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Surgical Sperm Retrieval(PESA, TESA, TESE)

What is surgical sperm retrieval?

Surgical sperm retrieval (SSR) is one of the surgical treatments for men who have little or no sperm in their ejaculate. It is composed of several surgical methods to retrieve the sperm surgically from the testes. After SSR, the sperm will be harvested from the testicular tissue later and be used to fertilize eggs using ICSI technique.

Testicular Sperm Aspiration(TESA)

An average of 10% of men who have male infertility have no sperm in the ejaculate.

The cause of no sperm can be

  • A blockage of the small ejaculatory duct (vas deferens) or a blockage between the ejaculatory duct and the testes(epididymis).
  • The testes cannot produce mature sperm congenitally or they fail to produce the sperm later due to testicular failure.

The technique of SSR can retrieve the sperm successfully only in the case of blockage. The SSR technique cannot retrieve sperm in case of testes failing to produce sperm or testicular failure, which accounts for about 30% of azoospermia. Therefore, SSR technique can retrieve sperm successfully in at least 70% of cases of azoospermia.

Testicular Sperm Extraction(TESE)

Indications for surgical sperm retrieval
  • Azoospermia (no sperm in ejaculate) and the need to check the cause of azoospermia
  • Poor quality of sperm in ejaculate with a high degree of sperm DNA fragmentation
Types of surgical sperm retrieval

There are several different types of surgical sperm retrieval.

  • PESA – percutaneous epididymal sperm aspiration
  • TESA – testicular sperm aspiration
  • TESE – testicular sperm extraction

Testicular Tissue After TESA

Is this a painful technique?

Surgical sperm retrieval is usually done under general anesthesia or local anesthesia with deep sedation and pain relief. For our own setting, we use only general anesthesia to make sure that the patient will feel no pain and will feel comfortable enough for go back home a few hours after the procedure.

The general process of the surgery

A fine needle no. 16–18 connected to a syringe is used to aspirate the collection of fluid from the epididymis in the case of known blockage of the ejaculatory duct, such as post-vasectomy (PESA). The collection of fluid will be aspirated. The sperm are harvested in a physiologic culture medium and prepared for use in the ICSI technique.

Testicular Tissue After TESE

If there is no fluid that can be aspirated, the next technique is TESA. The same size of fine needle is inserted into the testicular area and a piece of testicular tissue is aspirated (TESA).  In the case where not enough tissue can be retrieved, a small incision is made in the skin to extract the testicular tissue directly (TESE).

The risk of SSR

Surgical sperm retrieval is of relatively low risk. The main risks of these procedures include bleeding and infection, but these occur in less than 5% of patients. After surgery, the patient will be given a pain and some antibiotic prophylaxis for infection. Usually, the patient will feel a slight discomfort. The surgical wound should be dried off and the patient should avoid showering the wound directly for a week in order to prevent infection. The surgical wound will be completely healed within one week.

Additional benefits of SSR and other indications

The male factor is responsible for the cause of infertility in 50% of couples. of the majority of the male factor is poor semen quality. Poor semen quality can be a low sperm count, low sperm motility and a low percentage of normal sperm morphology. About 30% of poor sperm quality will have additional problems of sperm DNA damage and high sperm DNA fragmentation. Sperm DNA damage and DNA fragmentation will not show in a basic semen analysis at all, and these factors can be the cause of unsuccessful ICSI.  There are some published studies showing the benefit to improve pregnancy outcome using testicular sperm and ICSI who failed multiple IVF cycles due to high levels of sperm DNA fragmentation.