One in 100 men have no sperms in their semen. If you have no or extremely low numbers of sperms in your semen which means you can’t have a standard fertility treatment, you may be able to have sperm collected surgically and still father a child. These procedures are indicated for men with irreparable obstruction (congenital or acquired) resulting in azoospermia (lack of sperms). Your chances of extracting sperm will depend on the reason for the lack of sperm in your sperm. If you’re having a MicroTESE for non-obstructive azoospermia, there’s a 40-50% chance of sperm being successfully extracted. Your chances are much higher if you’re having a procedure for obstructive azoospermia There is no evidence that sperm collected surgically affects your chances of getting pregnant or that it poses a risk to the health and wellbeing of any children you might conceive.
Testicular sperm extraction (TESE) is a surgical biopsy of the testis whereas testicular sperm aspiration (TESA) is performed by inserting a needle in the testis and aspirating tissue with negative pressure. In percutaneous epididymal sperm aspiration (PESA), a small needle is passed directly into the head of the epididymis and fluid is aspirated. It does not require surgical incision. Retrieved fluid and tissue is then processed in embryology laboratory. You will need to have a fertility treatment like ICSI using these extracted sperm cells.
Most recently, sperm has been fairly reliably extracted (60-70% of the time) from the testes of men with sperm production problems of such severity that no sperm is found in the ejaculatory ducts. It is important to realize, however, that in vitro fertilization (IVF) technology is required to achieve a pregnancy with the vast majority of these extraction procedures, and thus success rates are intimately tied to a complex and complementary program of assisted reproduction for both partners .In rare instances, if you’ve had surgical sperm extraction and it hasn’t been successful, other options for having a family still exist, such as using donor sperm in treatment or adopting.
In some individuals, spermatozoa may not be present in the ejaculate. This condition is called Azoospermia. Azoospermia can be caused by an abnormality or blockage in the epididymis or the vas deferens. This is referred to as obstructive azoospermia. In these cases, sperm are being produced in the testes, they just can’t get out due to obstruction to the flow of semen through a ductal system that normally carries sperm to the ejaculate being absent (i.e. congenital absence of the vas deferens) or blocked completely or unable to be reconstructed.
Sometimes however, sperm production in the seminiferous tubules does not occur at all or is happening at such a low level that sperm are not detectable in the ejaculate due to problems in sperm production itself. This is referred to as non-obstructive azoospermia.
Reproductive tract obstruction can be acquired – as a result of infection, trauma, iatrogenic injury which can occur during bladder neck, pelvic, abdominal or inguino-scrotal surgery. Congenital anomalies may be relatively uncommon in the general population, but can occur in up to 2 percent of infertile men. Best known condition is congenital bilateral absence of the vas deferens (CBAVD) which occurs in almost all men with cystic fibrosis.
Who can benefit from PESA/TESA?
The possible causes of lack of sperm in your ejaculate include:
- Testicular problems resulting in poor sperm production. These can be caused by various factors such as genetic issues, previous infection (e.g. mumps), maldescended testes.
- An irreversible obstruction of the genital tract (possibly caused by a previous infection, trauma or surgery)
- Congenital absence (absence from birth) of the vas deferens, which is common in carriers of cystic fibrosis
- A previous vasectomy or an unsuccessful vasectomy reversal.
A surgical sperm retrieval procedure used in fertility treatment for men who have no sperm in their ejaculate is beneficial in such cases. Using surgical procedures to try and extract sperm from the epididymis (PESA) or to dissect it out of tubules from the testis (TESA) can be an effective way of diagnosing what is causing the azoospermia. More importantly though, these procedures can also be effective ways of isolating sperm for use in treatment to try to achieve a pregnancy. Even in non-obstructive azoospermia, as long as some sperm production is occurring, PESA/ TESA can still be an effective way of retrieving sperm for use in treatment.
