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Male Infertility

Sperm production occurs within the seminiferous tubules, a network of microscopic tubules that make up the majority of the testicle. The seminiferous tubules then ultimately form the rete testis, which then drains into the a single convoluted tubule known as the epididymis. The epididymis ends at the vas deferens, a tubular structure for transport of sperm during ejaculation.

A complete cycle of sperm production in the testicle, from an undifferentiated germ cell, to a spermatozoa capable of fertilizing an oocyte takes approximately 64 days. The epididymis acts a reservoir for sperm, also allowing for further maturation. In a normal unobstructed state, sperm found the further along the epididymis tends to be more motile and mature, while sperm closer to the testicle tend to be less vigourous. However, in a chronically obstructed state (i.e. after a vasectomy), more the sperm tends to be more viable and motile closer to the testicle.

Surgical sperm retrieval is performed when a man cannot produce an ejaculated sample himself for a variety of reasons. This may include non-reconstructable causes of obstruction, such as a congenital absence of the vas deferens. In addition sperm can also be collected at the time of other procedures, such as a vaso-epididymostomy. In some cases of a previous vasectomy, sperm retrieval and IVF/ICSI may be undertaken rather than a vasectomy reversal attempt based on the length of time from the original vasectomy or the woman’s age. Finally, in cases of non-obstructive azospermia where there is an underlying problem with sperm production itself, it may be possible to harvest sperm directly from the testicle.

The quantities of sperm retrieved surgically are quite small and must be combined with IVF/ICSI. The sperm can either be used fresh, or cryo-preserved for future uses. Sperm can be taken from epididymis through an open incision and the use of an operating microscope (micro-epididymal sperm aspiration – MESA), or percutaneously (PESA) using a needle to aspirate sperm. Retrieval can also be taken directly from the testicle through an open incision (TESE- Testicular Extraction Sperm).

MESA is usually done under a general anesthetic. The epididymis is visualized and using an operating microscope dilated tubules are identified. These are then incised and sperm is collected. The advantage of this approach is that since there is direct identification of dilated tubules, more sperm can be retrieved than by other routes. However, an open incision is required resulting in more discomfort post-operatively. In addition, a general anesthetic also adds to the complexity of the procedure.

PESA is done under a local anesthetic with a needle inserted into the epididymis to aspirate sperm. Its advantage is that this is generally quicker and easier for the patient with a short recovery time. However, as this is done by feel without identifying the most dilated tubules, this approach generally does not get as much sperm as the MESA.

In some situations, sperm must be harvested directly from the testicle itself using the TESE procedure. This can be done under local anesthetic through a small incision directly into the testicle. A small piece of the testicle is harvested and sperm is teased out from the seminiferous tubules.

In cases of non-obstructive azospermia where even previous biopsy does not show sperm, it may still be possible to retrieve sperm through a procedure known as micro-dissection of the testicle (micro-TESE). In this case, under a general anesthetic the entire testicle is opened and using an operating microscope dilated seminiferous tubules are identified. The chances of finding sperm with this approach are approximately 30-50%.

Vasectomy Reversal

For men who have had a vasectomy, the vas deferens has been divided resulting in an obstruction to sperm passage during ejaculation. It is still possible for them to try to conceive either through sperm retrieval and IVF/ICSI or a vasectomy reversal. The method recommended is based on a number of factors including the length of time from the original vasectomy, the age of the man’s partner and personal preference of the couple.

A microscopic approach under a general anesthetic offers the most accurate method of vasectomy reversal. This involves isolating the vas deferens above and below the site of obstruction, examining the vasal fluid from the testicular side for sperm and then suture the ends together using fine micro-sutures (vaso-vasostomy). The success of the seen from the following table.

Years Since Vasectomy
Patency
Pregnancy Rate
< 3 years
97%
76%
3-8 years
88%
53%
9-14 years
79%
44%
> 15 years
71%
30%

In cases where the severed ends of the vas deferens fails to produce clear fluid or sperm a vaso-epididymostomy may be required. This is a more extensive procedure involving suturing the vas deferens to the tubules of the epididymis itself. The need for this procedure is determined intra-operatively at the time of the vasectomy reversal.

 

 

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