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    male fertility

    Testicular Biopsy – Indications, Procedures, Risks and Results

    • 10722 views
    • 4.5   (1 Votes)
    Medically Reviewed by Dr. Deepika Tiwari - MS, MBBS on 30 Jul 2019 - Written by Dr. Rupal Shah - MBBS, DGO, MD - Grammatically Approved by Dr. Kavita Jaggi Agrawal - MS, MBBS

    In a testicular biopsy, a tissue sample from testicles is removed for laboratory examination. Indications for testicular biopsy are obstructive and non-obstructive Azoospermia. Percutaneous and Open biopsy are two types of testicular biopsy. Success rates of testicular biopsy are worth appreciating.

    Infertility is the inability to conceive after trying for a year or more with natural intercourse. It can affect both men and women in a visible manner. The good news is that the condition can be reversed with the help of advanced medical technologies in infertility treatments. Male infertility today contributes to the occurrence of a high number of infertility cases in couples. Infertility in men poses no other outward symptoms other than the inability to impregnate the partner within a stated period of time. Treatments associated with male infertility are based on the underlying cause of infertility, or in the case of unidentified problem, evidence-based medical treatments to improve fertility levels are recommended by the best fertility doctors. Male infertility treatments include surgery to correct or repair anatomic abnormalities or damage which has occurred to any of the crucial parts of the reproductive system. There are certain lifestyle changes which can also help men to improve their fertility such as eating right, maintenance of the recommended weight as per height, reducing stress, and physical fitness levels. According to various highly popular research studies, hot testicles are considered less efficient at producing sperm. It is thus recommended that men should avoid wearing tight underwear, bathing in hot saunas and tubs. The success rates of testicular biopsy with micro-TESE, have been reported in men up in up to 63 percent cases. However, conventional and more limited sperm retrieval procedures have reported success rates of 20 percent in percutaneous testicular biopsies to 45 percent in open biopsies. Thus, testicular biopsy has contributed to tremendous cases with the highest success rates.

    This article gives detailed information about:

    Male infertility issues are a major concern for most of the couples who are not able to conceive naturally. Testicular biopsy is considered as the cornerstone of male factor infertility diagnosis for many years. This is particularly the scenario in men who are diagnosed with unexplained infertility and diagnosed with azoospermia. (1) Azoospermia is a medical condition in men where there is an absence of sperm in their semen. Azoospermia occurs in about 15 percent of infertile men and in 1 percent when men are considered at a global platform. This condition usually doesn’t pose any potential symptoms in men and is most probably diagnosed at the time of planning for a baby. The only sign of being diagnosed with Azoospermia is when a man is unable to impregnate his partner.

    Testicular Biopsy

    Testicular Azoospermia takes place due to a groin injury and a childhood illness like viral orchitis. This leads to swelling in one or both testicles. Cancer treatments or certain radiation therapies are also considered among certain prominent causes of testicular Azoospermia. In some cases, Azoospermia also occurs due to reproductive tract obstruction or due to inadequate production of spermatozoa. In the past, the only treatment for azoospermia was reconstructive surgery (in case of obstruction) or donor insemination. Now, with the immense advancement in the field of Artificial Reproductive Technology (ART) procedures, Intracytoplasmic Sperm Injection (ICSI) has enabled many men suffering from Azoospermia to become biological fathers without taking the assistance of last resort procedures such as Surrogacy. Pregnancy rates with ICSI procedures are the same irrespective of the sperm retrieval technique used in the procedure.

    What is Testicular Biopsy?

    Testicular biopsy is a surgical procedure in which a piece of tissue is removed from the testicles in a male individual. This tissue is then examined under a microscope. The procedure of a Testicular biopsy, which is also known as needle aspiration involves removing a small amount of tissue from one or both testicles. This tissue is then sent to the medical laboratories for examination under a microscope. The tissue is examined to determine the presence of sperm and whether they can be frozen for future use or if they need to be used immediately for Assisted Reproductive Techniques (ART) procedure. Some men who are suffering from cancer are advised to undergo testicular biopsy procedure to check if the cancer treatment is the cause of infertility issues.(2)There are several treatments in cancer that may intrude with future fertility in men.

