Sperm Retrieval Procedures

Sperm Retrieval Procedures

Sperm harvesting is entirely different from a diagnostic testicular biopsy since in this setting the goal is not to identify what is happening in the testis but instead it is to find sperm.  Only men with no sperm in their ejaculate (azoospermia) need to have sperm retrieved directly from the testis or epididymis.
This may involve a simple aspiration for men who have a blockage or require much more extensive sampling of the testis for men who have a sperm production problem. As a result, there is a significant difference in the amount of time it takes, the need for anesthesia and the equipment utilized.
Very few tests allow for an accurate prediction of whether or not sperm will be found in the testes of men with testicular problems. Genetic testing may give insight into the chance of finding sperm but are not absolute. The pattern of the problem of the testis found at the time of a diagnostic testicular biopsy may be slightly predictive but again there is no finding that absolutely predicts the presence or absence of sperm. Other blood tests including hormonal studies are not predictive.
Finally, even having sperm found on previous harvesting session does not guarantee that sperm will be found on future harvesting attempts. Thus, diagnostic testicular biopsy is not routinely performed in patients who are to undergo testicular harvesting of sperm when the cause of their zero sperm count is already established through other means.
The Timing of Sperm Retrieval
The timing of sperm harvesting in conjunction with the IVF cycle is a difficult matter to resolve. There are advantages for and against doing the sperm harvesting prior to the IVF cycle or in conjunction with the harvesting of the female partner’s eggs. The ultimate decision is made by the preference of the IVF program. Performing the harvesting in advance and freezing the sperm until the eggs are harvested allows the couple to make an informed decision whether to go forward with IVF since in most circumstances the chance of finding sperm may be only 60% or less.
Moreover, it is difficult for many couples to undergo operative procedures the same day since it requires their enlisting other resources to help them get to and from the hospital and assistance at home. IVF laboratories frequently prefer to work with fresh rather than frozen sperm and thus their desire to have fresh sperm trumps any other consideration.
As a result, simple sperm retrievals are typically performed the day of egg retrieval.  Simple sperm retrievals are procedures performed in men with known obstruction who make sperm without a problem.  These procedures are summarized below, and include Testicular Sperm Aspiration (TESA), Percutaneous Sperm Aspiration (PESA), and Testicular Sperm Extraction (TESE).
Microdissection TESE is a much more involved procedure and is performed the day before the female partner’s egg retrieval. Microdissection TESE is carefully coordinated with the reproductive endocrinologist and is performed at designated times on a quarterly basis.
Which Sperm Retrieval Procedure is Recommended?
There are numerous ways to harvest sperm from a man with normal sperm production and a blockage. The simplest and most cost-effective is an aspiration of sperm. This is routinely performed under local anesthesia and takes approximately ten minutes.
Harvesting sperm from a man with a testicular problem is much more difficult and often takes several hours. The ideal procedure, Microdissection Testicular Sperm Extraction, is performed with the aid of a surgical microscope whereby the chances of finding sperm are increased and the amount of tissue taken out of the testis can be minimized.
It is important to understand that the microscope utilized in the operating room does not have sufficient magnification to see sperm but instead just helps sort out which tubules within the testis are more likely to contain sperm. Small amounts of tissue are sent to the IVF laboratory during the course of the procedure so that they can assess whether sufficient numbers of sperm have been harvested. A more powerful microscope is used by the IVF laboratory to evaluate this tissue. Repeated biopsies from one or both testes are obtained until sufficient sperm has been harvested for that IVF cycle. Extra sperm may be harvested to preserve for future cycles of IVF in case the current cycle is unsuccessful or the couple desires more children in the future. This procedure can take as long as four hours depending upon how quickly sperm are found.
Here is a summary of the procedures available for sperm harvesting:
Testicular sperm aspiration (TESA)
Testicular sperm aspiration (TESA) is a procedure performed for men who are having sperm retrieved for in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI).  It is done with local anesthesia in the operating room or office and is coordinated with their female partner’s egg retrieval.  A needle is inserted in the testicle and tissue/sperm are aspirated.  TESA is performed for men with obstructive azoospermia (s/p vasectomy).  Occasionally, TESA doesn’t provide enough tissue/sperm and an open testis biopsy is needed.
Percutaneous Epididymal Sperm Aspiration (PESA)
PESA is a procedure performed for men who are having sperm retrieved for in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) who have obstructive azoospermia from either a prior vasectomy or infection.  It is done with local anesthesia in the operating room or office and is coordinated with their female partner’s egg retrieval.
Testicular sperm extraction (TESE)
TESE involves making a small incision in the testis and examining the tubules for the presence of sperm.   It is either done as a scheduled procedure or is coordinated with their female partner’s egg retrieval.  TESE is usually performed in the operating room with sedation, but can be performed in the office with local anesthesia alone.  Patients usually cryopreserve sperm during this procedure for future IVF/ICSI.  Microdissection TESE has replaced this as the optimal form of retrieval for men with no sperm in their ejaculate (azoospemia) from a problem with production.
Microepididymal Sperm Aspiration (MESA)
MESA is a procedure performed for men who have vasal or epididymal obstruction (s/p vasectomy, congenital bilateral absence of the vas deferens).  It is either done as a scheduled procedure or is coordinated with their female partner’s egg retrieval.  MESA is performed in the operating room with general anesthesia utilizing the operating microscope.  Patients usually cryopreserve sperm during this procedure for future IVF/ICSI.  MESA allows for an extensive collection of sperm as compared to aspiration techniques, and is the preferred method of retrieval for men with congenital bilateral absence of the vas deferens (CBAVD).
Microdissection TESE (microdissection testicular sperm extraction)
Microdissection TESE is a procedure performed for men who have a sperm production problem and are azoospermic.  Microdissection TESE is performed in the operating room with general anesthesia under the operating microscope.  Micro TESE is carefully coordinated with the female partner’s egg retrieval, and is performed the day before egg retrieval.  This allows for each partner to be there for the other’s procedure.  Patients frequently have donor sperm backup in the case that sperm are not found in the male partner.  Micro TESE has significantly improved sperm retrieval rates in azoospermic men, and is a safer procedure since less testicular tissue is removed.  Patients cryopreserve sperm during this procedure for future IVF/ICSI.

