Management of obstructive and non-obstructive azoospermia by intracytoplasmic sperm injection following Percutaneous Epididymal Sperm Aspiration (PESA) or Testicular Sperm Aspiration (TESA)
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.
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.
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 : -
- 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.
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