Surgical Sperm Retrieval

About one man in a hundred produces no sperm (10-15% of all sub fertile men) – a condition known as azoospermia. Various factors can contribute towards these conditions, some of which may be inherited. To achieve pregnancy, surgically retrieved sperm are used in an IVF/ICSI treatment cycle.

What is surgical sperm retrieval (SSR) and what does this treatment involve?

Surgical Sperm Retrieval is a technique used for collecting sperm directly from a man’s testicles or epididymis. It is a procedure usually carried out as a day case under general anesthetic. An SSR is usually planned, but in exceptional circumstances can also be carried out as an emergency procedure. This would usually be if the man is unable to produce a sperm sample on the day of his wife’s or partner’s egg collection. The procedure is carried out under general or spinal anesthetic or with sedation. The team may use different sperm retrieval methods. The method is determined according to the FSH level and testicular size. Your surgeon will advise you which procedure will be suitable for you.

Who may benefit from surgical sperm retrieval (SSR)?

This method is helpful to a man who has low-quality sperm or no sperm in their ejaculate. This can be the result of several causes:

• • Men who have had a vasectomy (the male sterilization operation), that is, removal of vas deferens (the tube which carries the sperm to the penis) or a failed vasectomy reversal.
• Men who are carriers of certain genetic conditions, such as cystic fibrosis.  These men do not have a vas deferens or a blockage in the epididymis.
• Men who cannot produce sperm in their semen.
• History of any testicular surgery and undescended testes.
• Illness (such as mumps in adolescence affecting the testis).
• May be suitable for men with a spinal injury and where there are problems with normal ejaculatory function (such as Multiple sclerosis, Diabetes).
• Men with congenital or acquired endocrine conditions.
• Men with a genetic condition like Klinefelter syndrome.
• Medications like steroids, testosterone.

Most of the men produce healthy sperm in the testicles which can be retrieved by SSR. Unfortunately, some men have the testicles that fail to produce any sperm.

Pre-operative (pre-op) appointment

Once you are listed for SSR, you will be sent a separate appointment to see a consultant to sign both the HFEA consent forms and a surgical consent form. This appointment will be held in the Department of Reproductive Medicine. You will also be invited to attend a pre-op assessment, usually 1-2 weeks before your surgery date.

What are the different methods of SSR?

There are different methods of SSR. The cause of your azoospermia will determine the best way to retrieve sperm in your case.

1. Percutaneous Epididymal Sperm Aspiration (PESA)

PESA is performed in theatre at the Prasad Hospitals, under sedation. It is a short, relatively painless procedure and requires no surgical incision. It is the least invasive method and involves inserting a fine needle into the epididymis, from which fluid is aspirated. Embryologists then inspect the fluid under a microscope for sperm motility and content which takes about 30 minutes. If the aspirates fail to show any viable sperm then the surgeon will proceed to the other options (TESE), usually on another day. This is particularly suitable for men who have had a vasectomy, obstruction or who were born without a vas deferens (cystic fibrosis). We will inform you of the outcome of the PESA procedure on the day of the procedure.

2. Testicular Sperm Aspiration (TESA)

A fine needle is used with a biopsy gun to remove small lengths of seminiferous tubule (sperm-producing tubules). These are then carefully dissected under a microscope by embryologists.

3. Micro-epididymal Sperm Aspiration (MESA)

Instead of using a needle in PESA, a small cut is made through the scrotum and into the epididymis. The fluid is collected and taken for microscopic examination by embryologists to see whether there is any viable sperm or not.

4. Testicular Sperm Extraction (Open conventional TESE)

TESE will be performed if-else no sperm is found in PESA, TESA or MESA. This procedure is performed in the Prasad Hospitals. TESE can be performed by

Single biopsy (unifocal)

If the hormone level and testicular size are normal, then a small incision is made into the testis itself. A small sample of testicular tissue is taken which is then examined for sperm. Stitches are applied that are dissolvable and so will not need to be removed. Pain relief is given in the form of a local anesthetic and nerve block to the genital region.

Open scrotal exploration and multifocal testicular biopsies

This involves performing a midline or horizontal incision on the scrotal skin. Three to four biopsies are taken from each testicle in different areas. Stitches are applied that are dissolvable and so will not need to be removed. Pain relief is given in the form of local anesthetic and nerve block to the genital region. This provides pain relief for 15-16 hours. This procedure will cause some pain and tenderness afterward, however, full recovery is expected within a few days. It is not possible to tell you on the day if sperm were present in the biopsy material, as it may require special culture technique. It may take 3-5 days before the embryologist will be able to give you any information about the presence or absence of sperm in the biopsy material. This result will be informed to you in the clinic appointment, usually in 1-2 weeks.

Effectiveness of SSR

Surgically retrieved sperm, if viable, are stored frozen and this does not affect their ability to subsequently fertilize an egg. Surgically retrieved sperm (SRR) is not comparable to normally ejaculated sperm. As the number of sperm retrieved by surgical means is usually low in numbers with reduced motility and may not be mature, and therefore cannot successfully fertilize an egg using IVF techniques. Because of this, the embryologist will pick out a single sperm to inject into each egg, this procedure is called Intracytoplasmic Sperm Injection, (ICSI). Fertilization rates are dependent upon the quality of sperm and eggs. If non-motile sperm are all that are available for selection, it is impossible to tell whether the sperm is alive or dead, so fertilization rates will be adversely affected. It is also possible that no sperm at all will be obtained after the stored frozen sperm is thawed.

Possible Complications

SSR is a relatively low-risk procedure. Possible complications include pain, bleeding, infection, hematoma (swelling of testicles with blood in the testicle) that would require immediate exploration of the testicle within a few hours of surgery. The risk of these complications occurring is small. There is a very small risk of testicular damage and chronic testicular pain, but these occur rarely. Any procedure that requires a general anesthetic also carries an increased risk of complications of anesthesia.

Preparing for SSR

Before coming to the hospital (24 hours prior) you should shave all the hair off the scrotum or use a cream depilatory. You should bring with you a tight pair of ‘slip’-style underpants or swimming trunks – not boxer shorts. You will need to be accompanied by a driver or to arrange a lift/taxi as you will not be able to drive for 24 hours after the procedure.

Before your procedure

You will be required to fast (this includes no chewing gum and sucking on sweets) for at least 6-8 hours before the procedure. You are also advised to avoid alcohol for at least 24 hours.

After your procedure

You will be able to leave the unit about four hours after the procedure. As with any surgical procedure, there is a slight risk of bleeding, bruising or infection. In order to reduce this risk, we would advise you to wear reasonably tight-fitting pair of underpants rather than boxer shorts for at least 48 hours (including overnight) from the day of your operation and then wear your own scrotal support (jock strap) daily (changing every day) for further 12 days to minimize discomfort and protect your scrotum and testes. Showering is advised and avoid hot baths to prevent infection. You should avoid alcohol, taking drugs that contain aspirin and refrain from strenuous exercise for a few days after SSR. Sexual activity is not advised for a week after the procedure. If you had an open SSR procedure you would be advised to be off work for 7-14 days. If you experience any discomfort, you may take up 4g (usually 8 tablets) of paracetamol, or 240mg codeine, or 1200mg ibuprofen in any 24 hours. You should follow the information on the medication to ensure you do not exceed the recommended dosage in any 24 hours.