    What is Testicular Biopsy

    These treatments include:

    • Bone marrow therapy
    • Chemotherapy or Radiation therapy
    • Certain types of testicular or pelvic surgery

    Fertility issues may only occur for a short time until after their treatment is over. However, in some men, the presence of infertility following cancer treatments is seen to be permanent.

    Indications for Testicular Biopsy and Needle Aspiration:

    Testicular biopsy is indicated in the following scenarios:

    • Obstructive azoospermia: Obstructive azoospermia is a condition which is referred to as complete absence of sperm from the ejaculate. Apart from several causes of azoospermia, obstruction of the ductal system is highly responsible for approximately 40 percent of cases.
    • Non-obstructive azoospermia: Non-obstructive Azoospermia is a condition which is present in men who have areas of focal spermatogenesis.
    • Testicular biopsy may also be offered to men who are unable to ejaculate during ICSI procedure. (3)

    Uses of Testicular Biopsy:

    The test is most often performed to find the cause of male infertility. It is performed when a semen analysis test shows the presence of abnormal sperm and when other tests have failed to find the cause. In some cases, sperm obtained from a testicular biopsy can be used to fertilize a woman's egg in a fertility lab. This process is called In Vitro Fertilization. A testicular biopsy is used for the following purposes:

    Uses of Testicular Biopsy

    • Diagnose causes of male infertility
    • Diagnose the condition and location of a lump present in the testes
    • Sperm retrieval for In Vitro Fertilization (IVF)
    • To find out whether sperm production problems are caused by a blockage
    • Diagnose testicular cancer
    • To identify the cause of abnormally low levels of sperm
    • Poor quality of sperm
    • Azoospermia (absence of sperm)

    Diagnostic Uses of a Testicular Biopsy:

    A testicular biopsy is considered to be an important tool in diagnosing male factor infertility. However, it is not the first step. For the initial phase in a fertility evaluation, an experienced fertility doctor will take a medical history followed by suggested blood tests and semen analysis of the patient. Semen analysis helps in looking at the quantity and quality of the sperm. The initial semen sample is usually collected with the help of masturbation. Various problems are identified in the semen analysis test. Hormone and blood tests can identify the reasons for low sperm levels in the concerned individual. However, when these tests are not conclusive, the patient may need to undergo testicular biopsy procedure.

    Types of Testicular Biopsy:

    A testicular biopsy test/procedure is generally performed in order to investigate the cause of male infertility after conducting hormonal assays and semen analysis test. The procedure is also performed to evaluate infertile men with risks of testicular cancer. It is to be noted that testicular biopsy is usually conducted rarely to test testicular cancer as it can lead to the spread of cancer. There are two types of testicular biopsy procedure:

    • Percutaneous Testicular Biopsy:

    Percutaneous testicular biopsy is a procedure conducted through the skin and it is also called as a "Fine Needle Biopsy". In this procedure, a thin biopsy needle is inserted through the skin of the patient. The needle contains a syringe on the end to obtain the testicular tissue of the respective man. This procedure does not require a cut or stitches. Percutaneous testicular biopsy procedure can be performed with a fine needle aspiration biopsy. The procedure can also be done with a trucut needle biopsy or core needle biopsy procedure. It is a convenient and effective procedure useful in small testicular lesions, hematological malignancies, multifocal lesions, and focal lesions in single testis. A core needle biopsy is a variation in this procedure. It is performed using a hollow, spring-loaded needle to remove a cylinder of cells. This is known as a 'core sample'. A core sample is a larger specimen as compared to one from a fine needle biopsy procedure. (4)

