Procedure: TESTICULAR SPERM ASPIRATION (TESA)

1. Patient Details

I, __________________ (patient/next of kin/legal guardian), aged ____ years, voluntarily consent to undergo Testicular Sperm Aspiration (TESA) for ____________________.

Major illness/comorbidities: ____________________.

2. Authorization

I authorize Dr. __________ and the surgical team, assistants and trainees under supervision to perform the planned procedure.

3. Nature of Procedure

TESA is a minimally invasive procedure performed under local, regional or general anaesthesia in which a needle is inserted into one or both testes to aspirate seminiferous tubules and retrieve sperm for assisted reproduction (ICSI/IVF). Multiple aspirations may be required. If adequate sperm cannot be obtained, conversion to TESE or Micro-TESE may be recommended if clinically appropriate and previously authorized.

4. Benefits

To retrieve sperm for assisted reproductive techniques in men with obstructive or selected non-obstructive azoospermia, and to obtain tissue for sperm cryopreservation when indicated.

No guarantee has been made regarding successful sperm retrieval, sperm quality, fertilization, embryo formation or pregnancy. Additional procedures may be required.

5. Risks and Complications

General risks: bleeding, infection, pain, swelling, bruising, hematoma, anaesthetic complications, allergic reactions. Procedure-specific risks: failure to retrieve sperm, injury to testicular tissue, intratesticular hematoma, epididymal injury, transient reduction in testosterone (rare), testicular atrophy (very rare), chronic scrotal pain, need for repeat TESA/TESE/Micro-TESE.

6. Postoperative Course

Day-care procedure in most patients. Mild pain and swelling are expected. Scrotal support, ice packs, analgesics and avoidance of strenuous activity and sexual intercourse for approximately one week are advised.

7. Alternatives

PESA, MESA, TESE, Micro-TESE, donor sperm, IVF/ICSI using previously cryopreserved sperm, adoption or no treatment. All these alternative treatment options have been explained to the patient

8. Anaesthesia

The risks and benefits of local, regional or general anaesthesia have been explained.

9. Photography/Data Use

I consent to anonymized photography/video and academic use while maintaining confidentiality.

10. Intraoperative Decision

I authorize the surgeon to modify or extend the procedure if necessary in my best medical interest.

11. Team-Based Care

Residents and fellows may participate under direct supervision.

12. Patient Declaration

I have understood the procedure, risks, benefits, alternatives and expected outcomes. My questions have been answered. I voluntarily consent.

Signatures

Patient Name & Signature: __________________ Date: ______ Time: ______

Doctor Name & Signature: __________________ Date: ______ Time: ______

Witness Name & Signature: ________________ Contact: ______________

Attendant Consent (If Applicable)

Reason patient unable to consent: __________________________
Attendant Name: __________________ Relationship: __________ Signature: __________ Contact: __________