Microsurgical Testicular Sperm Extraction (Micro-TESE)

Microsurgical Testicular Sperm Extraction (Micro-TESE)

Advances in reproductive medicine over the last 10 years have allowed men who were previously considered absolutely sterile to father biological children.

Those advances have come on two fronts. The first was the advent of In-Vitro Fertilization (IVF) with Intra-Cytoplasmic Sperm Injection (ICSI).

This technological breakthrough reduced the requirement of the number of sperm needed to fertilize an egg from millions to just one sperm per egg. It meant that men with very low sperm counts who could not be improved with other means had a new way of effectively conceiving. It also led us to reexamine our understanding how the testicles function.

It turns out that men who have no sperm in the ejaculate because of problems with sperm production, a condition called Non-Obstructive Azoospermia (NOA), actually may have small pockets of sperm production within the testicle. In fact, greater than 60% of men with NOA actually do produce small amounts of sperm inside the testicle that can be used with IVF/ICSI to create a baby.

Sounds like great news all around, right? Well, the challenge for experts has been to develop techniques that improve the chances of finding sperm inside the testicle and then to create effective strategies to best harvest that sperm IN THE SAME PROCEDURE, for use with IVF.


Extracting that single sperm takes skill and technology

A new surgical technique, called Microsurgical Testicular Sperm Extraction or “Micro-TESE” has been developed to detect sperm in the testicles of men who have poor sperm production.

Because the testicular tubules are microscopic structures, they cannot be distinguished by the naked eye. However, by using an operating microscope to examine the tubules at the time of testicular biopsy, So that the Andrologist can selectively remove the “better” or more normal appearing tubules. He is very aware that there is a higher chance that he will find sperm 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 specimens under the microscope. It can take up to five hours to search for sperm in the specimens. This is a very involved and tedious process, but very thorough and important. Once they are found, the sperm are then either incubated and injected into awaiting eggs or frozen for future injection.

This advanced technique allows us to direct the biopsy to the best areas and increase the chance of finding sperm while removing smaller amounts of tissue then a random biopsy, causing less damage.

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 and timed with an egg retrieval/IVF cycle so that 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.

The chance of finding sperm with Micro-TESE is better than 60%. This is twice the chances of finding sperm by non-microsurgical or needle biopsies taken by general urologists.

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What is pre-ejaculate or precum?

What is pre-ejaculate or precum؟

Pre-ejaculate, sometimes called precum, is a clear fluid that is released when a man becomes sexually aroused, but before he ejaculates. Sometimes, it can be seen at the tip of the penis, but many men don’t even notice it.

The fluid is produced by a pair of pea-sized glands called the Cowper’s glands, located near the urethra, a tube in the penis with a dual purpose: allowing urine and semen to exit the body.

Pre-ejaculate fluid neutralizes any acidity left by urine in the urethra, protecting sperm that flows through.

Men produce differing amounts of precum, from a few drops to about a teaspoon. Generally, the amount is nothing to worry about.

In rare cases, men produce much more fluid, and there have been reports of men whose clothes are soiled when they become aroused. Medications might help, and men in this situation are advised to see their doctor.

Many people wonder whether a woman can get pregnant from pre-ejaculate fluid. The answer is yes – although this is not common.

Typically, precum does not contain any sperm. However, if a man has ejaculated recently, sperm cells might still be found in the urethra and mix with the pre-ejaculate fluid. When this happens, it is still possible for a woman to become pregnant. For example, if a man removes his penis from his partner’s vagina before ejaculating (“pulling out”), sperm in the precum can still travel up the vagina and fertilize an egg.

For this reason, couples who do not wish to become pregnant should use condoms during all sexual activities.

It’s also important to know that sexually-transmitted infections, like HIV and chlamydia, can be transmitted through precum. For instance, if a person gives oral sex to a man, he or she could become infected through contact with pre-ejaculatory fluid. This is another important reason to practice safe sex.

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Painful Orgasm

What causes painful orgasm in men, and how can it be treated?

