Surgical Sperm Aspiration (SSR)
This booklet has been written to help fully inform you of the purpose and techniques of this procedure. It is important that you read this in combination with your IVF-ICSI booklet. Please ask for clarification and let us have your comments and suggestions for future editions. It is important that you read and understand all the material as our intention is to keep the risk of an error in treatment at its minimum.
The epididymis is part of the male reproductive system and is present in all male mammals. It is a narrow, tightly-coiled tube connecting the efferent ducts from the rear of each testicle to its vas deferens.
Surgical Sperm Aspiration by Epididymal or Testicular Sperm Aspiraration
Mature sperm can be aspirated from the epididymis and or the testis surgically.
This is done in men who have absence of sperm (azoospermia) because of the obstruction of the tubes that carry sperm from the testis to the outside of the body (the Epididymis and the Vas Deferens).
Sperm obtained in this manner can usually only is used in a cycle of In-vitro Fertilisation (IVF) incorporating Intracytoplasmic Sperm Injection (ICSI) cycle because:
- It would be rare to obtain sperm in this way in sufficient numbers to perform simple insemination procedure.
- It is also exceptional to see sperm not bound to antibodies in these circumstances especially in men with a previous vasectomy. These antibodies restrict the ability of the sperm to fertilise the egg naturally.
IVF simply refers to fertilising the egg outside the body and ICSI involves drawing up a single sperm into a very fine glass needle and injecting it through the zona pellucida (shell of the egg) directly into the cytoplasm or centre of the egg. As the sperm are injected right inside the egg, it does not need to be very motile to fertilise the egg. In this way even with very few aspirated sperm and with very little motility we can fertilise eggs and create embryos for a pregnancy.
How and Where is the procedure performed?
- We can perform this procedure under a local anaesthetic in The Centre for Reproductive Medicine for most men especially those with failed vasectomy reversal or those with evidently blocked tubes but normal hormone levels. This is known as the PESA procedure (Percutaneous Epididymal Sperm Aspiration).
- General anaesthesia is deemed necessary usually when it is expected that PESA is less likely to be successful, on patient request or MESA/TESE is needed. For this admission to the hospital on a day case basis is arranged. The operation is carried out by a trained Surgeon, either an Urologist or Gynaecologist under sterile conditions.
PESA (Per-cutaneous Epididymal Sperm Aspiration)
This term stands for After local or a general anaesthetic, the surgeon palpates and identifies the epididymis and directs the aspiration needle directly into the epididymis.
This is always performed in the first instant and the surgeon will progress to MESA only if this procedure fails on both sides after two or three attempts on each side. Whilst undergoing this procedure under a local anaesthetic you will retain the feeling of touch but we expect that most of the pain sensation would be absent.
MESA (Microsurgical Epididymal Sperm Aspiration)
This term stands for Microsurgical Epididymal Sperm Aspiration. A cut is made into the scrotum to expose the testis and its collecting system which is known as the epididymis so the surgeon can actually see the lattice work of fine tubes inside.
These tubes, known as tubules are then aspirated using a fine needle attached to a syringe under direct vision. This fluid is then examined for the presence of viable sperm.
TESE (Testicular Sperm Extraction)
This term stands for Testicular Sperm Extraction. Unfortunately it is not always possible to retrieve sperm. If no sperm are seen in the PESA and MESA aspirates, it is usual for the surgeon to take a biopsy from the testis.
This tissue is then divided into two parts. One is sent to the laboratory for examination by the pathologist who would report on whether sperm are actually being made in the testis. The other part is dissected to see if mature sperm can be retrieved from the very tubes inside the testicular tissue directly (TESE).
About the process
- First of all we assess the sperm production within the testis and the likelihood of unsuccessful sperm retrieval by assessing your hormone levels.
- If these are normal that makes successful sperm retrieval more likely (but does not guarantee).
- In selected cases with obstructive azoospermia, in the first instance we perform the PESA procedure under local analgesia within The Centre.
- An embryologist will check the fluid aspirated from the testicular tubules. If sperm are identified, they are assessed for viability and if found suitable, they will be stored by freezing in aliquots for use in a future cycle.
- Sometimes sufficient numbers are retrieved with in the first PESA procedure to be sufficient for several treatment cycles.
- If sperm are not identified in this fluid, the MESA procedure is performed after an incision is made in the scrotal skin and the epididymis is directly exposed. This requires operating theatre's facilities and is usually done under general anaesthesia. If the sperm are identified, they are assessed for viability and if found suitable, they will be stored by freezing for use in a future cycle.
- Freezing of live sperm does not guarantee that live sperm will definitely be available after thaw. There is always some damage to the sperm cell membrane during freezing as a result of which not all sperm will survive the freeze-thaw process.
- Occasionally when sperm survival after freeze-thaw is very poor and there is severe reduction in motility, we may perform a repeat PESA procedure on the day of egg collection especially when we know that sperm retrieval is otherwise easy.
- It will usually take about 2-3 hours to recover from your operation if performed under the general anaesthetic. Recovery after the local anaesthetic is much more rapid. You may feel bruised and possibly a little sore.
- If you have had a general anaesthetic or if you are experiencing discomfort, you will need someone to take you home and look after you that evening. It would be helpful to have some mild painkillers available at home.
- You must be prepared to stay in overnight if advised.