Surgicalprocedures of sperm retrieval in azoospermia Approachtowards treatment of male infertility was revolutionised by the introduction ofnovel method of ICSI in  1992 . (1 2).

The use of surgical sperm retrieval from thetestis or epididymis associated to ICSI has given the chance for azoospermicpatients of fathering their own genetic children.  Asingle embryo can be injected intoan oocyte which resulted in normal fertilization, embryonic development and implantation.source of sperm can be preferentially by ejaculation or from epididymis ortestis in azoospermic males irrespective of obstructive or non obstructive aetiology.This process opened up an unique opportunity for azoospermic male for asuccessful parenthood putting an end for their never ending agony of beingchildless for the rest of their life.

Surgical sperm recovery for ICSI hasbecome an indispensable part of clinical andrology. Spermscan still be retrieved in some cases of non obstructive azoospermia as thetestis persists to possess some isolated foci of active spermatogenesis. Pregnanciesresulting from surgically retrieved sperms were first published by 1993 and 1995(3-4). Anejaculationand azoospermia- A clinical dilemma.

Successfulpregnancy is plausible only when intravaginal ejaculation is successful.Primarily this is possible by an intact ejaculatory mechanism which is a  neurologic reflex arc  which can bedisrupted through any type of trauma or disease causing damage to the CNSand/or peripheral nerves. Ejaculation may be psychogenic or may result from spinalcord injury or retroperitoneal lymph node dissection. These include 95% ofaetiology followed by diabetic neuropathy , multiple sclerosis, Parkinsondisease, bladder neck surgeries are less encountered causes.Ocassionally drugssuch as antidepressants ,antipsychotics and antihypertensive may causeanejaculation. Since the outcome of medical treatment for anejaculation isguarded penile vibratory stimulation or electroejaculation is considered thefirst line management than offering surgical sperm retrieval since they are non-invasiveand does not require anaesthesia and they are successful ion 80% of the time 5.often epidydimal ortesticular sperm retrieval are offered initially as facilities of EVS or EJ maynot be available at all centres . Scrotal hematoma and risk of iatrogenic epidydimalobstruction may preclude surgical sperm retrieval being offered as the firstline and should only be indicated when first line non-invasive management fail.

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It is reasonably good to refer anejaculatory patients especially with spinal cord injuries to tertiary care centreswhere assisted ejaculation and semen cryopreservation facilities are present.Surgicalsperm retrieval may be a treatment option for men with:AbsoluteIndication:1.     An obstruction preventing spermrelease, due to injury or infection.

2.     Congenital absence of the vas deferens 3.     Vasectomy4.     Non-obstructive azoospermia – thetesticles are producing such low numbers of sperm that they don’t reach thevas.Relative indictions: 1.

     Sperms with increased DFI (DNAfragmentation Index).2.     Severe Oligoasthenoteratozoospermia(SOAT)3.     Intractable Leucocytospermia. In the first three conditions, sperm are  produced by the testes, but are unable to beejaculated primarily due to obstruction of transport  or congenital absence of the vasdeference.They  can still ejaculate seminal fluidbut this fluid will not contain any sperm. It is possible to collect spermdirectly from the epididymis.

most azoospermic patients suffer from primarytesticular ailure(60%).because these subset of patients do not show any clinicalsigns of obstruction and they are often referred to as non obstructiveazoospermia NOA. However in few cases of azoospermia ensues due to hypogonadotropichypogonadism and not due to obstruction.

These patients have an earlymaturation arrest in spermatogenesis and adequate treatment with FSH and humanchorionic gonadotrophins might restore spermatogenesis.Different types of SSR1.     Percutaneous epididymal spermaspiration (PESA).2.     Microsurgical epididymal spermaspiration (MESA).3.

     Testicular sperm aspiration (TESA).4.     Testicular sperm extraction (TESE) -single or multi-site.5.     Microscope-assisted testicular spermextraction (MicroTESE).

All theseprocedures can be safely  performed  as an outpatient basis with effectivepreparation by local anesthesia or under general anesthesia. Preoperative assessment.Pre-operative evaluation consists of recording   thepatient’s health and social history, conducting a physical examination,developing a plan of anesthesia care and developing a safe plan for dischargeto home from the practice after recovery from the procedure.1.

Percutaneous approaches-(PESA / TESA).Advantages1.Minimal training2.

