This article describes sperm retrieval procedures that may be performed in an office setting. Indications for sperm retrieval, preprocedural preparation, and anesthetic considerations are discussed. Vasal sperm aspiration, percutaneous epididymal sperm aspiration, microsurgical epididymal sperm aspiration, testicular sperm aspiration, conventional, and microdissection testicular sperm extraction are reviewed. Success and complication rates as well as factors that may influence success (histopathology, cancerous cause, Klinefelter syndrome, Y microdeletions, varicocele, and hormone administration) are reviewed.
Key points
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Sperm retrieval is indicated in men with obstructive azoospermia, nonobstructive azoospermia, and in some cases of severe oligospermia.
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For analgesia and anesthesia, local anesthetic infiltration, spermatic cord regional block, or conscious sedation may be used for office-based procedures. Proper personnel training and facility accreditation are needed to use conscious sedation.
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Appropriate discussion before any procedure, including possibility of repeat procedures, must be held, and if indicated, referral to genetic counseling should be provided.
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Success rates of different procedures for nonobstructive azoospermia depend on histopathology, cause, and procedural approach.
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Complication rates of sperm retrieval procedures are low, but rare clinically apparent side effects may be seen.
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Sperm cryopreservation capability is an important component of sperm retrieval procedures.
Introduction
Minimally invasive sperm retrieval procedures have become increasingly relevant in the last 2 decades as intracytoplasmic sperm injection (ICSI), a technique allowing conceptions from minimal sperm recovery, has revolutionized success rates of assisted reproductive technology (ART). ICSI was described by Palermo and colleagues in 1992, who reported successful pregnancies in 4 couples with severe male infertility using this technique. The success of ICSI has been shown to be better than conventional in vitro fertilization (IVF) in terms of fertilization rates. Bungum and colleagues studied fertilization rates in couples with unexplained infertility who had failed intrauterine insemination. The fertilization rate after ICSI was significantly higher than conventional IVF, at 68% and 46%, respectively. In a randomized study, fertilization rate per oocyte after IVF was 41%, whereas the rate after ICSI was 50%. Before development of ICSI, infertility caused by certain male factors, such as nonobstructive azoospermia (NOA), was difficult to treat and had low success rates. However, ICSI has the ability to surpass some of the most challenging cases of impaired spermatogenesis.
Along with development of more efficient ways of sperm implantation came the need to retrieve sperm successfully. Advanced, more refined and less invasive sperm retrieval techniques have been developed to provide viable sperm for these difficult cases. Anatomically, the main areas for sperm retrieval are the testis, vas deferens, and epididymis. Choice of target for sperm retrieval depends on the cause of infertility and the likelihood of retrieving viable sperm. For example, the epididymis may be aspirated percutaneously in a man with congenital bilateral absence of vas deferens. Surgical sperm retrieval techniques produce quantities of sperm that are insufficient for intrauterine insemination but may be adequate for multiple trials of ICSI.
For cost-effectiveness and efficiency, office-based procedures are becoming increasingly pertinent. A myriad of surgical techniques to retrieve sperm exist, but not all of them may be used in an office-based setting. Successful office-based procedures require adequate training of surgeons as well as staff. The advantages of performing procedures in an office setting include avoidance of general anesthesia, cost benefit, time efficiency, and quicker patient recovery. The goal of this article is to review office-based sperm retrieval procedures for ART. The indications for sperm retrieval from each anatomic target, preoperative considerations and preparation, surgical details, success rates, factors that play a role in success, and complication rates of each procedure are reviewed.
Introduction
Minimally invasive sperm retrieval procedures have become increasingly relevant in the last 2 decades as intracytoplasmic sperm injection (ICSI), a technique allowing conceptions from minimal sperm recovery, has revolutionized success rates of assisted reproductive technology (ART). ICSI was described by Palermo and colleagues in 1992, who reported successful pregnancies in 4 couples with severe male infertility using this technique. The success of ICSI has been shown to be better than conventional in vitro fertilization (IVF) in terms of fertilization rates. Bungum and colleagues studied fertilization rates in couples with unexplained infertility who had failed intrauterine insemination. The fertilization rate after ICSI was significantly higher than conventional IVF, at 68% and 46%, respectively. In a randomized study, fertilization rate per oocyte after IVF was 41%, whereas the rate after ICSI was 50%. Before development of ICSI, infertility caused by certain male factors, such as nonobstructive azoospermia (NOA), was difficult to treat and had low success rates. However, ICSI has the ability to surpass some of the most challenging cases of impaired spermatogenesis.
