A step-by-step guide to office-based sperm retrieval for obstructive azoospermia

Abstract

A variety of surgical options exists for sperm retrieval in the setting of obstructive azoospermia (OA). With appropriate preparation, the majority of these techniques can safely be performed in the office with local anesthesia and with or without monitored anesthesia care (MAC). The available techniques include percutaneous options such as percutaneous epididymal sperm aspiration (PESA) and testicular sperm aspiration (TESA), as well as open techniques that include testicular sperm extraction (TESE) and microsurgical epididymal sperm aspiration (MESA). In addition to providing a step-by-step description of each available approach, we introduce and describe a new technique for sperm retrieval for OA called minimally invasive epididymal sperm aspiration (MIESA). The MIESA utilizes a tiny keyhole incision, and the epididymis is exposed without testicular delivery. Epididymal aspiration is performed in the style of MESA, except using loupe magnification rather than an operating microscope. MIESA is a safe, office-based procedure in which millions of motile sperm can be retrieved for cryopreservation. While we prefer the MIESA technique for OA, there remain distinct advantages of each open and percutaneous approach. In the current era of assisted reproductive technology, sperm retrieval rates for OA should approach 100% regardless of the technique. This reference provides a roadmap for both advanced and novice male reproductive surgeons to guide them through every stage of sperm retrieval for OA, including preoperative evaluation, patient selection, procedural techniques, and complications. With the incredible advances in in vitro fertilization (IVF), combined with innovative surgical treatment for male factor infertility in recent years, OA is no longer a barrier for men to become biologic fathers.

Keywords: MESA; MIESA; Obstructive azoospermia (OA); PESA; TESA; TESE; epididymal sperm; sperm retrieval; testicular sperm.

Figure 1

Exposure during minimally invasive epididymal sperm aspiration (MIESA). (A) Initial exposure of the epididymis during MIESA; (B) detailed view of the epididymis with dilated epididymal tubules visible.

Figure 2

Aspiration during minimally invasive epididymal sperm aspiration (MIESA). (A) The ophthalmic blade makes an epididymotomy while the assistant aspirates the tubular fluid; (B) the fluid is placed on a slide for evaluation by the embryologist for motile sperm.

Figure 3

Closure of the minimally invasive epididymal sperm aspiration (MIESA). (A) Upon completion of the obliterative aspiration, monopolar electrocautery is used for hemostasis of the epididymis; (B) closure of the skin demonstrates the 1 cm incision used for the MIESA.