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.