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M-TESE. Treating infertility in men with no spermatozoa in semen

On 6 October 2012 nOvum conducted the first in Poland M-TESE (Micro-Testicular Sperm Extraction) procedure, entailing the dissection of small fragments of tissue during an open testicular biopsy monitored using an operating microscope. On 14 November 2012 an ultrasound confirmed a regular 5-week pregnancy developing in the uterus of the future mother. The use of M-TESE opens a whole new chapter in the treatment of male infertility.

Infertility is always a disease shared by the couple, but the identification of the causes of the inability to produce offspring is extremely important for the selection of effective treatment methods. For men showing significantly decreased or extremely low sperm parameters a viable solution is the in vitro fertilisation (IVF), supported by the intracytoplasmic sperm injection (ICSI). The first successful procedure involving the above was performed in Poland at the Warsaw nOvum Clinic in January 1995. The ICSI can be performed even when the semen shows singular spermatozoa, often identified by the embryologist during a multi-hour examination of semen slides under the microscope.

What happens when the semen contains no spermatozoa?

When the semen contains no spermatozoa (azoospermia), they can be identified as a result of a percutaneous or microsurgical epididymal sperm aspiration (PESA, MESA), or testicular sperm aspiration or extraction (TESA, TESE). The extracted material is then transferred to an IVF laboratory where it is microscopically analysed for spermatozoa which could then be used for the IVF-ICSI protocol. The first ICSI-PESA procedure in Poland was performed at the nOvum Clinic in April 1996, and the ICSI-TESA in September 1996. The procedures, although effective, have their limitations. Fragments of the testicular tissue used for examination and sperm analysis are extracted from 1 or 2 spots during a traditional biopsy, or 6 to 9 spots during a mapping biopsy. If the lab analysis shows that the extracted tissue contains no spermatozoa, there is still the question if spermatogenesis can be achieved in the remaining testicular tissue. Examining another portion of the tissue requires a subsequent procedure. Theoretically biopsies can be repeated, however, this is not the common practice as the procedure causes a substantial strain on the patient, with the probability of actually identifying spermatozoa during any subsequent extractions ( ≥ 3) practically approximating nought.

On 6 October 2012 nOvum performed the first in Poland microsurgical testicular tissue extraction (M-TESE), being a much more precise procedure than the PESA, MESA, TESA or TESE.

The procedure was performed on a patient with no spermatozoa in semen, who had shown no spermatozoa during a previous standard biopsy. The M-TESE, lasting for about 2 hours, was conducted by Dr Jan Karol Wolski and Dr Grzegorz Kapuściński (urologists and andrologists at nOvum). The male was subjected to general anaesthesia. During the procedure the testes were revealed from the scrota and the tissue was microscopically analysed to precisely identify the areas from which the seminiferous tubules were removed showing an increased potential of spermatogenesis. The samples were then analysed in detail at the IVF laboratory. Spermatozoa were found and cryopreserved (frozen) in liquid nitrogen awaiting the scheduled ICSI procedure. A classical histopathological examination was also performed which showed the presence of multiple spermatozoa. Following the examination the patient’s wife underwent hormonal stimulation and on 15 October an egg retrieval procedure was performed. Thawed fragments of the testicular tissue produced a sufficient number of spermatozoa which were then injected (ICSI) to the wife’s oocytes, producing three embryos.

On 14 November a singleton pregnancy was confirmed during an ultrasound examination, and the happy parents saw the beating heart of their baby. Since then the pregnancy has developed correctly, with antenatal care provided by the nOvum Clinic.

The successful M-TESE procedure is yet another stage in the process of developing the available assisted reproductive technologies. These highly advanced and relatively low-invasive procedures offer real fatherhood potential to men who before were either left with their inability to produce offspring, or had to resort to sperm banks.