Open It may distinguish between OA and NOA, extract

Open surgical approaches to surgical sperm retrieval .

Microsurgical
epididymal sperm aspiration (MESA)

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First reported by Temple-Smith et al , MESA was an endeavour at
retrieving more quality sperms in consideration against testicular sperms. This
was conclusively proved by major studies which resulted in superior outcomes in
ICSI with epidydimal sperms against testicular sperms (11)  Several different
techniques for MESA that have been reported in literature (
12,13 14). Extracting sperm from their storage site
in the epididymis is an excellent way of getting sperm to use for IVF in
patients with a blockage in the reproductive tract.Under spinal anesthesia with
a median incision healthier testicle is delivered out while  testis and epididymis is exposed. With the use
of operating microscope and under magnification epididymotomy is performed ,
identifiying a suitable dialated epididymal tubule for sperm aspiration
preferably at distal end of epiidymis where the sperms have completed
maturation process and have acquired motility while their transport as a part
of normal sperm development. More frequently multiple foci aspiration may be
necessary to evaluate before motile sperm are identified.

 

 

 

Microsurgical
epididymal sperm aspiration (MESA)

 

 

 

 

 

TESE (Testicular sperm extraction)

Most popular method of SSR is TESE. Because the
procedure is identical to a testicular biopsy as it does not use operative
microscope and requires extensive microsurgical training.
approximately, 1% of all men and 10%
of all male infertility men are because of NOA, as the result of testicular
failur14.  TESE combined with
ICSI is the first-line treatment in NOA patients. It may distinguish between OA and NOA, extract substantial
sperm for cryopreservation, while it supersedes testicular biopsy and the obtained
tissue can be subjected to histopathology examination contingent upon negative SSR. Using TESE-ICSI,
sperm retrieval leading to pregnancy and the delivery of healthy children is
possible for men with long-standing azoospermia after chemotherapy. Testicular
spermatozoa can be retrieved in some NOA males because of the existence of
isolated foci of active spermatogenesis with a retrieval rate approaching 50%.

 

TESE involves making a small incision in the testis and
examining the tubules for the presence of sperm. It is either done as a
scheduled procedure or is coordinated with their female partner’s egg
retrieval. TESE is usually performed in the operating room with sedation, but
can be performed in the office with local anesthesia alone. The retrieved tissue is then
finely minced with iris scissors within approximately 1 mL of sperm wash medium
in a glass petri dish, and a small drop is placed on a slide for evaluation by
the embryology staff. Hemostasis is achieved through bipolar electrocautery,
and the incision in the tunica albuginea is closed with the pre-placed suture
in running fashion. Multiple biopsy sites are often not necessary. The most appropriate number of biopsies to be
performed still remains controversial. To increase the chance of finding a
focus of sperm production, it is advisable to take multiple samples from
different sites of the testis. In addition, it has been reported that the
number of biopsies required is significantly higher in MA and SCO cases,
compared with hypospermatogenesis patterns, The tunica vaginalis, dartos fascia, and skin are
closed in running fashion with 3-0 chromic.

 

The most appropriate number of biopsies to be performed still
remains controversial. To increase the chance of finding a focus of sperm
production, it is advisable to take multiple samples from different sites of
the testis. In addition, it has been reported that the number of biopsies
required is significantly higher in MA and SCO cases, compared with hypo
spermatogenesis patterns ( 15 )

 

 

Testicular sperm extraction

 

 

Microdissection TESE (microTESE)

 Microdissection
technique was originally described in 1999 ( 16
). MicroTESE is a procedure performed
for men who have a sperm production problem and are azoospermic. MicroTESE is
performed in the operating room with general anaesthesia under the operating
microscope. MicroTESE is carefully coordinated with the female partner’s egg
retrieval, and is performed the day before egg retrieval. This allows for each
partner to be there for the other’s procedure. Patients frequently have donor
sperm backup in case sperm are not found in the male partner. MicroTESE has
significantly improved sperm retrieval rates in azoospermic men, and is a safer
procedure since less testicular tissue is removed. Patients cryopreserve sperm
during this procedure for future IVF/ICSI. Conventional
testicular sperm extraction (c-TESE) in patients with NOA has been partially
replaced by micro-TESE. It is still under debate the problem regarding the
higher costs related to micro-TESE when compared with c-TESE. 

Under
anaesthesia testis is opened widely in an equatorial plane along the mid
portion. This allows wide exposure of seminiferous tubules in a physiological
approach that follows intratesticular blood flow. Due to the heterogeneity of
sperm production in the testicle, microdissection must permit examination of
all seminiferous tubules. Use of the operating microscope with magnification
allows identification of the seminiferous tubules that are most likely to
contain sperm. If sperm production is present within a seminiferous tubule,
then the tubule appears larger and more opaque . Targeting the larger
tubules, improves the yield of sperm retrieval and limits the amount of
testicular tissue that needs to be removed. A comparative study including 116 men found a significantly
higher SRR with micro-TESE 47% vs. 30% in conventional TESE (17) .

