Surgical Sperm Retrieval

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Overview

PESA

MESA

TESE

micro-TESE

Retrograde Ejaculation

 

Overview

 

Men who are looking at surgical retrieval of sperm fall in to two broad groups:

 

  1. Men who we are fairly certain are making sperm. 
  2. Men who we are uncertain if they are making sperm.

 

Men who we are fairly certain are making sperm.

Men in this group have nothing to suggest that there is not sperm production - basically everyone who has obstruction of the reproductive tract. The most common example is men who have undergone vasectomy but also includes any many who had had surgery of the lower urinary tract (e.g. TURP) and patients with ejaculatory problems (e.g. retrograde ejaculation, neurological issues).

 

Most men will have a good result with either a perctaneous sperm extraction (PESA) or testicular sperm extraction (TeSE). The goal is always to obtain enough sperm for use with IVF - and then some. It is desirable to have some extra in the freezer for future use if the plan does not go as expected.

 

Men who we are uncertain if they are making sperm.

This includes men who have 'non-obstructive' azospermia. The selection of the surgical approach depends on a number of factors, but most importantly:

  1. Probability of successful sperm retrieval.

  2. Potential complications of retrieval.

  3. Cost and patient preference.

 

In all patients, the overall goal is to find a procedure with the right balance of successful retrieval, potential complications and cost to suit you.

 

It is important to note that while sperm can be found in many men 

there is no guarantee that sperm will be found.

 

Your urologist will discuss the probability of finding sperm based on your individual circumstances and the different surgical approaches to retrieval. Surgially retrieved sperm almost always require in vitro fertilization (with or without ICSI) to obtain a pregnancy because they are often limited and number nor have the maturity to use for insemination.

 

Another important consideration in sperm retrieval is whether the sperm will be used 'fresh' or 'frozen'. Using 'fresh' sperm means that once the sperm are retrieved, they are used immediately to fertilize an egg. Using 'frozen' sperm means that the sperm are frozen for future use (see our section on cryopreservation) and then thawed when the eggs are available. When sperm are used fresh any excess sperm are usually frozen for possible future use. In some circumstances, frozen sperm are as good as frozen sperm (including cases when sperm are retrieved after vasectomy). However, in cases where very low numbers or quality of sperm are retieved, the sperm may not survive the freeze-thaw cycle or be usable for egg fertilization. Therefore, if it is likely that only a few sperm will be found we typically recommend using fresh sperm.

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Surgical Sperm Acquisition

When no or poor quality sperm are found in the ejaculate, retrival of sperm further 'upstream' is necessary. In most cases, the sperm acquired surgically require the use of IVF with or without ICSI. They cannot be used for intrauterine insemination because of either immaturity of lack of sufficient numbers. It is important to recognize that there is no guarantee that sperm will be found at the time of surgery and that finding sperm does not guarantee a pregnancy or successful delivery of a healthy child. For men with obstructive azospermia (e.g. following vasectomy or with cystic fibrosis), the chances of obstaining sperm approach 100%. In cases of non-obstructive azospermia, we can provide an individualized estimate of the chances of success based on your diagnosis and clinical features.

 

The risks of the procedures vary but most are minimaly invasive with a quick recovery. For those procedures which require a cut in the skin (TeSE, microTeSE) the risks include bleeding, wound infection and pain. The combined risk of bleeding (resulting in a hematoma) or infection is a combined 2%. As with any testicular/scrotal surgery there is a risk of loss of the testis - this risk is challenging to quantify because the risk is very low (much less than 1%).

 

The terminology for the different types of sperm retreival can be confusing. Here are common-language descriptions for the most commonly performed types of surgical sperm retrieval.

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Olive Fertility: Instructions for Transport of Sperm

 

PESA - Percutaneous Epididymal Sperm Aspiration

 

What is it? Use of a needle to 'suck' sperm from the storage sack attached to the back of the testicle. This is a 'blind' procedure in that individual tubles are not targeted.

 

When is it done? Highly successful in men with obstruction, though slightly less so than MESA. Can be performed under local anesthetic without an incision and with a rapid recovery. High success rate and relatively low cost make this the initial approach in most men with obstructive azospermia - e.g. following vasectomy or with congenital absence of the vas deferens. In almost all circumnstances, IVF with our without ICSI are required to use sperm harvested in this manner. If a PESA is unsuccessful, we can transition to a TESE at the same sitting.

 

Preparation and potential complications. Please shave the scrotum before coming for the procedure.You do NOT need to fast prior to this procedure. Mild pain lasting hours to a few days and potentially some bruising. 

 

Would also recommend that you bring an athletic support or wear tight fitting brief-style underpants. The major potential complication is bleeding and bruising. While a small amount of brusing is relatively common, it is very, very rare to have scrotal bleeding which results in swelling. Limiting activity following the procedure, scrotal support and an ice pack for a day or two should suffice.