    The tissue is then examined at the labs under the microscope. Some important blood tests are performed prior to percutaneous biopsy in order to ascertain the risk of bleeding in the patient. The advantages of percutaneous testicular biopsy is that it is minimally invasive. Also, the procedure requires only local anesthesia. This medical test can also be performed on an outpatient basis. However, one of the theoretical disadvantages to percutaneous testicular biopsy has been the risk of tumors seeding due to a presumed scrotal violation. The theoretical basis for this relates to the differential lymphatic supply of the testis, which drains via para-aortic lymph nodes, and the scrotal skin, which drains to inguinal lymph nodes. This medical technique should be performed by an operator with experience of ultrasound-guided biopsy. No skin shaving is undertaken. A local anesthetic is infiltrated into the scrotal skin, which is moderately sensitive, and into the tunica vaginalis, which is sensitive. There are no pain fibers present in the testicular parenchyma. Also, in such cases no deeper infiltration is required. (5)

    Types of Testicular Biopsy

    • Open Biopsy:

    An open biopsy is performed under sedation and local or general anesthetic to numb the targeted area. It is also called as a 'surgical biopsy'. In order to expose and remove tissues, a small surgical incision is made through the skin. The biopsy tissue is then examined under a microscope at the medical laboratory. An open biopsy is done at a doctor’s clinic or in the fertility hospital. The procedure is performed to ascertain the presence of cancer or any other abnormal cells in the body. Open surgical biopsy is referred to as the gold standard for retrieving testicular tissues and evaluation of spermatogenesis. Certain complications associated with open surgical biopsy are obvious pain, trauma, hematoma, and infection. In some cases, the procedure also leaves an impact on the testicular blood supply. This makes its application of the open biopsy procedure a limited one. (6)

    Preparation for a Testicular Biopsy:

    The preparations required for Testicular Biopsy procedure are minimal. The patient should inform the doctor about any current consumption of over-the-counter medications. The intake of these medications should be discussed with the doctor beforehand. For patients who are receiving general anesthesia, are asked not to eat and drink for at least eight hours before their test. If patients are given a sedative to take at home before the biopsy, they will not be able to drive themselves to the procedure. It is important for a patient to inform their doctor about the allergic reaction to certain medications or any bleeding problems.

    The drugs that may pose a specific risk during the treatment include:

    • Anticoagulants (blood thinners)
    • Non Steroidal Anti-Inflammatory Drugs (NSAIDs), including Ibuprofen or Aspirin
    • Any medications affecting blood clotting

    Testicular Biopsy Procedure:

    Testicular biopsy can be performed in certain specific ways. Testicular Biopsy is done when a piece or sample of tissue is extracted from the testicles to analyze it in the fertility laboratories. The tissue is analyzed under a microscope in the laboratories. Testicular biopsy or aspiration is usually performed in cases when the male partner is diagnosed with obstructive azoospermia. In conditions such as azoospermia, sperms are taken either through aspiration or through a testicular biopsy. The sperms are then sent to the IVF lab for performing Assisted Reproductive Technology methods such as In Vitro Fertilization or Intracytoplasmic Sperm Injection (ICSI) procedures. Usually, the patient is discharged on the same day as the completion of the procedure. The patient is generally put on an oral course of antibiotics and is advised to avoid performing heavy activities for at least one week.

    Testicular Biopsy Procedure

    The type of biopsy relies on the reason for the medical test being performed. The skin over the testicle is cleaned with an antiseptic or germ-killing medicine. The area around the testicle is covered with a sterile towel. To numb the area, a local anesthetic is given to the patient in the targeted area. A small surgical incision is made through the skin. A small piece of the testicle tissue is removed to be examined under the guidance of infertility specialist. The opening in the testicle is closed with the help of a stitch. Another stitch closes the incision in the skin. The procedure is repeated for the other testicle as and when necessary. Needle biopsy is usually performed in the doctor's office. The area is cleaned and local anesthesia is used, similar to open biopsy. A sample of the testicle is collected using a special needle. The procedure does not require an incision in the skin of the patient. It is entirely dependent on the reason for conducting the test that a needle biopsy would be recommended to the patient or not. (7)

