Micro TESE & IVF/ICSI Progress in Male Infertility (Azoospermia)

By Dr. Surveen Ghumman Sindhu:

Over the last 10 years the rapidly innovating technology in assisted reproduction has enabled male infertility due to men with very low sperm count to become fathers. Where earlier sperms were needed in the millions now only 2-3 sperms are needed for intracytoplasmic sperm injection leading to a successful IVF. Technology has gone further to help men with no sperms in the ejaculate, a condition called non-obstructive azoospermia, to father a child. These men may have small areas within the testis which may have sperm production. 50-60 % men diagnosed with absent sperms due to non-obstructive azoospermia do have small areas of sperm production within the testis. Thus with these technological advances, newer modalities of treatment for male infertility have come into the picture.

In these men sperms may be retrieved from the testes which, may have isolated foci of active sperm production, by aspiration or biopsy. A single sperm is then injected by a micro-needle into the egg under the microscope a process called intracytoplasmic sperm injection (ICSI). Usually, for retrieval of sperms, multiple blind testicular biopsy samples are taken (conventional TESE) and sperms are searched for in the IVF laboratory. Since tubules which contain sperms are microscopic and cannot be seen with the naked eye one cannot make out the healthy from the unhealthy tubule.

At present, in select advanced centers like this one, this treatment has been replaced by microdissection TESE done under the microscope where only microscopic tissue (tubule) is dissected out from areas with dilated seminiferous tubule, identified as having active spermatogenesis. The tubules which have sperms are more dilated and opaque and those which do not have sperm are thin and fibrotic, a fact which can be appreciated only under the microscope. This is done under 25X magnification by using an operating microscope. If sperm is found there is no need to go further, if not one will need to look in the other testis. Sperm may be found in 50-60% of well-selected cases. Since only tubules which have higher chances of having sperm are removed, unnecessary trauma and removal of testicular tissue is not done.

The testicular sperms may not survive the freezing process, hence it is advocated that egg retrieval (for ICSI) of the female partner must be carried out on the same day. Once sperms are retrieved the motile sperms are extracted in the laboratory and injected into an egg. Since testicular sperms cannot fertilize the egg on their own they need to be injected.

Prior to this procedure its important to do karyotyping and Y chromosome microdeletion test through blood, as certain microdeletions have a complete absence of sperms in testis and this procedure is not indicated in them. Hormone analysis with  FSH, LH Testosterone and prolactin should also be done.

Men with small testis must be given the option of microdissection to remove minimal tissue with higher chances of sperm retrieval, thus preventing further testicular insufficiency in already compromised testis.