Testicular Biopsy for Infertility: Procedure & RecoveryFertility Treatment
What Is Testicular Biopsy?
Testicular biopsy involves removing a small piece of testicle to check for sperm production. The process of producing sperm takes place in the seminiferous tubules in the testicles. Inside the seminiferous tubules, there are germ cells that develop into mature sperms within 64 days and through 16 stages.
By examining the samples obtained from testicular biopsy, the doctor can check out the presence or absence of germ cells and sperms as well as the development of the germ cells. If there is a healthy sperm, it can be extracted and used in IVF and other assisted reproductive techniques. Needle biopsy technique is often used to diagnose infertility in patients who have azoospermia (lack of sperm) with normal FSH (Follicle-stimulating Hormone) levels because in these patients, it is not possible to distinguish obstructive azoospermia problems from spermatogenesis defects.
It should be noted that the testicular biopsy technique is the only way to definitely diagnose the presence or absence of sperm in men with azoospermia. This technique is performed either by surgery (TESE method) or with a special needle (PESA method); in both methods, sampling is performed under local anesthesia (in most cases) and in a sterile room.
What Is Azoospermia?
Lack of sperm in at least two semen samples is called azoospermia. This problem is caused when there is a blockage preventing sperm from entering the ejaculate or when the testicles do not produce sperm due to medical injuries, infections, and genetic disorders. Although the only definitive way to diagnose azoospermia is the testicular biopsy, sometimes blood tests for checking the hormones, clinical examinations, and genetic tests are used as well.
Testicular biopsy is very important for two reasons; first, it is used in microinjection method, by the means of which the infertile couple can have babies with a small number of sperms. Second, the testicular cancer can be diagnosed in its early stages with biopsy test while it cannot be detected by ultrasound.
By using testicular biopsy, the sperms are collected for artificial insemination methods such as IVF and IUI. Of course, when the male partner doesn’t have the bilateral seminal vesicles, the biopsy test is not be needed.
In the past, testicular biopsy used to be done on a single part of the testicle; however today, the testicle is divided into four parts and different samples are received from each part. The reason for dividing the testis is that the different parts of the testicle produce various amount of sperm. This is especially important in men with azoospermia because maybe only one certain part of the testicle is able to produce sperm (called relative testicular insufficiency). If the testicles produce no sperm at all, it is called Primary Testicular Failure (PTF).
Why Is Testicular Biopsy Done?
Testicular biopsy is used with the aim of diagnosing sperm problems such as insufficiencies and diseases as well as retrieving sperm from the testicle to be used in IVF and other fertility treatment techniques such as IUI and ICSI.
Of course, it’s worth mentioning that not all azoospermic patients need a biopsy test. If the azoospermia is due to the lack of seminal vesicles on both sides, the biopsy test will not be taken. Since the process of sperm production is different in various parts of the testicle, biopsy is done on different points of it. Today, four parts are considered for the testicle and then, testicular biopsy is done on each individual part.
After testicular biopsy, if mature sperms are collected, the samples are frozen to be used in later assisted reproductive processes. This is done because of the fact that in some cases, these samples are the only sperm left for the patient and the doctor may not be able to find mature sperms in subsequent biopsies.
Best Candidates for Testicular Biopsy
The best candidates for testicular biopsy are those who have very few sperm in their semen and their sperm problem is caused by the following factors:
- Congenital lack or blockage of the vas deferens;
- Hormonal problems;
- Radiation exposure, especially in patients with cancer;
- Genetic factors and the formation of sperm-producing genes on the Y chromosome;
- Infectious diseases such as mumps;
- Some drugs, especially the ones used in cancer treatment; etc.
Preparation for a Testicular Biopsy
Before doing testicular biopsy, the patient should take care of himself and inform the doctor about the following points:
- Any kind of bleeding;
- Having allergy to any drug including anesthetics; and
- The medications he takes.
Also, the patient has to shave the hair on the scrotum, around the penis, and on the groin the night before surgery.
Normally, biopsy is done under local anesthesia, but if, at the doctor's discretion, it has to be done under general anesthesia, the patient should avoid eating and drinking before the surgery.
What is Testicular Biopsy Procedure?
Testicular Biopsy sample is taken in two ways; Percutaneous Epididymal Sperm Aspiration (PESA) and Testicular Sperm Extraction (TESE).
