Treatment of Male Infertility

Surgical Sperm Retrieval (SSR) is a method that is used to try to obtain sperm directly from the testis or the epididymis. It can be used for men where we have been unable to recover sperm from the ejaculate or who have had a failed vasectomy reversal. It may also be suitable for men with spinal injuries and where there are problems with normal ejaculatory function. Following sedation and a local anaesthetic, a fine needle is then used to extract small pieces of tissue directly from the site of sperm production. If sperm is found, it can be frozen for use in an IVF cycle later. Because the number of sperm aspirated is small and the motility is reduced, ICSI (Intra- Cytoplasmic Sperm Injection) is required to achieve fertilization.

Treatment of male infertility

PESA (Percutaneous Epididymal Sperm Extraction)

PESA and TESA are similar procedures where a needle is used to extract sperm from the testicle or epididymis.  The epididymis is an organ that lives behind the testicle and is the location where sperm mature and develop the ability to move.  The epididymis can be enlarged after a vasectomy or in other conditions where there is blockage.  Both of these procedures can often be performed with only mild sedation and local anesthetic.  A needle is inserted into the testicle or epididymis and an attempt is made to collect sperm.  The sample collected is immediately examined under a microscope to look for healthy appearing sperm.  These sperm can be used immediately to fertilize an egg or can be frozen for use at a later time.

These techniques can be used as a first line approach for sperm collection.  Both PESA and TESA are most effective when trying to collect sperm in a man who has undergone a vasectomy and the epididymis is enlarged.  The benefits of this approach are that they are relatively painless and do not require an incision in the scrotum or a general anesthetic.  The risks of the procedure include bleeding, damage to the epididymis and not being able to obtain sufficient sperm.  If these techniques fail, sperm may be found using more advanced methods.

MESA (Microscopic Epididymal Sperm Extraction)

MESA is a technique for collecting sperm that involves using a surgical microscope to open the small tubes within the epididymis to look for sperm.  This technique works well in conditions where sperm are being produced in adequate numbers but are blocked from traveling from the testicle to the ejaculate. Examples of such conditions include: a prior vasectomy, prior hernia repair with mesh, blockage of the seminal vesicles, cystic fibrosis, and immotile cilia syndrome.  This is the favored approach when harvesting sperm after a vasectomy.

An operating microscope and special skills are necessary to identify the tubes most likely to contain sperm and the samples are immediately examined to look for sperm.  Sperm harvested from the epididymis is generally considered better quality than sperm harvested directly from the testicle because they have had more time to mature.

This procedure requires a general or spinal anesthetic and involves an incision in the scrotum to gain access to one or both testicles. The sperm harvested can be used immediately or frozen for use at a later time.  In cases where no sperm are found, it is necessary to look in the testicle for viable sperm, a procedure called TESE or testicular sperm extraction.

TESE (Testicular Sperm Extraction)

TESE is very similar to the MESA procedure.   In a TESE, tissue is taken directly from the testicle and examined for the presence of sperm.  This technique is very successful in cases of obstructive azospermia where there is blockage of the tubes responsible for transporting sperm from the testicle to the ejaculate.  However, TESE can also be very useful in patients with non-obstructive azospermia as well.  There are several genetic, infection related and hormonal conditions that lead to low levels of sperm production that can be uncovered through surgery.

TESE or micro-TESE (performed with a microscope) requires general or spinal anesthesia and an incision on the scrotum to gain access to the testicles.  Depending on the underlying medical condition, the testicle is either incised in several locations to harvest sperm or completely opened to reveal all of the sperm producing cells.  Several samples are taken and immediately examined for the presence of sperm. Any sperm found can be used immediately to fertilize an egg of they can be frozen for later use. The testicle is then repaired and placed back into the scrotum.  The testicle is generally able to function normally after the procedure and continue to produce testosterone.  This procedure has been successful in finding sperm is many conditions thought to result in infertility such as Klinefelter’s syndrome and congenital absence of the vas deferens.

If there is a high degree of uncertainty about whether sperm will be found, a couple undergoing TESE will often be counseled to have the procedure performed before eggs are harvested or to have a donor sperm sample as a back-up.