Testicular biopsy

The necessity of biopsy emerges when a man is diagnosed with azoospermia (the absence of spermatozoons in the ejaculate).

"Vitromed" clinic is fully equipped to perform various methods of biopsy, including open microsurgical biopsy of testicle and epididymis.Biopsy is performed by a qualified and experienced urologist-andrologist with the knowledge of all conservative and surgical methods according to European and USA standards.

An experienced physician-biologist is as well present at the OR during biopsy to examine the biopsy sample harvested from the testicle for the detection of spermatozoon.

The clinic is fully equipped(including surgical Wallach (USA) microscope) to perform an open surgical biopsy of testicles

In case of spermatozoa detection in biopsy sample:

1.  the biopsy sample undergoes  cryopreservation later to be used for in vitro fertilization
2. in case of testicle biopsy from man and simultaneously oocyte capture from woman, detected spermatozoa are used for oocyte fertilization; the rest of the biopsy sample undergoes cryopreservation to be used in assisted reproductive programs.

Testicle biopsy is a surgical procedure, aimed to get a tissue from the testicle or from epididymis for carrying a mycroskopic examination and detecting spermatozoons later to perform assisted reproductive procedures in patients with azoospermia.

Indication for testicular biopsy is azoospermia (absence of sperm in the ejaculate), which affects about 5% of patients seeking treatment for infertility.

There are two basic types of azoospermia.

• Obstructive azoospermia, when spermatogenesis in testicles is preserved, but the sperm produced in the testicles do not fall in the ejaculate because of the absence or obstruction of vas deferens.
• Non-obstructive azoospermia which is caused by the insufficiency of sperm.

Depending on method two modifications of biopsy are distinguished-percutaneous aspiration and open biopsy of testicles.

Biopsy in ‘’Vitromed” clinic is performed in any type of azoospermia when obtaining sperm is impossible with any other method.

Depended on infertility causes, testicle and epididymis biopsy can be performed by different modifications, each of which has its peculiarities. That’s why each man passes through a complex examination, including laboratory tests allowing detection of dysfunctions of spermatogenesis led to the interruption of reproductive function.

Based on the results, the urologist-andrologist desides the necessity of performing any method of biposy.

The right approach to the preliminary diagnosis  will allow to maximize the probability of spermatozoons' capture and their later usage from biopsy sample, which allows to avoid double biopsy.

Percutaneous aspiration biopsy

PESA (Percutaneous Epididymal Aspiration)

Method

It is relatively simple manipulation which is carried at the OR under local anesthesia. It is performed without any alignment and the duration is 15 minutes.

The liquid is dissipated from the epididymis with the help of a puncture needle and syringe passed through the testicle skin. The liquid is therefore sent to the laboratory for microscopic examination where the number and quality of available mature spermatozoa is detected.

The patient can go home just after the procedure or stay at clinic for 1-2 days. Absorbable sutures are used.

TESA (Testicular Sperm Aspiration)-Percutaneous testicle biopsy with thin needle

Method

It is performed under local anesthesia at OR. The model of testicle tissue is captured with the help of special biopsy apparatus, charged with biopsy needle.

Instructions

Obstructive azoospermia (excretory form of infertility). In case of obstructive azoospermia it is considered as an optimal method of spermatozoon capture. Nearly in all cases it is possible to get sufficient number of spermatozoons for the performance of IVF-ICSI procedure. (In Vitro Fertilization- Intracytoplasmic Sperm Injection)

Differentialdiagnosis of obstructive and non-obstructive infertility

Advantages:

• less invasive,
• short duration.
• low risk of complication,
• preservation of work capacity after the operation,
• multifocality

Disadvantages:

• impossibility to get the necessary number of tissues for morphological exmination,
• absence of visual control. The operation is performed blindly:  testicle tissue is captured randomly which doesn't exclude the occurrence of complications,
• there is a high risk of vascular damage and hemorrhages which can lead to scrotal or intratesticular hematomas and testicle atrophy.

Efficiency

15 -50 percent of pregnancy with embryo transfer occur from this method depending on the type of azoospermia.

Open biopsy of testicle

Technically it is much more difficult and generally  performed when it's impossible to get biopsy material through percutaneous puncture.