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Varicocele

Varicocele

What is a varicocele?
A varicocele is a variation of normal anatomy in which veins in the scrotum (the sac that holds the testicles) become enlarged and sometimes even visible.
Varicocele usually is first found at puberty and is much more common on the left side than on the right side. Sometimes it occurs on both sides.
What causes a varicocele?
Doctors aren’t sure what causes a varicocele. In almost all cases, males are born with this condition but it doesn’t becomes apparent until puberty when there is an increase in blood flow to the genitals.
How common is it?
It is relatively common, occurring in about 15% of adult males.
How is a varicocele detected?
A varicocele is found by physical exam while the man is standing. Varicocele is much less prominent and may disappear while lying down. An ultrasound is not required to diagnose a varicocele. A varicocele that is shown on ultrasound but cannot be felt on physical exam is called a subclinical varicocele.
Is a varicocele harmful?
In most men, varicocele is just an anatomical finding of no clinical significance. However, a varicocele can lead to reduced fertility or scrotal pain. Less than half of men with varicocele have a reduction of sperm count and/or sperm motility (sperm activity), reducing their reproductive potential. Less than 5% of men with varicocele have pain in the scrotal sac due to the varicocele. Varicoceles do not cause any other health problems.
How can a varicocele cause infertility?
It is not known how a varicocele might cause infertility. The most popular theory is that varicocele elevates the temperature of the scrotum because of dilated veins and pooling of blood.
When should a varicocele be treated?
Men with infertility and an abnormal semen analysis  may consider varicocele treatment. Men with a normal  semen analysis do not need to have varicocele treatment. Men who have pain associated with a varicocele can consider varicocele treatment. A subclinical varicocele does not require treatment.
How is a varicocele treated?
The most common treatment is surgery. An incision is made in the groin and the spermatic cord (which contains the vas deferens and blood vessels going to the testicle) is examined. Veins are tied off while arteries, the vas deferens, and lymph vessels are left
alone. This surgery is done as an outpatient procedure under either general or local anesthesia.
Two thirds of men see improvement in their semen analyses and about 40% can achieve a pregnancy. An alternative to surgery is embolization, performed by a radiologist. During embolization, the radiologist uses a catheter to put a coil or fluid in the vein to block blood flow through the vein.
What are the risks of varicocele surgery?
Serious complications are rare. Risks include bleeding, infection, injury to the testicle, blood clots in the legs, and the risks of general anesthesia. About 10%15% of men who
have varicocele surgery will have a recurrence or persistence of varicocele after surgery.

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What is intracytoplasmic sperm injection (ICSI)?

What is intracytoplasmic sperm injection (ICSI)?

