Current Clinical Application and Indications of TESE/ICSI in China

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Author: Clinician at Reproductive Medicine Center | Knowledge Base Content · Non-Promotional

1. TESE/ICSI in China: Clinical Positioning and Current Status

TESE/ICSI has been performed in China for over twenty years, evolving from exploratory use in a few early reproductive centers to a mature standard procedure in the male infertility treatment system. TESE (Testicular Sperm Extraction) combined with ICSI (Intracytoplasmic Sperm Injection) primarily addresses two issues: "having sperm but insufficient for natural fertilization" or "having sperm in the testicles but no sperm in the ejaculate."

Clinically, azoospermia is classified into two main categories: obstructive (OA) and non-obstructive (NOA). OA patients typically have normal testicular spermatogenesis and a very high sperm retrieval rate; NOA patients, due to spermatogenic impairment, have a more variable retrieval rate requiring more detailed preoperative evaluation. The value of TESE/ICSI lies in the fact that as long as a few morphologically usable sperm are found, there is an opportunity to achieve fertilization and obtain embryos through ICSI.

Reproductive medicine centers in China generally have the technical capability to perform TESE/ICSI. However, differences in laboratory standards, embryologist experience, and preoperative evaluation systems among centers directly impact the final sperm retrieval rate and pregnancy outcomes.

2. Which Patients Are Suitable for TESE/ICSI – Clinical Decision Pathway

From the physician's decision-making perspective, recommending TESE/ICSI depends on three core judgments: etiology type, testicular spermatogenic potential, and genetic risk.

2.1 Obstructive Azoospermia (OA)

OA patients have obstruction in the epididymis or vas deferens but normal testicular spermatogenesis. These patients are ideal candidates for TESE/ICSI. Typical clinical presentation: no sperm in semen analysis, but normal testicular volume (≥15ml), normal FSH levels, and intact seminiferous epithelium on testicular biopsy. The sperm retrieval rate for OA patients via TESE is over 95%, and the ICSI fertilization rate is not significantly different from conventional IVF.

2.2 Non-obstructive Azoospermia (NOA)

NOA patients have spermatogenic impairment due to genetic, endocrine, environmental, or unknown causes. The success of TESE in retrieving sperm depends on the presence of focal spermatogenesis within the testis. Preoperative evaluation indicators include:

• Testicular Volume: Detection rate of spermatogenic foci is significantly lower when volume is less than 8ml.
• FSH Level: More than twice the upper normal limit indicates severely impaired spermatogenesis.
• Inhibin B: Levels below 15 pg/ml are associated with a low sperm retrieval rate.
• Testicular Pathology Classification: Sperm retrieval rate is about 5%–15% for Sertoli cell-only syndrome (SCOS), 30%–50% for maturation arrest, and 60%–80% for hypospermatogenesis.

These indicators help physicians determine the value of TESE surgery, avoiding unnecessary surgical trauma.

3. Technical Process: From Preoperative Evaluation to Embryo Transfer

TESE/ICSI is not a single procedure but a complete treatment chain. The standardized process is as follows:

4. Differences in Management Based on Etiology

There are significant differences in the TESE/ICSI pathway between OA and NOA patients, which directly affect surgical approach selection and patient expectation management.

NOA patients must be informed preoperatively about the possibility of "retrieval failure." Clinically, about 30%–50% of NOA patients will have no sperm found during surgery. These patients need to be aware of alternative paths such as donor sperm or adoption in advance. Physicians should clearly discuss this during preoperative consultations and advise patients to be mentally prepared.

