Breaking Barriers: A Complete Guide to Surgical Sperm Retrieval Procedures
Introduction
In the evolving landscape of fertility treatments, surgical sperm retrieval has emerged as a groundbreaking solution for many couples facing male infertility challenges. These procedures offer hope to men who cannot produce sperm through conventional means, enabling them to father biological children through assisted reproductive technologies. For years, testicular biopsy was the standard of care for males with unexplained infertility and azoospermia. New guidelines for male infertility say that diagnostic testicular biopsy should only be done on men with obstructive azoospermia and normal testes and reproductive hormones. Males with non-obstructive azoospermia now primarily use testicular biopsies to harvest sperm for intracytoplasmic sperm injection. Men at risk for testicular cancer get biopsies. Infertile men with cryptorchidism, testicular cancer, or atrophy are at risk for testicular cThese men are more likely to get carcinoma in situ (CIS) if they have ultrasonographic abnormalities like testicular microlithiasis, inhomogeneous parenchyma, and testicular lesions. ma in situ (CIS). Histological categorization requires accurate tissue handling, fixation, specimen preparation, and assessment. Testicular biopsies should be standardized. Also required is testicular immunohistochemistry for testis CIS detection. In this mini-review, we discuss currently used testicular biopsies for male infertility diagnosis and treatment.
What is surgical sperm retrieval?
Surgical sperm retrieval comprises various specialised procedures designed to extract viable sperm directly from the male reproductive tract. These procedures become necessary in cases of azoospermia (absence of sperm in ejaculate), failed vasectomy reversal, or other conditions affecting sperm production or transport. The original documentation of epididymal sperm extraction for IVF focused on secondary obstructive azoospermia. The authors aspirated sperm from the exposed epididymal ductule using a micropipette. Silber then popularised an open procedure for males with vas aplasia, which involved microsurgical dissection, opening, aspirating, and suturing the epididymal ductule. Instead of microsurgical dissection or suturing, we directly aspirated sperm from the exposed epididymis using a 26-G needle. Shrivastava et al. described a simpler percutaneous aspiration method.
Initially, IVF and ICSI used testicular sperm for obstructive azoospermia. Subsequently, men with testicular failure had numerous open biopsies to find spermatogenesis foci. Several studies have found that performing numerous conventional biopsies can cause harm to the testes. Therefore, Schlegal and Li suggested selective microsamples, utilising magnification to locate favorable seminiferous tubules (microdissection-testicular sperm extraction (TESE), to take comprehensive biopsies without injury. We then proposed a less traumatising method of conducting multiple microbiopsies, which involves puncturing the tunica to take single seminiferous tubule biopsies. Recently, ultrasound has been used to avoid blood vessels during percutaneous treatments and identify regions of enhanced vascularity that may harbor sperm.
Types of Surgical Sperm Retrieval Procedures
Testicular Sperm Aspiration (TESA)
TESA represents the simplest form of surgical sperm retrieval, performed under local anesthesia. The procedure involves directly inserting a fine needle into the testicle to extract tissue containing sperm. This technique proves particularly effective for men with obstructive azoospermia, where sperm production is normal but blocked from reaching the ejaculate. TESA offers minimal recovery time and relatively low risk of complications, though success rates vary depending on the underlying cause of infertility.
Percutaneous Epididymal Sperm Aspiration (PESA)
PESA involves extracting sperm directly from the epididymis using a fine needle. This procedure is particularly suitable for men with obstructive azoospermia due to conditions affecting the vas deferens or epididymis. Local anesthesia can perform PESA, which typically takes less than 30 minutes. While less invasive than some alternatives, its success depends heavily on the presence of normal sperm production.
Microsurgical Epididymal Sperm Aspiration (MESA)
MESA represents a more sophisticated approach, utilising an operating microscope to precisely identify and extract sperm from epididymal tubules. This technique offers superior sperm quality and quantity compared to PESA, making it particularly valuable for couples planning multiple IVF cycles. The procedure requires general anaesthesia and microsurgical expertise but provides higher success rates in appropriate candidates.
Open Testicular Biopsy
This traditional approach involves making a small incision in the testicle to remove tissue samples for sperm extraction. While more invasive than needle aspiration techniques, it allows for better tissue sampling and potentially higher sperm yields. When previous less invasive attempts have failed or when diagnostic information about testicular function is required, the procedure becomes particularly useful. We can use both local and general anaesthesia for testicular biopsy. Day-care surgery at an outpatient clinic is typical. A 2–3 cm scrotal incision can expose the testis tunica albuginea for diagnostic testicular biopsy. We perform a 0.5 cm incision in the testicular capsule to retrieve a 3x3x3 mm biopsy. The excised tissue must have 100 seminiferous tubules to classify spermatogenesis. Forceps can damage testicular tissue architecture and make seminiferous tubule assessment difficult. Absorbable sutures close wounds.
Transcutaneous puncture of the testis with a tru-cut needle or tiny needle aspiration might replace an open diagnostic testicular biopsy. Under local anesthesia, one can perform FNA of the testis outpatiently without the need for surgical equipment or experience. Rammouu-Kinia et al. found an 88.5% association between fine needle biopsies and normal histology across patient categories. FNA may assist in diagnosing minor testicular lesions. However, whether FNA can identify Testis CIS is unknown. Using a tiny butterfly needle and syringe, FNA of the testis can harvest spermatozoa for ICSI, particularly in males with OA. The procedure yielded a lower sperm retrieval rate in men with NOA compared to open biopsy.
