Sperm Retrieval

Sperm retrieval refers to any procedure that is used to obtain sperm for fertility purposes. In general, sperm retrieval is performed when there is either no sperm present in the semen or if men are unable to ejaculate. In almost all cases, sperm retrieval must be utilized in combination with in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) for reasonable pregnancy rates to be obtained.

There are a number of different techniques of sperm retrieval. The choice of which procedure to use depends on a number of different factors, including the reason why sperm are not present in the semen. Patient preference and skill of the surgeon may dictate which procedure is performed.

What does happens with a normal ejaculation?

Sperm are produced in the testicle. They travel through the epididymis into the vas deferens. The vas deferens joins with the seminal vesicles and when ejaculation occurs semen is deposited within the urethra. When a man reaches a climax during sexual activity (orgasm), coordinated and rhythmic contractions of the pelvis muscles (ejaculation) push semen out of these organs and out the tip of the penis.

When would sperm retrieval be recommended?

The only way to see is there are sperm in the semen is to perform a semen analysis. This involves delivering a semen sample to the doctor's office where the fluid is examined under a microscope. If sperm are not present in the semen, this is called azoospermia and sperm retrieval may be indicated. There generally are two main reasons why a man can have azoospermia:

Obstructive azoospermia sperm are produced by the testicles, but are unable to be released into the semen due to a blockage in the reproductive tract. For example, after a vasectomy, a man has obstructive azoospermia because the sperm are being made but are blocked. Occasionally, the vas deferens may be absent. This is a genetic birth defect and can be due to having the gene that causes cystic fibrosis. Other examples of blockages are blockages in the epididymis and ejaculatory duct or injury to the vas deferens from previous surgery such as a hernia repair.

Non-obstructive azoospermia sperm are either not being produced at all, or they are being produced in such low levels such that there is not enough of them to reach the end of the reproductive tract. Blood tests and genetics tests are usually recommended and may help in determining the cause of non-obstructive azoospermia.

During sexual activity, if a man has an orgasm and no semen is released from the tip of the penis, this can be due to an ejaculation or retrograde ejaculation.

An ejaculation refers to no seminal fluid being released from the reproductive tract into the urethra.

Retrograde ejaculation refers to semen being released into the urethra, but instead of travelling out the tip of the penis, it is pushed backwards into the bladder. Although this can be a cause of infertility, it does not cause any harm to the body.

Both anejaculation and retrograde ejaculation can occur due to injuries or certain types of medical or surgical conditions that prevent the body from being able to ejaculate semen out the tip of the penis in the usual fashion.

It is possible to differentiate between anejaculation and retrograde ejaculation by checking a urine sample for sperm after a man has had an orgasm. If viable sperm cannot be obtained from standard optimized collection methods, sperm retrieval may be necessary.

The types of sperm retrieval techniques are listed below. This information should help you and your partner be better prepared to discuss treatment options with your urologist.

What are Treatment Options?

If a man has azoospermia, sperm can be retrieved from the reproductive tract by various approaches. In each case, the goal is to obtain the best quality and number of sperm, and minimize damage to the reproductive tract so future attempts at retrieval or surgical reconstruction are not jeopardized. Often known by their acronyms, these procedures include:

Testicular sperm extraction (TESE): This technique can be used to not only diagnose the cause of a man's azoospermia, but also to obtain sufficient tissue for sperm extraction to be used either fresh or as a cryopreserved (frozen) specimen for IVF with ICSI. It involves one or multiple small incisions in the testes and can be performed in the office with a nerve block or under anesthesia in an ambulatory surgery center.

Testicular sperm aspiration (TESA) is also sometimes referred to as Testicular fine needle aspiration (TFNA): TESA can be a diagnostic and therapeutic procedure in azoospermic men and can be utilized to recover sperm from the testicles. Using a nerve block in the office or in the operating room, a needle and syringe are used to puncture the skin and testis directly to aspirate a sperm specimen without a formal scrotal incision.

TESA with MAPPING: In some cases, this technique is employed with patients with non-obstructive azoospermia. Multiple TESA needle aspirations are spread throughout the entire area of the testes. Some feel that this technique has a better chance at recovering sperm than standard techniques.

Percutaneous epididymal sperm aspiration (PESA): This technique is ONLY utilized for men with obstructive azoospermia, for example after a vasectomy. Advocated because it can be performed repeatedly at low cost, PESA, like TFNA, can be completed without a surgical incision. Because it does not require a high-powered microscope, it also does not necessitate microsurgical expertise. Instead, it is done under local or general anesthesia with the physician inserting a needle attached to a syringe into the epididymis, then gently withdrawing fluid. Sperm may not always be obtained with this approach, so you and your urologist must be prepared to perform an open procedure if necessary.

