What are TESE, micro-TESE, TESA and PESA, how do they differ and when are they used? Risks, the period afterwards, genetic testing and doctor questions.
TESE is the procedure of obtaining sperm cells directly from testicular tissue when there is no sperm in the ejaculate or it is not sufficient. Micro-TESE, TESA and PESA are similar methods serving the same purpose. Which one is suitable is determined by the type and cause of the azoospermia; the choice is made together with you by the doctor who will perform the procedure. The sperm obtained is used with microinjection (ICSI). The information below offers a general framework and does not replace a diagnosis or treatment recommendation specific to the individual.
What can be done if no sperm is found in the semen sample?
In men in whom no sperm is seen on semen analysis, obtaining the sperm directly from the testis or from the sperm pathways may be an option. This decision is made after the type and cause of the azoospermia have been assessed. The type of azoospermia is determined by your doctor's assessment.
How is the retrieved sperm used in treatment?
Sperm taken surgically or with a needle is used with ICSI for fertilisation. In this method a single sperm cell is selected in the laboratory and placed inside the egg. The processing and selection of the sperm obtained in the laboratory is a separate stage.
How is TESE performed?
It is the taking of a piece of testicular tissue and searching for the sperm cells in it. According to current expert guidelines on this subject, in the classic form of this method, bleeding inside the testis and tissue changes may be seen.
How is micro-TESE performed?
It is also known as microdissection TESE. It rests on a detailed examination, under the operating microscope, of the tubules in the testis that produce sperm (seminiferous tubules). According to current guidelines on this subject, bleeding inside the testis and tissue changes are seen less than with classic TESE. The micro-TESE procedure is performed at Ota Jinemed, in collaboration with Prof. Dr. Erkan Erdem.
How is TESA performed?
It is the procedure of entering the testis with a needle and drawing up (aspirating) sperm. According to current guidelines on this subject, this procedure can be performed under local anaesthesia.
What is the difference between PESA and MESA?
It is the drawing up of sperm with a needle from the structure of the sperm pathways called the epididymis. Taking sperm from the same region by microsurgery is called MESA; the two methods are used for a similar purpose.
How is the method chosen in azoospermia due to blockage?
If sperm is produced but cannot get out, the level of the blockage affects the method. According to current guidelines on this subject, if the blockage is inside the testis, only testicular sperm can be retrieved. If the problem is at the level of the epididymis, for example when the sperm duct is congenitally absent, PESA and MESA are suitable methods; TESE and TESA with a needle are also counted as options. In some blockages, repair rather than sperm retrieval may also be considered as an option.
Which method is preferred if there is a problem with sperm production?
If the testis cannot produce enough sperm, sperm retrieval surgery is needed before assisted reproduction treatment. Current guidelines on this subject assess micro-TESE as the preferred method in this group; however, this recommendation is weak. Another joint guideline also gives a recommendation in the same direction at a moderate level. This is a preference based on the data available, not proof of superiority. The same guidelines strongly recommend that TESA and fine-needle aspiration not be done in this group.
Why are hormone and genetic investigations done before the procedure?
Before the procedure, the history, examination and hormone assessment are completed. Current guidelines on this subject strongly recommend chromosome analysis and genetic counselling in azoospermia and severe sperm deficiency. If a complete loss is found in the AZFa and AZFb regions of the Y chromosome, it is recommended that a sperm retrieval attempt not be made. For this reason the genetic investigation is done before the surgical decision.
How can you learn about the anaesthetic and the plan for the day of the procedure?
The type of anaesthetic and the setting in which the procedure is performed vary with the chosen method. You can learn the details of preparation and the plan for the day of the procedure from the doctor who will perform it.
Will sperm be found?
Whether sperm will be found cannot be said reliably before the procedure. Current guidelines on this subject state that one should not rely on predicting the result by looking at hormone and clinical findings before the operation; there is no single determinant that tells the result beforehand. In some people no sperm may be found at all. This is not an inadequacy or a failure; it should be dealt with as a medical outcome. You can talk with your doctor about the route to be followed if no sperm is found.
