Latest / Becker’s Healthcare - Clinical Leadership Podcast / Dr. Kian Asanad, Urologist and Male Fertility Specialist with Keck Medicine of USC

Transcript

Dr. Kian Asanad, Urologist and Male Fertility Specialist with Keck Medicine of USC · Becker’s Healthcare - Clinical Leadership Podcast

• 0:00
  Welcome everyone to the Becker's Healthcare podcast series.
• 0:02
  I'm Mariah Muhammad, writer and moderator of Becker's
• 0:05
  Healthcare. And I'm thrilled to have with me
• 0:07
  today doctor Kian Asinath,
• 0:08
  urologist and male fertility specialist with Keck Medicine
• 0:11
  of USC.
• 0:13
  Doctor, welcome to the podcast. We're very excited
• 0:15
  to have you join us today.
• 0:16
  To get us started with our in-depth,
• 0:19
  topic,
• 0:20
  would you mind,
• 0:21
  kinda explaining what is a microsurgical
• 0:24
  to testicular sperm extraction
• 0:26
  or microtessi?
• 0:29
  Absolutely. It's really nice to join you today.
• 0:31
  A microtessi
• 0:32
  stands for a microsurgical
• 0:34
  testicular sperm extraction.
• 0:36
  It's a microsurgical
• 0:38
  procedure. It's used to extract sperm directly from
• 0:42
  the testicle
• 0:43
  for men who have no sperm in the
• 0:46
  ejaculate,
• 0:47
  also known as non obstructive
• 0:49
  azoospermia,
• 0:50
  meaning they have no sperm and it's not
• 0:52
  due to some sort of blockage or obstruction
• 0:55
  in the pathway
• 0:56
  of sperm transport.
• 0:59
  Got it. Thank you so much for giving
• 1:00
  us that that definition really quick. So how
• 1:03
  does a how does a microtessi
• 1:05
  change
• 1:06
  when the patient has a test testicular cancer?
• 1:10
  Well, it it's different in the sense that
• 1:13
  there's a tumor in the way. Right? And
• 1:15
  so we're typically doing a microtessy
• 1:18
  for men,
• 1:19
  generally, with two testicles who have no sperm
• 1:21
  in the ejaculate.
• 1:23
  The procedure itself can take anywhere from two
• 1:26
  to three up to four hours depending
• 1:29
  on how much tissue we're we're looking through
• 1:31
  with the microscope to find sperm. And so,
• 1:33
  you know, we open up one testicle. We
• 1:36
  look through the seminiferous tubules. We try to
• 1:38
  find areas that are dilated with sample tissue
• 1:40
  systematically
• 1:41
  and look under a microscope to see if
• 1:43
  we find any sperm. And if we don't
• 1:44
  find
• 1:45
  any sperm on one side or very little
• 1:48
  sperm on the on one testicle, then we'll
• 1:50
  open the other testicle and do the same
• 1:52
  approach.
• 1:53
  In a patient with testicular cancer,
• 1:56
  their the real estate, if you will, or
• 1:58
  the amount of tubes or tubules
• 2:01
  that are normal are are much less depending
• 2:03
  on how big the tumor is. Sometimes the
• 2:06
  entire testicle is occupied by cancer.
• 2:09
  And so it makes it rather much more
• 2:11
  difficult,
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  to look for sperm.
• 2:14
  That's that's kind of the first approach.
• 2:17
  And then the difference is also, you know,
• 2:19
  when we do a micro oncotecee
• 2:22
  or a microtesti for a patient with cancer,
• 2:26
  the testicle
• 2:27
  and stromatic cord is removed from the patient,
• 2:30
  and the procedure is performed ex vivo, which
• 2:33
  means it's outside of the human body. So
• 2:35
  we use it as a back table microscope,
• 2:38
  and we open up the testicle
• 2:40
  in a longitudinal
• 2:41
  plane rather than a typical equatorial or or
• 2:44
  transverse plane.
• 2:46
  Perfect. Thank you so much for explaining that.
• 2:48
  And, obviously, it seems like you know,
• 2:51
  a lot about this topic. So can you
• 2:52
  explain what is your background and experience with
• 2:55
  performing this procedure?
• 2:57
  Absolutely. Well, you know, I did a, completed
• 2:59
  my residency in urology at USC, which I'm,
• 3:02
  you know, really,
• 3:04
  fortunate to be able to join the world
• 3:05
  class faculty. But I completed my fellowship in
• 3:08
  male fertility and reproductive microsurgery
• 3:11
  at Northwestern University,
• 3:13
  under the training of, doctor Bob Branigan. And
• 3:16
  so, you know, I spent a year with
• 3:18
  him really learning the intricacies
• 3:20
  and and the finesse of male reproductive microsurgery
• 3:24
  and was able to really learn these techniques
• 3:27
  for for many of these patients.