Microsurgical epididymal sperm aspiration (MESA): Also performed only for obstructive azoospermia, MESA involves direct retrieval of sperm from individual epididymal tubules using an operating microscope. It is completed by isolating the tubules and then aspirating the epididymal fluid. This can be performed by direct aspiration or incision and collection of epididymal fluid as it is released from the tubules using a small aspirating syringe. Designed to limit damage to the epididymis, while avoiding blood contamination of its fluid, MESA yields high quantities of motile sperm that can be readily frozen and thawed for multiple subsequent IVF treatments. It is usually performed in the operating room with local anesthesia and sedation and occasionally general anesthesia. In most cases, better and more highly motile sperm are obtained and is usually sufficient for multiple cycles of IVF and ICSI. MESA is a simple and safe, sperm recovery technique.

Microsurgical testicular sperm extraction (Micro-TESE): Performed only in cases of non-obstructive azoospermia, micro-TESE involves opening the outer cover of the testicle and examining the inside of the testis under an operating microscope. Using this technique, your urologist can see areas that may appear "different" than other areas where sperm are being produced, compared to areas where sperm are absent. Although this technique is performed by a urologist that is trained in microsurgery usually in the operating room under local anesthesia with sedation or general anesthesia. In this procedure, more testis is examined, however less testicular tissue is removed. Damage to testicular blood vessels is minimized, and some feel that success rates of finding sperm may be slightly higher than a conventional TESE that is performed without the use of high-powered optical magnification.

Are there other situations where sperm retrieval may be performed?

If a man has anejaculation or retrograde ejaculation due to a spinal cord injury, advanced diabetes, multiple sclerosis, psychological issues or from pelvic surgery, it may be possible to induce an ejaculation. Penile vibratory stimulation (PVS) can be used to induce ejaculation by placing a specially designed vibrator to the tip of the penis. If this is not successful, electroejaculation (EEJ) may also be used by delivering electric energy to the prostate and seminal vesicle through a rectal probe. EEJ may be performed in the office for men with spinal cord injuries and no sensation but requires a general anesthetic for men who have normal sensation. If penile vibratory stimulation or electroejaculation are unsuccessful, a testis sperm procedure may be indicated or may be utilized as a primary procedure in some cases.

What to expect after treatment?

If a man has had a testicular or epididymal sperm retrieval, the recovery time depends on what technique was used and can range from a few days to a couple of weeks.

Most men will be instructed to avoid strenuous activity and use a scrotal or athletic supporter until they are fully recovered. Ice packs are useful in the immediate post operative period. Oral pain medications are generally prescribed. Your urologist may also prescribe an antibiotic before and/or after a sperm retrieval to reduce the risk of an infection. You may or may not have stitches placed in the skin, depending on what approach to sperm retrieval is used. Most patients can return to office work in 24-48 hours and heavy work within 5-10 days.

Possible complications can include bleeding, infection, pain, the chance of not finding sperm, the need for future procedures, and rarely testicular injury or loss.

Frequently asked questions:

How long does a sperm retrieval take?

Depending on the cause of the azoospermia, the type of sperm retrieval technique used, and how soon sperm are found, the procedure can take anywhere from minutes to hours.

How much does a sperm retrieval cost?

The cost of a sperm retrieval can depend on a number of different factors including the type of procedure being performed, the location of the procedure (i.e. in the office or in the operating room), how long the procedure takes, whether or not sperm are being used fresh or will be frozen for later use.

Office procedures performed under straight local anesthesia do not require the cost of a surgical suite or a formal anesthesia team.

What happens if no sperm are found?

In cases of obstructive azoospermia, failure to obtain sperm is rare. In cases of non obstructive azoospermia, inability to retrieval sperm occurs in 20-80% of cases depending on the associated condition.

Not finding sperm is always a possibility and can be emotionally devastating to men and their partners. Couples should thoroughly discuss this with each other and their doctors well in advance of the procedure. If no sperm are found at the time of a sperm retrieval procedure, one option is to be prepared to use donor sperm as backup for assisted reproductive technologies such as IVF/ICSI. The decision to use donor sperm is a very personal one that individual couples need to address and prepare for PRIOR to surgery. If the use of donor sperm is not an option for couples, then adoption remains a viable option for family planning.

Links to Support Groups
American Society for Reproductive Medicine (ASRM)
Society for the Study of Male Reproduction's (SSMR)