No need for microscopic instruments3.Percutaneous route more approachable4.No need for sedation.5.

Lower complication rate  Disadvantages 1.    Low yield of sperm retrieved compared with openapproaches. 1. Percutaneous epididymal spermaspiration (PESA)PESA is a needle aspirate of the head of theepididymis for attempted retrieval of more mature, motile sperm. Glina andcolleagues reported a sperm retrieval rate of 82% patients who underwent PESA,while no complications were reported 6, whilethe  complication rate of PESA was 3.

4%and included pain, hydrocele, infection, and swelling.(7)   Technique: Under local anaesthesiascrotum is initially painted with antibiotic solution followed by repeatpainting with normal saline to remove any residual antibiotic solution. Ondependant hand supports the testis and the head of the epididymis is palpatedand stabilised with thumb and forefinger. Aspiration of epididymis is performed with a 27. G needlemounted with tuberculin syringe containing culture medium.

With the needle stillwithin the epididymis the syringe is advanced in different direction whilemaintaining continuous suction. The needle is gently withdrawn from theepididymis while the suction is released. The aspirate is then emptied into thedish containing the sperm wash media to be examined under microscope for thepresence of any sperms which can be eventually cryopreserved for future useduring an ICSI. A repeat attempt at an aspiate is made in case of negativeaspiration but at a different location along the epididymal head and repeatedon the contralateral testis. Since this is a blind procedure sometimes severalattempts are required before good quality sperm are found.  Advantages Disadvantages ·       Fast and low cost. ·       Minimal morbidity, repeatable.

·       No microsurgical expertise required. ·       Few instruments and materials. ·       No open surgical exploration. ·       Few sperm retrieved. ·       Limited number of sperm for cryopreservation. ·       Fibrosis and obstruction at the aspiration site. ·       Risk of hematoma/spermatocele .  Percutaneousepididymal sperm aspiration (PESA) Testicular sperm aspirationTESA is a needle aspirate of seminiferous tubulesmost often containing only non-motile or immature sperm first described in Israel by Lewin andcolleagues in 1996 ( 8 ) .

It can be considered “therapeutic” for cases of electivecryopreservation of retrieved sperms or can be coordinated and concurrent with theirfemale partner’s egg retrieval for ICSI. Occasionally, TESA doesn’t provideenough tissue/sperm and an open testis biopsy is needed. TESA is also of “diagnostic”utility when the diagnosis of azoospermia is not certain of obstructive or non- obstructive aetiology anda focussed counselling and plan  oftreatment can be laid down for subsequent sperm retrieval. Jensen et al. reported a spermretrieval rate of 100% in OA, with a complication rate of 3% ( 9)Technique: Under spermatic cord block of short generalanesthesia scrotum is initially painted with antibiotic solution followed byrepeat painting with normal saline to remove any residual antibiotic solution.Testicularsperm aspiration can be done either by 18G butterfly needle attached to a 20 mlsyringe  containing 1 ml of culture media. Multi-quadrant testicular tissue aspiration can be done by applyingcontinuous suction and aspirating the testicular fluid and tissue. The aspirated tissue is thenprocessed in the embryology laboratory and the sperm cells extracted are usedfor ICSI.

The aspirated tissue is then processed in the embryology laboratoryand the sperm cells extracted are used for ICSI or cryopreservation.In case ofsample collection stress syndromes or anejacualtion TESA is a quick way forsperm retrieval in cases of known spermatogenesis on the day of oocyteretrieval. Testicular sperm aspiration  Advantages Disadvantages ·       Fast and low cost. ·       Minimal morbidity, repeatable. ·       No microsurgical expertise required. ·        Few instruments and materials. ·       No open surgical exploration. ·       blind procedure ·       damage to tunical blood vessel and hematocele formation.

·       Few sperm retrieved. ·       Limited number of sperm for cryopreservation. ·       Fibrosis and obstruction at the aspiration site. ·       Risk of hematoma/spermatocele .  Percutaneousvasal sperm aspiration (PVSA) Not very popular amongreproductive endocrinologist is most widely utilised among cases of obstructivelesions of vas deference resulting from herniorrhaphyp surgery , vasectomy orejaculatory duct obstruction.