5. Most Commonly Overlooked Preoperative Evaluation Details

Based on clinical observation, the following evaluation steps are often overlooked by patients but are crucial for decision-making:

• Y-chromosome Microdeletion Testing: Deletions in AZFa, AZFb, or AZFc regions directly determine the value of TESE. Complete AZFa or AZFb deletions make TESE almost meaningless with current technology.
• Combined Interpretation of Inhibin B and FSH: Single indicators have limitations; combined evaluation improves the accuracy of assessing spermatogenic function.
• Genetic Counseling: Even if TESE is successful, some genetic variants (e.g., CFTR mutations, chromosomal balanced translocations) may be transmitted to offspring, requiring prior discussion of PGT or prenatal diagnosis.
• Testicular Pathology Classification: Some patients have had biopsies elsewhere without a clear classification. Reviewing pathology slides is recommended to avoid repeat surgery.

6. Cognitive Misconceptions and Common Pitfalls

The following are frequent cognitive biases seen in outpatient clinics that directly affect patient decision-making:

• Myth 1: "Azoospermia means no sperm at all, so just go straight for TESE." — NOA patients need thorough preoperative evaluation of retrieval probability to avoid ineffective surgery.
• Myth 2: "Sperm retrieved by TESE are definitely of poorer quality than ejaculated sperm." — In fact, TESE sperm may have better DNA integrity than some ejaculated sperm, especially for patients with epididymal obstruction or varicocele.
• Myth 3: "TESE surgery will affect testosterone levels and cause sexual dysfunction." — Multiple studies show that unilateral or bilateral micro-TESE has a limited impact on long-term testosterone levels, which typically return to baseline 6–12 months post-surgery.
• Myth 4: "ICSI has a 100% fertilization rate." — The ICSI fertilization rate is about 60%–80%, depending on sperm morphology, motility, and oocyte quality.
• Myth 5: "If TESE finds sperm, pregnancy is guaranteed." — Pregnancy outcomes are influenced by multiple factors, including embryo chromosomal euploidy and endometrial receptivity.

7. Cost Structure and Influencing Factors

The total cost of TESE/ICSI varies significantly by region, hospital level, and individualized plan. The approximate breakdown is as follows:

Factors influencing cost include: regional economic level, hospital type (public/private), use of imported medications, TESE method (micro-TESE is most expensive), and need for additional procedures (e.g., embryo freezing, PGT).

8. Frequently Asked Questions

8.1 How long does TESE surgery take? How long is recovery?

The surgery itself takes about 30–60 minutes. Patients can be discharged after 2–4 hours of observation. Scrotal swelling and mild pain are normal; ice packs for 48 hours post-surgery can help. Rest for 1–2 weeks is recommended, avoiding strenuous exercise and heavy lifting.

8.2 Is the sperm found in one TESE procedure sufficient?

The laboratory thoroughly grinds, centrifuges, and searches the retrieved testicular tissue. Usually, the number of sperm obtained is sufficient for ICSI. Any surplus can be cryopreserved for future cycles, reducing the need for repeat surgery.

8.3 Are children born from TESE/ICSI healthy?

Current follow-up data indicate that the birth defect rate in TESE/ICSI offspring is not significantly different from conventional IVF/ICSI. However, some genetic variants (e.g., Y-chromosome microdeletions) may be passed to male offspring, which should be thoroughly discussed preoperatively, and prenatal diagnosis is recommended.

8.4 If no sperm is found on the first TESE, is there still a chance?

Yes. Some patients may have focal spermatogenesis in the contralateral testis, or sperm may be successfully retrieved using a more refined micro-TESE approach. However, the value and trauma of repeat surgery must be carefully assessed. Clinically, it is recommended to wait 3–6 months before considering another attempt.

8.5 Does the female partner's age significantly affect TESE/ICSI outcomes?

Very much so. The ICSI pregnancy rate is closely related to the female partner's age, with a stepwise decline across the age groups under 35, 35–40, and over 40. TESE solves the "presence or absence of sperm" issue, but embryo developmental potential remains highly dependent on oocyte quality.

9. Risk Reminders and Precautions

This article is compiled based on clinical practice and published literature, intended to provide objective knowledge reference and does not constitute specific medical advice. Treatment plans should be based on consultation with physicians at a reproductive medicine center.