microTESE for the Treatment of Male Factor Infertility

August 6, 2020

For men with forms of nonobstructive azoospermia, sperm extraction techniques, including microsurgical testicular sperm extraction (microTESE), can offer some individuals the chance to conceive a child who otherwise would be unable.

microTESE is an established procedure, but is only offered at high-level centers with the necessary equipment, staffing, expertise, and specialized laboratory capabilities to navigate the complexities and challenges of the procedure to maximize chances of successful sperm extraction. 

Kathleen Hwang, MD“microTESE is not a procedure that any facility can offer. There are many large academic institutions across the United States that cannot offer it. It requires a good deal of infrastructure and specialized services. We are fortunate in that UPMC has invested heavily in male and female infertility treatments and reproductive endocrinology and to bring in house the expertise and resources needed to offer such complex procedures to patients,” says Kathleen Hwang, MD, associate professor of Urology and director male reproductive health at the UPMC Men’s Health Center.

Ideal Candidates for microTESE

microTESE is used to treat patients with various forms of nonobstructive azoospermia. The category of nonobstructive azoospermia is broad and all-encompassing for all etiology. 

Because the potential list of causes of nonobstructive azoospermia is quite large, a thorough workup and analysis of the patient is conducted by Dr. Hwang and colleagues to determine the underlying mechanisms at play and help predict who are ideal candidates for a microTESE procedure. Not all patients with nonobstructive azoospermia can benefit from the procedure. Patient selection for microTESE is highly correlated with its success in extracting sperm.

Some of the more common reasons for nonobstructive azoospermia that may be amenable to microTESE include gonadotoxic chemotherapy or radiation treatments for cancer – primarily childhood cancer survivors who are now adults.

Various genetic conditions, such as Klinefelter syndrome, also are common causes of nonobstructive azoospermia

"Y chromosome microdeletions affecting the genetic code for sperm production also can frequently cause the condition. Depending on the segment that is missing, this will dictate whether a patient is a good candidate for the procedure. Historically, with certain segments deleted, no one has ever found sperm in those individuals. Typically, in those cases, patients are not candidates for sperm retrieval procedures, including microTESE," says Dr. Hwang.

Versions of the microTESE Procedure and General Procedural Overview

The microTESE procedure can be divided into two basic types: 'frozen' and 'fresh.' The terms 'frozen' and 'fresh' refer to how the sperm is treated at the time of the procedure. Frozen is the more commonly occurring procedure where tissue and sperm samples that are retrieved are cryogenically preserved for future use by the couple. 

'Fresh' microTESE procedures entail using the harvested sperm almost immediately with assistive reproductive technologies. In the 'fresh' microTESE procedure, its timing is sequenced and coordinated to occur at the same time as the female partner's in vitro fertilization cycle.

In February, Dr. Hwang and colleagues at the UPMC Men’s Health Center, and their collaborators at UPMC Magee-Womens Hospital where all microTESE procedures are conducted, performed the first-ever ‘fresh’ version of the procedure on a patient at UPMC.

“Our first ‘fresh’ case was a tremendous success for everyone. The couple in question had undergone two prior sperm extraction procedures at another institution without success. Our teams were able to find and extract sperm from the male partner, and they successfully conceived a child. They are expecting their firstborn in a few months. It is a heartwarming story," says Dr. Hwang. 

And a stressful one for everyone involved. ‘Fresh’ microTESE procedures require an incredible amount of coordination and expertise from all the teams involved – the urologic surgery team, operating room staff, andrology lab, assistive reproduction experts, hospital administration, and others. Because of the level of coordination needed between the teams, facility, and patients, 'fresh' microTESE cases are confined to a designated two-week period during the year where everyone is on call and at the ready. During these two weeks, the team can offer up to six couples the opportunity for a 'fresh' microTESE.

“With the ‘frozen’ version of microTESE, we have the ability for many more cases and probably average three per month right now,” says Dr. Hwang.

Aside from how the sperm is treated in the ‘frozen’ and ‘fresh’ versions of the microTESE procedure, the remainder of the procedure and how it is conducted is essentially the same.

Procedures can range anywhere from two to four or more hours. The length of the procedure is related to whether or not sperm are located in the first testis. If the teams do find and extract sperm and are satisfied with the results, the other testicle is spared from surgery. If sperm is not located in the first testis, the team will operate on the second one to attempt to find a sample. 

