Welcome everyone to the Becker's Healthcare podcast series.
I'm Mariah Muhammad, writer and moderator of Becker's
Healthcare. And I'm thrilled to have with me
today doctor Kian Asinath,
urologist and male fertility specialist with Keck Medicine
of USC.
Doctor, welcome to the podcast. We're very excited
to have you join us today.
To get us started with our in-depth,
topic,
would you mind,
kinda explaining what is a microsurgical
to testicular sperm extraction
or microtessi?
Absolutely. It's really nice to join you today.
A microtessi
stands for a microsurgical
testicular sperm extraction.
It's a microsurgical
procedure. It's used to extract sperm directly from
the testicle
for men who have no sperm in the
ejaculate,
also known as non obstructive
azoospermia,
meaning they have no sperm and it's not
due to some sort of blockage or obstruction
in the pathway
of sperm transport.
Got it. Thank you so much for giving
us that that definition really quick. So how
does a how does a microtessi
change
when the patient has a test testicular cancer?
Well, it it's different in the sense that
there's a tumor in the way. Right? And
so we're typically doing a microtessy
for men,
generally, with two testicles who have no sperm
in the ejaculate.
The procedure itself can take anywhere from two
to three up to four hours depending
on how much tissue we're we're looking through
with the microscope to find sperm. And so,
you know, we open up one testicle. We
look through the seminiferous tubules. We try to
find areas that are dilated with sample tissue
systematically
and look under a microscope to see if
we find any sperm. And if we don't
find
any sperm on one side or very little
sperm on the on one testicle, then we'll
open the other testicle and do the same
approach.
In a patient with testicular cancer,
their the real estate, if you will, or
the amount of tubes or tubules
that are normal are are much less depending
on how big the tumor is. Sometimes the
entire testicle is occupied by cancer.
And so it makes it rather much more
difficult,
to look for sperm.
That's that's kind of the first approach.
And then the difference is also, you know,
when we do a micro oncotecee
or a microtesti for a patient with cancer,
the testicle
and stromatic cord is removed from the patient,
and the procedure is performed ex vivo, which
means it's outside of the human body. So
we use it as a back table microscope,
and we open up the testicle
in a longitudinal
plane rather than a typical equatorial or or
transverse plane.
Perfect. Thank you so much for explaining that.
And, obviously, it seems like you know,
a lot about this topic. So can you
explain what is your background and experience with
performing this procedure?
Absolutely. Well, you know, I did a, completed
my residency in urology at USC, which I'm,
you know, really,
fortunate to be able to join the world
class faculty. But I completed my fellowship in
male fertility and reproductive microsurgery
at Northwestern University,
under the training of, doctor Bob Branigan. And
so, you know, I spent a year with
him really learning the intricacies
and and the finesse of male reproductive microsurgery
and was able to really learn these techniques
for for many of these patients.
Got it. Yeah. That definitely makes a lot
of sense. Can you tell me a little
bit about this case, and what does this
patient,
what made this patient unique, and what also
led to the decision to perform this procedure,
would you say?
Yeah. So it's a really,
really unique case, actually. So this is a
patient that, was referred to me, from about
an hour, two hours away from the USC
campus.
He was a young male, otherwise healthy, but
he only had one testicle.
When he was born, he his other testicle
was undescended, and it was removed,
when he was a child, not due to
cancer. It was just
atrophic and small. So he was he was
sent to me. He only had one testicle.
And so, unfortunately, he developed
a cancer in that one testicle, a pretty
sizable testicular
cancer.
And so, you know, the treatment for a
testicular tumor is you remove the testicle, and
so that would make him infertile.
And so he, you know, he was wanted
to, be able to maintain his fertility or,
you know, be a parent and be a
father biological father someday. So he went to
free sperm prior to surgery on two to
three different occasions,
and he had no sperm in the ejaculate.
And, his hormones prior to surgery were all
really elevated, which suggested
that there was a problem with sperm production,
meaning it's not some sort of blockage.
