Micro-TESE Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Microsurgical Testicular Sperm Extraction

1. Patient Identification

I, ______________________________ (patient/next of kin/legal guardian), aged ____ years, in my full senses, voluntarily authorize and give my complete consent for performance of the following procedure(s)/operation(s)/treatment(s):

Procedure: _______________________________
Diagnosis: ________________________________
Major illness & comorbidities: ________________________________

2. Authorization for Procedure

I authorize Dr. __________________ to perform the above procedure, along with such assistants and associates as may be selected by him/her.

I understand that members of the surgical team, including residents or trainees under appropriate supervision, may perform parts of the procedure according to their training and competence.

3. Nature of Procedure

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 sperm are found in one testis, the procedure is completed with an incision over just one testis. If sperm are not found in one testis, the second testis incision may also be 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

  • Bleeding/hematoma (~1–5%)
  • Infection (~1–3%)
  • Pain and scrotal swelling
  • Anaesthetic complications (rare)

Procedure-Specific Risks

  • Failure to retrieve sperm
  • Testicular injury or atrophy (rare)
  • Temporary reduction in testosterone levels
  • Need for repeat sperm retrieval procedure
  • Wound complications or delayed healing

7. Postoperative Course

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

  • Conventional TESE or TESA (where appropriate)
  • Donor sperm
  • Adoption
  • 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 authorize 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: ____________________

Witness Name & Signature: ____________________________________

Contact No.: ______________________________

ATTENDANT CONSENT (If applicable)

Reason patient unable to consent:

Attendant Name: __________________________________________

Relationship: _____________________________________________

Signature: ________________________________________________

Contact No.: ______________________________________________

INTERPRETER STATEMENT (If applicable)

I confirm an accurate explanation in understandable language.

Name: _________________________________________________

Signature: ______________________________________________

Contact: ________________________________________________

HIGH-RISK CONSENT (If applicable)

High-risk factors explained due to:

Patient Signature: ________________________________________

Doctor Signature: _________________________________________

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