    Testicular Biopsy for Testicular Cancer:

    Testicular biopsy is sometimes also used to effectively diagnose testicular cancer. Usually, it is done when the diagnosis is uncertain. This is because a biopsy, unfortunately, elevates the likelihood that cancer will spread. The physician is more likely to use ultrasound monitoring for cancer diagnosis. The testicle can also be examined and removed with the help of open surgery. This is known as a radical inguinal orchiectomy. A radical inguinal orchiectomy to diagnose testicular cancer includes the following steps:

    • The physician will make an incision in the groin
    • The testicles will be removed from the scrotum for further examination
    • If abnormal tissue is found, a small portion will be taken for further analysis in labs.
    • The tissue is examined by a pathologist.
    • If the tissue sample is noncancerous, the testicle will be returned to the scrotum.
    • The testicle will be removed if the tissue sample is cancerous. In such cases, the spermatic cord will be removed to prevent the spread of cancerous cells in other parts of the body.

    Other tests for Testicular Cancer include ultrasound of the testicles, blood tests for tumor markers, surgery, and imaging tests.(8)

    Recovery Time of Testicular Biopsy:

    A fertility doctor provides patients with certain important and useful instructions after the testicular biopsy procedure which helps the patient in recuperating from their illness. Instructions may vary depending on the type and severity of biopsy. In most cases, the patient is suggested to avoid sexual activity for a week or more after the procedure is performed to avoid any further infection. The patient is especially informed about the pain and discomfort at the site of the cut, swelling, or discoloration in the scrotum and a small amount of bleeding. These are the common side-effects of the testicular biopsy procedure, which are expected to get fixed in a few days. An ice pack can be used in order to reduce the swelling.

    Recovery Time of Testicular Biopsy

    Testicular Biopsy Risks:

    The advent of advanced technologies in the field of infertility treatments has reduced the risk of testicular biopsy. However, the patient should be aware of certain after-effects or side-effects and risks associated with testicular biopsy. The procedure usually has mild side effects in most of the cases. Only in some cases, major side-effects are also recorded in the patient. The side effects of testicular biopsy are:

    • Unbearable pain or swelling in the biopsy area
    • Blood soaking through the bandage or dressing
    • Infection at the site of the incision
    • Discolored scrotum

    One should talk to the fertility experts and discuss possible risk factors associated with testicular biopsy.

    Testicular Biopsy Results:

    An accurate biopsy interpretation is significant in determining both reproductive prognosis and therapeutic considerations for men diagnosed with conditions like Azoospermia. The use of standardized nomenclature for diagnosis as outlined in this article enhances the clinical benefit of the testicular biopsy. (9)The result of a testicular biopsy is normal when sperm development appears normal and no cancerous cells are found.

    What do abnormal results mean?

    Abnormal results of the test may mean a problem with the sperm or hormonal function in the male individual. A biopsy can help in finding the actual cause of the problem. In some cases, a semen analysis test shows no sperm or reduced sperm even when the sperm development appears normal in the testicles. This indicates an obstruction of the tube through which the sperm travel from the testes to the urethra. This blockage can be treated with the help of a surgery.

    Other causes of abnormal results:

    • A cyst-like lump filled with dead sperm cells and fluid (spermatocele)
    • Orchitis – inflammation of the testicles

    The fertility specialist will explain and discuss the possible abnormal results with the patient.

    Considerations after Testicular Biopsy:

    A healthcare provider who specializes in infertility treatments may suggest the patient wear an athletic supporter for some days after the testicular biopsy. In most cases, patients are recommended to avoid sexual activity for 1 to 2 weeks. Following considerations are suggested to patients after a biopsy:

    • Using a cold pack on and off for the initial 24 hours to lessen the swelling and discomfort.
    • Continue to consume using aspirin or medicines that contain aspirin for a week following the procedure.
    • Try to keep the area dry as possible for several days after the completion of the testicular biopsy procedure.