Along with development of more efficient ways of sperm implantation came the need to retrieve sperm successfully. Advanced, more refined and less invasive sperm retrieval techniques have been developed to provide viable sperm for these difficult cases. Anatomically, the main areas for sperm retrieval are the testis, vas deferens, and epididymis. Choice of target for sperm retrieval depends on the cause of infertility and the likelihood of retrieving viable sperm. For example, the epididymis may be aspirated percutaneously in a man with congenital bilateral absence of vas deferens. Surgical sperm retrieval techniques produce quantities of sperm that are insufficient for intrauterine insemination but may be adequate for multiple trials of ICSI.
For cost-effectiveness and efficiency, office-based procedures are becoming increasingly pertinent. A myriad of surgical techniques to retrieve sperm exist, but not all of them may be used in an office-based setting. Successful office-based procedures require adequate training of surgeons as well as staff. The advantages of performing procedures in an office setting include avoidance of general anesthesia, cost benefit, time efficiency, and quicker patient recovery. The goal of this article is to review office-based sperm retrieval procedures for ART. The indications for sperm retrieval from each anatomic target, preoperative considerations and preparation, surgical details, success rates, factors that play a role in success, and complication rates of each procedure are reviewed.
Indications for sperm retrieval
Sperm retrieval is often necessary for azoospermia and severe oligospermia with unfavorable viability. Azoospermia is defined as the absence of spermatozoa in the ejaculate, and severe oligospermia is the presence of fewer than 5 million spermatozoa per milliliter of the ejaculate. Azoospermia is classified into obstructive and nonobstructive. Azoospermia is present in 1% of all men, but 15% of infertile men. In 1 study, obstruction caused 40% of azoospermic cases. In obstructive azoospermia (OA), the production of spermatozoa from the testes is normal. However, there is either extrinsic or intrinsic blockage or absence of epididymis, vas deferens, or ejaculatory ducts.
Vasal obstruction may result from previous vasectomy, fibrotic reaction from inguinal hernia repair with mesh, radical prostatectomy, and cystic fibrosis. For men with OA caused by vasal abnormalities, sperm may be retrieved from the vas deferens proximal to the site of obstruction. This procedure is almost always performed in the setting of microsurgical reconstructive surgery, when vasal fluid may be collected and cryopreserved in association with planned vasovasostomy or vasoepididymostomy. Vasal fluid aspiration may rarely be performed as a separate procedure without reconstruction. Vasal sperm have undergone full maturation as they have traveled through the epididymis.
The epididymis is a more common site used for sperm retrieval. Indications include OA caused by congenital bilateral absence of the vas deferens (CBAVD) or vas deferens occlusion in a setting in which patients are not candidates for or do not desire microsurgical reconstruction. Extraction from the epididymis may be performed percutaneously as well as microsurgically.
Indications for testicular sperm retrieval include NOA, OA with failed reconstructive surgery or epididymal aspiration, and in cases of increased sperm DNA fragmentation and previous unsuccessful IVF/ICSI with ejaculated or epididymal sperm. Testicular sperm extraction may be performed percutaneously, open, or microsurgically.
Anesthesia for office-based sperm retrieval
Office-based procedures require adequate training of all involved personnel, as well as preparedness for emergency situations. Local or regional anesthesia, or conscious sedation, may be used in an office setting. Percutaneous procedures may require only local or regional anesthesia, whereas multifocal, bilateral, or open procedures may need conscious sedation. Patient and physician preference influence final choice of anesthetic.
Local anesthesia involves injecting the skin and subcutaneous tissue with anesthetic medications. It is easy to use, avoids side effects of general anesthesia, and provides adequate local analgesia. Local anesthetics block sodium channels to inhibit the action potential of a neuronal impulse. They can be divided into amide and ester classes. The most commonly used amide is lidocaine, whereas a commonly used ester is tetracaine. If a patient is allergic to lidocaine, an ester class analgesic may be used. Different concentrations of these medications exist, and the lowest concentration needed to provide adequate analgesia should be used. Side effects are a result of intravascular injection and high dose, and include tinnitus, perioral numbness, confusion, seizures, and even cardiovascular collapse.
A spermatic cord block provides regional anesthesia. The block is made by holding the spermatic cord between the thumb and the index finger at the inguinoscrotal junction and injecting 0.5% to 1% lidocaine at 3 different angles around the cord. In addition to a cord block, one must inject the skin at the incision site, because scrotal skin is supplied by pudendal nerve and a perineal branch of the posterior cutaneous nerve of the thigh, which are not blocked by the cord block.
Use of conscious sedation in an office setting requires that the facility be accredited by the Joint Commission, Accreditation Association for Ambulatory Health Care, or the American Association for Accreditation of Ambulatory Surgical Facilities. It also requires appropriate staff training, airway management capability, emergency transfer protocol, and appropriate postprocedural monitoring as well as detailed discharge policies.
