Sperm retrieval – PESA & TESA

Earlier it was assumed or believed that fertility problems are majorly in women. There were very few cases wherein the cause of the female not being able to get pregnant was the infertility of her male partner. But in past years, our lifestyles have changed drastically. Also, thanks to technological advancements, our knowledge in the field of male infertility have increased. This has thrown light on many male infertility scenarios or problems. 
The fertility of a couple depends upon many factors in both the male and female partner. Among all cases of infertility, approximately 20 percent can be traced to male factors, 40 percent can be traced to female factors, 25 percent can be traced to factors in both the male and female partners, and 15 percent cannot be traced to obvious factors in either partner. 
One of the problems found in males is azoospermia. It is a condition where there is a complete absence of sperm from the fluid ejaculated during orgasm. This can cause male infertility. It is found in 10% of male infertility scenarios.  
Azoospermia can further be categorized into two. One is obstructive azoospermia (OA) and another is non-obstructive azoospermia (NOA). In obstructive azoospermia, sperm is produced in testes but the reproductive ducts are blocked and hence are not ejaculated. In non-obstructive azoospermia, there is no sperm production with normal anatomy. 
Now, there are a number of treatments available for azoospermia including non-surgical, surgical and assisted reproductive technology.

Non-Surgical Treatments Include:

  • Electroejaculation therapy
  • Hormone deficiency treatments
  • Clomiphene Citrate
Surgical Treatments Available Are:
  • Varicocele Ligation
  • Sperm retrieval technique
  • Transurethral Resection of Ejaculatory Duct
Assisted Reproductive Technologies;
When sperm are produced, but in low numbers, IVF or In-Vitro Fertilization along with assisted fertilization method named “ICSI” (Intracytoplasmic Sperm Injection) is used for helping out couples facing problems in achieving pregnancy. Until the mid-1990s, donor sperm was the only treatment available for azoospermia. But now that is not the case. The technology has advanced and there are better treatments available for the same. There is a procedure named TESA which is Testicular Sperm Aspiration which may be offered to collect sperm directly from testis where it is produced and then use the same in IVF treatment.  

Sperm Retrieval:

Before we get into details of sperm retrieval, let us first know what sperm retrieval is. Under normal conditions, the sperms are produced in the testis, stored in the epididymis and travel through the vas deferens to reach the ejaculatory duct. At ejaculatory duct, the semen released by the seminal vesicles takes the sperms to be ejected from the tip of the penis during ejaculation.
This may not be possible with obstructions preventing sperm release that may be caused by injury or infection or the congenital absence of the vas deferens.
Non-obstructive azoospermia is a condition in which the testicles are producing such low numbers of sperm that they don’t reach the vas. Retrograde ejaculation is the condition in which semen enters the bladder instead of emerging through the penis during orgasm.
These conditions can be rectified by simple sperm retrieval during the pathway of sperm ejaculation.
In cases of non-obstructive azoospermia (complete absence of sperm), very small amounts of sperm may be produced and can be collected directly from the testes with a testicular biopsy. This will be sent to the laboratory for analysis as to the possible cause of the problem.
In men with obstructive azoospermia, there is a very high chance of recovering sperm by this method (>90%). In men with non-obstructive azoospermia, the chances of recovering sperm are approximately 40%. If sperm can be retrieved, the pregnancy rate for this treatment is very similar to that of ICSI with ejaculated sperm.

Why is this Performed?

As we all know that infertility is not restricted to females. It can also be from the male partner. Male infertility could be less number of sperms or abnormal sperm functions or blockages or any such similar thing. Also, the reasons for male infertility could be many, from illness, injuries to chronic health problems or lifestyle choices. The good thing is that to a number of male infertility problems, treatments are available. Medical tests are needed to confirm if a man is infertile.
Once the tests have confirmed about male infertility, and also the cause of the same, the required solution can be suggested by a specialist.  In case the sperm is being produced but not being able to eject or maybe in case the sperm count is low sperm retrieval is done. Through this process, one sperm is collected, and the same is used directly to fertilize an egg through treatments like intracytoplasmic sperm injection (ICSI) and in vitro fertilization (IVF).

How is this Performed?

Following are the procedures for sperm retrieval:

PESA (Percutaneous Epididymal Sperm Aspiration)

This is the collection of sperm through a fine needle directly from the epididymis, where sperm is stored, after it is formed in the testes. This treatment is used when there is a blockage in the epididymis. It does not require a surgical incision.  This can be performed under local anesthesia. After the sample has been collected, it is studied and examined under the microscope to confirm if the sperm is present. If this procedure does not produce the desired result, TESA procedure is suggested.

