Micro-TESE in Thailand: Which Azoospermia Patients Are Suitable

Opening: Real consultation scenario

In the outpatient clinic, a 34-year-old man came for consultation with a semen analysis report and hormone test results. The report showed: no sperm in the semen, FSH 19.2 IU/L, LH 9.8 IU/L, bilateral testicular volume approximately 7–9 ml. He asked, "Doctor, is there still a chance for me to have my own child?" This is a typical patient with non-obstructive azoospermia (NOA). For such patients, microdissection testicular sperm extraction (Micro-TESE) is currently the clinically recommended standard technique. Thailand, as one of the more mature countries for assisted reproductive technology in Asia, has over a decade of clinical experience in performing Micro-TESE, with a considerable number of NOA patients traveling from within the country for evaluation and surgery each year.

What is Micro-TESE?

Micro-TESE, or Microdissection Testicular Sperm Extraction, is a surgical procedure for exploring testicular tissue and retrieving sperm assisted by an operating microscope. Unlike conventional testicular sperm aspiration (TESA) or standard testicular sperm extraction (TESE), Micro-TESE uses 10–25x magnification to more precisely identify focal areas within the testicle that may contain active spermatogenesis. This allows for the retrieval of sufficient sperm for ICSI while minimizing damage to testicular tissue.

Core Differences Between Micro-TESE, TESE, and TESA

* Sperm retrieval rates are based on multiple clinical studies and vary individually.

When is Micro-TESE Suitable?

Suitable Candidates

• Patients diagnosed with non-obstructive azoospermia (NOA): Semen analysis shows no sperm, and obstructive factors (e.g., congenital absence of the vas deferens, ejaculatory duct obstruction) have been ruled out.
• Elevated FSH with small testicular volume: Typically FSH > 10 IU/L, testicular volume < 12 ml, indicating impaired spermatogenesis.
• Previous testicular aspiration or TESE failed to find sperm: These patients still have approximately 20%–30% chance of sperm retrieval via Micro-TESE.
• Certain types of Y-chromosome microdeletions (AZFc region): Some deletion types may still have focal spermatogenesis.
• Azoospermia after chemotherapy or radiotherapy: If a small number of spermatogonial stem cells remain in the testicle, there is a chance to retrieve sperm.

Unsuitable Candidates

• Obstructive azoospermia (OA): These patients have blocked reproductive ducts but normal spermatogenesis. Epididymal sperm aspiration or vas deferens reconstruction should be prioritized; Micro-TESE is unnecessary.
• Complete deletion of AZFa or AZFb regions on the Y chromosome: Usually indicates severely impaired spermatogenesis with extremely low probability of sperm retrieval; surgery is not clinically recommended.
• Bilateral testicular volume < 4 ml and FSH > 25 IU/L: Spermatogenesis may be essentially absent, and surgical benefit is limited.
• Uncontrolled genital tract infection: Anti-infective treatment is required first; reassess after inflammation is controlled.

Actual Process of Micro-TESE in Thailand

Preoperative Evaluation (Approx. 2–4 weeks)

• Semen Analysis: At least 2 centrifuged sediment examinations confirming azoospermia.
• Hormone Testing: FSH, LH, total testosterone, inhibin B, AMH (to assist in evaluating spermatogenic status).
• Karyotype + Y-chromosome microdeletion: To rule out Klinefelter syndrome (47,XXY) and AZF deletions.
• Urological Ultrasound: To evaluate testes, epididymis, prostate, and seminal vesicles, ruling out obstruction or masses.
• Genetic Counseling: If abnormalities are detected, discuss genetic risks and implications for offspring.

Surgical Procedure

Performed under general or spinal anesthesia. A unilateral or bilateral scrotal incision is made to expose the tunica albuginea. Under the operating microscope (10–25x), the seminiferous tubules are carefully examined to identify areas that appear fuller, opaque, and have better blood supply. A small amount of tissue (usually 10–30 mg) is removed and placed in sperm culture medium. Embryology laboratory staff then dissect, mince, observe, and collect sperm under a microscope. If sufficient sperm are obtained from one testicle, the other side can be closed to minimize damage.

