Microsurgical Sperm Aspiration

Sometimes, the only way for a man to achieve fatherhood in a biologic way is through surgical sperm aspiration. In some men spermatozoa may not be present in the ejaculate (fluid coming out of penis during orgasm). Spermatoozoa refers to mature male reproductive cell. In such cases sperm retrieval techniques are the only way to collect motile sperm cells. There can be two reasons for this condition”

obstruction to the flow of semen during ejaculation – obstructive azoospermia
due to problems in producing healthy sperm – non-obstructive azoospermia

Obstruction or blockage in the reproductive tract could be due to a variety of reasons. Some of them are testicle infection, trauma, genetic conditions, iatrogenic injury which can occur during a medical treatment, injury in the bladder neck and pelvis, hormone-related abnormalities, abdominal or inguino-scrotal surgery, prior hernia repair with mesh. Prior vasectomy is attributed to the main reason for obstructive azoospermia. Though not very common, congenital abnormalities can also be the reason. The above-mentioned conditions can interrupt the production of healthy sperm. Thankfully, even in these conditions, there are often areas of healthy sperm production. It is estimated that in up to 2% of people, the absence of motile sperm is congenital. Mostly known congenital abnormality is the absence of vas deferens bilaterally, which occurs virtually in all men with cystic fibrosis.

Technology in the fertility field has progressed considerably to give a ray of hope to men who were previously considered to be incapable to biologically father a child. Sperm can be aspirated by using an open surgical approach or through the skin using a needle. With advancement of technology, now sperm thus taken can be injected directly into an egg and as a result fertilization happens. This process is called intra-cytoplasmic sperm injection. The primary advantage of this treatment method is only very few sperm is needed to achieve a successful pregnancy. As you may be aware, sperm is produced in the testicle and transported to the penis, where fluid from the prostate blends with the sperm to produce semen. Today there are advanced microsurgical techniques to extract sperm to be used for in-vitro fertilization. It is done in conjunction with the female partner’s reproductive specialist so fresh sperm can be used or sperm can be frozen to be used at a future date. Surgically sperm can be obtained from either vas deferens, epididymis or testis.

Why sperm is aspirated surgically?

It is estimated that as many as 10% to 15% of infertility among men is as a result of no sperm in their ejaculate. This condition is called azoospermia. However, 40% of infertility among men is due to obstruction in the reproductive tract. Inadequate sperm production is the other cause. Whatever, the reason may be, men with such condition can father a child through microsurgical sperm extraction as the sperm is aspirated surgically from the genital area.

Goals of surgical sperm aspiration:

To get the sperm that is of superior quality
To get enough sperm that can be used without delay and for freezing so that it can be used at a later date
To minimize the risk of injuring the testicle in particular and genital region in general

There are several ways to extract sperm, the method used depends on:

Whether the procedure can be done through skin or requires a percutaneous or open incision.
The amount of tissue required and the mode of retrieval.
The location from which the sperm is aspirated – testicle, epididymis or vas deferens

There are many names for microsurgical sperm extraction; some of the prominent ones are the following:

PESA (percutaneous epididymal sperm aspiration)
MESA (microsurgical epididymal sperm aspiration)
TESE (testicular epididymal perm extraction)

The choice of a particular method for harvesting sperm depends on various factors. Each approach carries certain pros and cons and there is not a one-single approach that suits everybody. For example incision through the skin generally requires only local anesthesia and there is no need of using microsurgical equipment. Though it is possible to get enough sperm for intrauterine insemination (IUI), where the sperm is injected directly into the woman’s uterus, in the case of in-vitro fertilization (IVF), more often than not, harvested sperm is used. The sperm taken through a microsurgical approach can be injected immediately to fertilize an egg. However, if the sperm is extracted with a view to fertilize an egg later on; it is absolutely okay to freeze the sperm for use at a later date.

As a precursor to microsurgical sperm aspiration, a fertility evaluation of the man is done along with the evaluation of the female partner. If the semen analysis reveals you have no sperm or very few sperm, you should undergo a complete physical examination and sometimes laboratory testing as well. Doctor specializes in reproductive medicine (preferably, urologist) can suggest the appropriate sperm retrieval method that is best suited for your particular condition.

