Sperm Retrieval Procedures
Sperm Retrieval Procedures
Men with no sperm when ejaculating need to have sperm retrieved directly from the testis or epididymis in the testicles. Absence of sperm when ejaculating is called azoospermia.
This may be a simple sperm aspiration for men who have a blockage problem or require more extensive search of the testis for men who have a sperm production problem.
Let’s start with the basics: Semen and sperm is not the same thing.
Sperm is just one of the many components of semen. The other elements are to help the sperm in reaching the egg. These other parts help the sperm by its mobility, lubrication, and even by reducing the resistance of the egg to the sperm.
A typical male can produce from 2 – 6 mL of semen when ejaculating.
Overview of the male reproductive system
The function of the male reproductive system is to produce, store and transport the sperm outside the body through the penis. The organs that produce sperm are the testes. Sperm is produced by the testes and is stored in the epididymis. The epididymis is a reservoir in the back of the testicles. From this reservoir, the sperm travels upstream (through the vas deferens) by the ejaculatory ducts where it will be ready to leave. Sperm production begins with immature sperm cells that grow and develop within the seminiferous tubules. These tubes are very tiny and the sperm inside them are not fully mature. As a result they are unable to move on their own. As they travel along the length of the epididymis they mature and become motile. During ejaculation they are carried from the epididymis to the penis along the vas deferens.
Until recently there was no treatment available for men who have a complete absence of sperm in the ejaculate (azoospermia), and it has been estimated that about 10–15% of cases of male infertility are due to azoospermia. Azoospermia has many causes; some of the causes are called “obstructive” meaning that there is a blockage in the sperm delivery system. Other causes are “non-obstructive” meaning that there is an absence or a very marked reduction of sperm production in the testes.
Obstructive Azoospermia
Obstructive azoospermia accounts for about 40% of azoospermia cases. Obstruction may result from defects in any of the ducts (passage ways) involved in the sperm delivery system. The obstruction may be either congenital (you were born with it) or acquired (you were not born with it). Vasectomy is a common form of male contraception. With this the vas deferens is cut forming an acquired obstruction. It is the most common cause of obstruction. Another cause is infection, which can scar the epididymis. Congenital obstruction can be due to either a malformation or the absence of a ductal structure. Congenital absence of the vas deferens is a genetic disorder associated with cystic fibrosis and with this the vas deferens is either absent or malformed. In obstructive azoospermia the reason for the absence of sperm in the ejaculate is physical and in general, does not involve the process of sperm production. Therefore in most cases surgically retrieved sperm are normal in their function and fertilization rates and pregnancy rates are similar to those obtained using ICSI on ejaculated sperm.
Non-obstructive Azoospermia
Non‐obstructive azoospermia is defined as no sperm in the ejaculate due to failure of spermatogenesis (sperm production) and is the most severe form of male infertility.
There are numerous causes of non-obstructive azoospermia:
• Genetics
• Y Chromosome deletion
• Karyotype abnormality
• Radiation and toxins
• Medications
• Hormone imbalances
• Varicocele
The 4 major causes for reduced sperm production are genetical, hormonal problems, testicular failure and varicocele. A significant proportion of men with non-obstructive azoospermia have testicular failure caused by Karyotype abnormalities and chromosomal abnormalities such as Klinefelter’s syndrome or abnormalities of the Y chromosome, Y microdeletions. If azoospermia is due to chromosomal abnormalities the concern is that male offspring could inherit the disorder, and therefore the implications of inheritance of the genetic disorder need to be considered.
Very few tests allow accurate prediction of whether or not sperm will be found in the testes of men with testicular problems. Genetic testing may show if there will be a chance of finding sperm but are not absolute. Blood tests including hormonal studies are also not predictive.
Even having sperm found on previous sessions does not guarantee that sperm will be found on future attempts.
The timing of sperm retrieval:
The timing of sperm extraction in conjunction with the IVF cycle is a difficult matter to resolve. There are advantages and disadvantages in doing the sperm extraction before the IVF cycle or in conjunction with the egg retrieval. The final decision is made usually depending on the IVF program. Making the sperm extraction in advance and freezing the sperm until the eggs are retrieved allows the couple to make a decision whether to go forward with IVF since in most cases the chance of finding sperm may be about 60%.
