Men with azoospermia but with functioning spermatogenesis confirmed by normal hormonal profiles (FSH,LH and Testosterone) are able to father children following surgically retrieved spermatozoa from the epididymes or testes and by applying ICSI. Such men may have a congenital presentation such as absence of the Vas Deferens (the duct which conveys sperm from the testicle to the urethra), obstruction of the Vas Deferens due to past infection, irreversal vasectomy, retrograde ejaculation (sperm is conveyed into the urinary bladder due to compromised muscular synergy), anejaculation due to medical conditions or past surgical interventions and all fall in a category known as obstructive azoospermia.
Similarly certain men who present non-obstructive azoospermia exploring the possibility of viable surgical sperm retrieval may prove beneficial. These candidates may have a deranged hormonal profile predictive of poor spermatogenetic potential yet at times spermatozoa are retrieved which are acceptable for egg fertilisation. Such men are called to manifest non-obstructive azoospermia. Whether a man presents obstructive or non-obstructive azoospermia sperm can be retrieved from his reproductive tract using one of several approaches. The aim is to acquire sufficient spermatozoa of acceptable quality to implement ICSI while at the same time minimize damage to the testes which may impair spermatogenesis or compromise the potential of future attempts at retrieval. Pending the density of the retrieved spermatozoa or the viability of the tissue excised cryopreservation following completion of ICSI is considered prudent so that future surgical repetitions can be avoided.
This is the simplest approach to retrieving spermatozoa. It is comparatively faster and does not necessitate a surgical incision and can be undertaken with mere local anaesthetic. It is only useful for men who had been diagnosed with obstructive azoospermia (i.e. congenital absence of the Vas Deferens or vasectomy). A very fine needle connect via a tube to a syringe is inserted following digital exploration of the testis into the epididymis which is normally dilated. By exerting continuous pressure transits of spermatozoa are aspirated through the tube into the syringe which is passed on to the andrology lab for microscopic investigation and subsequent processing. Such aspirates normally contain pure spermatozoa populations with associated spermatogenesis cells. Mobility must be evident from such specimens which can be frozen following completion of the ICSI procedure for the patient’s subsequent utilization. The recovery of the patient following completion of PESA is immediate and while adverse effects are not common a short course of antibiotics may be prescribed as a precaution measure. Since the possibility exists that PESA may fail to recover viable spermatozoa or indeed any at all, the patient must be aware that the endeavour may be diverted to an open biopsy which necessitates general anaesthesia..
2. Testicular Sperm Extraction (TESE)
This procedure is generally implemented under general anaesthesia and entails the extraction of testicular tissue from either of the two testes. The volume of tissue is normally at the level of 0.5 cm3 or even less. The biopsy is collected in a sterile tube containing nutrient culture fluid avoiding as much as possible blood contamination and passed on to the andrology lab for processing. With the aid of very fine needles the embryologist spread the tissue into its individual tubules potentially containing sperm. By applying gentle agitation or short vortex the spermatozoa normally disaggregate so they can be concentrated via rigorous centrifugation. This laboratory procedure is relatively short. If spermatozoa are not retrieved the surgeon is advised to perform an additional biopsy normally onto the counterpart testicle. At Genesis only half of each biopsy is processed while the rest is segmented and frozen intact using several cryo-vials. Such specimens can be used for future treatments and therefore repeated biopsies are avoided. The incision is closed using self-dissolving sutures and heals completely within a week. During this time, the patient is advised to use sterile gauzes and antiseptic solutions to clean the wound while a course of antibiotics and painkillers are prescribed to obliterate possible infection and/or local inflammation. Other than some itchiness at the vicinity the patient should not experience any major discomfort while he can resume normal activities immediately
This approach aims at retrieving spermatozoa mediated by the use of a surgical microscope and by direct isolation of individual epididymal tubules. Following incision the epidydimal tubules are exposed and with the aid of a very fine needle and pressure exerted constantly by a small syringe the fluid within is aspirated. MESA which is only useful to patients with obstructive azoospermia limits damage to the epididymes while blood contamination of the extract is avoided. Normally sufficient volumes of spermatozoa are recovered for both ICSI to be performed and cryopreservation for potentially future use. The surgical procedure is safe and necessitates the use of general anaesthesia. While it is more advantageous than MESA or TESE, it is time consuming and necessitates the expertise of a specialist surgeon urologist; hence it is more expensive than its counterpart interventions.
Micro-TESE which is contemplated only for individuals with non-obstructive azoospermia makes use of an operating microscope to explore different parts of the testes following superficial incision therefore determining the most productive areas of the tissue. The investigation of the micro-surgeon urologist which may be time consuming enables the removal of mere testicular tissue considered to be consistent with improved sperm production. In this way smaller volumes of testicular tissue is removed thereby minimizing the risks of testicular blood vessel damage. This technique is performed under general anaesthesia and is believed to yield superior results than the conventional TESE, mainly due to the use of high powered optical magnifications. It is however, considerably more expensive.