And so, you know, it was it was
very much all hands on deck. You know,
this was his last chance to try to
achieve, you know, maintain, and preserve his fertility
after this surgery. So one testicle with a
tumor in it and no sperm in the
ejaculate, you know, it's pretty high stakes. And
so, you know, I was able to participate
in his care and really lead him through
this process.
And so, took him to the Operating Room,
and we I removed the testicle and spermatic
cord.
And using the same micro testy approach, we
performed a micro oncoteesi,
which refers to the testicular sperm extraction in
a patient with testicular cancer or any form
of cancer.
Again, this is done ex vivo, which just
means outside of the human body using a
back table,
and a surgical microscope. And so
it made the case really challenging because there's
only one testicle. Right? We don't have a
second testicle that we can go through the
testicular tissue to look for sperm. And
the
sperm. And the one testicle that we have
had a lot of cancer in it. So,
you know, really had to take our time,
take my time, and and and look through
areas of seminiferous tubules not affected by cancer,
number one, that also looked potentially dilated and
sampled those to see if there was any
sperm found,
on that side.
And, you know, ultimately, the case was a
success.
I did find rare sperm, which was, you
know, really the silver lining because his hormones
were so elevated. I'd never
seen preoperative
hormones,
known as FSH
be as high as almost 60.
And, you know,
you know, he really trusted in me. He
really believed in the process. And,
you know, he knew that we had we
were doing our best to find sperm for
him that day. You know, I I always
tell patients prior to surgery who undergo a
micro test whether it's due to cancer or
not.
I can't promise you we'll find sperm, but
I could promise you that,
we're doing everything we can today to give
you the best sort of outcome. And so
while we didn't find millions of sperm, which
we typically don't find in this case, we
did find some rare sperm.
His family ultimately transported the tissue to the
Fairfax Cryobank, which is a local cryobank near
our hospital, and they were able to freeze
that. And so, you know, one day down
the road when he's looking to achieve a
pregnancy,
they could thaw that tissue and and use
some of that sperm for in vitro fertilization
or IVF.
Got it. Yeah. That definitely sounds like a
a very difficult process,
but, obviously, kinda rewarding.
For those professionals who are also in your
field and kinda do what you do, can
you tell us a bit more about what
you needed from the, hospital
operations perspective
to kinda make this procedure possible. Like, what
kind of teams had to be involved,
how long it it took to kinda set
up this process,
the most challenging aspect, any of that.
Absolutely. Well, you know, this was the first
time,
we had performed this sort of surgery at
the Keck Medical Center of USC. You know,
we do a lot of, microsurgical
work with cancer patients.
It's typically at one of our satellite hospitals,
at the Verdugo Hills Hospital.
You know, I actually tried to take the
patient there, but it it's there's an insurance
issue, so it only had to be done
at Keck.
And so you know? And then when a
patient has cancer, there's a little bit of
a time rush with these things. We can't
just, like, take our time to try to
set things up. It's we wanna take this
taken care of within ultimately, hopefully, within the
first one to two weeks of of meeting
him. So,
you know, there's a few things involved in
in doing this procedure. You need a surgical
microscope, which we have. You need a back
table phase contrast microscope, which is a separate,
microscope, kinda like a tabletop microscope if, you
know, folks remember in in in in, high
school or or college doing the laboratory experiments.
It's a little bit more of a higher
end version of that where we can look
at different,
degrees of magnification. So we had to get
that set up, which we hadn't had or
used in in a long time.
We had to obtain,
a special
fluid or media for the sperm and testicular
tissue for transport known as sperm wash media,
which we never had at Keck at the
Keck Hospital because we don't do these kinds
of the cases there routinely.
And the last part was we had to
get
a kind of, consent form from the patient
in the hospital that the patient was gonna
be
taking
specimen or tissue from surgery outside of the
hospital to a local cryobank, which is not
routinely done at Keck Hospital.
