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Chapter -20 Surgically Retrieved Sperm Samples

BOOK TITLE: Andrology Laboratory Manual

Author
1. Pasqualotto Fabio Firmbach
2. Lara Luana Venturin
3. Pasqualotto Eleonora Bedin
ISBN
9788184489019
DOI
10.5005/jp/books/11172_20
Edition
1/e
Publishing Year
2010
Pages
8
Author Affiliations
1. University of Caxias do Sul, RS, Brazil, Institute of Biotechnology, University of Caxias do Sul, RS, Brazil, Centro de Reproducao Humana, Caxias do Sul, RS, Brazil
2. Conception – Center for Human Reproduction, Rua Pinheiro Machado, 2569, Sl 23/24, Bairro Sao Pelegrino, Caxias do Sul, RS Brazil
3. University of Caxias do Sul, RS, Brazil, CONCEPTION – Center for Human Reproduction, Caxias do Sul, RS, Brazil, Center for Human Reproduction, Caxias do Sul, RS, Brazil
Chapter keywords

Abstract

Azoospermia, the absence of sperm in ejaculated semen, is the most severe form of male factor infertility, present in approximately 5% of all investigated infertile couples. The condition is currently classified as “obstructive” or “non-obstructive,” although it is important to also consider the specific etiology of each individual case. Some cases of obstructive azoospermia are treatable using microsurgical reconstruction of the seminal tract (for example, vasectomy reversal). Unreconstructable obstructive azoospermia and non-obstructive azoospermia historically have been relatively untreatable conditions that required the use of donor spermatozoa for fertilization. The advent of intracytoplasmic sperm injection (ICSI), however, has transformed treatment of this type of severe male factor infertility. Sperm can be retrieved for ICSI from either the epididymis or the testis, depending on the type of azoospermia. Different methods for recovering epididymal or testicular spermatozoa have been described, and each has its drawbacks and advantages. Percutaneous aspiration of the testis may be the method of choice in cases of irreparable obstructive azoospermia. Using a 21-gauge needle, spermatozoa may be recovered in 96% of patients. More patients undergoing fine-needle aspiration experienced less pain than expected as compared with those undergoing open biopsy. Microsurgical epididymal sperm aspiration (MESA) is the preferred method in patients with an incomplete work-up because, if indicated, a vasoepididimostomy can be performed concomitantly with a full scrotal exploration. In azoospermic patients with testicular failure, the sperm recovery rate (the chance of finding at least one spermatozoon) is around 50% after multiple open biopsies. However, fertilization rates after ICSI are significantly lower than in men with normal spermatogenesis, and complete fertilization may occur more frequently. Although the combination of testicular sperm extraction (TESE) and ICSI may be the sole treatment available for infertility because of non-obstructive azospermia, the overall rate is limited and ongoing pregnancies are obtained in < 20% of ICSI cycles. In patients with incomplete Sertoli cell-only syndrome, testicular damage may be limited by use of a selective microsurgical approach; less invasive methods such as fine-needle aspiration are not useful in these patients. Although the pregnancy rates reported after ICSI with frozen-thawed testicular spermatozoa from patients with primary testicular failure are relatively low, the recovery of testicular spermatozoa by open biopsy followed by cryopreservation may be the method of choice by which to prevent repeat surgery and pointless ovarian stimulation in the female partner. Data from randomized trials are insufficient to recommend any particular surgical sperm retrieval techniques for either obstructive or non-obstructive azoospermia. Nonobstructive azoospermia is a difficult area to analyze as the physiology of the testis may differ significantly between individuals. Techniques are modified rapidly and there is much variation among different centers and surgeons. Using the least invasive and simplest (and thereby most cost-effective) method for surgical retrieval of sperm is logical in the absence of evidence to support more invasive or more technically difficult methods. The more invasive methods should currently be reserved for situations where sperm cannot be retrieved by a less invasive technique (such as needle aspiration of the epididymis or testis) or for evaluation in the context of a randomized trial.

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