Male Infertility
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Sperm aspiration from the epididymis or testicle - PESA or TESA - and then ICSI and IVF

Sperm can be aspirated with a needle from the testicle or from the vas deferens (a structure right next to the testicle that also contains sperm). The man is given some drugs to sedate him and some local anesthesia is also used to numb the area. Then a small needle is inserted and sperm is aspirated from either the epididymis or the testicle. There should be no severe pain. The procedure generally takes about 30 minutes.

The different sperm aspiration and extraction procedures have long names and also short names (acronyms) : -
  • PESA - Percutaneous Epididymal Sperm Aspiration (can be done in the office)

  • TESA - Testicular Sperm Aspiration (can be done in the office)

  • TESE - Testicular Sperm Extraction (involves a small incision and snipping off some tissue from inside the testicle - often done in a hospital or free-standing surgicenter)
MESA is used in cases of severe male infertility. MESA (micro-epididymal sperm aspiration), is performed under general anesthesia. Using microsurgery techniques, fertility specialists make a small incision in the scrotum and remove fluid and tissue. The wound is closed with dissolvable stitches and swelling and pain subsides within a few days, during which prescribed painkillers may be taken to ease the pain.

Sperm extracted from any of the above procedures can be frozen and cryopreserved for future use.

Patients with a prior vasectomy that wish to have another child have several options. Vasectomy reversal is surgery to reconnect the vas deferens, the structure that carries sperm from the epididymis to the urethra. This procedure is done in the hospital under general anesthesia. The couple may have intercourse to hopefully get pregnant. A vasectomy reversal may fail because of scar tissue formation causing the vas deferens to re-occlude or partially occlude (i.e. low sperm count), or the presence of anti-sperm antibodies (ASA). The other option is IVF (In Vitro Fertilization) with Percutaneous Epididymal Sperm Aspiration (PESA) or Microsurgical Epididymal Sperm Aspiration (MESA). These are forms of Assisted Reproductive Technology. These procedures involve using a small needle to aspirate the sperm under local anesthesia (PESA) or a slightly larger incision to use a microscope for isolation of sperm from the epididymis (MESA). Because the numbers of sperm are typically low and there may be anti-sperm antibodies, IVF with ICSI (intra-cytoplasmic sperm injection) is used to assure fertilization.

CANDIDATES FOR MESA: Obstructive Azoospermia

Candidates for sperm retrieval include men with acquired or congenital reproductive tract obstruction, and men who elect to undergo sperm retrieval as an alternative to surgical reconstruction. Acquired reproductive tract obstruction can occur as a result of infection, trauma, iatrogenic injury or previous failed vasovasostomy or vasoepididymostomy. Iatrogenic injury can occur during bladder neck, pelvic, abdominal or inguino-scrotal surgery.

Congenital anomalies of the male reproductive tract are relatively uncommon in the general population, but can occur in up to 2 percent of infertile men. Perhaps the best known congenital anomaly of the male reproductive tract is congenital bilateral absence of the vas deferens (CBAVD) which occurs in almost all men with cystic fibrosis. CBAVD is now regarded as most commonly reflecting a mild form of cystic fibrosis in which only the reproductive tract anomalies are manifest without pulmonary or digestive symptoms. CBAVD can also probably occur as a result of Wolffian duct anomalies without evidence of cystic fibrosis gene mutations. Unilateral vasal aplasia occurs in less than one percent of the male population and can also be associated with cystic fibrosis gene mutations.

In all cases of reproductive tract obstruction, the optimal treatment is one that will allow the couple to conceive with minimal intervention . When this is impossible (as in CBAVD) or has already failed (as in previous attempts at vasovasostomy or vasoepididymostomy) consideration must be given to the use of sperm retrieval directly from the epididymis or testis with assisted reproduction. Preferably, sperm should be retrieved and cryopreserved during attempts at reconstruction. Because of the association of CBAVD with cystic fibrosis mutations and Wolffian duct anomalies, all men with CBAVD should have renal ultrasounds and their wives should have cystic fibrosis gene mutation analysis prior to attempts at fertility.


Although reports on microsurgical epididymal sperm aspiration with IVF appeared in the literature as early as 1984, the first live birth was not reported until 1990. As it was first described, the procedure of microsurgical epididymal sperm aspiration involved careful dissection of the epididymis under the operating microscope and incision of a single tubule.

Once incised, fluid spills from the epididymal tubule and pools in the epididymal bed. This pooled fluid is then aspirated. Because the epididymis is richly vascularized, this technique invariably leads to contamination by blood cells that may affect sperm fertilizing capacity in vitro.

Our initial experience with this "pool and aspirate" technique was unsuccessful due to contamination of the aspirated sperm with blood products. This appeared to result in impaired sperm function and the inability to fertilize oocytes in vitro. For this reason we developed a technique of micropuncture of the epididymal tubule to avoid blood product contamination. This technique, combined with improved ovarian stimulation techniques and micromanipulation of retrieved sperm, has resulted in markedly improved fertilization and pregnancy rates in our patients with unreconstructable reproductive tract obstruction. The technique of microsurgical epididymal sperm retrieval offers the advantages of minimizing contamination of epididymal fluid with bloodcells, repeated aspirations can be performed, and aspiration of sufficient quantities of fluid for immediate use as well as for cryopreservation are possible.

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