Sperm Retrieval Techniques Research Articles

A step-by-step guide to office-based sperm retrieval for obstructive azoospermia.

A variety of surgical options exists for sperm retrieval in the setting of obstructive azoospermia (OA). With appropriate preparation, the majority of these techniques can safely be performed in the office with local anesthesia and with or without monitored anesthesia care (MAC). The available techniques include percutaneous options such as percutaneous epididymal sperm aspiration (PESA) and testicular sperm aspiration (TESA), as well as open techniques that include testicular sperm extraction (TESE) and microsurgical epididymal sperm aspiration (MESA). In addition to providing a step-by-step description of each available approach, we introduce and describe a new technique for sperm retrieval for OA called minimally invasive epididymal sperm aspiration (MIESA). The MIESA utilizes a tiny keyhole incision, and the epididymis is exposed without testicular delivery. Epididymal aspiration is performed in the style of MESA, except using loupe magnification rather than an operating microscope. MIESA is a safe, office-based procedure in which millions of motile sperm can be retrieved for cryopreservation. While we prefer the MIESA technique for OA, there remain distinct advantages of each open and percutaneous approach. In the current era of assisted reproductive technology, sperm retrieval rates for OA should approach 100% regardless of the technique. This reference provides a roadmap for both advanced and novice male reproductive surgeons to guide them through every stage of sperm retrieval for OA, including preoperative evaluation, patient selection, procedural techniques, and complications. With the incredible advances in in vitro fertilization (IVF), combined with innovative surgical treatment for male factor infertility in recent years, OA is no longer a barrier for men to become biologic fathers.

Outcome of surgical sperm retrieval and ICSI in Iraqi azoospermic patients

Although ICSI technique represents the cornerstone in the management of infertility worldwide, this technique was only recently introduced to our country and this might be the first prospective study of its kind that done in Iraq which tries to evaluate the outcome of surgical sperm retrieval in azoospermic Iraqi patients using different methods of surgical sperm retrieval technique and to evaluate the pregnancy rate for those patients who tried ICSI.Patients and methods:- This was a single center prospective study, which was performed at the reproductive and ICSI center, department of urology at AL-SADER MEDICAL CITY. The time of enrollment was from sixteenth of February to sixteenth of December 2011. A total of 146 azoospermic patients have been included in this study. Surgical methods which were used for sperm retrieval included PESA, TESA, simple TESE, open surgical epididymal sperm aspiration, open multiple TESE and Micro surgical TESE.Results:- The aim of our treatment is to obtain and freeze sperm sufficient for at least two ICSI cycles. The total number of patients who had met the above criteria after surgical sperm retrieval (SSR) was 92 patients out of 146 patients included in the study. The overall success rate was 63%, this including 100% success rate in obstructive azoospermia and 45% success in NOA. For those patient who try ICSI at time of this study the fertilization rate was 85% , embryo transfer was done in 75% , and the pregnancy rate was 23%.Conclusion:-Although the combination of surgical sperm retrieval (SSR) and ICSI may be the sole treatment available for male factor infertility with uncorrectable azoospermia, the overall success rate is limited particularly in NOA and ongoing pregnancies are obtained in <25% of ICSI cycles. However every azoospermic patients should offer such option of treatment and for those patients who had succeed sperm retrieval, multiple ICSI cycle trials may increase the chance of pregnancy without the need for repeated surgery. Open surgical methods of SSR, has been shown to increase the options available to the embryologist to use , select and cryopreserved sperms, however it will increase the surgical trauma to the testicles and increase the tissue extracted , the effects of these factors on the future testicular function needs to be investigated by further studies.

