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.
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.