 

        Microdissection TESE (microTESE)

Minimal testicular damage is the rule
since only seminiferous tubules are evaluate and thereby increasing chances of
successful sperm retrieval as wide area of testis is examined under
magnification. Though only a small amount of tissue is removed, the large
tunical incision and the dissection of the testicular tissue can cause devascularization
and fibrosis of the testis.

 

 

Comparison of conventional (c) and
microdissection (m) testicular sperm extraction (TESE) sperm retrieval rates
(SRR) ( 18 )

 

 

 

 

 

Single seminiferous
tubule – biopsy (19 )

Vascular injury and
hematoma or fibrosis can result with both open and percutaneous techniques of
sperm retrieval . Shah RS advocated a novel way of examining seminiferous tubule
from an avascular area on tunica albugenia of the testis after it has been
exposed by medial scrotal incision. A single seminiferous tubule is expressed
out of the punctured site and examined for presence of sperms. If sperms are
present more of tubules are retrieved from the same site and can be
cryopreserved for future use of can be used for ICSI concurrently. If negative
for sperms it can be repeated at different sites. Advantage of this procedure
is that punctured sites need not be sutured as these are very small and they
are not bleeding.

Open conventional biopsy versus
microsurgical biopsy techniques

If a single biopsy shows sperm
then the method of biopsy does not make a difference. However, in men with
testicular failure, in whom multiple biopsies have to be done, microsurgical
biopsy techniques – which minimize testicular damage while allowing extensive
sampling – are preferred to the conventional open testicular biopsy.

 

Percutaneous versus open
testicular biopsy

The percutaneous  technique gives adequate tissue in most cases
and is psychologically more acceptable to patients. The open methods (microdissection
and SST) allow for extensive sampling and give the best chances of sperm
recovery, especially when the testis is small and fibrotic.

 

Use of testicular sperm for
increased DNA fragmentation index.

Genetic make up of
the sperm which is vital for normal development of embryo is not ascertained  by normal sperm testing  which is considered a gold standard for
evaluating male  and fertility and it  gives  information only of count, motility and viability.
Levels of DNA damage in the sperms  can
be measured by testing for DNA fragmentation index (DFI). Increased utility of DFI
used in assesing  the outcome of ICSI in
centres where facilities for measuring high DFI is available. Increased DFI of
sperms   is due to excessive production of reactive
oxygen species. Conditions like  infection  leucocytospermia,
high fever ,elevated testicular temperature, varicocoele, advanced age,  obesity and  cigarette smoking.

 

Life style modifications , smoking caesation. exercise
and weight loss , and antioxidant supplementation to reduce ROS levels,  antibiotics  and treating high grade varicocele by
microsurgical varicocelectomy may reduce DFI index in some cases. Not all case
of increased DFI are treatable. It is suggested that damage to DNA occurs at
the post testicular level and in such situation, use of testicular sperm for
ICSI has resulted in improved success rate compared to ejaculated sperm (20 21).

 

Prognostic factors for sperm retrieval in non-obstructive
azoospermia

 

Tough surgical sperm retrieval is practised extensively
still clinicians are unable to predict the percentage chances of successful
sperm recovery as there is still paucity of data derived from  clinical and laboratory prognostic factors. No reliable positive prognostic factors
guarantee sperm recovery for patients with non-obstructive azoospermia. The
only negative prognostic factor is the presence of AZFa and AZFb microdeletions (22 23 )

.

 

1.       
ROC curves for
inhibin B, FSH, and inhibin B/FSH. The table reflects the area under the curve,
the optimal cut-off point, the sensitivity and specificity of each of the
parameters

 

For non-obstructive azoospermia, these
three prognostic factors are typically considered alone or combined with
endocrinologic data. No parameters can reliably
predict whether sperm will be found on TESE. Sperm may be found in men with
very small testesand high FSH levels, irrespective of the general histological
pattern.

 

1.   
Sperm retrieval
rate in azoospermic patients with genetic alterations

 

 

 

2.       
Sperm retrieval
rate in azoospermic patients with genetic alterations

 

 

3.Sperm retrieval rate in patients with nonobstructive
azoospermia depending on testicular size

 

 

 

The
use of surgical sperm retrieval from the testis or epididymis associated to
ICSI has given the chance for azoospermic patients of fathering their own
genetic children. NOA subjects may retrieve spermatozoa through TESE, giving
the chance for an assisted reproductive technology process.  The sperm
retrieval rate in OA patients is about 100%. In NOA, the most frequently
reported sperm retrieval rate is about 50% .

 

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