Painful orgasm (painful ejaculation) is commonly described as a pain or burning sensation that happens when a man ejaculates. He may feel pain between his anus and genitals or in his testes. He may also feel it in the urethra, the tube that semen passes through. Pain may be mild or severe.

A man may become so frustrated by this pain that he starts to avoid sex. His relationship with his partner may suffer as a result. Many men with painful ejaculation experience depression and anxiety.

Painful orgasm can have a number of causes:

Inflammation and Infections

  • Prostatitis - inflammation of the prostate gland, which is involved with semen production

  • Orchitis - inflammation of one of both testes, the glands that make sperm

  • Urethritis - inflammation of urethra, the tube that semen passes through when a man ejaculates.

  • Sexually-transmitted infections – such as trichomoniasis

Pelvic Conditions and Treatments

  • Prostate cancer

  • Pelvic radiation

  • Lower pelvic surgery– such as radical prostatectomy (removal of the prostate)

  • Nerve damage in the penis– such as from an injury or complications of diabetes.

  • Chronic pain in the pelvis

  • Blockages in the ejaculatory system- from cysts or stones

Some antidepressants, spermicides, and contraceptive creams have also been linked to painful ejaculation.

Sometimes, the cause of painful ejaculation is more difficult to pinpoint. Psychological problems can play a role, especially if a man has pain only with a partner, not when he masturbates.

To treat painful orgasm, a doctor must first determine the cause. Usually this involves a thorough medical exam. Sometimes, samples of urine or semen are analyzed.

Medications may help if there is inflammation of the testicles, prostate or urethra. Men who have sexually-transmitted infections are usually given antibiotics.

If painful ejaculation is a side effect of medication, it may help to lower the dose (with a doctor’s guidance) or change the medication type.

Men who have painful ejaculation due to nerve damage often find that the situation gets better as the nerve heals. This may take up to two years.

Counseling or sex therapy can be helpful if the problem is psychological.

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Cancer and Male Fertility

Male cancer, cryopreservation, and fertility

What is the difference between semen and sperm?

This can be confusing since the terms are often used interchangeably in the media and casua conversation.

However, they are very different. Sperm are the male reproductive cells that contain genetic material.  A sperm is made up of three main parts: the head, the midpiece, and the tail. Semen is the liquid that is ejaculated and may or may not contain sperm. This liquid is produced by glands in the reproductive system and also contains enzymes and fructose in addition to sperm.

How can cancer treatment affect my ability to have a child?

Chemotherapy or radiation can affect your ability to make sperm or impact the ability of the sperm to fertilize an egg.
The type, location, and duration of the treatment can affect whether those changes are temporary or permanent.  For some types of cancer, the reproductive organs are removed or damaged during surgery that is performed to remove the cancer.

Are there options for preserving fertility in men who have been newly diagnosed with cancer?

Yes! Sperm can be collected and frozen for later use before cancer treatment is started. This way, you may be able to have children after your treatment. This process is called
cryopreservation or freezing. The kind of cancer you have and the treatments you will receive can determine what your options are.

What is involved in sperm collection?

For many men, collecting sperm to freeze is a simple, noninvasive procedure. You will be shown to a private room, asked to masturbate to orgasm, and collect your semen in a special container.
A usual semen sample will contain around 5-20 million sperm per milliliter and is able to be divided into several vials for storage. Often, since sperm production is affected by many factors, you may be asked to collect more than one sample. This helps to improve your chances of being able to have a child later.

What if I can’t give a sample?

Some men are unwilling or unable to collect a sample through masturbation. For these men, a special condom may be used to collect semen during intercourse.
Other men have a blockage in their reproductive tract; as  a result, no sperm are found in their semen. Sperm can be obtained through various procedures that remove them
directly from the testicle or reproductive tubes located beside the testicles.
Some men may have a condition that causes sperm and some or all of the semen to collect in the bladder instead of being released through the tip of the penis. For those men,
sperm can often be collected from the urine after intercourse.
If a man is unable to ejaculate (release semen durin orgasm), there are options. Sperm can be surgically removed from the testicles and injected directly into an egg in a process called intracytoplasmic sperm injection (ICSI).

