A sperm extraction is a surgical procedure performed to retrieve sperm from the testicle or the epididymis for future in vitro fertilization (IVF). There are many different types of procedures utilized to retrieve sperm.
Percutaneous Epididymal Sperm Aspiration (PESA)
This is a minor surgical procedure typically performed on men who have had previous vasectomy and need sperm extracted for IVF with a female partner. It does not require general anesthesia and typically results in high quality sperm, but there may not be enough remaining sperm to freeze should IVF fail and more cycles are needed.
Occasionally, the physician will need to make a small surgical incision into the testicle (TESE) to get sperm if no sperm are found at the time of PESA or if sperm quality is poor.
Microsurgical Epididymal Sperm Aspiration (MESA)
Requires general anesthesia and surgeon who is trained in microsurgery. Microscopic incision is made in the epididymis (area to the side of testicle where sperm mature) and sperm are obtained for IVF. Quality of sperm is typically excellent with ample sperm retrieved. Unused sperm may be frozen and used at a later date if needed.
Testicular Sperm Extraction (TESE)
This is an open surgical biopsy of the testicle typically done in men who have had a vasectomy and would like to retrieve sperm for IVF. Anesthesia is required. A small opening is made in the scrotum and testicle. A small amount of testicular tissue is then removed and processed by a lab. Some of the sperm will be used for IVF and the rest can be frozen and used at later date if needed. Usually results in ample number of sperm so that repeat procedures can be avoided.
Generally speaking, there are no significant differences in IVF outcomes if frozen sperm are used instead of fresh sperm. We will defer to the REI (Reproductive Endocrinologist) regarding which type they prefer.
Testicular Sperm Aspiration (TESA)
This is a percutaneous approach and is less invasive than TESE. Testicular tissue and sperm are typically obtained through a small needle puncture in the scrotal skin. General anesthesia is usually not necessary and typically results in sufficient quantity/quality of sperm for IVF. Leftover sperm can then be frozen if more rounds of IVF are needed.
Mirco-Testicular Sperm Extraction (Micro-TESE)
Microsurgical testicular sperm extraction is a procedure performed in men with non-obstructive azoospermia (NOA). This means that these men do not have sperm in the ejaculate, and the cause is not obvious (such as a man who has undergone a prior vasectomy or is taking exogenous testosterone)
Success rates for finding sperm in properly evaluated men are approximately 50%. While success rates are not perfect, Micro-TESE does provide an alternative option for couples who desire biological children of their own before pursuing donor sperm or adoption.
Causes for NOA and Genetics Testing
It is often difficult to know the exact cause of NOA in most men. Genetic testing consisting of Y-chromosome microdeletion assay and Karyotype (examination of the patient’s chromosomes).
A Y-chromosome microdeletion is found in a small number of men with NOA. There are 3 different varieties of Y-chromosome microdeletions (A, B, and C) that can affect sperm production. If a man has a complete AZFa or complete AZFb microdeletion, then micro-TESE is NOT recommended as there is no chance for finding sperm at the time of surgery. These couples are not candidates for surgery and may need to consider donor sperm or adoption.
If Y-chromosome microdeletion AZFc is found, then it is ok to proceed with micro-TESE. Success rates for finding sperm in these men is about 50%. If sperm are found during a micro-TESE, then couples should be aware that all male offspring will have this deletion too.
A karyotype analysis is important to rule out a genetic condition called Klinefelter syndrome. These men are typically 47, XXY as opposed to the normal 46, XY karyotype seen in unaffected men. This means that men with Klinefelter syndrome have an extra X chromosome. Males with Klinefelter syndrome typically have small testicles and hypogonadism (low testosterone). The good news is these males also have about a 50% chance of finding sperm at the time of micro-TESE.
If sperm are found, the chance of having offspring with this syndrome returns to baseline for the general population. In other words, it would be very rare for a man with Klinefelter syndrome to have another child with this condition. It is unknown whether sperm retrieval rates are higher in young adolescent males or in adult-aged men with this condition. Many experts believe the sperm producing capability declines over time for these males and an earlier intervention may be warranted while they are still adolescents.
Hormonal Evaluation and Optimization
Hormonal optimization is also very important for men undergoing a micro-TESE. Some studies suggest that success rates will be higher in men who are hormonally optimized.
Many men with NOA will also have low testosterone (hypogonadism). A normal testosterone level is typically defined as a serum testosterone greater than 300 ng/dL for most men. If men are found to have a testosterone less than 300ng/dL then they can consider clomiphene citrate (clomid) or hCG (human chorionic gonadotropin). This is because natural testosterone is vital for sperm production.
Many male fertility experts recommend that men be hormonally optimized at least 3 months prior to surgery. This is because it takes almost 72 days to complete a full sperm cycle.
Importantly, you cannot give men testosterone (shots, gels, or pellets) that is not produced by men themselves as this can shut down sperm production.
Clomid: Clomid is not FDA-approved for men, but it is FDA-approved for women. Clomid has been used safely in men for many years with low testosterone. It is a tablet that is generally taken once a day. It works by blocking estrogen effects in the brain to help men produce more of their own testosterone.
hCG: hCG is another option to help men make more of their own testosterone when their levels are low. It is FDA-approved for men with certain types of low testosterone. It is a subcutaneous injection that is typically given 3 times per week (M, W, F). It works by directly stimulating the testicles in order to make more of their own testosterone.
Follistim (FSH): Follistim is another male hormone that can be given in appropriately selected men to help them produce sperm. This hormone is typically produced by the brain and stimulates the testicles directly to produce sperm. In some men, levels of this hormone can be very low.
If these levels are low, many times this medication is needed. It is a subcutaneous injection that is typically given 3 times per week (M, W, F). It is generally very expensive and usually is not covered by insurance.
What About the Cost of a Sperm Extraction?
Regional Urology offers very competitive pricing. This cost is procedure-specific. These procedures are typically NOT covered by insurance and we offer package pricing (cost of general anesthesia, facility fee, and surgeon fee).
We encourage patients to inquire about pricing before or after their initial consultation in order to receive the most up to date pricing package by calling 318-683-0411 and asking for Male Fertility Coordinator.
We do offer financing through CareCredit.com as needed.
Please alternate ice packs to scrotal incisions for the next 24 hours.
- Ok to remove scrotal support the following day at noon and then shower. No tub baths as stitches in the skin are absorbable.
- No heavy lifting (greater than 10 lbs) for the next 48 hrs. After that it is ok to ease back into activity. Common sense rules apply: if it hurts, don’t do it. Please wear supportive briefs until follow up appointment.
- Swelling, mild bruising, and discomfort are very normal.
- Most men require narcotic pain tablets for 48-72 hours.
- Please call the office if you do not have a follow up appointment scheduled. We generally like to see you back in the office around 2 weeks following your procedure.
- If you had a micro-TESE: spasms of testicular cord occur in about 20% of men. This causes a sudden increase in the pain within the testicle, but it is not dangerous. Please apply warm compresses to the groin area where the cord is located and take the prescribed narcotic pain medication. This will help to ease the spasms.