Alternatives to Vasectomy Reversal
For some men, sperm is not present in the ejaculate. Obstructive azoospermia is the result of a blockage in the male reproductive tract, typically due to vasectomy, an absent vas deferens or epididymal obstruction. In this case, sperm production is normal in the testicle but the sperm are trapped inside the epididymis; this entity is known as obstructive azoospermia. Non-obstructive azoospermia (NOA) is when sperm production is impaired or non-existent.
Patients diagnosed with these conditions who wish to initiate a pregnancy may be candidates for sperm retrieval combined with Intracytoplasmic Sperm Injection (ICSI). ICSI is an advanced micromanipulative technique in which a single sperm is injected into an oocyte (immature egg cell) retrieved through an in vitro fertilization (IVF) cycle. Now, men previously considered untreatable and incapable of fathering their own genetic offspring are potentially able to initiate a pregnancy with ICSI. There are two main techniques for sperm retrieval: Microsurgical Epididymis Sperm Aspiration (MESA) and Testicular Sperm Extraction (TESE).
Microsurgical Epididymis Sperm Aspiration (MESA)
Microsurgical Epididymal Sperm Aspiration (MESA) has perhaps been the procedure most commonly performed in men with vasal or epididymal obstruction. A scrotal skin incision is made, and the testis and epididymis are exposed. Using an operating microscope, a single epididymal tubule is opened and sperm are aspirated (extracted). This procedure may be performed with a general anesthetic, or a local anesthetic with intravenous sedation.
MESA has been our procedure of choice because of the ability to retrieve large numbers of sperm that may be cryopreserved (frozen) and used in future cycles. Thus, the need for future procedures is eliminated and the amount of epididymal damage limited. Many men may be candidates for a reconstructive Epididymovasostomy (connection of the vas and epididymis, thereby bypassing a blockage) at the same time of sperm harvest, thus increasing the chances of having sperm appear in the ejaculate. Recovery time from this operative procedure is only a few days, and complications, such as infection or excessive bleeding, are rare.
Testicular Sperm Extraction (TESE)
Testicular Sperm Extraction (TESE) is similar to the MESA technique, but only involves the testis (testicle). A small skin incision is utilized to expose the testis. The biopsy specimen is obtained under direct vision and may be immediately assessed for sperm. The performance of an open testis biopsy for extraction of sperm is an out-patient procedure and may be performed with either a local or general anesthetic. For men with severe impairment of sperm production, only microscopic areas of mature sperm may be present. To find these areas, a careful dissection of the testis is performed using the operating microscope. Known as microsurgical testicular sperm extraction (micro TESE), this technique has enabled sperm retrieval that was previously impossible.