Because it is not widely performed, a standard technique ofPVSA is relatively unknown. First described by Qiu and colleagues(10) The vas deferens was held between the surgeon’s thumb andforefinger and fixed under the scrotal skin or exposed by a paramedian incision. The  vas deferens is then cannulated by by using a 21-gauge sharp needle, and a23-gauge blunt tip needle with a central hole and a side hole was introducedthrough the sharp needle in the direction of the epididymis. The blunt-tippedneedle was connected to a 10-mL syringe with 1.0 mL of sperm culture.

Alternativelyvasotomy or partial vasectomy can be performed for successful cannulation. Thesperm preparation medium was pushed into the vas deferens approximately 0.2 to0.3 mL, suction was applied to the syringe, and the needle was withdrawn graduallyto a point at which segments of fluid from the vas entered the spermpreparation medium (i.e., the fluid became turbid). A small drop of fluid wassmeared onto a slide, and routine semen analysis was performed immediately.  Open surgical approaches to surgical sperm retrieval .

Microsurgicalepididymal sperm aspiration (MESA)First reported by Temple-Smith et al , MESA was an endeavour atretrieving more quality sperms in consideration against testicular sperms. Thiswas conclusively proved by major studies which resulted in superior outcomes inICSI with epidydimal sperms against testicular sperms (11)  Several differenttechniques for MESA that have been reported in literature (12,13 14). Extracting sperm from their storage sitein the epididymis is an excellent way of getting sperm to use for IVF inpatients with a blockage in the reproductive tract.Under spinal anesthesia witha median incision healthier testicle is delivered out while  testis and epididymis is exposed. With the useof operating microscope and under magnification epididymotomy is performed ,identifiying a suitable dialated epididymal tubule for sperm aspirationpreferably at distal end of epiidymis where the sperms have completedmaturation process and have acquired motility while their transport as a partof normal sperm development. More frequently multiple foci aspiration may benecessary to evaluate before motile sperm are identified.   Microsurgicalepididymal sperm aspiration (MESA)     TESE (Testicular sperm extraction) Most popular method of SSR is TESE.

Because theprocedure is identical to a testicular biopsy as it does not use operativemicroscope and requires extensive microsurgical training.approximately, 1% of all men and 10%of all male infertility men are because of NOA, as the result of testicularfailur14.  TESE combined withICSI is the first-line treatment in NOA patients. It may distinguish between OA and NOA, extract substantialsperm for cryopreservation, while it supersedes testicular biopsy and the obtainedtissue can be subjected to histopathology examination contingent upon negative SSR. Using TESE-ICSI,sperm retrieval leading to pregnancy and the delivery of healthy children ispossible for men with long-standing azoospermia after chemotherapy. Testicularspermatozoa can be retrieved in some NOA males because of the existence ofisolated foci of active spermatogenesis with a retrieval rate approaching 50%. TESE involves making a small incision in the testis andexamining the tubules for the presence of sperm. It is either done as ascheduled procedure or is coordinated with their female partner’s eggretrieval.

TESE is usually performed in the operating room with sedation, butcan be performed in the office with local anesthesia alone. The retrieved tissue is thenfinely minced with iris scissors within approximately 1 mL of sperm wash mediumin a glass petri dish, and a small drop is placed on a slide for evaluation bythe embryology staff. Hemostasis is achieved through bipolar electrocautery,and the incision in the tunica albuginea is closed with the pre-placed suturein running fashion. Multiple biopsy sites are often not necessary. The most appropriate number of biopsies to beperformed still remains controversial. To increase the chance of finding afocus of sperm production, it is advisable to take multiple samples fromdifferent sites of the testis.

In addition, it has been reported that thenumber of biopsies required is significantly higher in MA and SCO cases,compared with hypospermatogenesis patterns, The tunica vaginalis, dartos fascia, and skin areclosed in running fashion with 3-0 chromic. The most appropriate number of biopsies to be performed stillremains controversial. To increase the chance of finding a focus of spermproduction, it is advisable to take multiple samples from different sites ofthe testis. In addition, it has been reported that the number of biopsiesrequired is significantly higher in MA and SCO cases, compared with hypospermatogenesis patterns ( 15 )  Testicular sperm extraction  Microdissection TESE (microTESE) Microdissectiontechnique was originally described in 1999 ( 16).

