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Testicular Biopsy

Testicular Biopsy

Testicular biopsies are necessary to assess spermatogenesis in men with presumed genital tract obstruction. A significant proportion of men with azoospermia, normal testicular size, and normal FSH are found to have severe sperm production  disorders. Some severe sperm production defects may be incomplete, and because ICSI can be performed if sperm can be obtained from the testes, diagnostic testicular biopsies should be offered to men with severe primary spermatogenic tubule disorders with persistent azoospermia. If any elongated spermatids can be found, it should be possible to perform ICSI. However, if no elongated spermatids are seen in the diagnostic biopsies it still may be possible to find spermatids by more extensive sampling of testicular tissue with open biopsies .

Testis biopsies may be performed under local or general anesthesia. Needle biopsy usually provides sufficient material for a histologic diagnosis of the state of the seminiferous epithelium despite some deformation artifacts. It is also useful for obtaining testicular sperm for ICSI. Complications include failure to obtain tissue, particularly with fibrosed or small (<5mL) testes, minor bleeding in the skin and testis, and rarely hematoma or reactions to the local anesthetic.

Testicular Microdissection (MICRO-TESE)

A new surgical technique known as Micro TESE has been developed to detect sperm in the testicles of men who have poor sperm production (non-obstructive azoospermia). Many men who have been diagnosed with non-obstructive azoospermia  have been found to have small “pockets” of sperm production within the testicles. This concept is named  “focal spermatogenesis”.

The challenge is to locate the areas of sperm production within the testicle and retrieve the sperm for use with ICSI. As the testicular tubules are microscopic structures,  the procedure is being done under the magnification of  an operating microscope or highly magnifying loupes. During the operation,  sperm is being found in “fuller”, more normal tubules than in scarred or fibrotic tubules. Once the specimens are removed, the tubules are opened in a Petri dish containing sperm wash media and the search for sperm begins by examining the minced specimens under the microscope. It can take up to 4-5 hours to search for sperm in the specimens and is a very involved and tedious process but very thorough. Once found, the sperm are then either incubated and injected into awaiting eggs or frozen for future injection.

Micro TESE is currently recognized as the best way of finding sperm in men with non-obstructive azoospermia. Very few surgeons are able to perform this technique so it is unfortunately not widely available. Random biopsies are not adequate to truly and accurately asses sperm production. Dr Barak has performed Micro TESE on men seeking help with male infertility who had prior biopsies with no sperm found.  The combination of using high magnification, dissecting the testicular tubules and having trained personnel available to search for sperm can make the difference between success and failure for many couples.

Micro TESE can be performed as a diagnostic procedure and if usable sperm are found then they can be frozen and the couple is recommended to proceed with ICSI. It can also be performed timed with an egg retrieval cycle and the sperm are injected into the eggs without freezing. Freezing the sperm from men with sperm production problems can be difficult since these sperm are usually few in number and don’t thaw well. Therefore the best chance of pregnancy is to use fresh sperm obtained just prior to IVF.