IVF clinics prefer to work with fresh rather than frozen sperm and thus their desire to have fresh sperm wins.
As a result, usually simple sperm retrievals are done on the day of the egg retrieval. Simple sperm retrievals are procedures done in men with known obstruction who make sperm without a problem. Those procedures include Testicular Sperm Aspiration (TESA), Percutaneous Sperm Aspiration (PESA), and Testicular Sperm Extraction (TESE).
Which Sperm Retrieval Procedure is recommended?
There are lots of ways to extract sperm from a man with normal sperm production and a blockage. The simplest and most cost-effective is direct aspiration of sperm from the testicles (TESA). This is routinely performed under local anesthesia and takes about ten minutes.
Extracting sperm from a man with a testicular problem is much more difficult. The ideal procedure is micro-dissection Testicular Sperm Extraction (Micro – TESE), and is done to take out tissues from the testis.
Small amounts of testicular tissue are given to the IVF laboratory during the procedure so that they can search under a microscope for the presence of enough numbers of sperm. A powerful microscope is used by the IVF laboratory to evaluate this tissue. Repeated biopsies from one or both testes are obtained until sufficient sperm has been collected for the IVF procedure. Extra sperm may be extracted to freeze and preserve for future IVF treatments in case the current cycle is unsuccessful or the couple want more children in the future. Once the sperm extraction procedure is done, it can take the embryologists as long as four hours of sperm searching depending upon how quickly sperm is found.
Surgical sperm collection:
TESA, TESE, PESA, and MESA,
Testicular sperm aspiration (TESA)
TESA is a procedure where a sample of sperm cells and tissue are aspirated from the testicle by a small needle attached to a syringe without opening the testicle. The needle is inserted in the testicle and tissue/sperm are aspirated with negative pressure produced by the syringe. It is done with local anesthesia in the operating room of an IVF center and is usually done after the partner’s female egg retrieval. Under a microscope in the laboratory, the sperm is separated from the tissue. It may then be used right away to fertilize the eggs or frozen for future infertility treatment.
After the procedure the man will be asked to wear a very tight pair of underpants to provide support to the scrotum and to put ice over the underpants on the testicles to prevent inflammation. There is no other special preparation for the patient.
How TESA is performed?
TESA is performed under local anesthesia. This means that an anesthetic is injected into the scrotum by the specialist to make the area numb. When this has been achieved the doctor will swab the scrotum with a warm antiseptic. The doctor will examine the testes by gently feeling the scrotum. A small needle will be inserted into the testes and the doctor will instruct the nurse assisting to draw back the syringe in order to aspirate seminal fluid and tissue. When fluid and testicular tissue is obtained it is passed to the embryologist to be examined for sperm under a microscope. The procedure may need to be attempted again until sperm will been found. The procedure is usually performed just prior to the woman’s oocyte collection (on the same day).
Sperm donation back up will be prepared by the IVF center in case the couple asked for it.
TESA is done for men who are having sperm retrieved for IVF/ICSI in the following cases:
• TESA may be useful for men who have fertility problems caused by a blockage that keeps sperm from being ejaculated. This is called obstructive azoospermia that might be caused by certain genetic conditions, ejaculation problems, infection, or other conditions.
• Previous vasectomy.
• High Sperm DNA Fragmentation.
• After having treatment that may cause infertility, such as certain cancer treatments.
Sometimes TESA doesn’t provide enough tissue/sperm for the IVF + ICSI and an open testis biopsy is needed (TESE).
Testicular sperm extraction (TESE)
TESE involves making a small incision in the testis and examining the tubules for the presence of sperm. TESE is usually done in the operating room with sedation or with local anesthesia alone. It is either done as a scheduled procedure or is coordinated with their female partner’s egg retrieval. During TESE the testis is opened by an incision and a biopsy is done and testicular tissue is removed and examined under a microscope to search for sperm. Then the incision will be sutured. The patient will be asked to put some ice on the testicles after the procedure to reduce the inflammation and he can continue his life as usual without any pain. Patients usually cryopreserve sperm during this procedure for future IVF/ICSI or use the fresh sperm found for the ICSI.
Patients frequently have donor sperm backup in case sperm are not found in the male partner.
You have the following options in case sperm is not found by TESE:
1. Egg retrieval of the IVF might be cancelled if the doctor sees no harm in cancelling it or the egg retrieval can be done without fertilization, and then the eggs can be destroyed.