• 3:29
  Got it. Yeah. That definitely makes a lot
• 3:31
  of sense. Can you tell me a little
• 3:32
  bit about this case, and what does this
• 3:35
  patient,
• 3:36
  what made this patient unique, and what also
• 3:38
  led to the decision to perform this procedure,
• 3:40
  would you say?
• 3:42
  Yeah. So it's a really,
• 3:44
  really unique case, actually. So this is a
• 3:46
  patient that, was referred to me, from about
• 3:50
  an hour, two hours away from the USC
• 3:52
  campus.
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  He was a young male, otherwise healthy, but
• 3:56
  he only had one testicle.
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  When he was born, he his other testicle
• 4:00
  was undescended, and it was removed,
• 4:03
  when he was a child, not due to
• 4:05
  cancer. It was just
• 4:06
  atrophic and small. So he was he was
• 4:08
  sent to me. He only had one testicle.
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  And so, unfortunately, he developed
• 4:13
  a cancer in that one testicle, a pretty
• 4:15
  sizable testicular
• 4:17
  cancer.
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  And so, you know, the treatment for a
• 4:20
  testicular tumor is you remove the testicle, and
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  so that would make him infertile.
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  And so he, you know, he was wanted
• 4:27
  to, be able to maintain his fertility or,
• 4:30
  you know, be a parent and be a
• 4:31
  father biological father someday. So he went to
• 4:34
  free sperm prior to surgery on two to
• 4:37
  three different occasions,
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  and he had no sperm in the ejaculate.
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  And, his hormones prior to surgery were all
• 4:44
  really elevated, which suggested
• 4:46
  that there was a problem with sperm production,
• 4:49
  meaning it's not some sort of blockage.
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  And so, you know, it was it was
• 4:54
  very much all hands on deck. You know,
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  this was his last chance to try to
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  achieve, you know, maintain, and preserve his fertility
• 5:01
  after this surgery. So one testicle with a
• 5:04
  tumor in it and no sperm in the
• 5:06
  ejaculate, you know, it's pretty high stakes. And
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  so, you know, I was able to participate
• 5:10
  in his care and really lead him through
• 5:12
  this process.
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  And so, took him to the Operating Room,
• 5:16
  and we I removed the testicle and spermatic
• 5:19
  cord.
• 5:21
  And using the same micro testy approach, we
• 5:23
  performed a micro oncoteesi,
• 5:25
  which refers to the testicular sperm extraction in
• 5:28
  a patient with testicular cancer or any form
• 5:31
  of cancer.
• 5:32
  Again, this is done ex vivo, which just
• 5:34
  means outside of the human body using a
• 5:36
  back table,
• 5:38
  and a surgical microscope. And so
• 5:40
  it made the case really challenging because there's
• 5:43
  only one testicle. Right? We don't have a
• 5:43
  second testicle that we can go through the
• 5:43
  testicular tissue to look for sperm. And
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  the
• 5:49
  sperm. And the one testicle that we have
• 5:51
  had a lot of cancer in it. So,
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  you know, really had to take our time,
• 5:55
  take my time, and and and look through
• 5:57
  areas of seminiferous tubules not affected by cancer,
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  number one, that also looked potentially dilated and
• 6:04
  sampled those to see if there was any
• 6:05
  sperm found,
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  on that side.
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  And, you know, ultimately, the case was a
• 6:11
  success.
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  I did find rare sperm, which was, you
• 6:14
  know, really the silver lining because his hormones
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  were so elevated. I'd never
• 6:19
  seen preoperative
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  hormones,
• 6:21
  known as FSH
• 6:23
  be as high as almost 60.
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  And, you know,
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  you know, he really trusted in me. He
• 6:29
  really believed in the process. And,
• 6:31
  you know, he knew that we had we
• 6:33
  were doing our best to find sperm for
• 6:35
  him that day. You know, I I always
• 6:36
  tell patients prior to surgery who undergo a
• 6:39
  micro test whether it's due to cancer or
• 6:41
  not.
• 6:42
  I can't promise you we'll find sperm, but
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  I could promise you that,
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  we're doing everything we can today to give
• 6:48
  you the best sort of outcome. And so
• 6:50
  while we didn't find millions of sperm, which
• 6:51
  we typically don't find in this case, we
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  did find some rare sperm.