If a man is not able to ejaculate due to spinal cord injury, vibratory stimulation or electroejaculation can be used. 

How is sperm cryopreserved?

Once collected, the semen sample is mixed with cryoprotectants. These are liquids that help protect the sperm against damage during freezing and thawing. The sample is then frozen by a slow-cooling method or a flash freezing method called vitrification.

How long can sperm be stored?

Sperm can be stored indefinitely. Sperm that have been frozen for over 20 years have been used to create pregnancies. Testicular tissue cryopreservation Because very few sperm are necessary to fertilize an egg in a dish, it is possible to obtain sperm directly from the testicle. In cases where very few sperm are produced, this may be the best option. Additionally, some patients have
not yet reached a point of puberty where they have sperm in their ejaculate. It is important to note that it will be necessary to have intracytoplasmic sperm injection (ICSI) when using testicular sperm.

When a boy has not begun to make mature sperm, options are limited. In some research centers across the world, samples of testicular tissue are removed and frozen. When
it’s time to attempt pregnancy, the tissue is examined for stem cells. Stem cells are cells that have the potential to develop into many different kinds of cells. The hope is to
isolate these few cells and mature them into functional sperm. So far, animal research is promising and human studies are ongoing. It is important to remember that this is
an experimental procedure and whether it will be successful is not known.


The most important thing to remember about fertility  preservation is that it should be done prior to any cancer treatment if possible. This will give you the best chance of having usable sperm.

