23 Muhammad A. Akhtar, Elizabeth Hester, Solmaz Gul Sajjad, and Yasmin Sajjad Surgical management of male infertility, including surgical sperm retrieval (SSR), has greatly improved treatment outcomes for those affected. Around 5% of men suffer with infertility, presenting as either azoospermia, in which no sperm is found in the semen, or oligozoospermia, which is a decreased sperm count with other semen parameters (shape, motility) also frequently altered (Rittenberg and El‐Toukhy 2010). The former, more severe finding may have an obstructive or nonobstructive aetiology (Raheem and Ralph 2011). Obtaining sperm through methods of SSR and using it to attempt conception through intracytoplasmic sperm injection (ICSI) has widened the scope for the success of assisted reproduction (Silber et al. 1994; Devroey et al. 1995). SSR includes either obtaining sperm from epididymis in men with obstructive azoospermia, or obtaining testicular biopsies in men with both obstructive and nonobstructive azoospermia. Laboratories analyse the tissue for the presence of viable sperm and then use cryopreservation if feasible, for use in assisted reproductive treatment. As with all scientific advances, the benefits of treating previously incurable infertility through assisted conception must be weighed up against the drawbacks, not least the risk of hereditary conditions being passed down unimpeded to the next generation (Hansen et al. 2002; Schieve et al. 2002) Whilst other surgical treatment for male infertility exists, this chapter will focus on SSR as a management method for azoospermic patients, and will discuss the different methods of SSR and any pre‐ or postoperative considerations. Azoospermia affects 15% of the infertile male population. It is defined as the presence of no sperm in the semen (Jarow et al. 1989). Two semen analyses should be performed to confirm this according to NICE fertility guidelines (NICE 2013). Obstructive azoospermia (OA) is usually due to mechanical obstruction, mostly in the reproductive ductal system, rather than defective sperm production. Therefore, sperm can be effectively retrieved from the epididymi (Goldstein and Tanrikut 2006). OA may result from epididymal, vasal, or ejaculatory duct pathology. OA may be acquired or congenital, i.e. present from birth. Cystic fibrosis is a common cause of OA due to congenital bilateral absence of vasa deferentia (Anguiano et al. 1992; Chillon et al. 1995). Cystic fibrosis carrier status in either partner may produce consequences for the next generation; therefore, genetic counselling is offered (Sharlip et al. 2002). Acquired causes could be due to infections, iatrogenic injury, or injuries such as testicular torsion which can cause tubular blockage in the testes. Acquired obstructive conditions are often due to bacterial infections such as sexually transmitted or urinary tract infections, which cause scarring and blockage of the epididymis. Vasectomy and other surgical procedures in the inguinal region, such as hernia repair and orchidopexy, can also damage the vas deferens (Baker and Sabanegh 2013). Investigative findings in cases of OA can depend on the underlying pathology; for example, absent vasa deferentia indicate a diagnosis of congenital bilateral absence of vasa deferentia (Schlegel 2004). Characteristic semen parameters with elements of epididymal sclerosis may be seen. However, scrotal ultrasound scans, hormone profiles (follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone, and inhibin), and testicular volume will be universally normal (Esteves et al. 2011b). Nonobstructive azoospermia (NOA) is generally considered a nonmedically manageable cause of male infertility. These patients, who constitute up to 10% of all infertile men, have abnormal spermatogenesis as the cause of their azoospermia. The establishment of in vitro fertilization using ICSI as a standard treatment modality has resulted in a number of these men successfully fathering a child through surgically retrieved sperm from the testis. NOA is caused by faulty sperm production; therefore, more complex retrieval techniques have to be employed, compared with epididymal retrieval for OA (Lopushnyan and Walsh 2012). Coexisting chromosomal (e.g. Klinefelter syndrome) or systemic disorders may become apparent during investigations for male infertility (Kamischke et al. 2003; Weber 2006). Diagnostic criteria for NOA may include reduced testicular volume (<10 cm3), loss of testicular resilience on palpation, and flat epididymis. Some men may have a history of cryptorchidism. In contrast to the normal investigation results in OA, patients with NOA have increased FSH levels, although testosterone and oestradiol levels may remain within a normal range. Palpation may reveal epididymal flattening and reduced testicular volume. Table 23.1 compares the characteristics of OA and NOA. Table 23.1 Comparison of characteristics of obstructive vs nonobstructive azoospermia. FSH, follicle‐stimulating hormone; LH, luteinizing hormone. It is thought that more than half of the infertile male population with azoospermia could be treated surgically (Esteves et al. 2011a) in order to increase the chance of