• 6:55
  His family ultimately transported the tissue to the
• 6:58
  Fairfax Cryobank, which is a local cryobank near
• 7:01
  our hospital, and they were able to freeze
• 7:03
  that. And so, you know, one day down
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  the road when he's looking to achieve a
• 7:06
  pregnancy,
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  they could thaw that tissue and and use
• 7:10
  some of that sperm for in vitro fertilization
• 7:12
  or IVF.
• 7:14
  Got it. Yeah. That definitely sounds like a
• 7:17
  a very difficult process,
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  but, obviously, kinda rewarding.
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  For those professionals who are also in your
• 7:23
  field and kinda do what you do, can
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  you tell us a bit more about what
• 7:27
  you needed from the, hospital
• 7:30
  operations perspective
• 7:31
  to kinda make this procedure possible. Like, what
• 7:34
  kind of teams had to be involved,
• 7:36
  how long it it took to kinda set
• 7:38
  up this process,
• 7:39
  the most challenging aspect, any of that.
• 7:43
  Absolutely. Well, you know, this was the first
• 7:44
  time,
• 7:45
  we had performed this sort of surgery at
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  the Keck Medical Center of USC. You know,
• 7:51
  we do a lot of, microsurgical
• 7:53
  work with cancer patients.
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  It's typically at one of our satellite hospitals,
• 7:58
  at the Verdugo Hills Hospital.
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  You know, I actually tried to take the
• 8:02
  patient there, but it it's there's an insurance
• 8:04
  issue, so it only had to be done
• 8:05
  at Keck.
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  And so you know? And then when a
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  patient has cancer, there's a little bit of
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  a time rush with these things. We can't
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  just, like, take our time to try to
• 8:14
  set things up. It's we wanna take this
• 8:16
  taken care of within ultimately, hopefully, within the
• 8:18
  first one to two weeks of of meeting
• 8:20
  him. So,
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  you know, there's a few things involved in
• 8:23
  in doing this procedure. You need a surgical
• 8:25
  microscope, which we have. You need a back
• 8:28
  table phase contrast microscope, which is a separate,
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  microscope, kinda like a tabletop microscope if, you
• 8:35
  know, folks remember in in in in, high
• 8:38
  school or or college doing the laboratory experiments.
• 8:41
  It's a little bit more of a higher
• 8:42
  end version of that where we can look
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  at different,
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  degrees of magnification. So we had to get
• 8:47
  that set up, which we hadn't had or
• 8:49
  used in in a long time.
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  We had to obtain,
• 8:54
  a special
• 8:55
  fluid or media for the sperm and testicular
• 8:58
  tissue for transport known as sperm wash media,
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  which we never had at Keck at the
• 9:02
  Keck Hospital because we don't do these kinds
• 9:04
  of the cases there routinely.
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  And the last part was we had to
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  get
• 9:09
  a kind of, consent form from the patient
• 9:12
  in the hospital that the patient was gonna
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  be
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  taking
• 9:16
  specimen or tissue from surgery outside of the
• 9:18
  hospital to a local cryobank, which is not
• 9:21
  routinely done at Keck Hospital.
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  Right? And so to get those set up,
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  you know, I really worked closely with our
• 9:27
  urology,
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  surgical coordinator,
• 9:30
  who is incredible at helping get, sperm wash
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  media in a really rapid manner,
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  getting the back table microscope
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  up and ready to go,
• 9:40
  securing the surgical microscope on a, you know,
• 9:43
  in a in a timely fashion.
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  And then the last piece was getting the,
• 9:47
  you know, the legal department, the legal teams
• 9:50
  involved in drafting a
• 9:53
  a liability waiver or consent that the patient
• 9:55
  and his family would sign prior to surgery
• 9:58
  to give them the authorization to take the
• 10:01
  specimens
• 10:02
  outside of USC. Right? Typically, when you do
• 10:04
  surgery at a hospital,
• 10:06
  they go to the pathology laboratory where they
• 10:08
  study it in the lab, and it's all
• 10:10
  done in house in the hospital. It's we've
• 10:12
  never had this case where the patient would
• 10:14
  be able to take their their,
• 10:16
  specimen outside. And so we had to get
• 10:18
  that drafted up. So it was really a
• 10:21
  huge team process. It really took a village
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  to to get there. It was by no
• 10:25
  means you know, while I would may maybe
• 10:27
  spearheading the process, you know, it really required
• 10:29
  effort and help from all sorts of different
• 10:32
  folks. So surgical coordinator,
• 10:34
  operating room director,
• 10:36
  the, you know, the legal team was involved.
• 10:38
  You know, patient was highly motivated. I was
• 10:40
  highly motivated as his physician. So,
• 10:43
  you know, ultimately led to a a great
• 10:45
  outcome.
