Sperm Extraction
Sperm Retrieval is required in patients with zero sperms or very low quality sperms in the natural ejaculate. The live sperms obtained via the retrieval can be used for IVF (test tube baby). Even a few sperms or sometimes one sperm can lead to pregnancy via IVF and ICSI. ICSI involves injecting one sperm into one egg (female) to create an embryo, grow it artificially and achieve pregnancy by implanting that embryo in the uterus of the female partner.
The success rate depends on the female partner age and other anatomical and physiological factors in the female partner and the quality of the sperms obtained.
A. N TESE (TESA)
Neddle TESE involves extracting tubules containing sperms using a scalp vein as shown in the image. The needle is inserted t multiple points (4-5) to obtain testicular tissue which is processed to look for viable sperms. The chance of obtaining sperms by this technique varies as per individual patient, as this is a random sampling of the testicular tissue to pick up testicular tissue which may contain sperm.
The advantage is that it is a minimally invasive procedure with minimal trauma to the testis. The tissue can be analyzed to predict the status of spermatogenesis in the testis whether, it is arrested at a particular premature or mature stage or there are a few area of spermatogenesis. Based on this the future changes of being able to obtain live sperms can be defined if one proceeds to extensive microscopic microdissection TESE (Testicular sperm Extraction).
This is a day care procedure and can be performed under local or general anesthesia as per patient and anesthetist preference. The patient can go home the same day and resume work within a couple of days.
B. PESA( Percutaneous Epididymal Sperm Extraction)
In cases where there is block at the level of the epididymis and vas deferens ( sperm carrying tubes) , sperms can be obtained from the epididymis via a fine needle and 1 cc syringe . Due to the block the epididymis can be dilated due to baclpressure and can have a large number of sperms .
In cases of congenital Bilteral absence of vas Deferens (CBAVD) – The sperm carrying tubes are absent since birth , the epidiymis carries sperm and these can be extraxted via PESA and the sperms used for IVF-ICSI to obatin and embryo and subsequent pregnancy . Generally motile sperms are obtained from the epididymis
In case of adhesions and fibrosis around the epididymis open surgical dissection of the epididymis with extraction of sperms by visualisng the tubules under the microscope can be done. (MESA-microsurgical epididymal sperm aspiration)
C. Microdissection TESE
When the Testis size is very small or when the needle extraction fails to find sperms then the last stage is to cut open the testis in 2 halves and inspect under 20-25x magnification to visualise tubules which are dilated and might contain sperm. This is a specialized technique which requires microsurgical skills to inspect all the areas of the testis and a qualified embryologist has to look for sperms within the tubules and use them for IVF.
A thorough search for sperms requires 3-4 hours when both the testis are searched for sperms. Procedure can be done under General or spinal anaesthesia (lower half anaesthetised). Rest for 4 – 5days is required and a tight scrotal underwear has to be worn to maintain compression and to avoid trauma to the testis. Patient can resume heavy regular exercises after 14 days
The chances of sperm retravel as per case will be discussed with you by me depending on the testicular size, hormonal levels and reports of previous biopsy or sperm extraction. They generally range from 25- 50 % . In those whom there are no sperms its generally found that the spermatogenesis is arrested. The development of sperms from the germ cells to the adult mature spermatozoa is arrested throughout at a particular stage. Patients with focal spermatogenesis are the ones where we expect to find sperms.
The Wife has to be prepared simultaneously for egg pick up and then subsequent embryo transfer. This is done in co ordination with a gynaecologist.
D. Single stage sperm Retrieval (Best chance of conception if sperm are found)
Patient is planned for Needle TESE and if sperm are not found, Microdissection Tese is done in the same sitting, as the wife is prepared prior and any sperm found are used for ICSI. In case a homogenous pattern is found in the 1st testis the opposite testis undergoes mapping TESE (pricking testis at multiple points to tease out the better looking tubules to look for sperms). All 3 procedures are performed at once so that the chances of sperm retrieval are best and if sperms are found at any point further extensive dissection is avoided preserving testicular function.
nTESE – Microdissection TESE – Mapping TESE
Complications – sometimes post microdissection TESE the Testosterone levels can fall marginally but they generally recover in a few months time. In patients with already low testosterone levels, the fall might require testosterone therapy for sometime till the testis recovers.