MP89-10 CRITICAL ANALYSIS OF MEDICAL TREATMENT BEFORE SURGERY IN NON-OBSTRUTIVE AZOOSPERMIA: A SYSTEMATIC REVIEW

You have accessJournal of UrologyInfertility: Therapy I1 Apr 2017MP89-10 CRITICAL ANALYSIS OF MEDICAL TREATMENT BEFORE SURGERY IN NON-OBSTRUTIVE AZOOSPERMIA: A SYSTEMATIC REVIEW THIAGO NUNES, RICARDO SAADE, and EDSON BORGES THIAGO NUNESTHIAGO NUNES More articles by this author , RICARDO SAADERICARDO SAADE More articles by this author , and EDSON BORGESEDSON BORGES More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2808AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Currently, treatment of men with nonobstructive azoospermia (NOA) is accomplished through assisted reproduction using testicular sperm retrieval techniques combined with in vitro fertilization (IVF) by intracytoplasmic sperm injection technique (ICSI). Among the sperm retrieval techniques, testicular microdissection (micro-TESE) is presenting the best results, with approximately 50% of success. In order to optimize the spermatogenesis process before the procedure, new therapies are being used towards a better chance of success in the recovery of sperm for IVF, through prior drug treatment. There is no consensus in the literature on the effectiveness of this treatment. The objective of this study was to conduct a systematic review regarding the use of previous clinical treatment for sperm retrieval in men with NOA, comparing sperm retrieval rates (SRR), drug used, levels of FSH / testosterone and the relationship with the testicular histology METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocols (PRISMA-P) 2015 statement. A total of 53 analyzed studies were selected 7 for the final analysis RESULTS The SRR with micro-TESE in the treated group ranged from 51.0 to 77.0%, while in the control group ranged from 33.0 to 51.0%. Regarding the medication used, it was not possible to compare the results of the studies, but men with Klinefelter Syndrome (KS), responded better to aromatase inhibitor (AI). With respect to hormone levels, we see improvement with treatment in the group of subjects with normal FSH levels. In the case of KS, with high levels of FSH and low levels of testosterone, SRR was also better when individuals showed an increase in testosterone levels. Regarding the histology of biopsy, the best responses were in patients with hypospermatogenesis (HS) and maturation arrest (MA), except in SK CONCLUSIONS The studies analyzed lead to the conclusion that the medical treatment in men with NOA, when the FSH levels are normal, histology showed MA or HS and men with KS, with high FSH levels and low levels of T. New prospectives randomized studies are needed to prove the real benefit of these treatments. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1205-e1206 Advertisement Copyright & Permissions© 2017MetricsAuthor Information THIAGO NUNES More articles by this author RICARDO SAADE More articles by this author EDSON BORGES More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Successful Pregnancy After IUI with Retrograde Ejaculated Sperm

Objective: To report a case of successful treatment of complete retrograde ejaculation by superovulation and intrauterine insemination (IUI), by collecting spermatozoa from post-ejaculatory urine.Design: Case report.Setting: Private infertility clinic (Harkaar Superspeciality Centre).Patient(s): A couple with primary infertility for 7 years due to male's complete retrograde ejaculation due to the congenital hypoplastic prostate gland. The woman was having subserosal fibroid but otherwise normal menstrual cycles. Intervention(s): Super-ovulation and Intrauterine insemination IUI was done after alkalinizing urine and preparing IUI sample by processing post-ejaculatory urine. IUI was done twice after HCG administration.Result(s): This protocol was used successfully to achieve pregnancy in this couple.
 Conclusion(s): To our knowledge, this is the first reported case of successful management of infertility through this protocol in Kashmir, J & K, India. This method obviates the need for more invasive sperm retrieval techniques. JMS 2016; 19(2):85-87.

Overview of reconstructive and sperm retrieval surgeries in male subfertility

Male subfertility is an important clinical entity. It entails direct medical, financial, and psychological impact on the couple. A standardization of protocol in its management is yet to be achieved. Detailed workup of the males presenting with subfertility is necessary to elucidate the etiology and prognosticate the disease. Microsurgical reconstruction holds an important place in the management of obstructive disease of male genital tract. With the advent of microsurgical sperm retrieval techniques, couples have a chance to become the biological parents in the cases of nonobstructive azoospermia. All available treatment options should be given to patients to help them achieve a long-term possibility of spontaneous conceptions.