Preprocedural preparation
Before making decisions about the type of procedure for sperm retrieval, it is of the utmost importance to discuss success rates of planned procedure and possible need for additional procedures. In addition, there should be a detailed discussion of possible procedural side effects, including a small risk of clinically apparent hematoma, possibility of changes in testicular volume with a chance of resultant hypogonadism from testicular procedures, infections, hydrocele, and postoperative pain. In addition, the risk of chromosomal abnormalities in offspring from assisted reproductive procedures should be discussed, and if appropriate, genetic counseling should be offered. Any antiplatelet medication should be discontinued 1 week before procedure, unless the risk of discontinuation is exceedingly high. The patient should be advised to abstain from sexual activity for 2 to 3 days to maximize epididymal sperm content. It is advisable to have an accompanying driver on the day of surgery. Close coordination with the andrology laboratory is required both for immediate cryopreservation, and if the specimen is to be used immediately for IVF.
Office-based sperm retrieval procedures
Vasal Sperm Aspiration
For all office-based surgeries described later, it is important to provide adequate anesthesia so that the surgical field is stable without any unintended patient movements. For this reason, extensive microdissection procedures are often performed under general anesthesia. Aspiration of vasal fluid is usually performed at the time of microscopic reconstruction (ie, vasovasotomy, vasoepididymostomy), which requires general anesthesia. On rare occasions, vasal fluid may be aspirated without reconstruction; however, this may complicate future reconstructive surgeries.
After administration of adequate anesthesia, the surgical field is prepared and draped in a sterile fashion. A 1.5-cm skin incision is made along the spermatic cord proximal to the area of vasal obstruction. The dartos fascia is divided with electrocautery and the spermatic cord is identified. The vas deferens is dissected free of surrounding tissues. The vas is partially incised perpendicular to its axis with a Beaver blade down to the lumen and the vasal exudate is collected in the appropriate media by aspiration ( Fig. 1 ). Vasal fluid is examined under the microscope before cryopreservation. The vasal edges may be reapproximated with fine interrupted sutures such as 8-0 or 9-0 nylon. The vas is returned to its correct anatomic position. Dartos fascia and skin are closed with 4-0 chromic suture.
Percutaneous Epididymal Sperm Aspiration
Spermatic cord block and local infiltration of analgesic medication, or local anesthesia alone, may be sufficient for percutaneous epididymal sperm aspiration (PESA). If needed, an anxiolytic or conscious sedation may be given. PESA is used for men with OA who make a sufficient quantity of sperm and are likely to have an adequate number of sperm in the epididymis. The testis and epididymis are stabilized by 1 hand, and a 23-gauge needle is inserted into the caput or dilated portion of the epididymis with the dominant hand. Negative pressure up to 60 mL is applied, and aspirate is collected ( Fig. 2 ). The aspirate is assessed for presence of sperm, and if needed, the procedure may be repeated on the contralateral side.
Microsurgical Epididymal Sperm Aspiration
Microsurgical epididymal sperm aspiration (MESA) allows direct magnified visualization of the epididymal tubules in an open setting. This procedure allows selection of the most optimal appearing tubules with the highest expected probability of containing sperm. Regional anesthesia and conscious sedation may be used for this procedure if performed in an office setting. It is also appropriate to perform this procedure under general anesthesia in the operating room. After preparing and draping, a 1.5-cm incision is made in the cranial part of a hemiscrotum. The dartos fascia is divided with electrocautery to assure adequate hemostasis. Testicles and epididymis are reached, and the parietal layer of the tunica vaginalis is divided to bring epididymis into the field. After opening the epididymis, the operating microscope with 20 to 25 optical magnification is brought into the field. A loop of epididymal tubule that appears dilated and opalescent is targeted, isolated, and opened. Epididymal fluid is aspirated, examined, and collected ( Fig. 3 ). The epididymal tubule and tunica are closed with fine suture before closure of the more superficial layers. The surgery may be repeated on the contralateral side if inadequate sperm are found on 1 side.
Testicular Sperm Aspiration
Testicular sperm aspiration (TESA) may be performed with a fine needle (20–23 gauge), large needle (18–20 gauge), or cutting biopsy needle (14–18 gauge). For fine-needle aspiration biopsy (FNAB) and large-needle aspiration biopsy (LNAB), spermatic cord block and local anesthesia or local anesthesia alone are adequate. However, conscious sedation with local anesthesia or cord block is preferred for large-needle cutting biopsy. The testicle is fixed against the scrotal skin and held by the nondominant hand. For FNAB, a 20-gauge to 23-gauge needle is inserted percutaneously into the testicle and negative pressure applied to aspirate and collect sperm. The procedure may be repeated at a different location in the testicle or in the contralateral testicle. For testicular mapping, the upper, mid, and lower poles are sampled several times to assess which area has the best probability of finding viable sperm. The only difference in an LNAB is the use of an 18-gauge to 20-gauge needle. For a cutting biopsy, a biopsy gun with a 14-gauge to 18-gauge needle is used to sample a larger area of the testicle ( Fig. 4 ).
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