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Originally published November 14, 2024
Last updated November 14, 2024
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Microsurgical testicular sperm extraction, or microTESE, has already given fertility hope to men with azoospermia. Physicians use this outpatient surgical procedure, which can take two to three hours, to microscopically search for and retrieve sperm from the testicles in cases when a patient’s ejaculate contains no sperm, a condition that affects about 1% of men globally. In most cases, a microTESE is performed on men with two testicles. The procedure, however, is more complicated when a patient has only one testicle — and that testicle is impacted by testicular cancer.
Kian Asanad, MD, a urologist at USC Urology, part of Keck Medicine of USC, explains how he and his colleagues recently performed Keck Medical Center of USC’s first onco-microTESE procedure on such a patient.
This patient faced health and fertility obstacles due to a series of medical events throughout his lifetime.
First off, the patient was born with two undescended testicles. “Men who have undescended testicles have an increased risk of developing testicular cancer,” Asanad explains. “It’s a known association.”
In addition, the patient had only one remaining testicle. The other testicle had been removed when he was younger during treatment for his undescended testicles. Surgeons had performed an orchidopexy to move the patient’s undescended testicles into his scrotum. During the procedure, they also detected an abnormality in the patient’s left testicle. They ultimately removed the left testicle via orchiectomy, leaving the patient with a solitary right testicle.
Eventually, the patient did develop a tumor in his sole remaining testicle. He was diagnosed with testicular cancer at 32 years old and was referred by a urologist to Keck Medicine for treatment.
Patients with testicular cancer often bank their sperm for fertility preservation ahead of treatment and chemotherapy. One problem these men face, however, is the possibility of having a low sperm count. “While some men with testicular cancer have a normal sperm count, up to 25%-30% of men have low sperm counts,” Asanad says.
This patient specifically was found to have non-obstructive azoospermia, meaning he had no sperm in his ejaculate. This fact was discovered when he made several unsuccessful attempts to bank sperm prior to undergoing surgery to have his cancerous testicle removed. Asanad says that when his team measured the patient’s follicle-stimulating hormone (FSH) level, it was 59. “I’ve never seen an FSH level that high,” Asanad says. “It’s usually less than 7, and if it’s high, it’s at a 10, 20, 30, or 40. I have never seen it go up to almost 60.” The extremely high FSH level indicated that the patient’s body was working overtime to try to stimulate sperm production.
Ultimately, the patient’s low sperm count, combined with having just one testicle with cancer, made fertility preservation extremely difficult.
“Normally, when a patient has two testicles, you can remove one testicle and there is still another testicle likely producing sperm, so sperm retrieval is generally not an issue,” Asanad says. “But in this case, the patient had only one testicle — and if we removed it, he wasn’t going to make any more sperm.”
He emphasizes the uniqueness of this case. “It’s quite uncommon to have cancer, to have only one testicle and be azoospermic,” Asanad adds. “That combination is very rare.”
One fertility preservation procedure offered to men with azoospermia is microsurgical testicular sperm extraction, or microTESE. During a typical microTESE procedure on patients with two noncancerous testicles, physicians use a microscope to search for sperm in the seminiferous tubules of both testicles.
In cases when a patient has two testicles, but one testicle is cancerous and therefore removed, physicians can still search for sperm in the detached cancerous testicle. Importantly, they still have the benefit of extracting sperm from the other healthy testicle. “You have a little more leeway,” Asanad says. “There’s more healthy tissue to go through to search for sperm. There’s a normal testicle with no cancer.”
In this patient’s case, Asanad’s team could only search for sperm in the patient’s one cancerous testicle. They performed what they call an onco-microTESE, so named because it is performed on a testicle with cancer. He says this is the first time an onco-microTESE was performed at Keck Medical Center in Los Angeles.
During the onco-microTESE, Asanad and his team removed the patient’s cancerous testicle. Once the testicle was detached, Asanad used a surgical microscope to look for any traces of sperm.
The difference between performing the procedure on a cancerous testicle versus a noncancerous testicle is that “there is a ton of cancer in there,” he says. “I bivalve the testicle, and under the surgical microscope, I look for areas of normal testicular architecture that don’t look cancerous. To do so, I’m trying to avoid the tumor and looking for tiny areas that resemble seminiferous tubules or the normal testicular tissue — and then trying to find sperm within those. However, the volume of tissue that I was able to go through was much less than normal because the patient only had one testicle. It was much more challenging.”
Using the onco-microTESE, Asanad and his team extracted what sperm they could from the cancerous testicle. “I found rare sperm,” he says. “In a case like this, when we find sperm, we’re not finding millions of sperm. But there are sometimes still rare sperm that are not able to come out in the ejaculate that can be found within the tissue of the testicle. We found rare sperm in the operating room, and I sent all that tissue to the sperm bank to freeze.”
Asanad says the patient understands that it remains to be seen whether the sperm retrieved will lead to paternity. “He understood the risk and that this was a last-ditch effort to find sperm, if you will,” Asanad says. “But it gives him hope. It gives him a chance. Down the road, they can thaw that tissue, and he can use it via IVF with a future partner to try to achieve a pregnancy.”
Being able to offer the onco-microTESE procedure at Keck Medical Center going forward gives patients facing testicular cancer and fertility roadblocks a new hope for fertility. Asanad explains some of the hurdles he and his colleagues overcame to lay the groundwork for this new procedure, including obtaining legal consent to release the testicular tissue specimen from the hospital so it could be sent to a sperm bank as well as sourcing a special sperm wash media to preserve the specimen for transport.
“The entire urology team — including our staff and my mentor, urologist Mary Samplaski, MD — really moved mountains to get this case across the finish line,” Asanad says. “It took a village to get here.”
He calls this case “incredibly gratifying.” In all fertility preservation cases, he says he always tells patients, “I can’t promise we’ll find sperm, but I can promise you that we’re going to do everything we can today to find sperm.”
He continues: “Whether they’re undergoing a microTESE or an onco-microTESE, I want patients who go into the operating room never looking back over their shoulder and thinking, ‘What if we did it differently?’ I want them to feel secure that they’re receiving world-class care. In this patient’s case, he has a few frozen sperm, and maybe that’s all he needs to be a biological parent one day.”
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