Metro Urology

Some couples undergoing in-vitro fertilization (IVF) will need a procedure to obtain sperm. This typically occurs in two scenarios:

• there is an obstruction or blockage and the man has no sperm in his semen (obstructive azoospermia) or
• the man makes very few sperm (nonobstructive azoospermia). We will address these two situations separately since the treatments are different.

Obstructive Azoospermia

This simply means that there are no sperm in the ejaculate because of an obstruction. The most common scenario would be a vasectomy but some blockages are congenital. Severe infections and trauma can also cause obstructive azoospermia. If the cause is congenital or unexplained, it is critical to make sure there is not a genetic cause prior to proceeding with IVF.

There are several sperm acquisition options available to men who have obstructive azoospermia and do not wish to undergo or are not candidates for surgical reconstruction. These include:

1. Percutaneous Epididymal Sperm Aspiration (PESA): With this technique, a tiny needle is passed through the skin and into the epididymis. The epididymis is the duct that channels sperm out of the testicle. In 85% of cases, we can obtain sperm adequate for IVF using this minimally invasive procedure. Recovery time is generally a few hours to a day. Sedation is an option but is not generally necessary since local anesthesia is generously applied. Complications are rare but include bleeding and infection.
2. Testicular Sperm Aspiration (TESA): With this technique, a tiny needle is placed into the testicle itself and passed through the testicular tissue several times with negative pressure applied to the syringe. This can also be performed without sedation in many men. Risks are similar to PESA but the recovery tends to be slightly longer.
3. Testicular Biopsy: A small incision (1 centimeter) is made in the scrotum and a small sample of testicular tissue is removed. This is a very reliable method of obtaining sperm but the recovery is longer than that for PESA or TESA. Sedation is not essential but many men prefer some form of anesthesia for a biopsy.
4. Microsurgical Epididymal Sperm Aspiration (MESA): This involves an incision in the scrotum, delivery of the testicle and removal of fluid from the epididymis under an operating microscope. There are very few reasons to do a MESA currently. It adds much expense without any significant benefit and is mostly of historical interest.

When Dr. Milbank evaluates you in the office he will discuss these options with you and help you decide which is best for you.

Nonobstructive Azoospermia or Severe Oligospermia

This means that there is a major problem with sperm production and the ejaculate contains few or no sperm. Even when no sperm are seen in the ejaculate it is quite possible that small areas of sperm production can be found within the testicles. Prior to proceeding with sperm acquisition it is important to screen for genetic causes of male infertility. The treatment options include:

1. Testicular biopsy: This is similar to the procedure described above but many more samples may be required.
2. Microdissection testicular sperm extraction (micro-TESE): This procedure takes advantage of the fact that some men with no sperm in their ejaculates will have small pockets of sperm production within the testicular tubules. The testicular tubules can be examined under an operating microscope. Tubules that contain sperm appear plumper than the empty tubules. Using this method, very little testicular tissue is removed. Moreover, a higher sperm retrieval rate can be obtained using this technique compared with multiple testicular biopsies. There are risks associated with the procedure and these risks must be discussed with your fertility specialist prior to proceeding with this technique.
3. Testicular mapping: This is a relatively new procedure in which a small needle is passed into numerous zones of the testicle and fluid is aspirated. The fluid is examined for sperm and a “map” of the testicle is created. If sperm are identified in a specific zone, a targeted biopsy of that zone can be performed. It is not yet clear what the sperm retrieval rate would be for men with negative maps who undergo micro-TESE.

Dr Milbank will help you determine which of these options is most suitable for you.

FAQ regarding Sperm Acquisition

Should the procedure be done before IVF and freeze the sperm or at the same time as egg retrieval so that the sperm are used fresh?

There are two different schools of thought amongst fertility experts. Some centers have better results with fresh sperm. Other centers note identical pregnancy and live birth rates with fresh and frozen sperm. There is no one right answer. The benefit of freezing sperm beforehand is that you can do a “test thaw” and know that you are likely (or not likely) to find sperm in the thawed specimen when you proceed to egg retrieval. Without a frozen specimen, you may have to cancel the IVF cycle if no sperm can be found at the time of egg retrieval. On the other hand, if sperm production is low and only a few sperm are identified, cryopreservation and thawing may destroy those few sperm. This would be most likely to occur in the setting of non-obstructive azoospermia. This is an excellent question to discuss with your fertility specialist.

Do I need anesthesia for these procedures?

Definitely for a micro-TESE. For the other procedures, local anesthesia may suffice. It is generally preferable to have the option of anesthesia if it is required.

Do you always find sperm?

No. We virtually always find sperm in the setting of obstructive azoospermia but occasionally the specimen will not cryopreserve well. With non-obstructive azoospermia, sperm are identified between 20% and 80% of the time depending upon the severity of disruption of sperm production and the technique used to obtain sperm.

Where do you do the procedure?

The procedure can be performed in an office setting or in an operating room. If performed at the time of egg retrieval, it is logistically preferable to do the procedure at the site where your partner is undergoing egg retrieval.