MicroTESE is a procedure performedfor men who have a sperm production problem and are azoospermic. MicroTESE isperformed in the operating room with general anaesthesia under the operatingmicroscope. MicroTESE is carefully coordinated with the female partner’s eggretrieval, and is performed the day before egg retrieval. This allows for eachpartner to be there for the other’s procedure. Patients frequently have donorsperm backup in case sperm are not found in the male partner.

MicroTESE hassignificantly improved sperm retrieval rates in azoospermic men, and is a saferprocedure since less testicular tissue is removed. Patients cryopreserve spermduring this procedure for future IVF/ICSI. Conventionaltesticular sperm extraction (c-TESE) in patients with NOA has been partiallyreplaced by micro-TESE. It is still under debate the problem regarding thehigher costs related to micro-TESE when compared with c-TESE. Underanaesthesia testis is opened widely in an equatorial plane along the midportion. This allows wide exposure of seminiferous tubules in a physiologicalapproach that follows intratesticular blood flow.

Due to the heterogeneity ofsperm production in the testicle, microdissection must permit examination ofall seminiferous tubules. Use of the operating microscope with magnificationallows identification of the seminiferous tubules that are most likely tocontain sperm. If sperm production is present within a seminiferous tubule,then the tubule appears larger and more opaque . Targeting the largertubules, improves the yield of sperm retrieval and limits the amount oftesticular tissue that needs to be removed. A comparative study including 116 men found a significantlyhigher SRR with micro-TESE 47% vs.

 30% in conventional TESE (17) .         Microdissection TESE (microTESE)Minimal testicular damage is the rulesince only seminiferous tubules are evaluate and thereby increasing chances ofsuccessful sperm retrieval as wide area of testis is examined undermagnification. Though only a small amount of tissue is removed, the largetunical incision and the dissection of the testicular tissue can cause devascularizationand fibrosis of the testis.  Comparison of conventional (c) andmicrodissection (m) testicular sperm extraction (TESE) sperm retrieval rates(SRR) ( 18 )  Single seminiferoustubule – biopsy  Open conventional biopsy versusmicrosurgical biopsy techniquesIf a single biopsy shows spermthen the method of biopsy does not make a difference. However, in men withtesticular failure, in whom multiple biopsies have to be done, microsurgicalbiopsy techniques – which minimize testicular damage while allowing extensivesampling – are preferred to the conventional open testicular biopsy.  Percutaneous versus opentesticular biopsyThe percutaneous  technique gives adequate tissue in most casesand is psychologically more acceptable to patients. The open methods (microdissectionand SST) allow for extensive sampling and give the best chances of spermrecovery, especially when the testis is small and fibrotic.  Prognostic factors for sperm retrieval in non-obstructiveazoospermia Tough surgical sperm retrieval is practised extensivelystill clinicians are unable to predict the percentage chances of successfulsperm recovery as there is still paucity of data derived from  clinical and laboratory prognostic factors.

No reliable positive prognostic factorsguarantee sperm recovery for patients with non-obstructive azoospermia. Theonly negative prognostic factor is the presence of AZFa and AZFb microdeletions ( 19 20 ). 1.       ROC curves forinhibin B, FSH, and inhibin B/FSH. The table reflects the area under the curve,the optimal cut-off point, the sensitivity and specificity of each of theparameters  For non-obstructive azoospermia, thesethree prognostic factors are typically considered alone or combined withendocrinologic data. No parameters can reliablypredict whether sperm will be found on TESE. Sperm may be found in men withvery small testesand high FSH levels, irrespective of the general histologicalpattern. 1.

   Sperm retrievalrate in azoospermic patients with genetic alterations   2.       Sperm retrievalrate in azoospermic patients with genetic alterations  3.Sperm retrieval rate in patients with nonobstructiveazoospermia depending on testicular size   Theuse of surgical sperm retrieval from the testis or epididymis associated toICSI has given the chance for azoospermic patients of fathering their owngenetic children.

NOA subjects may retrieve spermatozoa through TESE, givingthe chance for an assisted reproductive technology process.  The spermretrieval rate in OA patients is about 100%. In NOA, the most frequentlyreported sperm retrieval rate is about 50% . References 1,Palermo G1, Joris H, Devroey P, Van Steirteghem AC, Pregnancies after intracytoplasmic injection of single spermatozoon intoan oocyte. Lancet. 1992 Jul 4 ; 340(8810):17-8. 2. Van Steirteghem AC1, Nagy Z, Joris H, Liu J, Staessen C, Smitz J, Wisanto A, Devroey P.