Postoperative Recovery

• Bed rest for 6–8 hours post-surgery; scrotal ice packs to reduce swelling.
• Slow walking allowed after 48 hours; avoid strenuous exercise, straddling movements, and prolonged standing.
• Avoid showering for 1 week (keep incision dry); abstain from sexual activity for 2 weeks.
• Most patients can return to daily office work within 3–5 days; full recovery takes about 2–4 weeks.

Timing Coordination with ICSI

The retrieved sperm can be used directly for intracytoplasmic sperm injection (ICSI), so it must be synchronized with the female partner's egg retrieval cycle. Typically, the male undergoes Micro-TESE surgery around day 10–12 of the female's ovarian stimulation. If a large number of sperm are obtained, they can be cryopreserved for future cycles; if only a few viable sperm are available, same-day ICSI is the optimal choice.

Technical Characteristics of Micro-TESE at Thai Fertility Centers

Differences between Thai centers mainly lie in the precision of the surgical microscope, the ICSI experience of the embryology lab, and the efficiency of post-surgery sperm freezing and thawing. It is recommended that patients choose a center with an annual surgical volume > 30 cases based on their specific condition.

Easily Overlooked Details

• Preoperative Hormone Fluctuations: In some patients with extremely high FSH and very low inhibin B, the probability of successful surgery drops significantly. Hormone levels should be rechecked before surgery to avoid using outdated data from months earlier.
• Karyotype Results: For patients with Klinefelter syndrome (47,XXY), the Micro-TESE sperm retrieval rate is about 40%–50%, but genetic risks must be explained in advance, and PGT-A may be necessary.
• Previous Testicular Surgery History: If a patient has had a previous testicular biopsy or TESE, local fibrosis may increase the difficulty of Micro-TESE, requiring an experienced surgeon.
• Postoperative Sperm Freezing Strategy: Retrieved sperm should be preferentially frozen to avoid having no backup sperm if same-day ICSI fails. Some centers use single-sperm freezing techniques to improve post-thaw utilization rates.
• Psychological Expectation Management: Even with ideal indicators, approximately 30%–50% of NOA patients may not have sufficient sperm retrieved. Preoperative psychological preparation and discussion of backup plans (e.g., donor sperm, adoption) are essential.

Factors Affecting Cost

The cost of Micro-TESE surgery in Thailand varies by center, technical complexity, and whether it is synchronized with ICSI. The main components are as follows:

• Preoperative Examination Fees: Hormones, karyotype, ultrasound, etc., approximately 8,000–15,000 THB.
• Surgery Fee: Micro-TESE approximately 80,000–150,000 THB; slightly higher for bilateral surgery.
• Anesthesia Fee: General anesthesia approximately 15,000–25,000 THB.
• Sperm Processing and Cryopreservation: Approximately 25,000–45,000 THB (including freezing 1–2 vials).
• ICSI Coordination: If performed simultaneously, ICSI costs approximately 60,000–100,000 THB (excluding egg retrieval).

Total cost ranges from approximately 120,000 to 250,000 THB (approximately RMB 25,000–50,000), varying by center, medication, and anesthesia type. Additional costs include female partner's ovarian stimulation, embryo culture, and transfer.

Observations from Practitioners

Having worked in assisted reproduction coordination in Thailand for many years, I have observed the following:

• More and more NOA patients are opting directly for Micro-TESE rather than repeated aspirations, because the probability of sperm retrieval in a single surgery is higher, and the overall cost and time investment are lower in the long run.
• Some patients have overly high expectations of the term "micro," believing that sperm will definitely be found. In reality, Micro-TESE only increases the probability; it cannot reverse spermatogenic failure. Thorough pre-surgery communication between doctor and patient is crucial.
• Thai laboratories have unique experience in sperm cryopreservation, especially for very small numbers of sperm (single-sperm or low-count freezing), with a thawing survival rate of about 60%–75%, which is worth noting for patients from other countries.
• It is recommended that patients complete all genetic screening before surgery to avoid ethical dilemmas arising from post-surgery detection of chromosomal abnormalities.

#Micro-TESE #Non-obstructive Azoospermia #Thai Assisted Reproduction #Testicular Microdissection #ICSI #Azoospermia Treatment

This article is compiled by reproductive medicine editors based on clinical data and industry consensus from multiple Thai fertility centers. It is intended for learning and reference only. Please consult a licensed physician for specific diagnosis and treatment plans.