In the following, both methods are introduced in detail:
Percutaneous Epididymal Sperm Aspiration (PESA)
Before doing PESA, the doctor will usually advise you to shave your genital hair and attend the surgery center in the morning on an empty stomach. After sterilizing the room and administering local anesthesia, the sperms are extracted from the epididymis (inner tube of the testicle) with a syringe and insulin needle impregnated with a special substance. Then, the sperm sample is delivered to the laboratory for further examinations.
If the test is positive, the person can be a candidate for microinjection; but if the test is negative, a surgery is needed. It should be noted that PESA is usually used for the ones who have done vasectomy. The doctors advise this method to reduce the costs and avoid testicular sampling.
Testicular Sperm Extraction (TESE)
In the outpatient testicular biopsy or TESE, the patient should shave off his genital hair and attend the surgery center in the morning on an empty stomach. For doing TESE surgery, a caregiver is usually needed. In this method also, the surgery room is sterilized and local anesthesia in administered; however, at the doctor’s discretion and patient’s request, it is possible to inject intravenous sedatives.
To anesthetize the patient, the appropriate drug should be injected into the spermatic cord (blood vessels connecting the testicles to the abdominal cavity) as well as the incision place.
After examining the testis’s tissue under laboratory microscopes, if sperm is observed, the microinjection method can be used to treat the infertile man.
However, if the doctor does not find sperm in the tissue, he/she has to repeat the biopsy to make sure that the patient has azoospermia. In such cases, the Micro TESE method (testicular biopsy with a microscope) is repeated to enlarge the target tissue and better detect the presence or absence of sperm.
Testicular Biopsy Side Effects
Testicular biopsy is a simple operation and the person will not have severe bleeding or infection; of course, mild pain and swelling are perfectly normal. Some people are worried about the aggravation of fertility problems after the operation. It should be noted that this operation will not affect the erection or heighten the infertility, so the patients should not be worried.
In case of observing the following problems after testicular biopsy, contact your doctor:
- Severe pain;
- Extreme swelling;
- Fever above 38 degrees; and
- Severe bleeding.
Testicular Biopsy Recovery Time
After testicular biopsy, care must be taken to follow all postoperative instructions. Here are the things to do after a testicular biopsy:
- Not using tight underwear;
- Using painkillers and antibiotics;
- Absolute resting for 24 hours.
Interpretation of Testicular Biopsy’s Result
Interpretation of the results of biopsy is very important in choosing the best treatment. In fact, although testicular biopsy is a simple operation that is performed only through a small incision in the skin of the scrotum, interpreting its results is important and difficult. In fertility center, a pathologist examines the samples. In some cases, the patient is infertile and does not have any germ cell. At this situation, the doctor recommends the use of a donated embryo to the patient.
In some patients, the germ cells have evolved to several stages, but at a certain stage, this evolution has stopped. This group of people also do not have sperm in their semen, but the situation of this group is different from the ones who does not have any germ cell at all; because these people can get better by using special medicines and the developmental stage of their germ cells can get completed, or in some cases, their immature sperms can get mature in the laboratory. It is worth mentioning that both of these groups suffer from azoospermia.
In general, the interpretation of testicular biopsy’s result is divided into four categories:
- Natural: in these cases, testicular problems are not the cause of the lack of sperm.
- Stop in sperm evolution: sperm must go through 16 stages to evolve. Sometimes this evolution stops at one point.
- Insufficient sperm production: in this case, complete development of sperm occurs in some parts of the testicle, but these parts are so limited that the sperm does not appear in the semen.
- Lack of germ cells: these patients do not have any germ cell in their testicles.
Sometimes the biopsy test shows that the testicle has its normal function and the lack of sperm in the testicle relates to obstructive azoospermia (OA) which is the result of a blockage of the male reproductive tract.
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Concluding Remarks and Recommendation
Regarding the abovementioned points, it seems that today the best way to diagnose a variety of sperm problems (including low count, low quality, low motility, improper shape, etc.) is testicular biopsy because in addition to its diagnostic use, it provides the basis for using the most appropriate methods to treat male fertility problems.
Therefore, it is urgent to increase the awareness of the infertile couples about this operation when they refer to fertility centers and consult a specialist doctor.