Treating Azoospermia with Sperm Aspiration Procedures
Sperm aspiration is reserved for men who have the most severe types of male infertility including no sperm in their ejaculate (azoospermia) or sperm that are not motile or are dead (necrospermia). There are two main reasons why sperm may be absent from the semen (necessitating sperm aspiration).
Obstructive azoospermia is the result of a blockage in the male reproductive tract. Sperm production in the testicle is normal but the sperm are trapped inside the epididymis.
Non-obstructive azoospermia is the result of severely impaired or non-existent sperm production. It is precisely these situations that require advanced reproduction technologies such as ICSI to establish a pregnancy. Four different techniques can be used in sperm harvesting and each has a different name and acronym.
The procedures have clear-cut advantages and drawbacks, and not all are applicable to every situation. Dr. Werthman will need to have a thorough knowledge and understanding of the cause of your infertility prior to recommending and performing any particular procedure.
Surgical Techniques for Obstructive Azoospermia
MESA: Micro-surgical Epididymal Sperm Aspiration
MESA, or Microsurgical Epididymal Sperm Aspiration, is an optimal way of obtaining sperm in men with a reproductive tract blockage (i.e., after a vasectomy, or in the congenital absence of the vas deferens). In this procedure, Dr. Werthman will extract sperm from their storage site in the epididymis with the aid of a surgical microscope.
This is a relatively painless and minimally invasive procedure performed in our office under local anesthesia. MESA allows for the recovery of the best quality and highest quantity of sperm compared with the other techniques. It is also the safest procedure, and in our experience produces the least amount of complications, discomfort and swelling.
Each step of the procedure is clearly visualized under the microscope and the testicle itself is not entered. Any bleeding can be quickly halted. Most patients recover from MESA withinone1 day and can return to work and daily activities. The disadvantage of MESA is mainly the relative unavailability.
MESA is usually offered only at centers specializing in the treatment of male infertility because of the need for specialized equipment, an operating suite and a trained infertility microsurgeon. MESA is more cost effective than other techniques because it is usually a one-time expense whereas the other sperm retrieval techniques may need to be repeated multiple times.Click Here to Learn More About MESA
PESA: Percutaneous Epididymal Sperm Aspiration
PESA, or Percutaneous Epididymal Sperm Aspiration is less expensive than MESA, but it is also less effective. During this procedure, a needle is placed into the epididymis with the hope that a pocket o sperm will be found and aspirated. While PESA is conceptually appealing, very few sperm are actually collected for use and rarely are enough sperm obtained for freezing. In our experience, frequently a second type of procedure had to be performed to save the IVF cycle because PESA failed to yield usable sperm.
PESA is a blind procedure in that the surgeon cannot see where he is placing the needle. When a blood vessel is accidentally hit, it will continue to bleed and result in a collection called a hematoma. Male infertility experts rarely recommend PESA because of poorer results and a higher rate of complications.
Surgical Techniques for Non-Obstructive Azoospermia
Sperm are rarely present in the epididymal tissue of patients who have non-obstructive azoospermia. Therefore epididymal procedures such as MESA or PESA are inappropriate for retrieving sperm from these men. Micro-TESE or micro-surgical testicular sperm extraction is the optimal technique for obtaining sperm in this situation.
Men who produce very few sperm may need to have multiple areas of the testicle sampled before enough usable sperm are found. Needle biopsy does not yield as much tissue as Micro-TESE and therefore yields fewer sperm as well. Micro-TESE should be performed before canceling an IVF cycle if no sperm are found on a needle biopsy.
Micro-TESE: Microsurgical Testicular Sperm Extraction
If viable sperm cannot be found in the epididymis, Dr. Werthman may recommend harvesting sperm directly from the testicles in an effort to find viable sperm. Even men with very poor sperm production generally have areas in the testicles in which viable sperm are being produced; the challenge is in finding those pockets. With this micro-surgical procedure, Dr. Werthman can observe the interior of the testicle and select the best candidate areas to examine for sperm production.
Once a section is identified, Dr. Werthman will remove a small piece of testicular tissue. The tissue is placed in culture media, and exhaustively examined to find sperm that can be used for ICSI.Click Here to Learn More About Micro-TESE
Testicular Mapping: A technique to be avoided
A treatment approach called testicular mapping, was developed to allow the surgeon to blindly test multiple areas of the testicle for sperm. In this procedure, the doctor uses a fine needle to aspirate and sample multiple areas of the testicle. A grid with 9-12 sections is drawn over the testicle and a needle is blindly inserted into each area to remove (aspirate) a small section of the tubules and sample them for sperm. Too few sperm are found with this technique to use with IVF or freeze for the future because the fine needle can only remove a miniscule amount of tissue in the aspirate.
This means that once sperm are located and the map is created, another microsurgical procedure (microTESE) needs to be performed to find those tubules that have sperm and remove them to have enough sperm to use for IVF or to freeze.
In short, men who submit to testicular mapping will (at best) find an area or areas of their testicles that are actually producing sperm. They will need to undergo a second surgical procedure on their testicles in order to actually put any of that sperm to use in an IVF cycle.
Dr. Werthman strongly recommends against using testicular mapping as an unnecessary, painful and potentially dangerous procedure.Click Here to Learn More About Testicular Mapping
Sperm Aspiration is very successful when the proper technique is used
Sperm aspiration (when performed using the appropriate technique) is usually a very successful, minimally invasive procedure that allows even men who make very few sperm to conceive a child of their own.
Our goal at the Center for Male Reproductive Medicine in Los Angeles is to provide the safest, most effective patient care and to collect as much good quality sperm as possible to minimize the need for future multiple surgeries.
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