Influence of Post‐Mortem Sperm Recovery Method and Extender on Unstored and Refrigerated Rooster Sperm Variables

Many post-mortem sperm collection techniques have been described for mammalian species, but their use in birds is scarce. This paper compares the efficacy of two post-mortem sperm retrieval techniques - the flushing and float-out methods - in the collection of rooster sperm, in conjunction with the use of two extenders, i.e., L&R-84 medium and Lake 7.1 medium. To determine whether the protective effects of these extenders against refrigeration are different for post-mortem and ejaculated sperm, pooled ejaculated samples (procured via the massage technique) were also diluted in the above extenders. Post-mortem and ejaculated sperm variables were assessed immediately at room temperature (0 h), and after refrigeration at 5°C for 24 and 48 h. The flushing method retrieved more sperm than the float-out method (596.5 ± 75.4 million sperm vs 341.0 ± 87.6 million sperm; p < 0.05); indeed, the number retrieved by the former method was similar to that obtained by massage-induced ejaculation (630.3 ± 78.2 million sperm). For sperm collected by all methods, the L&R-84 medium provided an advantage in terms of sperm motility variables at 0 h. In the refrigerated sperm samples, however, the Lake 7.1 medium was associated with higher percentages of viable sperm, and had a greater protective effect (p < 0.05) with respect to most motility variables. In conclusion, the flushing method is recommended for collecting sperm from dead birds. If this sperm needs to be refrigerated at 5°C until analysis, Lake 7.1 medium is recommended as an extender.

Clinical characteristics of men with non-mosaic Klinefelter syndrome in northeastern China: implications for genetic counseling.

Klinefelter syndrome (KS) is the most common genetic cause of male infertility. Widespread development in assisted reproductive technology has provided non-mosaic KS patients with the opportunity of having biological children. Testosterone replacement therapy and micro-dissection testicular sperm extraction are effective sperm retrieval techniques for KS patients. Despite the success of sperm retrieval and intracytoplasmic sperm injection (ICSI), some areas of early aggressive hormonal spermatogenesis and appropriate management of KS remain controversial. Androgenotherapy, a common treatment for KS, carries a risk of decreasing focal spermatogenesis by lowering the gonadotropin content. Inadequately treated hypogonadism increases psychosocial morbidity in KS patients. Preventive care must be provided from the time of diagnosis, preferentially through a multidisciplinary approach. This indicates the need for improved genetic counseling of KS patients. The aim of this study was to report the prevalence of non-mosaic KS in a Chinese infertile male population. The rate of early diagnosis was lower in KS patients; most of these were diagnosed after rising concerns of reproductive capacity. The mean age of patients with sperm or germ cells was significantly lower, while the semen volume of these patients was significantly higher. However, the semen volume was negatively correlated with the age and ratio of luteinizing hormone/testosterone content in KS patients. Therefore, genetic counseling of KS patients should focus on early diagnosis and timely treatment, in addition to improving the quality of life of all KS patients. The use of testosterone replacement therapy and/ or micro-dissection testicular sperm extraction should be preferentially considered for fertility preservation.

EVALUATION OF EPIDIDYMAL AND TESTICULAR SPERM ASPIRATION IN AZOOSPERMIC INFERTILE MALES IN BASRAH

This study aimed to evaluate the safety and efficacy of percutaneous epididymal and testicular sperm aspiration as a diagnostic technique to confirm sperm production and as a therapeutic technique to harvest sperms for use in the intracytoplasmic sperm injection and the indications for performing testicular biopsy in azoospermic infertile males. Thirty married patients were included in this prospective study from February 2011 to December 2012 seen in Basrah General Hospital. Their age ranged from 20 to 40 years. All patients underwent full medical examination with laboratory tests which included seminal fluid analysis, serum leutinising hormone (LH), follicular stimulating hormone (FSH), testosterone, and prolactin in addition to color Doppler ultrasonography of the scrotum. Patients with history of undescended testes, varicocele, & testicular pathology were excluded from this study. All patients showed normal physical examination with normal secondary sexual characters. The external genitalia were normal with normal sizes of their testes. The percutaneous epididymal and testicular sperm aspirations were positive in 12 out of 30 patients (40%). The rest had negative aspirations (60%). The testicular biopsy which performed in the patients with negative aspiration showed normal germinal epithelium with mature spermatozoa in only 5 patients out of 18 (28%) while the rest 13 patients had spermatogenic arrest (72%). In conclusion, percutaneous epididymal and testicular sperm aspiration has been found helpful as a diagnostic technique for patients with non-reconstructable azoospermia. It is a minimally invasive sperm retrieval technique and appears to be an effective alternative to microsurgical epididymal sperm aspiration, which is more invasive and costly. It is less invasive than testicular biopsy and preferably performed as a first step procedure in an attempt to obtain sperms for both diagnostic and therapeutic purposes.