    Cost of Testicular Biopsy:

    The cost of a Testicular Biopsy across the world ranges between Rs. 6,000 and Rs. 25,000 on an average. The testicular biopsy cost majorly depends on factors such as the qualification and expertise of the IVF doctors, availability of modern, and advanced medical equipment at the fertility clinics or hospital, testicular biopsy success rates, and the unique medical history of the couple with respect to infertility treatments. Patients can also search for healthcare insurance options while planning for this procedure to seek high success rates with the procedure. (10)

    Cost of Testicular Biopsy

    Frequently Asked Questions (FAQ's) related to Testicular Biopsy:

    Q. Is the procedure of testicular biopsy painful?

    A testicular biopsy procedure is not painful. The procedure is performed under regional anesthesia and usually does not cause any kind of discomfort to the patient. When a testicular biopsy is performed under sedation, patients usually do not feel any pain or discomfort which occurs in the patient. Postoperatively, proper bed rest is only suggested for short periods of time, thus helping patients to carry on with their regular activities.

    Q. How long does it take to recover from testicular biopsy procedure?

    In most cases, the highly experienced fertility doctors use stitches that dissolve on their own (absorbable stitches) in 2 to 3 weeks and do not need to be removed. The cut made during the procedure will ooze fluid for about 3 to 4 days to allow fast and smooth recovery of the patient. Patients can expect to feel better each day, although they may face some mild to moderate discomfort for several days after the biopsy procedure.

    Q. Can you have a lump on the testicle and it cannot be cancer?

    Cancerous lumps are usually found on the sides of the testicle but can also be present on the front of the location in focus. Lumps on or attached to the epididymis are benign or non-cancerous in nature. If the patient finds a lump on the testicle or any of the other symptoms of testicular cancer, he should see a doctor, preferably a urologist, right away when diagnosed.

    It is a well-established fact that men don't like to discuss much regarding their infertility problems. Although this stereotype does often hold true, this should not be the case for each of the patients. Men must try and keep communication clear with their respective infertility experts. They don't have to broadcast it far and wide, but they should speak with a doctor, a nurse, a counselor, or a support group. It will ease their burden, and they might offer a new perspective and a chance for living a healthy life.

    To get the best recommendations regarding the right treatment and infertility expert, visit elawoman.com. For treatments like a testicular biopsy, the infertility specialists associated should be trained exclusively in the evaluation of male infertility and sexual dysfunction. At Ela, the infertility experts understand that even miracles require timely assistance. Ela provides fertility doctors who have a unique record of supervising and conducting a high number of deliveries. If you have any concerns related to male factor infertility or wish to know more about the testicular biopsy, Elawoman can help you out. For further information about a testicular biopsy or any other information related to infertility treatments like IVF procedure, visit elawoman.com and check out the different sections of the blog. You can also contact us at +918929020600to clarify your doubts related to medical tests and infertility procedures.

    Dr. Rupal Shah

    Written by

    MBBS, DGO, MD
    Infertility Specialist
    Surat
    Dr Rupal Shah is a leading Gynaecologist and Infertility specialist in Surat, Gujarat. It has been more than 2 decades for her while working as a professional doctor. She specializes in Endocrinology and all types of endoscopic and laparoscopic surgery. Dr Rupal is an MBBS, DGO and MD, she has completed her diploma in Reproductive medicine From Kiel University, Germany. She has also participated in Intense and hard training in advanced fertility treatment at a number of workshops and conferences in USA and Europe. Her areas of expertise are ICSI (Intracytoplasmic Sperm Injection), Reproductive Medicine/ IVF, Infertility Evaluation, Intrauterine Insemination (IUI), In Vitro Fertilisation (IVF) and so on. Currently, she is practising at Rupal Hospital For Women and Blossom Fertility and IVF Centre. Book an appointment with Dr Rupal on www.elawoman.com

    1 Comment

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    Indratan Sarup

    June 14, 2019, 10:16 a.m. 4.5

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