Weill Medical College
Cornell Institute for Reproductive Medicine
Center for Male Reproductive Medicine and Microsurgery
"State-of-the-Art Compassionate Care for the Infertile Couple"
Non-surgical sperm retrieval offers a less involved and invasive technique to procure sperm for use with assisted reproduction than open surgical procedures. However, sperm retrieval can only reliably be achieved in men who have normal sperm production and reproductive tract obstruction. Even in those cases, it is only possible to reliably retrieve enough sperm of adequate quality to use for one ICSI cycle-repeat retrieval procedures are needed from the man for each attempt at in-vitro fertilization. In contrast, the open sperm retrieval (MESA) typically results in retrieval of over 100 motile sperm with adequate mobility to reliably freeze 5-10 samples of sperm or more. The choice of MESA essentially means that only a single retrieval procedure is required, although the recovery may take several days longer than other percutaneous approaches. The cost per procedure of percutaneous procedures is less because these interventions are performed in the office under local anesthesia. The choice of percutaneous or open procedure is dependent on the couple's wishes, how many children are desired, and whether more than one IVF-ICSI procedure would be considered.
In addition to microsurgical techniques, percutaneous procedures are part of the armamentarium currently available for sperm retrieval. These procedures can be performed without surgical scrotal exploration, can be repeated easily and at low cost, and they do not require an operating microscope or expertise in microsurgery. Percutaneous epididymal sperm aspiration, as described by Craft et al., can be performed under local or general anesthesia. After induction of anesthesia, the testis is stabilized and the epididymis is held between the surgeon thumb and forefinger. A 21-gauge butterfly needle attached to a 20 ml syringe is inserted into the caput epididymis and withdrawn gently until fluid can be seen entering the tubing of the aspiration set. The procedure is repeated until adequate amounts of epididymal fluid are retrieved.
We recently reported our results in 38 azoospermic men using PESA and IVF/ICSI. A total of 42 attempts at PESA were made. In 38 of the 42 attempts adequate sperm was obtained. Fertilization occurred in 35 of 38 attempts for a fertilization rate per attempt of 92 percent. Ten pregnancies occurred for a pregnancy rate of 28.9 percent per embryo transfer or 24 percent per attempt at sperm and egg retrieval. Two of the ten pregnancies were biochemical and the remaining eight had single gestational sacs at 7 to 8 weeks gestation. The authors acknowledge that PESA yields very small amounts of epididymal fluid, and that contamination with blood cells is problematic. For the latter they recommend a combined Percoll gradient and swim-up technique to select the best quality sperm in the fluid. If sperm cannot be retrieved with this method, the authors recommend percutaneous aspiration of the testis described below.