TESE (TesticularSpermExtraction)- Open testicle biopsy is the most popular method in the world. At «Vitromed» clinic we prefer bilateral multifocal biopsy of the testicle.

The method of spermatozoa capture

It is performed under local anesthesia at OR. A small incision is made on the scrotum. Just from the little wedge incision a biopsy material is taken then divided into three parts. The first part is examined at the laboratory, where it undergoes processing for extraction of spermatozoons, the second part (in case of detection of mature spermatozoons)undergoes cryopreservation to be used in IVF-ICSI cycle, the third one is sent to histological examination which will later  allow to diagnose the  outcome  of the treatment based on the absence or presence of spermatozoons.

Indications

Non-obstructive azoospermia: patients with the dysfunction of spermatogenesis according to the results of spermogram, as in non-obstructive azoospermia local spermatogenesis can be maintained.

In case of detection of normal spermatogenesis sites the capture of spermatogenesis is done normally for their later usage during cryopreservation and IVF processes.

Advantages:

• it provides a visual control of the hemorrhage and the damaged vessel which minimizes the probability of complications,
• possibility to get great number of tissues required for the morphological examination,
• multifocality

Efficiency
Bilateral multifocal biopsy allows in 65% cases of non-obstructive azoospermia capture spermor spermatids suitable for IVF. Later the woman undergoes superovulation and sperm from cryopreserved biopsy sampleis used for the fertilization of the oocyte.

In some cases spermatozoа may not be detected during operation.In this case the patient is advised to undergo an open microsurgical biopsy of testicle.

MESА  (Micro-Epididymal Sperm Aspiration)

The method of spermatozoon capture

It is a microsurgical operation during which under microscope control larger diameter tube is allocated from which the semen fluid is aspirated.

Micro-TESE  (Micro-Testicular Sperm Extraction / Microdissection Testicular Sperm Extraction)
Method
It is the most difficult but optimal way of open biopsy. It's performed under general or spinal anesthesia at OR. Under microscope the urologist exopses the tissue of the testicle ,thoroughly examines the small tubes of the testicles, which allows to capture healthy tubes possibly containing spermatozoons. Captured samples are immediately examined by the biologist with another microscope to detect spermatozoons.  If the biopsy detects mature spermatozoons, they are either used for the oocyte fertilization or frozen to perform IVF later.
Indications
Do not differ from the TESE Indications
Non-obstructive azoospermia(primary testicular insufficiency).Patients with spermatogenesis disorder when the level of spermatogenesis is very low according to spermogram. In this case the appropriateness of biopsy is explained with the fact that tubes aren't always totally damaged in the testicle, very often local spermatogenesis can be preserved in form of islets that can be seen under the microscope.

Advantages:

• the number of captured spermatozoа increases on the contrary to standard testicular biopsy (57% vs 32%),
• the size of the tissue captured from the testicle decreases(2-3 mm3, 3-5 mg weight),
• it provides a visual control allowing to identify blood vessels, so surgeon is able to preserve them and minimize the complications,
• it allows man who suffers from non-obstructive  azoospermia with the absence of spermatozoа in biopsy substance to become a genetic father.

Terms

The operation is generally performed simultaneously with the capture of oocyte but as it’s known while the spermatozoa captured by the epididymis preserve the ability of fertilization for 12-24 hours, testicular spermatozoа preserve the ability of fertilization for 48-72 hours, which in some cases allows to perform the procedures not simultaneously.

Тhе usage of the cryopreserved tissue or testicle aspirtae is also possible depended on the patient's wish. In this case the sperm capture procedure is performed beforehand regardless the terms of woman's follicular puncture.

Efficiency

The possibility of spermatozoon's detection with the help of micro TESE increases from 50 to 70% after the previous ineffectual traditional biopsy.

In many cases non-obstructive azoospermia doesn't detect any spermatozoons in the testicle tissue, a situation like that is possible from 30 to 35% of cases, but the detection of both round and oblong spermatozoа by non-obstructive azoospermia allows men to have genetical children.

Our clinic allows men to solve these problems in correct and effective way.

Our workhas earned the gratitude and appreciation of our patients.

Trust our professionals.