for over 20 years.
Dr. Philip Werthman
Director, Center for Male Reproductive Medicine
Los Angeles, California