Surgical sperm retrieval is a broad term used to describe several types of procedures that can be used to recover sperm directly from the testicles when there is no sperm present in the ejaculate, or what is present is not suitable for fertility treatment. When there is no sperm in the ejaculate, this is called azoospermia. Occasionally, there may be sperm in the ejaculate, but the labs tell the clinicians that what is there is not suitable for injecting into eggs because for example, none of the sperm are moving or are alive.
What procedure do i need?
The type of procedure that you should be offered depends on the nature of the sperm quality problem that you have.
If there is no sperm in the semen due to a blockage in the male genital tract or a problem with sperm getting out due to a problem with ejaculating, then sperm may be recovered from the cap at the top of the testicle (the epididymis) or from the testicle itself.
Procedures for problems when sperm is being made in the testicles (but can’t get out)
Aspiration type Procedures
In this type of procedures, fluid is sucked out from the testicle with a needle. A scientist then looks at the fluid straight away to see if it contains sperm and if so, checks to see if the sperm is moving well. If the sample contains good numbers of sperm that are moving well (progressive motility), then the sample is likely to be good enough to use for intracytoplasmic sperm injection (ICSI – one sperm cell is injected into the egg) or to survive freezing and thawing. If no sperm is seen or if the sperm is of very poor quality then the doctor may then inject a bit more local anaesthetic and perform a biopsy. If a biopsy is performed then the tissue will need to be processed in the lab to extract sperm. This means that there can be a delay in letting you know if it is successful or not.
The Aspiration type procedures that may be discussed are:
- Percutaneous Epididymal Sperm Aspiration (PESA):
This procedure is normally carried out when the patient is awake. Local anaesthetic is injected into the scrotum to numb it and fluid is then drawn out from the epididymis with a needle using a syringe.
- Testicular Sperm Aspiration (TESA):
This is again performed after local anaesthetic has been injected into the scrotal skin. A needle is inserted directly into the testicle to draw fluid out.
- Microsurgical Sperm Aspiration (MESA):
This is usually performed under general anaesthetic (i.e. you will be put to sleep). The testicle is exposed through a cut in the scrotum and a fine needle passed into the epididymal tubule whilst the surgeon looks through an operating microscope. At the end of the procedure the surgeons will put stitches in the skin to close the wound, these will dissolve and won’t need to be removed.
Sometimes the doctor will recommend that a testicular biopsy should be performed or it may be needed if sperm suitable for treatment cannot be found in the epididymis by a PESA or MESA. Biopsies can be performed under local anaesthesia whilst you are awake, by making a tiny cut in scrotum after it has been numbed and cutting into the testicle, before closing the cut in the testicle and the cut in the scrotal skin with stitches that dissolve after a week or so. If it is carried out under local anaesthesia, then usually only one biopsy is taken from each testicle. If you are asleep (under general anaesthesia) for the procedure and a slightly larger cut has been made in the scrotal skin, then the surgeon may take a few biopsies from each side.
Procedures for sperm production problems
TESA, single site or multisite biopsies can be used, but the higher chance of getting sperm is with a procedure called a MicroTESE.
MicroTESE (Microsurgical Testicular Sperm Extraction) is usually performed under general anaesthesia. The testicles are exposed via a cut in the scrotum and the testicles then opened and the tissue inside the testicles examined under an operating microscope. The areas that are most likely to yield sperm are selectively taken, leaving the other areas behind. It is therefore a more targeted procedure than open biopsies and the total amount of tissue may be less. This procedure does take more time than the biopsy procedures. The testicle and scrotum are then closed with stitches that will dissolve after a time.
After the surgical sperm retrieval procedure
You will leave the hospital or clinic wearing a scrotal support and there will be a non-sticky dressing over the wound, possibly with some padding. This will need to stay on for 24 hours for the less invasive aspiration procedure, but longer for the open procedures (the ones where a cut has been made in the scrotum). You are likely to need pain killing medicines for a few days or so afterwards and the clinic will discuss this with you. You will then be seen again in the clinic to carry on with your treatment, once the result is known.
Which procedure is best?
For the problems where sperm is being made, but cannot get out, there is an excellent chance of getting sperm by any technique, although there may be differences in the amount of sperm recovered. For sperm-production problems MicroTESE is the procedure most likely to recover sperm and TESA the procedure least likely. Your clinical team will advise you on ½ their own success rates and what procedure they recommend that you have.
What are the potential complications?
Whilst usually surgical sperm retrieval is straightforward, like with any procedure there are potential risks. Bleeding into the scrotum or testicle can occur, which can cause swelling, bruising or pain. Infection is another risk. This can cause pain, swelling and sometimes a fever with a discharge from the wound. If you are having problems after a surgical sperm retrieval you should seek medical assistance immediately. Occasionally, more serious infections can result in shrinkage or even loss of a testicle, but this is very rare. Also in some situations, the procedure can affect the testicles ability to make the male hormone (testosterone), but this is rare also.
Your doctor will discuss the risks of you getting a complication before you have the procedure. The chance of the complications happening overall is low, but can vary according to what procedure is carried out.