"To perform this procedure, we essentially have to deconstruct the patient's testicle or testicles and then reconstruct them in a viable way. It is not an easy surgery to perform, so it is incumbent upon us to make sure we get it right the first time," says Dr. Hwang.

The Advantages of microTESE at UPMC

In the spectrum of sperm extraction techniques, microTESE is likely the most aggressive and invasive option that currently exists. microTESE is a complicated and taxing procedure for the patient, surgeon, and hospital – even hospitals with robust fertility treatment programs. The ability to perform microTESE procedures relies not just on the surgeon's abilities and experience but also on the hospital's resources and capabilities in surgical planning, andrology, fertility preservation, reproductive endocrinology, and assistive reproductive technologies.

“Equally important to our program is the andrology laboratory at UPMC Magee. They are incredibly talented and capable, and they are in the operating suite with the surgical team during the procedure. They have the tools and latest equipment to immediately process the samples we retrieve, find the sperm, and separate it using protocols that allow for maximum protective cryopreservation mechanisms," says Dr. Hwang. 

With the andrology laboratory working side-by-side with the surgeons in the operating room, it changes the level of sperm extraction rates possible, and it also cuts down on procedure time for the patient, which translates into less anesthesia time on the table, and a potentially less invasive procedure. 

Counseling Patients about microTESE – What Referring Physicians Should Know

Referring physicians should understand several important elements about microTESE procedures to discuss with patients before making a referral.  

Before a referral is made for a microTESE or other extraction procedure, patients should have a semen analysis twice to reveal a general picture of the man’s fertility health and indicate if a nonobstructive azoospermia may be present. The referring physician need not know the exact nature or cause of the azoospermia in order to make a referral.

"I do not expect patients to have a full workup and determination made as to the cause of their azoospermia prior to their referral. Once a semen analysis shows little or no sperm present, and the female's fertility is not in question, that is typically enough for a referral to our clinic for a consultation," says Dr. Hwang.

Beyond that, microTESE is an invasive procedure with no guarantee of success in finding sperm. The average sperm retrieval rate from all forms of extraction procedures for nonobstructive azoospermia is roughly 50%. Moreover, even if Dr. Hwang and colleagues can find viable tissue and sperm, it may turn out that the quality and characteristics of the sperm are suboptimal to conceive a child.

“Another aspect of microTESE that patients and referring physicians can sometimes fail to appreciate fully is that conceiving a child naturally will not be possible. Couples will need to undergo some form of assistive reproductive technology to give them the best chance of having a biological child. The amount of sperm we typically can extract in a microTESE procedure from a patient with nonobstructive azoospermia is exponentially lower – thousands or less versus tens of millions by comparison,” says Dr. Hwang. “That fact alone puts couples on a trajectory for an alternative to natural conception.”

Patients – couples – also must be prepared in advance for the possibility that the surgical team will be unable to locate and extract sperm.

Couples who are considering sperm retrieval procedures like microTESE, explains Dr. Hwang, need to have conversations and a decision in place before the procedure about what to do if the surgery is unsuccessful and the surgical teams cannot extract sperm. 

“For example, if the woman is simultaneously undergoing ovarian stimulation to have eggs extracted, what do we do with the eggs? Have they considered donor sperm as an option, or have they considered adoption as another means to having and raising a child? These are all difficult conversations and decisions that take time to work through,” explains Dr. Hwang.

In most cases, procedures such as microTESE are not covered by a patient’s health insurance and therefore must be paid for out-of pocket.

“The financial aspect of the procedure is something patient’s must grapple with. It behooves patients to do their research and ask questions related to an institution’s case volume and success rates,” says Dr. Hwang

microTESE has proven to be a viable method of sperm extraction that can help couples conceive a biological child. However, the procedure does have risks and it comes with no guarantees of success. A thorough consultation and testing with experienced male reproductive health experts is the first step in determining if a patient is a good candidate for the procedure. The UPMC Men’s Health Center has extensive experience treating a broad range of male reproductive health challenges using innovative procedures like microTESE to help patients achieve their treatment goals.

Referrals and Additional Information

To refer a patient, please call the UPMC Men’s Health Center at 1-877-641-4636. 

For additional information about the microTESE procedure and the UPMC Men’s Health Center, watch a short video presented by Dr. Hwang.