Percutaneous epididymal sperm extraction (PESA):

PESA is a type of microsurgical sperm extraction where a needle is used to aspirate the sperm from the testicle or epididymis (a long, coiled tube that stores sperm and transports it from the testes). It is in the epididymis that the sperm matures and develops the ability to move around. The epididymis can be enlarged due to a vasectomy or due to other reasons such as a blockage. This procedure can be performed with a mild sedation or local anesthesia. The procedure begins with inserting a needle into the testicle or epididymis and an attempt is made to extract the sperm. The sample thus obtained is then carefully examined under a microscope to look for the presence of motile and healthy sperm cells. These sperm cells can be either immediately injected into an egg for fertilization or can be frozen for future use.

This is the first-line treatment modality in case of microsurgical sperm aspiration. PESA works well when trying to collect sperm in a man who had prior vasectomy or with an enlarged epididymis. The main advantage of this procedure is it is largely painless. PESA does not call for a general anesthetic and no need of an incision in the scrotum as the sperm is drawn using a needle. In the unlikely event, if this technique does not work out, then it calls for more advanced methods like microscopic epididymal sperm extraction (MESA).

Microsurgical epididymal sperm aspiration (MESA):

MESA is a little more advanced technique for collecting sperm microsurgically, sperm is collected using a surgical microscope to open the small tubes within the epididymis to look for healthy sperm. This technique works well in cases where sperm is being produced in adequate number, but it is blocked while travelling from the testicle to the ejaculate. Blockage during the passage may be due a number of reasons such as previous surgery in the genital area, cystic fibrosis or immotile cilia syndrome (an autosomal recessive disease). This procedure is very much favored for harvesting sperm after a vasectomy.

A microscope used for surgical purpose and the expertise to figure out the tubes that most likely to contain sperm are necessary for the procedure. The sample thus collected is put under microscope immediately to look for healthy, motile sperm. It has been found out that sperm harvested from the epididymis is of better quality than the sperm extracted directly from the testicle because they have had more time to mature. The procedure is done under either general or spinal anesthetic. Upon proper anesthesia is administered, an incision is made in the scrotum to gain access to one or both testicles. The sperm thus extracted can be used either immediately for fertilization or can be frozen for future use. In cases where no viable sperm is found, it is necessary to look inside the testicle for sperm and a technique called testicular sperm extraction (TESA) is applied.

Testicular epididymal sperm extraction (TESA):

TESA is another sperm retrieval technique in which a small amount of testis tissue is taken by biopsy. The procedure is done under local anesthesia. It is a breakthrough in sperm retrieval as the sperm do not have to mature and pass through epididymis in order to fertilize an egg. This technique is generally adopted for patients in whom there is a blockage in epididymis very near the testis or an obstruction within the ducts of the testes – efferent ductules. The blockage could be because of prior surgery, genital infection or congenital defect. It is also ideal for man with drastically low sperm production and as a result it cannot reach the ejaculate.

The procedure is performed by injecting a needle in the testis and drawing fluid and tissue. The extracted tissue is then processed at the embryology laboratory and subsequently sperm cells are extracted for intracytoplasmic sperm injection (ICSI).

Only caveat of this procedure is in most cases the condition that causes poor sperm production may be still unknown and inadvertently the condition can be transmitted to the progeny.

Advantages of microsurgical method over conventional surgery:

Testicular sperm extraction can be done via microsurgically (using an operating microscope) or in the conventional way without a microscope. It should be understood that the microsurgical way offers higher chances of sperm retrieval compared to the conventional method. Other advantage is sperm can be found with microsurgical method even when the sperm production by the testicle is so low. The chances of injury to the testicular blood supply and testicular tissue is minimal. This aspect of the microsurgical approach is of prime importance as testicular bleeding can lead to scar formation, which can even damage the testicle.

Relationship between microsurgical sperm extraction and intracytoplasmic sperm injection (ICSI):

Microsurgical extraction of sperm would not have been become more popular if the extracted sperm wasn’t put to good use. ICSI with IVF has fulfilled the dream of some men to father a child who otherwise would not have been. Microsurgically extracted sperm can be used to fertilize an egg through ICSI. Even when the quantity of the sperm is so low, ICSI can improve the chances of pregnancy.

Being aware!

Understanding the clinical diagnosis, various treatment methods, its outcomes and potential advantages of microsurgical sperm extraction will help you prepare for your medical consultation with the reproductive specialist and aid you choose the appropriate procedure.

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