Right? And so to get those set up,
you know, I really worked closely with our
urology,
surgical coordinator,
who is incredible at helping get, sperm wash
media in a really rapid manner,
getting the back table microscope
up and ready to go,
securing the surgical microscope on a, you know,
in a in a timely fashion.
And then the last piece was getting the,
you know, the legal department, the legal teams
involved in drafting a
a liability waiver or consent that the patient
and his family would sign prior to surgery
to give them the authorization to take the
specimens
outside of USC. Right? Typically, when you do
surgery at a hospital,
they go to the pathology laboratory where they
study it in the lab, and it's all
done in house in the hospital. It's we've
never had this case where the patient would
be able to take their their,
specimen outside. And so we had to get
that drafted up. So it was really a
huge team process. It really took a village
to to get there. It was by no
means you know, while I would may maybe
spearheading the process, you know, it really required
effort and help from all sorts of different
folks. So surgical coordinator,
operating room director,
the, you know, the legal team was involved.
You know, patient was highly motivated. I was
highly motivated as his physician. So,
you know, ultimately led to a a great
outcome.
Yeah. That's amazing. And, doctor,
very quickly, what advice would you give to
other physicians
who may need to advocate for the patients
in new or unique ways,
just in general or maybe to do this
type of procedure?
Well, I think for, you know, this kind
of case, you know, we tip we generally
and guidelines recommend
always wanna free sperm and bank sperm prior
to removing the testicle. You know, a lot
of folks,
a lot of oncologists
and patients are kind of in a rush
to get the cancer out, which totally makes
sense.
And the thought process is there's another testicle
that make that's making sperm. And so you
can always freeze sperm after
the orchiectomy or removing the testicle, but definitely
wanna do it before the systemic chemotherapy if
that's needed.
But, really, I you know, I'd I'd wanna
shed light on the fact that up to
thirty percent of patients
will have
low sperm counts, low sperm production
even before removing the testicle.
And so we really wanna encourage banking sperm
prior to the orchiectomy
or at least getting some sort of semen
testing and hormone testing to make sure that
there's sperm present.
That's really the first case. And, you know,
this sort of testicular biopsy
or testicular sperm extraction,
should ultimately done for that reason at the
same time of the testicular removal. Right? Because
we don't wanna take the patient back to
the Operating Room for a second surgery
if in the event they did have no
sperm
and induce them to a second form of
anesthetic prior to chemotherapy. Right? It's it's, we
wanna take care of it in the same
setting. So I recommend, you know, all urologists,
oncologists,
trying to recommend and have the patient banks
from prior to norkiactomy or at least have
that fertility preservation discussion. You
know, ultimately, doing a micro testy or micro
onco testy,
is most commonly performed by really kind of
experienced reproductive microsurgeons. There's
not that many urologists who specialize in this
kind of work and this microsurgical work.
You know, there may be only a handful
or maybe up to 10 folks within the
entire state of California
doing this kind of work. So really encourage,
folks out in the community to kinda refer
these patients
to tertiary academic centers who may have a
male fertility specialist and,
reproductive microsurgeon who can carry out this kind
of work. And, ultimately, you know, for any
sort of work you want to do that's
never been done at a hospital,
you know, you need to have patients. There's
some regulatory hurdles that need to go through.
Really, obviously, test test your patience, but you
really need to have a team, and you
need to get you need to get the,
you know, folks in charge,
as a part of your plan. Right? And
so, ultimately, when this case was done, the,
you know, the operating room director reached out
to me and was like, this was a,
you know, really fascinating case because, a, it's
never been done before here at this hospital.
And so we should shed light on it
to the rest of the physicians here at
locally within USC. And so we presented the
case at, you know, one of our town
hall meetings. And so,
you know, I think shedding light on that
is very important.
Yeah. Definitely. I completely agree with you there.
And thank you so much for those final
thoughts, doctor. This has definitely been a very
informative discussion.
So I wanna thank you so so much
for coming on Becker's health care, especially for
the first time. And I look forward to
Absolutely. Again soon.
Thank you so much. It's been a pleasure
chatting with you today.