Desai Sethi Urology Institute Offers Rare Surgical Option for Men Who Don’t Produce Sperm
Summary
- Thomas Masterson, M.D., and Rodrigo Pagani, M.D., are offering fresh microdissection testicular sperm extraction (microTESE) for men who cannot make sperm.
- The specialized approach nearly doubles chances of paternity, compared to microTESE with frozen sperm.
- Desai Sethi Urology Institute has the infrastructure and expertise to coordinate the microTESE procedure in conjunction with IVF cycles.
Thomas Masterson, M.D., and Rodrigo Pagani, M.D., both assistant professors of clinical urology at the Desai Sethi Urology Institute, part of the UHealth — University of Miami Health System, have begun offering fresh microdissection testicular sperm extraction (microTESE) for men with azoospermia, or the inability to make sperm. The specialized approach nearly doubles these patients’ chances of paternity, compared to microTESE with frozen sperm.
UHealth is one of a few academic centers nationally and, to Dr. Masterson’s knowledge, the only in South Florida to offer this logistically challenging process.
What is microTESE?
Some men don’t make sperm at all or make sperm at undetectable levels, sometimes for unknown reasons. In men with azoospermia, the only way to determine if they have retrievable sperm is with microTESE, a surgical procedure during which doctors use a high-powered microscope to systematically search through the testicle looking for sperm, according to Dr. Masterson.
“Inside the testicle, there are thousands of microscopic tubes where sperm grow and develop,” Dr. Pagani explained. “In men with non-obstructive azoospermia, the majority of those tubes are empty and do not contain any sperm. However, in some of these men, there may be small islands of active sperm production. Under a high-magnification operating microscope, we systematically search through the tubules to identify larger, more plump tubes that may contain active sperm development. It’s like looking for penne in the background of angel hair pasta.”
This procedure, in conjunction with in vitro fertilization (IVF)-intracytoplasmic sperm injection (ICSI), offers these men the opportunity to have children that are genetically their own.
Why the “Fresh” Part Matters
For a man without infertility, freezing an ejaculated sperm sample is a reasonable option, according to Dr. Masterson.
“Some sperm will not survive the freezing and thawing process. But in a normal ejaculate that has millions of sperm, losing 50% in the freezing is not a clinically significant problem,” he said.
For surgically extracted sperm, freezing and thawing present two problems.
“The first is that if we find sperm, we usually don’t get a lot of it. The second is that surgically extracted sperm does not freeze very well,” Dr. Masterson said. “About half of men who elect to freeze surgically extracted sperm will not have usable sperm after the freezing and thawing processes.”
The microTESE procedure generally offers two options — surgery up front and then freeze the sample or schedule the microTESE at the same time as a planned IVF cycle.
There are benefits and drawbacks to each.
If a couple will only consider an IVF cycle if they know sperm exists, they might elect to do the man’s surgery up front and freeze the sperm, risking sperm loss in the freezing process. Their chances of having viable sperm for IVF, however, are considerably higher if they have fresh sperm. That approach means timing the man’s surgery with the woman’s egg retrieval.
“The benefit here is that whatever sperm we find can be utilized immediately to fertilize the eggs,” Dr. Masterson said. “The risk becomes that if we don’t find sperm, what is the backup plan for the eggs? That’s where we talk about donor sperm, egg freezing and reassess.”
Coordinating the Sperm Extraction
Scheduling the operating room time and staff, including O.R. nurses and an anesthesiologist, can be challenging, Dr. Masterson said.
“If Mrs. Smith is going to be starting her IVF cycle on January 1, the anticipated egg retrieval date might be January 12. But we won’t actually know when until about 36 to 72 hours in advance, because everyone’s eggs develop at different rates,” Dr. Masterson said. “When eggs get to a certain size, the couple will ‘trigger’ the eggs, and she will undergo egg retrieval 36 hours after the trigger. So, we have to schedule the sperm extraction procedure based on what’s going on with the female partner’s cycle. This leaves very little time to coordinate the operating room for the microTESE.”
To avoid conflict with the regularly scheduled surgical cases for the day, Dr. Masterson does fresh microTESE surgeries at 5:30 a.m. Once he retrieves a sample, he sends it to the UHealth Center for Reproductive Medicine, where the female partner is going to have her eggs retrieved.
“As far as I know, we’re the only center right now in South Florida that has been able to coordinate this process,” he said. “That may be why most centers offer only frozen microTESE.”
Coordinating fresh microTESE for this subset of infertile male patients has been well worth it. In a recent study, 58.1% of couples undergoing fresh cases had motile sperm for intra-cytoplasmic sperm injection. In frozen cases, only 19.6% retained motile sperm post-thaw, leading to their conclusion that there is a potential advantage of fresh microTESE, despite the logistical challenges.
Tags: Department of Urology, Desai Sethi Urology Institute, Dr. Rodrigo Pagani, Dr. Thomas Masterson, IVF, male infertility, Newsroom