TESA (Testicular Sperm Extraction)

This is the collection of sperm from a biopsy or several biopsies from the testicular tissue after making a small incision in the scrotal skin. This treatment is chosen when either PESA treatment has not been successful or when the sperm count is low in testis and also no sperm can be found in semen. By this way, the few sperms available in testis can be obtained for fertilizing the egg. This procedure too can be performed under local anesthesia. Post-surgery there might be slight pain or discomfort which can be controlled through normal painkillers. 

MESA (Microsurgical Epididymal Sperm Aspiration):

It is a variation of PESA in which the individual epididymal tubes are isolated by incising the scrotal skin, the tissue is observed under the microscope, and the epididymal fluid is aspirated from areas having maximum sperm density. This treatment is used wherein the patient has the condition called obstructive azoospermia. In obstructive azoospermia, sperm is produced in testes but the reproductive ducts are blocked and hence are not ejaculated. 
These are carried out as a day care procedure requiring only a few hours stay in a hospital. It is carried out under local anesthetic that may be combined with a light general anesthetic.
Once the specimen is obtained, it is checked to make sure that sperms are present. The material collected with sperm will be frozen and place in storage for use at a later stage. These specimens are then thawed and used to inject the eggs obtained during IVF treatment using the technique of ICSI. If surgical retrieval of sperm is successful, usually enough sperm is obtained for several cycles of treatment (if required).
Post-retrieval of sperm the same may be frozen and thawed later on. But in most of the cases, fresh testis sperm is preferred over frozen one. When the sperms are frozen, their motility decreases and hence the preference.      
  1. PESA method is low in cost and faster. It can be performed a number of times. It is the non-surgical method and hence risk is minimal.
  2. MESA procedure enables retrieval of a large number of sperms. The chances of performing cryopreservation are good. Reconstruction is possible.
  3. TESA is again low in cost and fast procedure. Post operation discomfort is minimal. 
  1. There is a huge risk of hematoma or spermatocele in PESA.
  2. There is post-operative discomfort in MESA as well as TESA.
  3. TESA procedure too involves risk of hematoma and testicular atrophy.
  4. PESA may lead to fibrosis and obstruction at the site of aspiration.
  5. All surgeries carry a risk of infection.
  6. Some patients may not be able to react well to local anesthesia. 
  7. Bruising is one of the most common risks involved in sperm extraction processes.
  8. The risk of nerve damage is rare but present.
  9. Shrinkage of testicle though rare but can happen. 
After Procedure Precautions
You can get back to work within 4-5 days. It is advised to wear a scrotal support for 48 hours to protect the scrotum and testes. The stitches need not be removed; they will dissolve within 14 days.
You may experience mild discomfort which includes pain, tenderness, infection, and cloudy discharge.
The Timing of Sperm Retrieval:
The timing of the sperm retrieval procedures works parallel with the in vitro fertilization technique. Although determining the exact timing may be a difficult task. There are pros and cons of performing it prior to in vitro fertilization cycle and post in vitro fertilization cycle. Performing both the procedures on the same day becomes difficult because it might not be possible for the couple to arrange all the required resources. Also, the couple may need time to decide if they want to go forward with in vitro fertilization technique or not because the chances of finding the sperm in sperm retrieval techniques are around 60% only. 
Success Rate of Sperm Retrieval Techniques:
All these techniques are new and still evolving hence determination of their success rate is a bit difficult. Yet it can be concluded that the best possible combination is MESA procedure followed by ICSI procedure.
Some treatments for male infertility may fail, and some cases of male infertility simply cannot be treated at this time. If this is the case, an infertility specialist can advise a couple of available alternatives. 
Men with irreversible infertility and testosterone deficiency may find testosterone treatment beneficial. Although it has to be kept in mind that this treatment may not address a couple’s goal of having a child, it can improve the male partner’s sexual function and mood and help increase and maintain bone and muscle mass. 
Q. Why should one choose sperm retrieval technique?
A. In case you are suffering from azoospermia and the same is not letting you have a family of your own then you should definitely opt      for the sperm retrieval techniques.
Q. What are the steps of performing sperm retrieval procedures?
A. The first step is sedation wherein you will be put under local anesthesia. The second step would be the extraction of the sperm and      the way of extraction would vary from one procedure to another.
Q. Is surgical sperm retrieval procedure right for me?
A. In case you have been suffering from blocked vas deferentia or low sperm count or maybe if you have had a vasectomy in the past,     surgical sperm retrieval can prove to be the perfect solution for you.
Q. What is the recovery time post surgery?
A. In the case of PESA, you may be able to resume work on the very same day. If in case TESA or MESA has been performed, a             maximum of a week shall be required for complete recovery.
Q. Do I need to take any precautions after the surgery?
A. Just as a precautionary, do not drive the day you have the surgery. 
Q. What are the possible complications post surgery?
A. The most common ones are infection and hematoma. 
Q. Can bath be taken post surgery?
A. It is imperative not to soak the wound for 7 days. Alternative showering would be a better option. 
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