Engaging practicing gynecologists in the management of infertile men.

In the modern era, contemporary management of male infertility has undergone groundbreaking changes with the introduction of new concepts, advanced testing, and therapeutic interventions. As practicing gynecologists are often the first physicians who encounter an infertile couple, it is essential that these clinicians are continuously updated about the new pearls and pitfalls of male infertility management. Semen analysis is commonly ordered by gynecologists. In 2010, the WHO released new cutoff reference values for the semen parameters adopting novel methodology, which has incited much debate. Reference values have been lowered in comparison with previous standards, with a direct clinical implication in decision-making strategies. Specialized sperm-function tests, such as sperm oxidative stress and sperm chromatin integrity assessments, became clinically available, thus offering an opportunity to better understand sperm dysfunctions concealed during routine semen analysis. Furthermore, the initial counseling of azoospermic men by an andrologically well educated gynecologist may alleviate the misconception and distress surrounding the false belief of sterility, and will clarify the available options of percutaneous and microsurgical sperm-retrieval techniques and assisted conception outcome. Regarding varicocele, which is commonly seen in infertile males, it is now clear that the best treatment option for infertile men with clinical varicocele is the microsurgical vein ligation. Natural conception is significantly improved after varicocelectomy, and recent data suggest that such treatment optimizes reproductive outcome of couples undergoing ICSI or micro-TESE sperm retrieval. Lastly, new therapeutic interventions, including oral antioxidant therapy and lifestyle modifications, have gained increasing attention, as they aid in alleviating male infertility.

Ejaculatory physiology and pathophysiology: assessment and treatment in male infertility.

Azoospermia is a heterogeneous condition with multiple etiologies and a variety of treatments. In this chapter we present a summary of retrograde ejaculation and anejaculation, both of which are characterized by an absence of antegrade semen propulsion through the male reproductive tract. Each of these affects fertility, but is pathophysiologically distinct disorders with differing evaluation and treatment. Retrograde ejaculation has a myriad of well-characterized causes, from pharmacologic disruption to interference of neural mechanisms by surgical intervention for a variety of diseases. Medication is the mainstay of treatment, although only a minority responds and develops antegrade ejaculation. For the men who are not responders to medical therapy, but still have fertility goals, there are a variety of sperm retrieval techniques to assist their reproductive abilities. Failure of emission is characterized by an absence of the emission phase and no antegrade or retrograde expulsion of ejaculatory products. If fertility is desired, these men must rely on assisted ejaculatory procedures, and treatment choice is guided by etiology and response. Ultimately, retrograde ejaculation and failure of emission are in a spectrum of ejaculatory disorders which impair male fertility.

Is ex vivo microdissection testicular sperm extraction indicated for infertile men undergoing radical orchiectomy for testicular cancer? Case report and literature review

To report a case of an infertile man with nonobstructive azoospermia who underwent simultaneous radical orchiectomy for testicular cancer and testicular sperm extraction (TESE) for preservation of fertility. Case report and literature review. University teaching hospital. A couple being treated for infertility. Radical orchiectomy with simultaneous TESE. Sperm retrieval, histologic evaluation of archived testicular pathology slides. We retrieved 20 spermatozoa from the multiple random TESE samples obtained at radical orchiectomy. Histologic evaluation of the archived testicular pathology slides revealed that the testis contained several foci of active spermatogenesis, suggesting that a significantly greater number of spermatozoa would likely have been retrieved had a microdissection TESE been performed instead of the multiple TESEs. We propose that microdissection TESE should be considered the preferred sperm retrieval technique at the time of radical orchiectomy in men with coexistent nonobstructive azoospermia and testicular cancer.

