Surgical
procedures of sperm retrieval in azoospermia

 

Approach
towards treatment of male infertility was revolutionised by the introduction of
novel method of ICSI in  1992 . (1 2). The use of surgical sperm retrieval from the
testis or epididymis associated to ICSI has given the chance for azoospermic
patients of fathering their own genetic children.  Asingle embryo can be injected into
an oocyte which resulted in normal fertilization, embryonic development and implantation.
source of sperm can be preferentially by ejaculation or from epididymis or
testis in azoospermic males irrespective of obstructive or non obstructive aetiology.
This process opened up an unique opportunity for azoospermic male for a
successful parenthood putting an end for their never ending agony of being
childless for the rest of their life. Surgical sperm recovery for ICSI has
become an indispensable part of clinical andrology.

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Sperms
can still be retrieved in some cases of non obstructive azoospermia as the
testis persists to possess some isolated foci of active spermatogenesis. Pregnancies
resulting from surgically retrieved sperms were first published by 1993 and 1995
(3-4).

 

Anejaculation
and azoospermia- A clinical dilemma.

Successful
pregnancy is plausible only when intravaginal ejaculation is successful.
Primarily this is possible by an intact ejaculatory mechanism which is a  neurologic reflex arc  which can be
disrupted through any type of trauma or disease causing damage to the CNS
and/or peripheral nerves. Ejaculation may be psychogenic or may result from spinal
cord injury or retroperitoneal lymph node dissection. These include 95% of
aetiology followed by diabetic neuropathy , multiple sclerosis, Parkinson
disease, bladder neck surgeries are less encountered causes.Ocassionally drugs
such as antidepressants ,antipsychotics and antihypertensive may cause
anejaculation. Since the outcome of medical treatment for anejaculation is
guarded penile vibratory stimulation or electroejaculation is considered the
first line management than offering surgical sperm retrieval since they are non-invasive
and does not require anaesthesia and they are successful ion 80% of the time 5.often epidydimal or
testicular sperm retrieval are offered initially as facilities of EVS or EJ may
not be available at all centres . Scrotal hematoma and risk of iatrogenic epidydimal
obstruction may preclude surgical sperm retrieval being offered as the first
line and should only be indicated when first line non-invasive management fail.
It is reasonably good to refer anejaculatory 
patients especially with spinal cord injuries to tertiary care centres
where assisted ejaculation and semen cryopreservation facilities are present.

Surgical
sperm retrieval may be a treatment option for men with:

Absolute
Indication:

1.     An obstruction preventing sperm
release, due to injury or infection.

2.     Congenital absence of the vas deferens

3.     Vasectomy

4.     Non-obstructive azoospermia – the
testicles are producing such low numbers of sperm that they don’t reach the
vas.

Relative indictions:

1.     Sperms with increased DFI (DNA
fragmentation Index).

2.     Severe Oligoasthenoteratozoospermia(SOAT)

3.     Intractable Leucocytospermia.

In the first three conditions, sperm are  produced by the testes, but are unable to be
ejaculated primarily due to obstruction of transport  or congenital absence of the vasdeference.
They  can still ejaculate seminal fluid
but this fluid will not contain any sperm. It is possible to collect sperm
directly from the epididymis. most azoospermic patients suffer from primary
testicular ailure(60%).because these subset of patients do not show any clinical
signs of obstruction and they are often referred to as non obstructive
azoospermia NOA. However in few cases of azoospermia ensues due to hypogonadotropic
hypogonadism and not due to obstruction. These patients have an early
maturation arrest in spermatogenesis and adequate treatment with FSH and human
chorionic gonadotrophins might restore spermatogenesis.

Different types of SSR

1.     Percutaneous epididymal sperm
aspiration (PESA).

2.     Microsurgical epididymal sperm
aspiration (MESA).

3.     Testicular sperm aspiration (TESA).

4.     Testicular sperm extraction (TESE) –
single or multi-site.

5.     Microscope-assisted testicular sperm
extraction (MicroTESE).

All these
procedures can be safely  performed  as an outpatient basis with effective
preparation by local anesthesia or under general anesthesia.

 

Preoperative assessment.Pre-operative evaluation consists of recording   the
patient’s health and social history, conducting a physical examination,
developing a plan of anesthesia care and developing a safe plan for discharge
to home from the practice after recovery from the procedure.

1.Percutaneous approaches-(PESA / TESA).

Advantages

1.Minimal training

2. No need for microscopic instruments

3.Percutaneous route more approachable

4.No need for sedation.

5.Lower complication rate

 

Disadvantages

 

1.    
Low yield of sperm retrieved compared with open
approaches. 

1. Percutaneous epididymal sperm
aspiration (PESA)

PESA is a needle aspirate of the head of the
epididymis for attempted retrieval of more mature, motile sperm. Glina and
colleagues reported a sperm retrieval rate of 82% patients who underwent PESA,
while no complications were reported 6, while
the  complication rate of PESA was 3.4%
and included pain, hydrocele, infection, and swelling.(7)

 

 

 

Technique:

 

Under local anaesthesia
scrotum is initially painted with antibiotic solution followed by repeat
painting with normal saline to remove any residual antibiotic solution. On
dependant hand supports the testis and the head of the epididymis is palpated
and stabilised with thumb and forefinger. Aspiration of epididymis is performed with a 27. G needle
mounted with tuberculin syringe containing culture medium. With the needle still
within the epididymis the syringe is advanced in different direction while
maintaining continuous suction. The needle is gently withdrawn from the
epididymis while the suction is released. The aspirate is then emptied into the
dish containing the sperm wash media to be examined under microscope for the
presence of any sperms which can be eventually cryopreserved for future use
during an ICSI. A repeat attempt at an aspiate is made in case of negative
aspiration but at a different location along the epididymal head and repeated
on the contralateral testis. Since this is a blind procedure sometimes several
attempts are required before good quality sperm are found.