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MESA - Microscopic Epididymal Sperm Aspiration

 

What is it? Similar to a PESA, but involves targeting individual epididymal tubules for aspiration. This requires delivering the testis from the scrotum through an 4-6 cm incision, an operating microscope, usually a general anesthetic. As such, it is much more expensive than a PESA with marginally higher success rates.

 

When is it done? There are not many indications for a MESA since if PESA fails, a TESE an be performed with a similar or higher success rate and with similar risk, but without the requirement for a general anesthetic. In almost all circumnstances, IVF with our without ICSI are required to use sperm harvested in this manner.

 

Preparation and potential complications. Please shave the scrotum before coming for the procedure. As this procedure requires a general anesthetic, you will need to FAST STARTING THE NIGHT BEFORE THE PROCEDURE and make arrangements to be accompanied home by a friend. You are not permitted to drive for 24 hours after the procedure and taking taxi unaccompanied is not acceptable. If you do not follow these requirements, your procedure will be cancelled and you may be required to pay a cancellation fee.

 

We recommend that you bring an athletic support or wear tight fitting brief-style underpants. The major potential complication is bleeding and bruising. While a small amount of brusing is relatively common, it is very, very rare to have scrotal bleeding which results in swelling. Other rare complications include spermatocele formation or hydrocele formation. Limiting activity following the procedure, scrotal support and an ice pack for a day or two should suffice.

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TESE - TEsticular Sperm Extraction

 

What is it? Sperm are retrieved directly from the testis itself. This is performed under local anesthetic through a small 1-2 cm cut in the scrotum. Some of the tubules in which sperm are formed are extruded and removed. The total amount of a testis that is removed is usually less than 5%. The sperm must be released from the tubules by special mechanical processing.

 

When is it done? This is generally used for obstructive azospermia but also in some cases where the underlying cause of azospermia is not clear. It is the most direct way to obtain a satisfactory number of sperm following vasectomy or any other non-obstructive cause and is the backup procedure if PESA fails. It is much less effective for non-obstructive azospermia, including conditions such as Klinefelter's syndrome, Y-chromosome microdeletion and idiopathic (unknown) causes of azospermia.

 

Preparation and potential complications. Please shave the scrotum before coming for the procedure. You do NOT need to fast prior to the procedure. Bruising, bleeding and wound infection can occur. Ensure you rest the day of the procedure and avoid exercise or heavy physical activity for at least a week.

 

We also recommend that you bring an athletic support or wear tight fitting brief-style underpants. The major potential complication is bleeding and bruising. While a small amount of brusing is relatively common, it is very, very rare to have scrotal bleeding which results in swelling. Other rare complications include spermatocele formation or hydrocele formation. Limiting activity following the procedure, scrotal support and an ice pack for a day or two should suffice.

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microTESE - Microdissection TEsticular Sperm Extraction

 

What is it? This is the gold standard treatment for men with non-obstructive azospermia. Dissection of the seminiferous tubules of the testis is performed under a high-powered operating microscope. Tubules which are suspected to contain sperm production are selectively harvested and searched for sperm. Dissection of one or both testes may be required.

 

When is it done? This technique has the single best chance of finding sperm in cases of non-obstructive azospermia. Even is sperm production is present in non-obstructive azospermia, it tends to be limited. There can be islands of sperm production within the testis which a standard TESE can simply miss by chance. These islands can often be identified based on their microscopic appearance - tubules without sperm production tend to look like uncooked pasta (narrow and dark yellow) whereas those with sperm production often look like cooked pasta (plump and pale yellow). The tubules are about the size of a human hair and doing a thorough assessment means opening up the testis and carefully sifting through the testes. This requires a general anesthetic. The chances of successful sperm retrieval are double that of a standard TESE. Because the number of sperm retrieved are usually small, it is highly recommended that they are used 'fresh' rather than 'frozen' (thawing after cryopreservation).

 

Preparation and potential complications. Please shave the scrotum before coming for the procedure. As this procedure requires a general anesthetic, you will need to FAST STARTING THE NIGHT BEFORE THE PROCEDURE and make arrangements to be accompanied home by a friend. You are not permitted to drive for 24 hours after the procedure and taking taxi unaccompanied is not acceptable. If you do not follow these requirements, your procedure will be cancelled and you may be required to pay a cancellation fee.

 

It because the scrotum and testes are opened, it can take a few weeks for the swelling and discomfort to resolve. While swelling, mild bruising and discomfort are common, other complications are fortunately very uncommon occuring in less than 5% of patients. The potential uncommon complications include: bleeding within the scrotum and hematoma formation, infection, a decrease in testosterone production (usually transient and clinically insignificant), hydrocele or spermatocele formation and atrophy (shrinkage or loss) of the testicle.

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Retrograde Ejaculation & Anejaculation

 

Retreival of sperm from the bladder in cases of failure to ejaculate forward (antegrade) is necessary. Instructions can be found here.

 

Author(s): K Poon  Major Revision/Review: January 2011