Procedure: MICRODISSECTION TESTICULAR SPERM EXTRACTION (Micro-TESE)

1. Informed Consent for Surgical Operation / Procedure

I, _______________________ (patient/next of kin/legal guardian), aged _____, sex M/F, in my full senses, authorize and give my complete consent for Micro-TESE for __________________________.
Major illness & comorbidities: __________________________

2. Authorisation for Procedure

I authorize Dr. __________ and such assistants and associates as may be selected by him/her to perform any part of the above procedure. I understand that qualified members of the surgical team may perform parts of the procedure under appropriate supervision.

3. Nature of Procedure (Explained)

I understand that Micro-TESE is a microsurgical procedure performed under anaesthesia in which the testis is opened and examined under an operating microscope to identify seminiferous tubules most likely to contain sperm. Retrieved tissue is examined by the embryology laboratory for sperm retrieval, which may be used immediately for ICSI or cryopreserved if appropriate. If the sperms are found in one testis, then the procedure gets completed with incision over just one testis, if the sperms are not found in one testis, the second testis incision is also made.

4. Benefits and Indications

• Highest sperm retrieval rate in men with non-obstructive azoospermia. ( 30-50%)
• May avoid the need for donor sperm.
• Minimizes removal of testicular tissue compared with conventional TESE.
• Provides tissue for histopathological examination if indicated.

5. No Guarantee Clause

I understand that no guarantee has been given regarding successful sperm retrieval, fertilization, pregnancy, or live birth. Additional fertility treatment or donor sperm/adoption may still be required.

6. Risks and Complications

General Risks:
1. Bleeding/hematoma (~1–5%)
2. Infection (~1–3%)
3. Pain and scrotal swelling
4. Anaesthetic complications (rare)

Procedure-specific Risks:
1. Failure to retrieve sperm
2. Testicular injury or atrophy (rare)
3. Temporary reduction in testosterone levels
4. Need for repeat sperm retrieval procedure
5. Wound complications or delayed healing

7. Postoperative Course (Explained)

I understand that I may be discharged the same day or after overnight observation. Scrotal support, analgesics, wound care, and avoidance of strenuous activity for 2–4 weeks are advised. Mild pain and swelling are expected.

8. Alternatives to Procedure

1. Conventional TESE or TESA (where appropriate)
2. Donor sperm
3. Adoption
4. No treatment

9. Anaesthesia and Pain Management

I understand the risks of general/regional anaesthesia and available pain management options.

10. Photography / Data Use

I consent to medical photography/video and anonymised use of my clinical data for academic/research purposes.

11. Intraoperative Decision Consent

I authorise the surgical team to modify or extend the procedure if clinically necessary based on intraoperative findings.

12. Team-Based Care

I understand that qualified assistants/trainees may participate under supervision.

13. Patient Statement

I confirm that I have understood the procedure, risks, benefits, and alternatives. My questions have been answered, and I give consent voluntarily.

Patient/Attendant to write in own handwriting:
“I have understood the procedure, risks, benefits, and alternatives explained to me in a language I understand.”

__________________________________________

Signatures
Patient Name & Signature: _______________________
Date: __________ Time: __________

Doctor Name & Signature: _______________________
Date: __________ Time: __________