 

Advantages

Disadvantages

·      
Fast
and low cost.
·      
Minimal
morbidity, repeatable.
·      
No
microsurgical expertise required.
·      
Few
instruments and materials.
·      
No
open surgical exploration.

·      
Few
sperm retrieved.
·      
Limited
number of sperm for cryopreservation.
·      
Fibrosis
and obstruction at the aspiration site.
·      
Risk
of hematoma/spermatocele .

 

Percutaneous
epididymal sperm aspiration (PESA)

 

Testicular sperm aspiration

TESA is a needle aspirate of seminiferous tubules
most often containing only non-motile or immature sperm first described in Israel by Lewin and
colleagues in 1996 ( 8 ) . It can be considered “therapeutic” for cases of elective
cryopreservation of retrieved sperms or can be coordinated and concurrent with their
female partner’s egg retrieval for ICSI. Occasionally, TESA doesn’t provide
enough tissue/sperm and an open testis biopsy is needed. TESA is also of “diagnostic”
utility when the diagnosis of azoospermia is not certain of obstructive or non- obstructive aetiology and
a focussed counselling and plan  of
treatment can be laid down for subsequent sperm retrieval. Jensen et al. reported a sperm
retrieval rate of 100% in OA, with a complication rate of 3% ( 9
)

Technique:

Under spermatic cord block of short general
anesthesia scrotum is initially painted with antibiotic solution followed by
repeat painting with normal saline to remove any residual antibiotic solution.Testicular
sperm aspiration can be done either by 18G butterfly needle attached to a 20 ml
syringe  containing 1 ml of culture media
. Multi-quadrant testicular tissue aspiration can be done by applying
continuous suction and aspirating the testicular fluid and tissue. The aspirated tissue is then
processed in the embryology laboratory and the sperm cells extracted are used
for ICSI. The aspirated tissue is then processed in the embryology laboratory
and the sperm cells extracted are used for ICSI or cryopreservation.In case of
sample collection stress syndromes or anejacualtion TESA is a quick way for
sperm retrieval in cases of known spermatogenesis on the day of oocyte
retrieval.

Testicular sperm aspiration

 

Advantages

Disadvantages

·      
Fast
and low cost.
·      
Minimal
morbidity, repeatable.
·      
No
microsurgical expertise required.
·       
Few
instruments and materials.
·      
No
open surgical exploration.

·      
blind
procedure
·      
damage
to tunical blood vessel and hematocele formation.
·      
Few
sperm retrieved.
·      
Limited
number of sperm for cryopreservation.
·      
Fibrosis
and obstruction at the aspiration site.
·      
Risk
of hematoma/spermatocele .

 

Percutaneous
vasal sperm aspiration (PVSA)

 

Not very popular among
reproductive endocrinologist is most widely utilised among cases of obstructive
lesions of vas deference resulting from herniorrhaphyp surgery , vasectomy or
ejaculatory duct obstruction. Because it is not widely performed, a standard technique of
PVSA is relatively unknown. First described by Qiu and colleagues(10) The vas deferens was held between the surgeon’s thumb and
forefinger and fixed under the scrotal skin or exposed by a paramedian incision
. The  vas deferens is then cannulated by
 by using a 21-gauge sharp needle, and a
23-gauge blunt tip needle with a central hole and a side hole was introduced
through the sharp needle in the direction of the epididymis. The blunt-tipped
needle was connected to a 10-mL syringe with 1.0 mL of sperm culture. Alternatively
vasotomy or partial vasectomy can be performed for successful cannulation. The
sperm preparation medium was pushed into the vas deferens approximately 0.2 to
0.3 mL, suction was applied to the syringe, and the needle was withdrawn gradually
to a point at which segments of fluid from the vas entered the sperm
preparation medium (i.e., the fluid became turbid). A small drop of fluid was
smeared onto a slide, and routine semen analysis was performed immediately.

 

 

Open surgical approaches to surgical sperm retrieval .

Microsurgical
epididymal sperm aspiration (MESA)

First reported by Temple-Smith et al , MESA was an endeavour at
retrieving more quality sperms in consideration against testicular sperms. This
was conclusively proved by major studies which resulted in superior outcomes in
ICSI with epidydimal sperms against testicular sperms (11)  Several different
techniques for MESA that have been reported in literature (
12,13 14). Extracting sperm from their storage site
in the epididymis is an excellent way of getting sperm to use for IVF in
patients with a blockage in the reproductive tract.Under spinal anesthesia with
a median incision healthier testicle is delivered out while  testis and epididymis is exposed. With the use
of operating microscope and under magnification epididymotomy is performed ,
identifiying a suitable dialated epididymal tubule for sperm aspiration
preferably at distal end of epiidymis where the sperms have completed
maturation process and have acquired motility while their transport as a part
of normal sperm development. More frequently multiple foci aspiration may be
necessary to evaluate before motile sperm are identified.

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