Microscopic Examination Procedure | Treating Azoospermia (Zero Sperm)

Microscopic examination is a modern technique to overcome infertility in cases of azoospermia (no sperm in semen). It relies on minimally invasive surgery to take samples of testicular tissue and then examine them in the lab to search for sperm. Overall, the procedure is highly safe. In this article, we discuss how the microscopic examination procedure is performed, the advantages and complications of testicular examination, in addition to the German technique that enhances the success of testicular opening surgery.

Microscopic Testicular Examination Procedure

Microscopic testicular sperm extraction (Micro-TESE) is a surgical procedure aimed at retrieving sperm from testicular tissue using a precise surgical microscope. Microscopic testicular examination is usually performed in cases of azoospermia in semen to overcome the associated infertility, as the retrieved sperm are later used in the ICSI procedure.

In which cases is microscopic examination indicated?

Microscopic testicular examination aims to treat non-obstructive azoospermia (zero sperm), which occurs in several cases, including:

• Undescended testicle.
• Klinefelter syndrome.
• Sertoli cell syndrome.

Microscopic examination may also be an effective option in some cases of obstructive azoospermia when surgical correction of the obstruction is not possible.

Instructions before the microscopic examination procedure

Before the procedure, it is important to follow these instructions:

1. Inform the doctor of your health condition in detail.
2. Complete all required tests and examinations.
3. Follow the doctor’s instructions regarding preparation for the procedure.
4. Discuss the benefits of the procedure and its side effects with the doctor.
5. Take antioxidants under medical supervision to improve sperm quality.

How is the microscopic examination procedure performed?

Testicular examination is easy to perform and is carried out through several steps as follows:

1. Preparing the patient under the supervision of the medical team.
2. Administering general, spinal, or local anesthesia, as most appropriate for the patient’s condition.
3. Making a small surgical incision in the scrotum to reach the testicles.
4. The doctor works directly on the testicle using a magnifying microscope (up to 40×).
5. The surgical microscope allows the doctor to see the seminiferous tubules precisely and select the most suitable ones to retrieve sperm from.
6. The doctor collects tissue samples from seminiferous tubules that are likely to contain sperm, then closes the surgical incision.

How is the testicle opened?

First, the scrotum is opened in the middle by only 2.5–3 cm, which is sufficient to reach both testicles. This surgical approach achieves better cosmetic results as the wound heals and reduces pain after the procedure. Based on manual examination of the testicles, the doctor determines which testicle is better to start with; the larger and firmer the testicle, the higher the chances of finding sperm.

Using a surgical microscope with up to 40× magnification, the doctor makes a surgical incision in the tissue surrounding the testicle (the testicular capsule). The testicle is then gently opened. Most seminiferous tubules are thin and shrunken, but careful microscopic examination helps identify dilated seminiferous tubules that are likely to contain sperm. The doctor takes samples of these tissues for laboratory examination and sperm extraction.

After that, the testicle is closed with an extremely fine suture after ensuring there is no bleeding, and the procedure is repeated on the other testicle. Once finished, the scrotal incision is closed with sutures that dissolve automatically within 3–5 weeks. The precise microscopic technique provides a high level of safety during the procedure to avoid any potential surgical complications after testicular examination.

Microscopic examination procedure using the German technique

The German technique is superior to the conventional method of microscopic examination in its ability to examine all parts of both testicles, providing a greater chance of finding suitable sperm. Doctors have also noted higher quality of the sample retrieved with the German technique, which increases the procedure’s success rate compared to the traditional method.

Dr. Mohamed Wael Ragab is considered one of the pioneers of the German technique for microscopic examination, using the renowned German microscope (Carl Zeiss), which ensures the highest success rates for the procedure.

How long does microscopic examination take?

The duration of testicular examination varies depending on the nature of the patient’s condition, testicular size, and the doctor’s skill in microscopic examination. The procedure usually takes between one and four hours, depending on these factors, and you can return home on the same day.

When do the results of microscopic examination appear?

The samples retrieved from the testicle are sent to a specialized lab for microscopic examination. It may take a few hours to find sperm suitable for use. The result of microscopic testicular examination is expected to appear within hours or, at the latest, the day after the procedure.

Success rate of testicular opening surgery

Several factors contribute to determining the success rate of the microscopic examination procedure, including the patient’s general health, the doctor’s competence, the number of times the procedure has been performed, and other factors. Overall, the success rate of testicular examination ranges between 40% and 60%, and Dr. Mohamed Wael Ragab offers the highest success rates for microscopic examination due to his extensive experience.

According to some studies, the success rate of testicular opening surgery—based on the cause of azoospermia—reaches the following rates:

Cause of azoospermia	Sperm retrieval success rate
Klinefelter syndrome	61-66%
Y chromosome microdeletion	67-75%
Undescended testicle	62%
Chemotherapy	42%
Unknown	48.5%

What happens after testicular examination?

Like any surgical procedure, you should follow the doctor’s instructions regarding rest and recovery after testicular examination. The patient usually returns home on the same day and may need to take painkillers to relieve pain, while keeping the wound clean to avoid infection. The doctor should be informed of any unusual symptoms or complications if they occur.

Recovery after the microscopic examination procedure

Scrotal tissue is among the fastest-healing tissues in the body, so recovery after the microscopic examination procedure takes only a few days. The patient usually resumes daily activities safely within a week. It is recommended to maintain a healthy diet and avoid strenuous effort to improve recovery.

