TESA Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Testicular Sperm Aspiration

1. Patient Details

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

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

The intended benefits include:

  • Retrieval of sperm for assisted reproductive techniques in men with obstructive or selected non-obstructive azoospermia
  • Obtaining 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

I understand that:

  • This is a day-care procedure in most patients.
  • Mild pain and swelling are expected.
  • Scrotal support, ice packs and analgesics may be advised.
  • Strenuous activity and sexual intercourse should be avoided for approximately one week.

7. Alternatives

The alternatives discussed include:

  • PESA
  • MESA
  • TESE
  • Micro-TESE
  • Donor sperm
  • IVF/ICSI using previously cryopreserved sperm
  • Adoption
  • 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.

Patient 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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