Researchers have developed and compared various TESE methods. The microsurgical TESE may have the best sperm retrieval rate and minimse testicular tissue damage. An operational microscope may see spermatozoa in dilated tubules. This approach requires microsurgical expertise and general anaesthesia. This study compares the sperm retrieval rates of standard and microsurgical TESE. Small testes may benefit from microsurgical TESE.
Microsurgical Testicular Sperm Extraction (Micro-TESE)
Micro-TESE represents the most advanced surgical sperm retrieval technique, particularly beneficial for men with non-obstructive azoospermia. Using powerful microscopy, surgeons can identify areas of the testicle that are most likely to contain sperm, maximizing extraction success while minimising tissue damage. This procedure offers the highest success rates for men with severe sperm production problems.
Comparing Surgical Sperm Retrieval Procedures
Each procedure offers distinct advantages and limitations. TESA and PESA provide simpler, less invasive options suitable for obstructive cases. MESA and micro-TESE offer higher success rates but require more extensive surgery. The choice depends on various factors, including the cause of infertility and specific patient characteristics.
Factors Influencing Procedure Choice
Selection criteria include the type and cause of azoospermia, previous fertility treatments, intended use of retrieved sperm, and overall health status. Hormone levels and genetic testing results also play crucial roles in determining the most appropriate procedure. A testicular biopsy seldom causes complications; however, bleeding and infection might occur. Biopsies of tiny, atrophic testicles may raise the incidence of hypogonadism, which necessitates lifelong testosterone replacement. Discuss this worry with the patient beforehand. Small-size testis TESE procedures carry the risk of hypogonadism following testicular biopsy. Ishikawa et al. found that Sertoli cell-only syndrome and Klinefelter enhance hypogonadism risk. Due to LH increase, most patients’ testosterone levels return to pre biopsy levels within a year. Age may cause late-onset hypogonadism in some guys. Patients with NOA should weigh the risk of damage from multiple-sited biopsies against their diagnostic and therapeutic advantages.
Preparing for surgical sperm retrieval
Preparation involves comprehensive medical evaluation, including hormone testing, genetic screening, and detailed discussion of expectations. Patients receive specific instructions regarding medications, fasting requirements, and other pre-operative preparations. A number of systems for categorising spermatogenesis are based on five main histological patterns: (i) absence of seminiferous tubules (tubular sclerosis); (ii) no germ cells in the tubules (Sertoli cell-only syndrome); (iii) incomplete spermatogenesis, not beyond the spermatocyte stage (spermatogenic arrest); and (iv) all germ cell stages present with spermatozoa. Often, these spermatogenesis phases occur together in a biopsy. This causes pathologists to classify spermatogenesis differently, limiting the diagnostic and prognostic utility of testicular biopsy.
Recovery after surgical sperm retrieval
Recovery varies by procedure type, ranging from minimal downtime for TESA to several days for micro-TESE. Most patients experience mild discomfort, which can be managed with over-the-counter pain medication. Typically, patients experience complete healing within 1-2 weeks, during which they should avoid strenuous activity.
Success Rates of Surgical Sperm Retrieval
Success rates vary significantly based on the procedure and underlying condition. Micro-TESE shows the highest success rates (50-60%) for non-obstructive azoospermia, while simpler procedures like PESA achieve better results (80-90%) in obstructive cases.
Cost and Insurance Considerations
Costs vary widely depending on the procedure’s complexity and geographical location. While some insurance plans cover diagnostic procedures, many consider sperm retrieval part of fertility treatment, often requiring out-of-pocket payment.
Emotional and Psychological Considerations
The journey through male infertility and surgical sperm retrieval can be emotionally challenging. Support from healthcare providers, counselors, and support groups has proven invaluable for many couples navigating this process.
Conclusion
Surgical sperm retrieval procedures have revolutionised male infertility treatment, offering hope for many previously untreatable cases. Success depends on careful patient selection, surgical expertise, and comprehensive care planning. We recommend visiting Ovum Fertility for the best possible care and treatment if you are suffering from such an acute problem.
FAQs
1.How long should I wait after my sperm retrieval surgery before attempting to conceive?
Recovery time varies by procedure. Generally, couples can proceed with IVF/ICSI as soon as the patient has fully healed, typically within 2–4 weeks post-surgery. Your doctor will provide specific timing recommendations based on your situation.
2.Can we freeze retrieved sperm for later use?
Indeed, it is possible to successfully freeze (cryopreserve) most retrieved sperm for future use. This is particularly beneficial for couples planning multiple IVF cycles or wanting to preserve fertility options.
3.What determines which sperm retrieval procedure is best for me?
The choice depends on several factors, including the cause of infertility, previous treatment history, hormone levels, and anatomical considerations. Your fertility specialist will recommend the most appropriate procedure based on your specific situation.
4.Are there any long-term effects on testosterone production after these procedures?
When performed correctly by experienced surgeons, these procedures typically don’t affect testosterone production. However, men with pre-existing hormone issues may require ongoing monitoring.
5.What is the success rate of achieving pregnancy using surgically retrieved sperm?
Success rates vary, but generally range from 30–60% per IVF cycle using surgically retrieved sperm. Factors affecting success include female partner age, sperm quality, and the specific assisted reproduction technique used.