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Sperm Retrieval Procedures

Sperm Retrieval Procedures

Sperm harvesting is entirely different from a diagnostic testicular biopsy since in this setting the goal is not to identify what is happening in the testis but instead it is to find sperm.  Only men with no sperm in their ejaculate (azoospermia) need to have sperm retrieved directly from the testis or epididymis.
This may involve a simple aspiration for men who have a blockage or require much more extensive sampling of the testis for men who have a sperm production problem. As a result, there is a significant difference in the amount of time it takes, the need for anesthesia and the equipment utilized.
Very few tests allow for an accurate prediction of whether or not sperm will be found in the testes of men with testicular problems. Genetic testing may give insight into the chance of finding sperm but are not absolute. The pattern of the problem of the testis found at the time of a diagnostic testicular biopsy may be slightly predictive but again there is no finding that absolutely predicts the presence or absence of sperm. Other blood tests including hormonal studies are not predictive.
Finally, even having sperm found on previous harvesting session does not guarantee that sperm will be found on future harvesting attempts. Thus, diagnostic testicular biopsy is not routinely performed in patients who are to undergo testicular harvesting of sperm when the cause of their zero sperm count is already established through other means.
The Timing of Sperm Retrieval
The timing of sperm harvesting in conjunction with the IVF cycle is a difficult matter to resolve. There are advantages for and against doing the sperm harvesting prior to the IVF cycle or in conjunction with the harvesting of the female partner’s eggs. The ultimate decision is made by the preference of the IVF program. Performing the harvesting in advance and freezing the sperm until the eggs are harvested allows the couple to make an informed decision whether to go forward with IVF since in most circumstances the chance of finding sperm may be only 60% or less.
Moreover, it is difficult for many couples to undergo operative procedures the same day since it requires their enlisting other resources to help them get to and from the hospital and assistance at home. IVF laboratories frequently prefer to work with fresh rather than frozen sperm and thus their desire to have fresh sperm trumps any other consideration.
As a result, simple sperm retrievals are typically performed the day of egg retrieval.  Simple sperm retrievals are procedures performed in men with known obstruction who make sperm without a problem.  These procedures are summarized below, and include Testicular Sperm Aspiration (TESA), Percutaneous Sperm Aspiration (PESA), and Testicular Sperm Extraction (TESE).
Microdissection TESE is a much more involved procedure and is performed the day before the female partner’s egg retrieval. Microdissection TESE is carefully coordinated with the reproductive endocrinologist and is performed at designated times on a quarterly basis.
Which Sperm Retrieval Procedure is Recommended?
There are numerous ways to harvest sperm from a man with normal sperm production and a blockage. The simplest and most cost-effective is an aspiration of sperm. This is routinely performed under local anesthesia and takes approximately ten minutes.
Harvesting sperm from a man with a testicular problem is much more difficult and often takes several hours. The ideal procedure, Microdissection Testicular Sperm Extraction, is performed with the aid of a surgical microscope whereby the chances of finding sperm are increased and the amount of tissue taken out of the testis can be minimized.
It is important to understand that the microscope utilized in the operating room does not have sufficient magnification to see sperm but instead just helps sort out which tubules within the testis are more likely to contain sperm. Small amounts of tissue are sent to the IVF laboratory during the course of the procedure so that they can assess whether sufficient numbers of sperm have been harvested. A more powerful microscope is used by the IVF laboratory to evaluate this tissue. Repeated biopsies from one or both testes are obtained until sufficient sperm has been harvested for that IVF cycle. Extra sperm may be harvested to preserve for future cycles of IVF in case the current cycle is unsuccessful or the couple desires more children in the future. This procedure can take as long as four hours depending upon how quickly sperm are found.
Here is a summary of the procedures available for sperm harvesting:
Testicular sperm aspiration (TESA)
Testicular sperm aspiration (TESA) is a procedure performed for men who are having sperm retrieved for in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI).  It is done with local anesthesia in the operating room or office and is coordinated with their female partner’s egg retrieval.  A needle is inserted in the testicle and tissue/sperm are aspirated.  TESA is performed for men with obstructive azoospermia (s/p vasectomy).  Occasionally, TESA doesn’t provide enough tissue/sperm and an open testis biopsy is needed.
Percutaneous Epididymal Sperm Aspiration (PESA)
PESA is a procedure performed for men who are having sperm retrieved for in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) who have obstructive azoospermia from either a prior vasectomy or infection.  It is done with local anesthesia in the operating room or office and is coordinated with their female partner’s egg retrieval.
Testicular sperm extraction (TESE)
TESE involves making a small incision in the testis and examining the tubules for the presence of sperm.   It is either done as a scheduled procedure or is coordinated with their female partner’s egg retrieval.  TESE is usually performed in the operating room with sedation, but can be performed in the office with local anesthesia alone.  Patients usually cryopreserve sperm during this procedure for future IVF/ICSI.  Microdissection TESE has replaced this as the optimal form of retrieval for men with no sperm in their ejaculate (azoospemia) from a problem with production.
Microepididymal Sperm Aspiration (MESA)
MESA is a procedure performed for men who have vasal or epididymal obstruction (s/p vasectomy, congenital bilateral absence of the vas deferens).  It is either done as a scheduled procedure or is coordinated with their female partner’s egg retrieval.  MESA is performed in the operating room with general anesthesia utilizing the operating microscope.  Patients usually cryopreserve sperm during this procedure for future IVF/ICSI.  MESA allows for an extensive collection of sperm as compared to aspiration techniques, and is the preferred method of retrieval for men with congenital bilateral absence of the vas deferens (CBAVD).
Microdissection TESE (microdissection testicular sperm extraction)
Microdissection TESE is a procedure performed for men who have a sperm production problem and are azoospermic.  Microdissection TESE is performed in the operating room with general anesthesia under the operating microscope.  Micro TESE is carefully coordinated with the female partner’s egg retrieval, and is performed the day before egg retrieval.  This allows for each partner to be there for the other’s procedure.  Patients frequently have donor sperm backup in the case that sperm are not found in the male partner.  Micro TESE has significantly improved sperm retrieval rates in azoospermic men, and is a safer procedure since less testicular tissue is removed.  Patients cryopreserve sperm during this procedure for future IVF/ICSI.