When is intercourse allowed after testicular examination?

It is usually recommended to abstain from intercourse for at least one week after the microscopic examination procedure, as this supports better recovery and reduces complications of testicular examination.

Is testicular examination safe?

Testicular examination is completely safe, and there is no need to worry about undergoing it. The surgical intervention is limited to a small incision that heals quickly, and the procedure does not take long. Side effects are usually limited to mild pain. Undoubtedly, the doctor’s experience and surgical skill increase the safety of the microscopic examination procedure.

Advantages of microscopic testicular examination

Microscopic testicular examination represents a major breakthrough in treating male infertility. The most important advantages of microscopic testicular examination include:

• Short procedure time.
• High safety rates.
• Fast recovery after the procedure.
• No major surgical intervention required.
• Rare complications after the procedure.
• You can leave the hospital on the same day.
• Returning to work safely within one to two weeks.
• High success rates when performed by an experienced doctor.

Harms of microscopic testicular examination

The harms of microscopic examination are limited to feeling some pain after the procedure, but there are no real harms resulting from testicular examination as long as it is performed under the supervision of a highly qualified medical team. Painkillers can be taken if needed.

Complications of testicular examination

Potential complications after the microscopic testicular examination procedure include:

• Bleeding.
• Infection.
• Anesthesia effects.
• Hematoma.
• Damage to testicular tissue (rare).

Such complications are uncommon, especially when choosing an experienced doctor to perform the procedure and following their instructions before and after it.

Can the microscopic examination procedure be repeated?

Of course, microscopic examination can be repeated more than once, whether due to failure of the first procedure or to retrieve more sperm. However, it is recommended to wait 6–12 months between procedures to ensure a higher success rate.

It is worth noting that the success rate with repetition depends on the patient’s health condition, the nature of the problem, and testicular size. Some recent studies have indicated that the success rate of repeating the procedure after the first attempt succeeds exceeds 90%. Therefore, the outcome of the first attempt is extremely important for predicting the result of repetition.

Contraindications for testicular examination

Is microscopic testicular examination suitable for everyone? There are some cases that require special medical care before undergoing testicular examination. The success rate decreases significantly in the following cases:

• Chemotherapy and radiotherapy sessions: Chemotherapy and radiotherapy for cancer patients affect the chance of success, so the procedure is postponed for a considerable period after the sessions end. The doctor then determines the most appropriate time to perform the procedure based on their assessment of the patient’s condition.
• Klinefelter syndrome with low testosterone: A recent German study reported that a testosterone level below 2.15 in patients with this syndrome clearly indicates failure of the microscopic examination procedure. In these cases, doctors focus on raising testosterone to an appropriate level before proceeding with the procedure.
• Varicocele: Despite the ongoing debate about its relationship to the procedure’s success, a large segment of doctors believe that treating varicocele first improves the success rate of microscopic examination.

Do you really need the microscopic examination procedure?

Aside from the cases mentioned above, there are other cases that do not require the procedure and can be treated in easier ways, such as:

• Azoospermia due to a defect in the secretion of pituitary hormones that stimulate the testicles (FSH, LH), known as (Hypogonadotropic hypogonadism).
• Testosterone injections, as it has been scientifically proven that external injections of these hormones suppress testicular activity and negatively affect sperm production.

Frequently asked questions about microscopic testicular examination

Before concluding, we answer the most important questions about microscopic examination and its role in treating azoospermia cases:

Are there cases that have recovered from azoospermia?

Indeed, some patients recover from azoospermia in treatable cases, depending on the nature of the problem. Hormonal therapy may be suitable to stimulate the testicles in some patients, and surgery may be an effective option as in cases of obstructive azoospermia. This depends on the doctor’s evaluation of the patient’s condition and response to treatment, or resorting to other options to overcome infertility such as microscopic examination and ICSI.

Can pregnancy occur with azoospermia?

That depends on the cause of azoospermia and whether it is treatable. However, when treatment is not possible and there is no chance of pregnancy, modern techniques such as microscopic examination can be used to retrieve sperm from the seminiferous tubules and use it in ICSI to achieve pregnancy.

Is the examination procedure dangerous?

Microscopic examination usually does not pose a risk to the patient as long as they prepare for it according to the doctor’s guidance and follow medical instructions for recovery after the procedure. It is limited to some pain at the wound site, which can be managed with painkillers until it resolves completely.

Conclusion

• Microscopic examination is one of the best methods for treating male infertility.
• Microscopic examination has a high success rate, especially when performed by an experienced physician.
• Microscopic testicular examination can usually be repeated, depending on the treating physician’s judgment.
• Do not hesitate to contact us and share your problem now to receive the necessary medical care as soon as possible.

Sources

• Repeated microdissection testicular sperm extraction in patients with non-obstructive azoospermia: Outcome and predictive factors – PMC (nih.gov)
• Sperm Retrieval Procedures | Johns Hopkins Medicine
• Microscopic Testicular Sperm Extraction – Cleveland Clinic
• Micro-TESE: Causes, Symptoms, and Treatment – Amir Zarrabi
• Microsurgical testicular sperm extraction (microTESE) – Mayo Clinic
• MicroTESE, TESE Procedure, & TESA Procedure | University of Utah Health
• Reproductive Chances of Men with Azoospermia Due to Spermatogenic Dysfunction – PMC