Outcomes with intracytoplasmic sperm injection of cryopreserved sperm from men with spinal cord injury.

BackgroundErectile dysfunction, ejaculatory dysfunction and poor semen quality are the main causes of infertility in men with spinal cord injury (SCI). Different sperm retrieval techniques such as penile vibratory stimulation (PVS), electro-ejaculation (EEJ) or surgical sperm retrieval (SSR) associated or not with sperm cryopreservation can be offered to these patients to preserve their fertility. If fatherhood cannot be achieved naturally, assisted reproductive techniques can be offered to these patients using either fresh or frozen/thawed sperm. The aim of the study was to report in SCI patients from Dijon (Burgundy) and in the literature, intracytoplasmic sperm injection (ICSI) outcomes using frozen sperm obtained either by antegrade ejaculation (PVS or sexual intercourse) or by SSR.MethodsA retrospective analysis was performed in Dijon, Burgundy over a 17 year period (1995-2011) on a cohort of 19 SCI men (6 quadriplegics and 13 paraplegics, mean age: 25.2 ± 5.6 years) who underwent a sperm cryopreservation followed or not by intracytoplasmic sperm injection (ICSI). Patients were divided into two groups according to the sperm retrieval method used (antegrade ejaculation group (n=10): penile vibratory stimulation (PVS) for 9 patients and sexual intercourse for 1 patient and surgical sperm retrieval (SSR) group: n=9). The sperm parameters in both groups were analyzed. Pregnancy outcomes in the 8 couples who underwent ICSI were evaluated.ResultsThe fertilization rates were 57 and 55%, the embryo’s cleavage rates were 90 and 93% in the antegrade ejaculation and SSR groups respectively. Among the 8 couples who underwent ICSI, 5 couples achieved pregnancy. The pregnancy rates per couple were 50% and 75% in the antegrade and SSR groups respectively.ConclusionsAlthough some studies don’t recommend freezing sperm in SCI patients, the pregnancy rates presented in this study are encouraging and warrant the use of frozen/thawed sperm in very specific situations.

Cryptorchidism and its impact on male fertility: a state of art review of current literature.

Cryptorchidism is associated with impairment of germ cell maturation and subsequent infertility in adulthood. The present report details common scenarios of referral of men with prior history of cryptorchidism and orchidopexy seeking advice for infertility, and examines the association between cyrptorchidism and male infertility. The increase in the understanding of the hormonal profiles and patho-physiological changes in germ cell maturation in cryptorchid boys may potentially change our approach and management strategies. Improvement in sperm retrieval techniques and micromanipulation techniques, such as intracytoplasmic sperm injection, has led to excellent fertilization and pregnancy outcomes of treatment cycles.

Micro-dissection testicular sperm extraction as an alternative for sperm acquisition in the most difficult cases of Azoospermia: Technique and preliminary results in India