2. Eggs retrieved can be frozen for later use.
3. Fertilize the eggs by sperm donation.
Micro TESE has replaced this as the optimal form of retrieval for men with no sperm in their ejaculate (azoospermia) from a problem with production.
Micro - dissection TESE (micro TESE)
Micro TESE is a procedure done for men who have a sperm production problem and are azoospermic. Micro TESE is done in the operating room with general or local anesthesia alone under an operating microscope. The testis is opened by an incision and under the microscope we can spot the places where sperm is found to obtain them. This allows us to remove less testicular tissue with higher possibility to find good sperm. Micro TESE is carefully coordinated with the female partner’s egg retrieval, and can be done the day before egg retrieval. Patients frequently have donor sperm backup in case sperm are not found in the male partner. Micro TESE has significantly improved sperm retrieval rates in azoospermic men, and is a safer procedure since less testicular tissue is removed. Patients can cryopreserve sperm during this procedure for future IVF/ICSI.
Percutaneous Epididymal Sperm Aspiration (PESA)
PESA is a simple technique to obtain sperm for Intra Cytoplasmic Sperm Injection (ICSI) in men who have an obstruction of the vas deferens, either due to vasectomy or other obstruction. PESA involves aspiration of sperm from the epididymis with a fine needle without opening the testicle through the skin. To minimize scarring and damage, PESA usually is attempted on one side only. It is sometimes necessary to aspirate from both sides. Sufficient sperm for ICSI is obtained in 80% of attempts. In 10% of cases we can also find enough suitable sperm for cryopreservation.
The procedure is performed in the operating room of an IVF Centre. After the procedure the man will be asked to wear a very tight pair of underpants to provide support to the scrotum. There is no other special preparation for the patient.
PESA is performed under local anesthesia. This means that an anesthetic is injected into the scrotum by the specialist to make the area numb. When this has been achieved the doctor will swab the scrotum with a warm antiseptic. The doctor will examine the testes to locate the vas deferens by gently feeling the scrotum. A small needle will be inserted into the vas deferens through the skin and the doctor will instruct the nurse assisting to draw back the syringe in order to aspirate seminal fluid. When fluid is obtained it is passed to the embryologist to be examined for motile (moving) sperm. The procedure may need to be attempted again until motile sperm have been found.
The procedure is usually performed just prior to the woman’s oocyte collection (on the same day). And sperm donation back up will be prepared by the IVF center in case the couple asked for it.
You have the following options in case good sperm is not found by PESA:
1. IVF egg (oocyte) retrieval might be cancelled if the doctor sees no harm in cancelling the egg retrieval, or the egg retrieval will be done without fertilization, then the eggs they will be destroyed.
2. Eggs retrieved can be frozen for later use.
3. Fertilize the eggs by sperm donation.
Microsurgical Epididymal Sperm Aspiration (MESA)
MESA is an open surgical sperm retrieval procedure that uses an operating microscopy to locate the tubules of the epididymis precisely, so that large numbers of sperm can be extracted.
MESA is a procedure performed for men who have vasal or epididymal obstruction (s/p vasectomy, congenital bilateral absence of the vas deferens). It is either done as a scheduled procedure or is coordinated with their female partner’s egg retrieval.
MESA is done in the operating room with general anesthesia under the operating microscope. MESA involves opening the testicle by an incision after locating the epididymis and then aspirating the sperm directly from the epididymis with a fine needle. One aspiration may provide enough sperm for several attempts at IVF using ICSI. MESA can be performed well in advance of any proposed IVF procedure. Patients usually cryopreserve sperm during this procedure for future IVF/ICSI. MESA allows an extensive collection of mature sperm as compared to aspiration techniques, and it is the preferred method of retrieval for men with congenital bilateral absence of the vas deferens as it does not impact steroid production of the testis.
Patients frequently have donor sperm backup in case sperm are not found in the male partner.
You have the following options in case sperm is not found by MESA:
1. Egg retrieval of the IVF might be cancelled if the doctor sees no harm in cancelling it or the egg retrieval can be done without fertilization, and then the eggs can be destroyed.
2. Eggs retrieved can be frozen for later use.
3. Fertilize the eggs by sperm donation.

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