• 10:46
  Yeah. That's amazing. And, doctor,
• 10:49
  very quickly, what advice would you give to
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  other physicians
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  who may need to advocate for the patients
• 10:55
  in new or unique ways,
• 10:58
  just in general or maybe to do this
• 11:00
  type of procedure?
• 11:02
  Well, I think for, you know, this kind
• 11:03
  of case, you know, we tip we generally
• 11:06
  and guidelines recommend
• 11:08
  always wanna free sperm and bank sperm prior
• 11:11
  to removing the testicle. You know, a lot
• 11:12
  of folks,
• 11:14
  a lot of oncologists
• 11:15
  and patients are kind of in a rush
• 11:17
  to get the cancer out, which totally makes
• 11:19
  sense.
• 11:20
  And the thought process is there's another testicle
• 11:22
  that make that's making sperm. And so you
• 11:24
  can always freeze sperm after
• 11:26
  the orchiectomy or removing the testicle, but definitely
• 11:29
  wanna do it before the systemic chemotherapy if
• 11:32
  that's needed.
• 11:33
  But, really, I you know, I'd I'd wanna
• 11:35
  shed light on the fact that up to
• 11:36
  thirty percent of patients
• 11:38
  will have
• 11:40
  low sperm counts, low sperm production
• 11:43
  even before removing the testicle.
• 11:45
  And so we really wanna encourage banking sperm
• 11:47
  prior to the orchiectomy
• 11:49
  or at least getting some sort of semen
• 11:51
  testing and hormone testing to make sure that
• 11:53
  there's sperm present.
• 11:56
  That's really the first case. And, you know,
• 11:58
  this sort of testicular biopsy
• 12:01
  or testicular sperm extraction,
• 12:03
  should ultimately done for that reason at the
• 12:06
  same time of the testicular removal. Right? Because
• 12:08
  we don't wanna take the patient back to
• 12:10
  the Operating Room for a second surgery
• 12:12
  if in the event they did have no
• 12:15
  sperm
• 12:15
  and induce them to a second form of
• 12:17
  anesthetic prior to chemotherapy. Right? It's it's, we
• 12:20
  wanna take care of it in the same
• 12:21
  setting. So I recommend, you know, all urologists,
• 12:24
  oncologists,
• 12:26
  trying to recommend and have the patient banks
• 12:28
  from prior to norkiactomy or at least have
• 12:30
  that fertility preservation discussion. You
• 12:33
  know, ultimately, doing a micro testy or micro
• 12:36
  onco testy,
• 12:37
  is most commonly performed by really kind of
• 12:40
  experienced reproductive microsurgeons. There's
• 12:43
  not that many urologists who specialize in this
• 12:45
  kind of work and this microsurgical work.
• 12:48
  You know, there may be only a handful
• 12:50
  or maybe up to 10 folks within the
• 12:51
  entire state of California
• 12:53
  doing this kind of work. So really encourage,
• 12:56
  folks out in the community to kinda refer
• 12:58
  these patients
• 12:59
  to tertiary academic centers who may have a
• 13:02
  male fertility specialist and,
• 13:05
  reproductive microsurgeon who can carry out this kind
• 13:07
  of work. And, ultimately, you know, for any
• 13:09
  sort of work you want to do that's
• 13:11
  never been done at a hospital,
• 13:13
  you know, you need to have patients. There's
• 13:15
  some regulatory hurdles that need to go through.
• 13:17
  Really, obviously, test test your patience, but you
• 13:19
  really need to have a team, and you
• 13:21
  need to get you need to get the,
• 13:23
  you know, folks in charge,
• 13:26
  as a part of your plan. Right? And
• 13:28
  so, ultimately, when this case was done, the,
• 13:30
  you know, the operating room director reached out
• 13:32
  to me and was like, this was a,
• 13:34
  you know, really fascinating case because, a, it's
• 13:37
  never been done before here at this hospital.
• 13:40
  And so we should shed light on it
• 13:42
  to the rest of the physicians here at
• 13:44
  locally within USC. And so we presented the
• 13:46
  case at, you know, one of our town
• 13:48
  hall meetings. And so,
• 13:50
  you know, I think shedding light on that
• 13:51
  is very important.
• 13:53
  Yeah. Definitely. I completely agree with you there.
• 13:56
  And thank you so much for those final
• 13:57
  thoughts, doctor. This has definitely been a very
• 13:59
  informative discussion.
• 14:01
  So I wanna thank you so so much
• 14:02
  for coming on Becker's health care, especially for
• 14:05
  the first time. And I look forward to
• 14:06
  Absolutely. Again soon.
• 14:08
  Thank you so much. It's been a pleasure
• 14:10
  chatting with you today.