Before a man’s sperm can fertilize a woman’s egg, the head of the sperm must attach to the outside of the egg. Once attached, the sperm pushes through the outer layer to the inside of the egg (cytoplasm), where fertilization takes place.
Sometimes the sperm cannot penetrate the outer layer, for a variety of reasons. The egg’s outer layer may be thick or hard to penetrate or the sperm may be unable to swim. In these cases, a procedure called intracytoplasmic sperm injection (ICSI) can be done along with in vitro fertilization (IVF) to help fertilize the egg. During ICSI, a single sperm is injected directly into the cytoplasm the egg.
How does ICSI work?
There are two ways that an egg may be fertilized by IVF: traditional and ICSI. In traditional IVF, 50,000 or more swimming sperm are placed next to the egg in a laboratory dish. Fertilization occurs when one of the sperm enters into the cytoplasm of the egg. In the ICSI process, a tiny needle, called a micropipette, is used to inject a single sperm into the center of the egg. With either traditional IVF or ICSI, once fertilization occurs, the fertilized egg (now called an embryo) grows in a laboratory for 1 to 5 days before it is transferred to the woman’s uterus (womb).
Why would I need ICSI?
ICSI helps to overcome fertility problems, such as:
• The male partner produces too few sperm to do artificial insemination (intrauterine insemination [IUI]) or IVF.
• The sperm may not move in a normal fashion.
• The sperm may have trouble attaching to the  egg.
• A blockage in the male reproductive tract may  keep sperm from getting out.
• Eggs have not fertilized by traditional IVF, regardless of the condition of the sperm.
• In vitro matured eggs are being used.
• Previously frozen eggs are being used.
Will ICSI work?
ICSI fertilizes 50% to 80% of eggs. But the following problems may occur during or after the ICSI process:
• Some or all of the eggs may be damaged.
• The egg might not grow into an embryo even  after it is injected with sperm.
• The embryo may stop growing. 
Once fertilization takes place, a couple’s chance of giving birth to a single baby, twins, or triplets is the same if they have IVF with or without ICSI.
Can ICSI affect a baby’s development?
If a woman gets pregnant naturally, there is a 1.5% to 3% chance that the baby will have a major birth defect. The chance of birth defects associated with ICSI is similar to IVF, but slightly higher than in natural conception.
The slightly higher risk of birth defects may actually be due to the infertility and not the treatments used to overcome the infertility.
Certain conditions have been associated with the use of ICSI, such as Beckwith-Wiedemann
syndrome, Angelman syndrome, hypospadias, or sex chromosome abnormalities. They are thought to occur  in far less than 1% of children conceived using this  technique.
Some of the problems that cause infertility may be genetic. For example, male children conceived with the use of ICSI may have the same infertility issues as their fathers. 

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Discolored semen

Discolored semen

Should I be concerned about discolored semen?
Semen is normally a whitish-gray color. It's usually quite thick after ejaculation, but liquefies within 30 minutes.
Changes in the appearance of semen might be temporary and not a health concern. However, sometimes these changes can be a sign of an underlying medical condition that requires further evaluation.
If changes persist for longer than a week or two or if the color change is associated with other symptoms such as pain, fever, sexual dysfunction or blood in the urine, see your doctor for an evaluation.

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Smoking and Infertility

Smoking and Infertility

Most patients know not to smoke, don’t they? Maybe so, but that doesn’t mean that they (and their partners) don’t smoke, or that they tell the truth to their doc, or that they aren’t exposed to significant amounts of secondhand smoke.
Does everyone remember the 2004 Surgeon General’s Report, The Health Consequences of Smoking? Chapter 5, Reproductive Effects, states, “…smokers may have decreased semen volume and sperm number and increased abnormal forms…Numerous studies have shown that smoking results in reduced fertility and fecundity for couples with one or both partners who smoke….An increasing number of studies have used couples seeking treatment for infertility. These studies have consistently shown that treatment success is affected by smoking. Several studies documented that the success of in vitro fertilization is significantly reduced among smokers compared with nonsmokers.”
Furthermore, nearly half of all nonsmoking Americans are still regularly exposed to secondhand smoke. Infants and children are especially vulnerable. A June 2006 Surgeon General’s Report, The Health Consequences of Involuntary Exposure to Tobacco Smoke, says that even brief secondhand smoke exposure can cause immediate harm, that secondhand smoke exposure is a known cause of sudden infant death syndrome, and that the only way to protect nonsmokers from the dangerous chemicals in secondhand smoke is to eliminate smoking indoors.
The good news is the ready availability of evidence-based Smoking Cessation Guideline materials for health care professionals and the public, including beneficial brief interventions designed for the busy doctor’s office. First developed in 1996, the Guideline is updated regularly.

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