High fertilization and implantation rates after intracytoplasmicsperm injection. Hum Reprod. 1993 Jul;8(7):1061-6. 3. Craft I, Bennett V, Nicholson N. Fertilising ability of testicular spermatozoa.Lancet. 1993 Oct 2;342(8875):864.

 4. Devroey P1, Liu J, Nagy Z, Goossens A, Tournaye H, Camus M, Van Steirteghem A, Silber S.Pregnancies after testicular sperm extractionand intracytoplasmic sperm injection in non-obstructive azoospermia.Hum Reprod. 1995 Jun;10(6):1457-60. 5 . Brackett NL1, Ibrahim E, Iremashvili V, Aballa TC, Lynne CM. Treatment for ejaculatory dysfunction in men with spinal cord injury:an 18-year single center experience.

J Urol. 2010 Jun;183(6):2304-8.  6. Glina S,Fragoso JB, Martins FG, et al. Percutaneousepididymal sperm aspiration (PESA) in men with obstructive azoospermia. Int Braz J Urol 2003;29:141-5 7. Esteves SC, LeeW, Benjamin DJ, et al. Reproductive potential of menwith obstructive azoospermia undergoing percutaneous sperm retrieval andintracytoplasmic sperm injection according to the cause of obstruction.

 J Urol 2013;189:232-7. 8.  Lewin A, Weiss DB,Friedler S, et al.

 Delivery followingintracytoplasmic injection of mature sperm cells recovered by testicular fineneedle aspiration in a case of hypergonadotropic azoospermia due to maturationarrest. HumReprod 1996;11:769-71.  9. JensenCF, Ohl DA, Hiner MR, et al. Multiple needle-passpercutaneous testicular sperm aspiration as first-line treatment in azoospermicmen. Andrology 2016;4:257-62. 10.

Qiu Y, Wang S, Yang D, et al. Percutaneousvasal sperm aspiration and intrauterine insemination in the treatment ofobstructive azoospermia. Fertil Steril 1997;68:1135-8.  11. Van Wely M, Barbey N, Meissner A, et al.

 Live birth rates after MESA or TESE in men with obstructiveazoospermia: is there a difference? HumReprod 2015;30:761-6. 12. Bernie AM, Ramasamy R, Stember DS, et al. Microsurgical epididymal sperm aspiration: indications,techniques and outcomes. Asian J Androl 2013;15:40-3. 13. Goldstein M, Tanrikut C.

 Microsurgicalmanagement of male infertility. Nat ClinPract Urol2006;3:381-91. 14. Palermo GD1, Schlegel PN, HariprashadJJ, Ergün B, Mielnik A, Zaninovic N, Veeck LL, Rosenwaks Z.

Fertilization and pregnancy outcome with intracytoplasmic sperm injection forazoospermic men. Hum Reprod. 1999 Mar;14(3):741-8. 15.  Tournaye H1, Liu J, Nagy PZ, Camus M, Goossens A, Silber S, Van Steirteghem AC, Devroey P.

Correlationbetween testicular histology and outcome after intracytoplasmic sperm injectionusing testicular spermatozoa. Hum Reprod. 1996 Jan;11(1):127-32.  16. Schlegel PN. Testicular sperm extraction: microdissectionimproves sperm yield with minimal tissue excision.

 Hum Reprod. 1999;14:131–5. 17. Amer M, Haggar SE, Moustafa T, Abd El-Naser T, Zohdy W.

Testicular sperm extraction: impact of testicular histology on outcome, numberof biopsies to be performed and optimal time for repetition. Hum Reprod. 1999;14:3030–4 18.

Saccà,A.; Pastore, A. L.; Roscigno, M.; Naspro, R.; Pellucchi, F.; Fuschi, A Conventionaltesticular sperm extraction (TESE) and non-obstructive azoospermia: is therestill a chance in the era of microdissection TESE? Results from a singlenon-academic community hospital. Andrology.

 2016May;4(3):425-9. 19. Bonarriba CR1, Burgués JP, Vidaña V, Ruiz X, Pizá P. Predictive factors of successful sperm retrieval inazoospermia.

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