achieving fatherhood. SSR, in combination with ICSI, using sperm obtained from testicular tissue together with an oocyte (Palermo et al. 1992; Silber et al. 1995), allows couples affected by azoospermia to conceive using autologous gametes, rather than be limited to the options of sperm donation or adoption as was previously the case (Lopushnyan and Walsh 2012). After the initial history and examination have been completed, certain investigations are necessary prior to surgery. In order to determine an obstructive or nonobstructive cause for azoospermia and thereby select the appropriate surgical technique, semen analysis and blood tests for a hormone profile must be carried out. The hormone levels of interest are: Karyotype analysis is important in infertile males, especially those with NOA or an especially low sperm count. Y chromosome abnormalities, namely deletions of sperm production genes (in the AZF region on Y chromosome) are more common in azoospermic men. (De Braekeleer and Dao 1991; Samli et al. 2006). Klinefelter syndrome, inversions, and translocations also show increased prevalence in the infertile population (Practice Committee ASRM 2008a). Determining the type of abnormality found during karyotype analysis can help predict the likelihood of viable sperm being found in the testes on retrieval (Brandell et al. 1998; Krausz et al. 2000; Hopps et al. 2003). As previously mentioned, use of assisted reproductive technology such as ICSI may lead to undesirable genetic material being passed through to future generations (Kent‐First et al. 1996). Therefore, karyotype testing and genetic counselling are advised prior to offering any assisted conception treatment. It is important to assess the scrotum and its contents in azoospermic men using scrotal ultrasound scanning (USS), not only to assess testicular volume (Ammar et al. 2012) but also to screen for the presence of testicular tumours, which infertile men are at greater risk of developing (Walsh et al. 2009). Further efforts should be made to offer scrotal USS to the following groups of men: Due to the sensitive nature of SSR and the accompanying patient unease, most operations are carried out using general or regional anaesthetic, especially for open approaches (men with NOA). Alternative strategies to this include inducing anaesthesia using spinal or epidural methods, which may be employed if a patient cannot tolerate general anaesthetic, or spermatic cord block combined with anaesthesia to the surrounding cutaneous regions. Pain can be controlled by local nerve block. Using surgical retrieval, sperm from testicular tissue can be used either fresh or cryopreserved for ICSI treatment. Future repeat attempts may be carried out if care and attention is taken to preserve the integrity of the testes (Esteves et al. 2013). SSR techniques vary depending on whether the cause of azoospermia is obstructive or nonobstructive, as the type of azoospermia determines the site used. In cases of OA, epididymal retrieval, known as percutaneous epididymal sperm aspiration (PESA), is attempted first, unless epididymal pathology inhibits this. Failure of epididymal retrieval warrants progress to testicular retrieval. Testicular sperm retrieval is always used in cases of NOA. Testicular volume and FSH levels can be used to predict presence of viable sperm in the retrieved testicular tissue (Bromage et al. 2007). The surgical approach, as well as the site of retrieval, varies with different techniques. Sperm can be retrieved percutaneously or by using an open approach, with the possibility of enhancing either method further using microscopic surgery (Silber et al. 1994; Craft et al. 1995; Okada et al. 2002). Table 23.2 summarizes the different techniques for OA and NOA and the different possible approaches. Table 23.2 Types of azoospermia and appropriate sperm retrieval methods.
Surgical Sperm Retrieval
Introduction
Azoospermia
Obstructive Azoospermia
Nonobstructive Azoospermia
Obstructive azoospermia
Non‐obstructive azoospermia
Cause
Mechanical obstruction in ductal system
Faulty sperm production in testes
Hormone profile
Normal FSH, LH, testosterone and inhibin
Raised FSH
Normal testosterone and oestradiol
Testicular palpation
Absent vasa deferentia
Epididymal thickening
Epididymal flattening
Reduced testicular tone
Testicular volume
Normal
Reduced
Use of SSR to Treat Azoospermia
Preparation for SSR
Hormone Profile
Karyotyping
Scrotal Ultrasound Scanning
Anaesthetic Considerations
Methods of SSR
Obstructive azoospermia
Epididymal retrieval
Percutaneous epididymal sperm aspiration
(PESA)
Microsurgical epididymal sperm aspiration
(MESA)
Testicular retrieval
(after failed epididymal retrieval)
Testicular sperm aspiration
(TESA)
Testicular fine needle aspiration
(TEFNA)
Testicular sperm extraction
Single or multiple biopsies
(TESE)
Nonobstructive azoospermia
Epididymal retrieval
N/A
Testicular retrieval
Testicular sperm aspiration
(TESA)
Testicular fine needle aspiration
(TEFNA)
Testicular sperm extraction
Single or multiple biopsies
(TESE)
Micro‐surgical testicular sperm extraction
(micro‐TESE)
Methods for Obstructive Azoospermia
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