Non-obstructive Azoospermia and Testicular biopsy (TESE)

Introduction
What is TESE?
Who is TESE suitable for?
What does TESE involve?
When is TESE carried out?
Where to do TESE?
Results
Summary

Introduction
Azoospermia may be due to either abnormal sperm production (non-obstructive azoospermia) or normal sperm production in the presence of obstruction (obstructive azoospermia). In cases of obstructive azoospermia ICSI is advised using sperms that will be aspirated by means of needle aspiration (that usually do not need general anaesthesia) from the area before the obstruction.

In cases of abnormal sperm production is usually caused by testicular failure. Testicular failure affects approximately 1% of the male population and 10% of men who seek fertility evaluation. In these cases the hope depends on finding sperm in testicular tissue obtained by testicular biopsy (TESE). We have observed that direct evaluation of testis biopsy specimens often demonstrates sperm in men with non-obstructive azoospermia, despite severe defects in spermatogenesis.

What is TESE?
TESE is a surgical sperm retrieval procedure used in fertility treatment for men who have no sperm in their ejaculate.

Who is TESE suitable for?
TESE is used for men with both obstructive and non-obstructive azoospermia. These men have no sperm in their ejaculate because either there is a blockage in the route between the site of sperm production (the testes) and ejaculation or because there is a partial or complete failure in sperm production in the testes.

What does TESE involve?
Under the care of a consultant andrologist, TESE is not a major procedure that be carried out under local anaesthesia. However, others would prefer to be carried out under general anaesthesia specially with the increased safety of general anaesthesia.

Sperm are retrieved from the testes and can be used to achieve fertilisation of eggs in the laboratory. However, because the numbers of sperm that retrieved is often very low, it is necessary to combine TESE with ICSI.

When is TESE carried out?
There are usually two options:-

A- Doing the TESE well before the ICSI. That means doing TESE before any stimulation for the wife. If sperms are found they are freezed for future use at the day of ICSI. The advantage of doing this is avoiding stimulating the ovaries of the wife, until it is proven that husband has sperms in the testes. There is no current available way to assess preoperatively that the husband’s testes have sperms. The disadvantage is that:

Testicular sperm from men with non obstructive azoospermia will often not survive freeze-thaw. That is why many advocate the following option:

B- To do the full ICSI steps to the wife and at the day of eggs retrieval, the procedure is scheduled 4 hours after performing TESE. The search for sperms extends for 4 hours searching for sperms in the fresh testicular sample. If sperms are found aspiration of the eggs will be performed and the sperms are immediately injected into the eggs. If there is no sperms the aspiration is cancelled.


Again, providing that there are suitable numbers of sperm present, the sample can sometimes be frozen for use in future treatment cycles.

Where to do TESE?
There is no medical indication to do TESE in anywhere that does not have a facility to freeze sperms! As if the examined specimen do have sperms it should be freezed for future use. Also there is no guarantee that even for those who have sperms in any one procedure that they will have in any future one! So TESE should be reserved to be done in only reproductive centers.

Results
At Ganin we have achieved clinical pregnancy rate of 54% for the year 2004 using testicular sperms in ICSI if the wife is less than 37 years of age.

Summary
Sperm retrieval for use with the advanced form of assisted reproduction, ICSI, is now possible for many men with non-obstructive azoospermia. Clinical pregnancy rate is still high for these cases.