Non-surgical sperm recovery: part I.

Abstract

For years, clinical andrology has been a discipline full of tradition and history. In the beginning clinical andrology was mainly the province of endocrinologists who were initiated in the secrets of the hypothalamo–pituitary–gonadal axis of men. Their treatments modulated this endocrinological axis in an attempt to improve spermatogenesis. Then urological surgeons introduced reconstructive surgical techniques. Since the 1980s, gynaecologists and clinical embryologists entered the field. They introduced techniques of assisted reproduction which were more successful than the common empirical treatments (O’Donovan et al., 1993). However, the major breakthrough came only with the introduction of intracytoplasmic sperm injection (ICSI) (Palermo et al., 1992). When injected into a metaphase II oocyte, a spermatozoon was found capable of activating this oocyte without further manipulations. The ease by which human oocytes are fertilized by spermatozoa, even if these spermatozoa are immature, has led to a widespread use of this technique of assisted reproduction. Because of this success, the clinical work-up of the patient with poor sperm quality is becoming more and more endangered (Devroey et al., 1998). A typical attitude, common among many fertility ‘specialists’ nowadays, can be summarized as follows: ‘catch the sperm and inject!’. However, without a proper clinical work-up and approach, an azoospermic man with a Kallman syndrome may one day be scheduled to undergo a testicular biopsy to retrieve sperm for ICSI! A great deal of apprehension exists concerning the safety of ICSI (Cummins and Jequier, 1995). It is the role of the clinical andrologist not only to try to elucidate the pathophysiological mechanisms behind a man’s reproductive failure, but also to formulate the most cost-effective and safest treatment. Only a rigorous clinical work-up may ensure that techniques of assisted reproduction such as ICSI are applied only when strictly indicated and when no alternative treatments are present. The introduction of surgical sperm recovery for ICSI has given the possibility to many sterile men to father children which are genetically their own. However, because of the simplicity of these surgical sperm recovery techniques, there is a tendency to propose ICSI with testicular sperm as a first-line treatment in many patients with ejaculatory disturbances as well. However, the long-term ramifications of using these immature spermatozoa for ICSI (Aslam et al., 1998), means that non-surgical methods are preferable in these patients in order to recover mature spermatozoa. These non-surgical methods are often more cost-effective and although they may not preclude the need for ICSI, they may offer the opportunity to use more mature spermatozoa. There are also other advantages. In patients with anejaculation because of spinal cord injury, ejaculated spermatozoa may be obtained by vibrostimulation or electro-ejaculation. Even if the quality of the semen obtained may be poor and often ICSI still has to be performed, the non-invasive character of these techniques represents a real advantage for these patients. Because of their neuro-vascular impairment, procedures such a testicular biopsy should be avoided as much as possible in order to prevent surgery-related complications. It will become obvious to the reader of this mini-symposium, published in two parts, that nonsurgical sperm recovery is a far neglected, but nevertheless very important area in the field that should be familiar to every clinician involved with clinical andrology.