What are the risks of sperm retrieval procedures?
According to current guidelines on this subject, mild bleeding, scrotal haematoma (a collection of blood in the scrotum) and pain have been reported in TESA. In ordinary TESE, a haematoma inside the testis and tissue fibrosis may be seen; with micro-TESE these are less. A temporary change in hormone levels is also possible. You can talk with your doctor before the procedure about the general risks related to anaesthesia.
What should you pay attention to after the procedure?
Your doctor explains to you before the procedure whether complaints such as mild pain or mild bleeding are to be expected after the procedure. You need to follow the instructions your doctor gives about activity, sexual intercourse and pain management.
What can you ask your doctor before the procedure?
- Which method is being considered in my type, and why?
- Which hormone and genetic investigations are needed before the procedure?
- What is the type of anaesthetic, and how does the day of the procedure go?
- What is the next step if no sperm is found?
- Which check-ups and hormone monitoring are planned after the procedure?
Frequently Asked Questions
Does testosterone fall after the procedure, and is it permanent?
According to current guidelines on this subject, after ordinary TESE the average total testosterone value falls temporarily and returns to the starting level in long-term follow-up. Another joint guideline states that the risk of testosterone deficiency continues even after micro-TESE. Long-term hormone monitoring is found reasonable; how monitoring is planned belongs to your doctor.
Is a genetic finding passed on to the child?
Some genetic changes can be passed on to the child. Current guidelines on this subject report that this loss is passed on to the sons of fathers who have a microdeletion on the Y chromosome. In men in whom the sperm duct is congenitally absent, it is recommended that the partner too be tested for the relevant gene.
Does the woman's ovarian reserve influence this decision?
In the group with acquired epididymal blockage, yes. Current guidelines on this subject recommend, in this group, repair if the woman's ovarian reserve is good, and sperm retrieval if repair cannot be done or the reserve is limited. That is, the question of repair versus sperm retrieval also depends on the state of the woman's side.
Is the retrieved sperm used fresh or frozen?
According to the joint guideline on this subject, in men who have had sperm retrieved surgically, fresh or frozen sperm can be used for ICSI; this recommendation is at a moderate level. You can clarify with your doctor which will be chosen and the conditions of freezing, according to your treatment plan and the centre's practice.
If there is no sperm in the semen sample, is the decision for surgery made directly?
No. The decision for sperm retrieval is made after the type and cause of the azoospermia have been assessed. Which method is suitable depends on these findings.
Is the retrieved sperm used with microinjection?
Yes. Sperm taken surgically or with a needle is used with ICSI. Its processing and selection in the laboratory is a separate stage.
Is the preference for micro-TESE proof of definite superiority?
No. It is assessed as the preferred method in azoospermia due to a production problem; the strength of the recommendations varies between guidelines. This is a preference based on the data available.
Is TESA recommended in azoospermia due to a production problem?
No. In this group it is strongly recommended that TESA and fine-needle aspiration not be done. This should not be confused with the method options in azoospermia due to blockage.
Is the genetic investigation done before the surgical decision?
Yes. Some results influence the decision for the attempt. If a complete loss is found in the AZFa and AZFb regions of the Y chromosome, it is recommended that a sperm retrieval attempt not be made.
Do hormone results show for certain that sperm will be found?
No. Whether sperm will be found cannot be reliably predicted before the operation from clinical and hormonal findings. In some people no sperm may be found at all.
Can some tissue problems be seen less with micro-TESE than with classic TESE?
Yes. Bleeding inside the testis and tissue changes are seen less. This does not mean that the risks have disappeared; hormone monitoring is also discussed separately.
Should I ask my doctor about activity and check-ups after the procedure?
Yes. You should follow the instructions on activity, sexual intercourse and pain management. You can also talk with your doctor about how hormone monitoring and check-ups will be planned.
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