10 Things to Ask Before a Testicular Sperm Retrieval Procedure

For the better part of your teenage years and beyond, you were probably worried to death that you might get someone pregnant. The irony is that now, when you’re all settled down and ready to build a family, you can’t! Your sperm is either nowhere to be found in your semen, or what’s there is not useful. I’m not sure who said this, but it’s another case of “If you want to make God laugh, tell him about your plans.”

The best sperm can be found where it’s made: in that priceless family jewel called the testicle. Along with your virility, you’ve also spent the better part of your life protecting these jewels from, as the US Postal Service says, snow, rain, heat and gloom of night. Now, against all hope and wish, someone is proposing to take a knife to your scrotum. Here’s what you should think about if this is your plight.

Unhappy Huevos

Testicles have two jobs. The first is to make sperm, which they normally do at an alarming rate of 1000 sperm/heartbeat. The second is to make testosterone, that most venerated of male hormones. Although most infertile men (with sperm malfunction) indeed have normal testosterone production, it’s also true that surgically fishing for sperm in the testicle can lower testosterone levels. And that, my friends, means early “manopause” as well as the need for lifelong testosterone replacement years earlier than it might normally happen. For sure, this is a quality-of-life issue that men would like to avoid if possible.

Better Baby Batter Checklist

Trust me, having a testicular sperm retrieval (TESE) procedure is nothing like providing a semen sample for IVF. Post-coital pleasure is replaced by anxiety, fear and pain. Here are 10 questions to consider if a TESE procedure is lurking in your future:

Is testis sperm retrieval necessary?

If the problem is azoospermia due to nonobstructive causes (e.g. Y chromosome deletion, cancer chemotherapy), then yes, the testicle is the only place where sperm will be found. With a blockage due to genetic or acquired causes, then epididymal sperm (MESA) may be an alternative source of sperm that avoids harming the testicle. If you have very few ejaculated sperm (cryptozoospermia), then a highly expert sperm lab may be able to find enough good sperm from the ejaculate to avoid TESE procedures. Similarly, if you have lots of ejaculated sperm of poor quality (i.e. it is highly DNA fragmented), then microfluidic sperm sorting of ejaculated sperm can be a less invasive alternative to TESE procedures.

What technique is being used?

Needle aspiration procedures (TESA) are less invasive and damaging to the testicle than incisional biopsies (TESE), and far less invasive than microdissection TESE. Shoot for the least invasive approach you can, which should be possible in all cases of obstructive azoospermia and in about 1/3 of cases of nonobstructive azoospermia.

What’s the chance we’ll find something?

In cases of blockage or obstruction, the chance of getting sperm is 100%. With nonobstructive azoospermia, it ranges from 50-60% depending on the cause, the surgeon and the lab.

Can we improve the chance of finding sperm?

This really only applies to nonobstructive cases. Predictive algorithms don’t help much here. Optimized health and hormonal levels have some value and should be pursued before sperm retrieval. The most significant way of predicting in advance if sperm will be present on TESE procedures is to have a testis FNA mapping procedure done. If the map shows sperm, then there is a 95-100% chance that a subsequent sperm retrieval procedure will find it again. It can also inform you whether a TESA/TESE or microTESE procedure is needed to obtain the sperm. If the FNA map shows no sperm, then alternatives to TESE should be considered, as the chance of successful sperm retrieval is <2%

How much sperm will we find?

This is a good question for the surgical team and a good measure of expertise. In my view, finding single digit sperm numbers is unlikely to result in a successful pregnancy since not all eggs fertilize, and not all fertilized eggs develop into usable embryos. One should shoot for at least 3x more sperm than eggs to give the embryologists a choice among sperm and to allow extra sperm to be frozen and avoid yet another TESE procedure.

Should I do the procedure first and freeze sperm?

If you look at large cohort studies of many patients, frozen and thawed testicular sperm seems to “perform” as well with IVF as freshly retrieved sperm. But it’s hard to apply population data to individual cases, and I have published that fresh sperm is two-fold more viable and usable than frozen-thawed sperm. And this is why I prefer offering fresh TESE sperm whenever possible: because it is the best sperm in many ways.

Will I have to do it again?  

A good quality TESE procedure will provide enough sperm for several IVF cycles, and this should be a top priority for the surgeon. This helps avoid repeat procedures and the testicles stay healthier longer. Getting sufficient sperm for several IVF cycles is also more likely to occur when FNA mapping is performed, as the richest “pockets” of sperm are known ahead of time.

What can go wrong?

Always ask about complications of TESE procedures, as they can happen. Some swelling and black and blue scrotal skin is not uncommon. However, infection, hematoma, bleeding, chronic pain and loss of testis should be <<1% in the best hands.

What’s the chance my testosterone will drop?

That depends on how aggressively a TESE procedure is done. Risk factors include larger incisions and more tissue removal. This makes TESA procedures the least risky and microTESE procedures the riskiest for altering testosterone levels. Shoot for the minimally invasive TESE methods to have happier, healthier testicles longer.

Will testicles look different afterwards?

With TESA or TESE procedures, your testicle appearance is not affected. After microTESE procedures, there is a chance of smaller size and altered shape.

My hope is that this checklist provides some level of comfort that you are doing all you can to get the best outcome from TESE procedure. It is inspired by the “measure twice and cut once” philosophy that I have held dear for my entire surgical career.

To schedule a consultation with Dr. Turek in Los Angeles or San Francisco, please call 1-888-TUREKMD today.