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What is a varicocele?
A varicocele is a variation of normal anatomy in which veins in the scrotum (the sac that holds the testicles) become enlarged and sometimes even visible.
Varicocele usually is first found at puberty and is much more common on the left side than on the right side. Sometimes it occurs on both sides.
What causes a varicocele?
Doctors aren’t sure what causes a varicocele. In almost all cases, males are born with this condition but it doesn’t becomes apparent until puberty when there is an increase in blood flow to the genitals.
How common is it?
It is relatively common, occurring in about 15% of adult males.
How is a varicocele detected?
A varicocele is found by physical exam while the man is standing. Varicocele is much less prominent and may disappear while lying down. An ultrasound is not required to diagnose a varicocele. A varicocele that is shown on ultrasound but cannot be felt on physical exam is called a subclinical varicocele.
Is a varicocele harmful?
In most men, varicocele is just an anatomical finding of no clinical significance. However, a varicocele can lead to reduced fertility or scrotal pain. Less than half of men with varicocele have a reduction of sperm count and/or sperm motility (sperm activity), reducing their reproductive potential. Less than 5% of men with varicocele have pain in the scrotal sac due to the varicocele. Varicoceles do not cause any other health problems.
How can a varicocele cause infertility?
It is not known how a varicocele might cause infertility. The most popular theory is that varicocele elevates the temperature of the scrotum because of dilated veins and pooling of blood.
When should a varicocele be treated?
Men with infertility and an abnormal semen analysis  may consider varicocele treatment. Men with a normal  semen analysis do not need to have varicocele treatment. Men who have pain associated with a varicocele can consider varicocele treatment. A subclinical varicocele does not require treatment.
How is a varicocele treated?
The most common treatment is surgery. An incision is made in the groin and the spermatic cord (which contains the vas deferens and blood vessels going to the testicle) is examined. Veins are tied off while arteries, the vas deferens, and lymph vessels are left
alone. This surgery is done as an outpatient procedure under either general or local anesthesia.
Two thirds of men see improvement in their semen analyses and about 40% can achieve a pregnancy. An alternative to surgery is embolization, performed by a radiologist. During embolization, the radiologist uses a catheter to put a coil or fluid in the vein to block blood flow through the vein.
What are the risks of varicocele surgery?
Serious complications are rare. Risks include bleeding, infection, injury to the testicle, blood clots in the legs, and the risks of general anesthesia. About 10%15% of men who
have varicocele surgery will have a recurrence or persistence of varicocele after surgery.

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Discolored semen

Discolored semen

Should I be concerned about discolored semen?
Semen is normally a whitish-gray color. It's usually quite thick after ejaculation, but liquefies within 30 minutes.
Changes in the appearance of semen might be temporary and not a health concern. However, sometimes these changes can be a sign of an underlying medical condition that requires further evaluation.
If changes persist for longer than a week or two or if the color change is associated with other symptoms such as pain, fever, sexual dysfunction or blood in the urine, see your doctor for an evaluation.

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Smoking and Infertility

Smoking and Infertility

Most patients know not to smoke, don’t they? Maybe so, but that doesn’t mean that they (and their partners) don’t smoke, or that they tell the truth to their doc, or that they aren’t exposed to significant amounts of secondhand smoke.
Does everyone remember the 2004 Surgeon General’s Report, The Health Consequences of Smoking? Chapter 5, Reproductive Effects, states, “…smokers may have decreased semen volume and sperm number and increased abnormal forms…Numerous studies have shown that smoking results in reduced fertility and fecundity for couples with one or both partners who smoke….An increasing number of studies have used couples seeking treatment for infertility. These studies have consistently shown that treatment success is affected by smoking. Several studies documented that the success of in vitro fertilization is significantly reduced among smokers compared with nonsmokers.”
Furthermore, nearly half of all nonsmoking Americans are still regularly exposed to secondhand smoke. Infants and children are especially vulnerable. A June 2006 Surgeon General’s Report, The Health Consequences of Involuntary Exposure to Tobacco Smoke, says that even brief secondhand smoke exposure can cause immediate harm, that secondhand smoke exposure is a known cause of sudden infant death syndrome, and that the only way to protect nonsmokers from the dangerous chemicals in secondhand smoke is to eliminate smoking indoors.
The good news is the ready availability of evidence-based Smoking Cessation Guideline materials for health care professionals and the public, including beneficial brief interventions designed for the busy doctor’s office. First developed in 1996, the Guideline is updated regularly.

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