Management of obstructive and non-obstructive azoospermia by intracytoplasmic sperm injection following Percutaneous Epididymal Sperm Aspiration (PESA) or Testicular Sperm Aspiration (TESA)
The injection of a single sperm directly into the center of an egg (ICSI) has now become the treatment choice for couples with a severe male factor. Pregnancy is prevented because poor sperm lack the progressive motility required to break through the outer membrane of the egg (zona pellucida) to achieve fertilisation. We Care's partner fertility centres have performed over 4000 ICSI procedures. Only 7% of patients fail to achieve fertilisation. The first babies were born in 1994, and since then many healthy babies have followed.
The same technology (ICSI) may be used with sperm recovered from those with an irreversible obstruction to the outflow of sperm from the testis, for example men who have no sperm in the ejaculate (azoospermia). Nowadays, this is most frequently due to a failed vasectomy reversal. Other irreversible obstructions include patients with an absent vas, or from previous severe infection.
Many couples now request vasectomy reversal in the hope of having a child when there are altered personal circumstances. However, in only approximately 50% do sperm return following reconstructive surgery and, even in some of these, pregnancy may not result because of the presence of sperm antibodies. The testis do not usually stop producing sperm which become "pent-up" in the epididymis, located on the side of the testis, leading to the vas. However, there may be a relationship between the interval of time since the vasectomy and subsequent pregnancy prospects as a lower success may occur if the vasectomy was performed eight or more years previously.
Until recently there were only a few ways for men with irreversible obstructions to become biological fathers. One way was for the man to undergo a complex open surgical operation on the scrotum using a magnifying microscope to allow for retrieval of sperm from the epididymal tubules located in the collecting epididymis adjacent to the testis. The other is for the couple to use donor sperm.
Details of Clinical and Laboratory Management
Routine ovulation induction, egg collection and embryo transfer will be employed. The husband/partner is required to produce a semen sample on the day of the egg collection. This sample will be especially prepared and will only be used for micromanipulation of the eggs subjected to IVF using ICSI. A second sample is not suitable or sufficient.
We will perform IVF with microinjection of sperm on the eggs recovered from those patients having at least one of the above selected criteria with the patients consent.
Treatment Variations
The eggs from each patient may be split into two groups and subjected to IVF and ICSI, or conventional IVF alone depending upon:
The number of eggs and sperm available and
The fertilisation outcome in previous treatment cycles.
Embryo Transfer
If available, a maximum of two embryos (for women under the age of 40) or three embryos (for women aged 40 or over), will be transferred into the uterine cavity.
These may be derived from : -
ICSI
IVF when the treatment variation has been used and the eggs split into two groups. There is now a large cohort of babies resulting from recovery of sperm from PESA/TESA.
The factors influencing the outcome of treatment The embryos derived following ICSI will be transferred in preference to the conventional IVF ones, leaving the IVF embryos for freezing. This is because micro-injected embryos do not freeze as well as ones fertilised by conventional IVF.
The management of patients after embryo transfer will be the same as our normal IVF programme.
PESA (Percutaneous Epididymal Sperm Aspiration)
PESA has many advantages and is much more acceptable to patients who usually return to work the next day and who generally have no anxiety about its repetition if this is required. If sperm cannot be found in the epididymis we then proceed to a Testicular Sperm Aspiration (TESA). The surgical technique is very similar - the needle is simply inserted into the testis itself.
Using ICSI with PESA/TESA include : -
The age of the woman producing the eggs.
The number of mature eggs available for micro-injection.
The number of embryos transferred.
Treatment with IVF/ICSI/PESA carries a success rate of around 25% per treatment cycle. This has been a tremendous advance for men with both obstructive and non-obstructive oligospermia. Prior to the development of these techniques very little help was available for men with these problem.
In summary IVF and ICSI after PESA is of value for : -
Men with failed vasectomy reversal
Those born with an absent vas
Those with other irreversible obstructions of the genital trac
Men with primary testicular problems with deficient spermatogenesis.
Which Option is Best for Us?
Having so many options is great because "one size does not fit all." A comprehensive male fertility evaluation and a careful discussion with you and your partner will determine which option is the safest and the most efficient way to locate and retrieve sperm for you. Each option has its advantages and disadvantages:
Option
Advantages
Disadvantages
MESA *
? Blood contamination
Lots of sperm back/? Retrieval rates
? Risk of hematoma
Best pregnancy rates
Requires microsurgery expertise
? Cost
General anesthesia
Requires scrotal exploration
? Post-operative discomfort
PESA
No microsurgery expertise required
Local or general anesthesia
Few instruments required
Fast/Repeatable
Minimal post-operative discomfort
? Cost
Feasiblility depends on anatomy
Less sperm back
Blood contamination
? Risk of hematoma
Damage to adjacent tissues
TESA
No microsurgery expertise required
Local or general anesthesia
Few instruments required
Fast/Repeatable
Minimal post-operative discomfort
? Cost
Less sperm back
Blood contamination
? Risk of hematoma
Risk of testicular damage/atrophy
TESE
No microsurgery expertise required
Local or general anesthesia
Few instruments required
Fast/Repeatable
If non-obstructive azoospermia,
Then less sperm back.
Risk of testicular damage/atrophy
Scrotal exploration required
Micro-TESE*
Few instruments required
Best for Non-Obstructive Azoospermia
Microsurgical expertise required.
General anesthesia
Not fast/Time consuming
Scrotal exploration required
??? Cost
?? Risk of testicular damage
?? Post-operative discomfort
Minimally repeatable
* Requires microsurgical expertise with fellowship-training preferable.
For more information, medical assessment and medical quote
send your detailed medical history and medical reports
as email attachment to
Email : - info@wecareindia.com
Call: +91 9029304141 (10 am. To 8 pm. IST)
(Only for international patients seeking treatment in India)
For a detailed evaluation send patient’s medical reports / X rays / doctors notes to info@wecareindia.com
Patient Storys
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