CONTEXT:Non-obstructive azoospermia (NOA) is an unfavorable prognostic condition for male infertility since spermatogenesis is disrupted. Sperm retrieval (SR) coupled with intracytoplasmic sperm injection (ICSI) is the only option for men with NOA who seek fertility. Among the SR techniques, microdissection testicular sperm extraction (micro-TESE) has been applied with encouraging results.AIMS:We describe how we implemented the micro-TESE procedure and present initial micro-TESE experience in a group of men with NOA and poor prognosis for SR.SETTINGS AND DESIGN:Case series of men with NOA treated in a tertiary healthcare center.MATERIALS AND METHODS:An Assisted Reproductive Technology (ART) facility was setup to perform SR using microsurgery. Fourteen men with NOA and previous failed retrievals or unfavorable histologic results underwent micro-TESE while their female partners received ovarian stimulation for oocyte pickup (OCP). Micro-TESE was performed the day prior to OCP and testicular sperm were used for sperm injections. We assessed retrieval rates and ICSI outcomes.STATISTICAL ANALYSIS:Outcomes of SR and ICSI were analyzed descriptively. Mann-Whitney and Fisher exact test were used to compare characteristics of men with successful and failed SR.RESULTS:The success of micro-TESE was 50.0% with no major complications. A clear microscopic distinction between enlarged and collapsed seminiferous tubules was seen in 35.7% of the cases, and sperm were retrieved in all but one of these cases. Patients with successful and failed retrieval did not differ with respect to baseline characteristics, use of medical therapy, presence of varicocele, and testicular histology. Sperm injections resulted in normal fertilization and embryo cleavage of 64% and 75%, respectively. A total of five transfers with an average of 1.5 embryos resulted in a cumulative clinical pregnancy rate per ICSI cycle of 28.6%, with an implantation rate of 33.3%.CONCLUSIONS:We were successful in integrating the micro-TESE procedures to the in vitro fertilization (IVF) laboratory. Our initial experience with micro-TESE applied to the most difficult cases of azoospermia is reassuring.

Microdissection testicular sperm extraction: an update

Patients with non-obstructive azoospermia (NOA) were once considered to be infertile with few treatment options due to the absence of sperm in the ejaculate. In the last two decades, the advent of intracytoplasmic sperm injection (ICSI), and the application of various testicular sperm retrieval techniques, including fine needle aspiration (FNA), conventional testicular sperm extraction (TESE) and microdissection testicular sperm extraction (micro-TESE) have revolutionized treatment in this group of men. Because most men with NOA will have isolated regions of spermatogenesis within the testis, studies have illustrated that sperm can be retrieved in most men with NOA, including Klinefelter's syndrome (KS), prior history of chemotherapy and cryptorchidism. Micro-TESE, when compared with conventional TESE has a higher sperm retrieval rate (SRR) with fewer postoperative complications and negative effects on testicular function. In this article, we will compare the efficacy of the different procedures of sperm extraction, discuss the medical treatment and the role of testosterone optimization in men with NOA and describe the micro-TESE surgical technique. Furthermore, we will update our overall experience to allow counseling on the prognosis of sperm retrieval for the specific subsets of NOA.

Microsurgical epididymal sperm aspiration: indications, techniques and outcomes

Microsurgical epididymal sperm aspiration (MESA) refers to retrieval of sperm-containing fluid from optimal areas of the epididymis that are selected and sampled using high-power optical magnification provided by an operating microscope. Retrieved sperm are subsequently used for intracytoplasmic sperm injection (ICSI) to induce fertilization and pregnancy. MESA is considered by many experts to be the gold standard technique for sperm retrieval in men with obstructive azoospermia given its high yield of quality sperm, excellent reported fertilization and pregnancy rates, and low risk of complications. However, MESA must be performed in an operating room, requires microsurgical skills and is only useful for reproduction using ICSI. Herein we present an overview of the evaluation of candidate patients for MESA, the technical performance of the procedure and the outcomes that have been reported.

Editorial Comment

No AccessJournal of UrologyAdult Urology1 Aug 2012Editorial Comment Sandro C. Esteves Sandro C. EstevesSandro C. Esteves More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.04.129AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 188(2), pp. 536–537 References 1 : Sperm retrieval techniques for assisted reproduction. Int Braz J Urol2011; 37: 570. Google Scholar 2 : Over expression of aromatase CYP19 in human testis is most likely reason for hypogonadism in men with Klinefelter syndrome. J Urol2009; 181: 681. abstract 1886. Link, Google Scholar 3 : An update on the clinical assessment of the infertile male. Clinics (Sao Paulo)2011; 66: 691. Google Scholar 4 : Intratesticular testosterone concentrations comparable with serum levels are not sufficient to maintain normal sperm production in men receiving a hormonal contraceptive regimen. J Androl2004; 25: 931. Google Scholar Androfert, Center for Male Reproduction, Campinas, São Paulo, Brazil© 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 188Issue 2August 2012Page: 536-537 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sandro C. Esteves More articles by this author Expand All Advertisement PDF downloadLoading ...