Intracytoplasmic sperm injection (ICSI) has revolutionized the treatment of male infertility. The sperm requirement for egg fertilization has dropped from hundreds of thousands for in vitro fertilization (IVF), to one viable sperm per egg required for ICSI when combined with IVF procedure. This has led to further development of aggressive new surgical techniques to provide viable sperms for egg fertilization from men with low or no sperm count and more challenging scenarios. This has also pushed urologists beyond the ejaculate and into the male reproductive tract to find sperm for biologic pregnancies. Presently, sources of sperm in otherwise azoospermic (no ejaculated sperm) patients include the vas deferens, epididymis and testicle using sperm aspiration techniques. Sperm aspiration techniques involve the use of minor surgical procedures to collect sperm from organs within the genital tract.
PESA or Percutaneous Epididymal Sperm Aspiration (PESA), does not require a surgical incision. A small needle is passed directly into the head of the epididymis through the scrotal skin and fluid is aspirated. The embryologist retrieves the sperm cells from the fluid and prepares them for ICSI.
Microsurgical Epididymal Sperm Aspiration (MESA) is used in conditions like obstructive azoospermia, involves dissection of the epididymis under the operating microscope and incision of a single tubule. Fluid spills from the Epididymal tubule and pools in the Epididymal bed. This pooled fluid is then aspirated. Because the epididymis is richly vascularized, this technique invariably leads to contamination by blood cells that may affect sperm fertilizing capacity in vitro.
TESA and TESE
TESE or testicular sperm extraction is a surgical biopsy of the testis wherein a small amount of testis tissue is taken by biopsy under anesthesia, whereas TESA or testicular sperm aspiration is performed by inserting a needle in the testis and aspirating fluid and tissue with negative pressure. The aspirated tissue is then processed in the embryology laboratory and the sperm cells extracted are used for ICSI. It is a breakthrough in that it demonstrates that sperm do not have to “mature” and pass through the epididymis in order to fertilize an egg. Because of their immaturity, however, testicular sperm compulsorily need ICSI. Testicular sperm extraction is indicated for patients in whom there is a blockage in the epididymis very near the testis (either from prior surgery, infection or from birth), or a blockage within the ducts of the testes (efferent ductules). It is also used for men with extremely poor sperm production, in which so few sperm are produced that they cannot reach the ejaculate.
One drawback of testis sperm is that is does not freeze as readily as epididymal or vasal sperm and thus it is more likely that the male partner will need to undergo repeated procedures for each IVF attempt.
How is PESA/TESA sperm used?
The number of sperm retrieved through PESA or TESA is usually very low compared to the number present in an ejaculate, so the sperm usually need to be used in combination with a specific type of IVF called ICSI( Intracytoplasmic sperm injection) . Surgically retrieved samples are rarely suitable for use in intrauterine insemination (IUI).
Your partner will undergo an IVF cycle and, once her eggs have been collected (usually the same day as your PESA or TESA), your sperm will be injected directly into her eggs (a process called ICSI). TESE is carried out in advance of any fertility treatment to confirm that sperm production is occurring. If suitable numbers of sperm are identified on this occasion, it is sometimes possible to freeze the testicular extract and to thaw and use this sample for subsequent treatment. More commonly however, once it has been confirmed that sperm production is occurring, the TESE procedure is repeated on the day of the egg retrieval and the fresh sample used for ICSI. Again, providing that there are suitable numbers of sperm present, the sample can sometimes be frozen for use in future treatment cycles. The fertilized eggs are then cultured for a few days in the laboratory before a healthy embryo is transferred into your partner’s uterus.
Sometimes enough sperm is retrieved for some to be frozen for use in future ICSI cycles.
What is the success rate of this procedure?
Two techniques – Epididymal sperm retrieval & micromanipulation (ICSI) have revolutionized treatment of male infertility in the past decade. Men with congenital bilateral absence of the vas defences (CBAVD) or reproductive tract obstruction are now able to achieve pregnancies from their own sperms with use of these advanced techniques. IVF treatment using PESA or TESA sperm is a regular procedure at Anmol Fertility & IVF Centre and it has a similar success rate to IVF/ICSI using fresh semen produced at the clinic.
Are there any concerns?
Pregnancies are now routine in cases of poor sperm production, but there is some concern with the use of this sperm because in most cases the underlying condition causing the poor sperm production is still unknown. Therefore, in these cases, it must be realized that the condition which may have caused the infertility, may be transmitted to the progeny.