Combined Trifocal and Microsurgical Testicular Sperm Extraction Is the Best Technique for Testicular Sperm Retrieval in “Low-Chance” Nonobstructive Azoospermia

BackgroundThere is no consensus for the best testicular sperm extraction (TESE) technique in patients with “low-chance” nonobstructive azoospermia (NOA). ObjectiveTo determine sperm retrieval rates in an intraindividual comparison using three locations of the testicle with and without the assistance of a microscope (microsurgical TESE [M-TESE]). Design, setting, and participantsA series of 65 patients with low-chance NOA presenting with low testicular volume (<8ml) and high serum follicle-stimulating hormone (FSH) (>12.4 IU/l) underwent trifocal-TESE plus M-TESE bilaterally (four biopsies per testis). InterventionSperm retrieval was performed as trifocal-TESE (upper, middle, and lower testicular pole) with and without the assistance of a microscope in the middle incision. Outcome measurements and statistical analysisThe number of evaluated tubules, the mean spermatogenetic scores, and the sperm retrieval rates were evaluated to determine retrieval locations and the use of the microscope. The Friedman and Cochrane Q tests were applied to determine statistical differences. Receiver operating characteristic curves were used for the analysis of serum FSH and testicular volume as preoperative prognostic factors. Results and limitationsThe sperm retrieval success of 66.2% using the combined technique, meaning the percentage of patients with at least one tubule containing elongated spermatids, was the highest in the combination of trifocal- and M-TESE (p<0.01), indicating this technique as optimal for patients with low-chance NOA. M-TESE and trifocal-TESE alone were not significantly better. The mean spermatogenetic score giving the number of tubules with elongated spermatids in relation to all tubules was significantly higher in M-TESE versus conventional TESE (p<0.01), indicating the superior quality of the tissue harvested using the microscope. These results are limited by the definition of “success” using “one” spermatid/tubule. Preoperatively, high serum FSH and low testicular volumes did not exclude successful sperm retrieval. ConclusionsThe combination of trifocal- and M-TESE is the best technique to reach high sperm retrieval rates in patients with low-chance NOA.

Contemporary Management of Male Infertility

Knowledge of normal male reproductive function and familiarity with the diagnostic evaluation and treatment of male subfertility is beneficial for most physicians. Male subfertility is often correctable, may be genetically transmissible, and may be associated with occult health-threatening conditions. Herein we present an overview of male reproductive medicine, which has been revolutionized in the past two decades by dramatic scientific and therapeutic advances. The development of intracytoplasmic sperm injection and its successful application to sperm retrieved from the epididymis or testis have made biological paternity possible in men previously considered sterile. Microsurgical techniques for vasal-epididymal reconstruction and sperm retrieval have been refined. Novel tests of semen quality have been developed. Medical therapies to improve sperm production, such as estrogen receptor modulation and aromatase inhibition, have been used increasingly in clinical practice. Finally, associations between male subfertility and a spectrum of health-threatening conditions have been recognized.

Sperm retrieval techniques for assisted reproduction

Different surgical methods such as PESA, MESA, TESA, TESE and micro-TESE have been developed to retrieve spermatozoa from either the epididymis or the testis according to the type of azoospermia, i.e., obstructive or non-obstructive. Laboratory techniques are used to remove contaminants, cellular debris, and red blood cells following collection of the epididymal fluid or testicular tissue. Surgically-retrieved spermatozoa may be used for intracytoplasmic sperm injection (ICSI) and/or cryopreservation. In this article, we review the surgical procedures for retrieving spermatozoa from both the epididymis and the testicle and provide technical details of the commonly used methods. A critical analysis of the advantages and limitations of the current surgical methods to retrieve sperm from males with obstructive and non-obstructive azoospermia is presented along with an overview of the laboratory techniques routinely used to process surgically-retrieved sperm. Lastly, we summarize the results from the current literature of sperm retrieval, as well as the clinical outcome of ICSI in the clinical scenario of obstructive and nonobstructive azoospermia.