Surgical Sperm Retrieval: Types, Procedure, Recovery, and Success in Fertility Treatment

What Is Surgical Sperm Retrieval?

Surgical sperm retrieval is defined as a collection of methods used to collect sperm directly from the reproductive tract of males. This process is used when sperm cannot be retrieved through ejaculation. In some cases, sperm may be collected from the epididymis, which is a tightly packed tube situated behind the testes, where the sperm matures and is stored. The sperm can also be collected directly from the testicles, where it is produced. Surgical sperm retrieval methods are chosen depending on the location of the sperm and the underlying cause of infertility.

Understanding the Procedure

Surgical sperm retrieval is a carefully planned process in which sperm is collected from the male reproductive tract, and the sperm is later prepared for the fertilisation procedure. Before the procedure, doctors consider different factors, such as the results of semen analysis, medical examination, and medical history of the individual, to choose the right method of sperm collection. The collected sperm is tested in the lab to choose the sperm cells that can either be used instantly or cryopreserved. As per the World Health Organisation (WHO, 2021), the semen and sperm cells are preserved and processed in such a way that the quality of sperm is ensured throughout the fertility procedures.

Why Is It Performed?

Surgical sperm retrieval is carried out when the sperm cannot be retrieved through ejaculation even when the sperm exists in the reproductive tract. The main purpose of surgical sperm retrieval is to collect the sperm, which will be used in the process of infertility treatments. It cannot be used to address the cause of the infertility problem.

This process is usually undertaken where there is an issue with the delivery of the sperm or the production of the sperm itself. In some cases, the sperm may be produced normally, but its transportation to the semen becomes restricted due to obstruction. In other instances, sperm production may be low, but a few sperm cells can be extracted from the tissue of the testicle.

The collected sperm is used along with other reproductive techniques such as in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). They involve the injection of a single sperm directly into the egg cell to enhance fertilisation.

Who May Need Surgical Sperm Retrieval?

Surgical sperm retrieval can be considered for males who cannot provide usable sperm during ejaculation but wish to use their own sperm during fertility treatment. The doctor might recommend this procedure in cases like

• Azoospermia: No sperm is present in the semen due to a blockage or lower sperm production.
• Blocked sperm pathways: Certain cases block the transport of sperm and cause blockade like previous surgeries, infections, or congenital conditions.
• Sperm retrieval after vasectomy: When a male patient wishes to use his own sperm for fertility treatment after a vasectomy procedure.
• Ejaculation difficulties: When certain health problems prevent the release of sperm naturally.

What Are the Types of Surgical Sperm Retrieval

The most appropriate type of surgical sperm retrieval depends on the location of the sperm and the cause of inability to obtain sperm through ejaculation. Some procedures obtain sperm from the epididymis, while other procedures obtain sperm directly from the testes. According to the Indian Journal of Urology (2011), the most common procedures used for sperm retrieval include epididymal aspiration techniques and testicular retrieval procedures. The techniques are selected based on the cause of male infertility and the expected availability of the sperm.

PESA (Percutaneous Epididymal Sperm Aspiration)

• Percutaneous epididymal sperm aspiration is a minimally invasive procedure in which the doctor uses a very thin needle to retrieve the sperm from the epididymis
• PESA is commonly used in obstructive azoospermia cases where sperm production is normal, but a blockage prevents the sperm from reaching the semen.

MESA (Microsurgical Epididymal Sperm Aspiration)

• Microsurgical epididymal sperm aspiration is a surgical procedure where the doctor uses a microscope to open the epididymal tubules within the epididymis to extract the sperm-rich fluid.
• It is also used for patients with obstructive azoospermia, where adequate sperm production may be blocked due to various causes.

TESA (Testicular Sperm Aspiration)

• Testicular sperm aspiration involves the insertion of a thin needle directly into the testicle to obtain a small amount of tissue or fluid
• It is recommended for individuals with non-obstructive azoospermia, where sperm production is limited, or in cases where testicular sperm is preferred.

TESE (Testicular Sperm Extraction)

• Testicular sperm extraction is a process through which a small segment of the testicular tissue is removed by a minor surgical incision.
• The tissue is then examined in the laboratory to locate the sperm cells, which will be used for assisted reproductive procedures.

Micro-TESE (Microsurgical Testicular Sperm Extraction)

• Microsurgical testicular sperm extraction is an advanced technique where the doctors use a high-powered microscope to identify parts of the testes with greater chances of containing sperm-producing tissues
• A part of the tissue from these regions is extracted and analysed to find usable sperm while reducing the amount of tissue removal required.

How Is Surgical Sperm Retrieval Performed?

Surgical sperm retrieval may follow specific procedures based on the cause of the patient’s infertility and the technique selected. However, most procedures involve a standard process to increase the chances of collecting viable sperm while minimising complications. 

Pre-Procedure Evaluation

Before starting the procedure, the fertility expert may evaluate the patient to establish the right method for collecting sperm. This may include:

• An analysis of past medical history, history of previous surgeries, or fertility treatments, including vasectomy
• Sperm analysis reports may help to check the presence or absence of sperm.
• Assessing hormonal levels like follicle-stimulating hormone (FSH) and testosterone to examine testicular function
• Undertaking a physical examination to assess testicular size, the epididymis and the vas deferens.
• Further diagnostic procedures, like genetic testing or scrotal ultrasound, could be suggested to men who suffer from non-obstructive azoospermia.

Anaesthesia

The type of anaesthesia used depends on the retrieval method and the general health condition of the patient.

• Simpler retrieval methods (TESA and PESA) - Local anaesthesia
• More complicated retrieval methods (TESR and Micro-TESE) - General anaesthesia or  regional anaesthesia

Sperm Retrieval

After the anaesthesia takes effect, the physician retrieves the sperm either from the epididymis or testicular tissue using the selected technique, such as PESA, MESA, TESA, TESE, or micro-TESE. Generally, the minimally invasive procedure that is appropriate for the patient’s health is selected. Micro-TESE may be recommended in case of severely reduced sperm production, as it helps to locate the sperm-producing regions more precisely.

Laboratory Processing

The tissue or fluid that has been collected is transferred to the embryology laboratory, where it is microscopically examined by experts for viable sperm. In case no sperm cells are found in the collected sample, other issues can be processed using TESE and micro-TESE. The sperm that are retrieved are prepared for use in assisted reproductive technology like IVF and ICSI.

Cryopreservation (If Appropriate)

If viable sperm cells have been retrieved, they can be frozen for future use through a technique called cryopreservation. Sperm freezing enables the storage of the sperm until an IVF or ICSI treatment is required. It eliminates the need for sperm retrieval when multiple fertility treatment cycles are needed. It depends on the number of sperm that have been retrieved from the surgery. 

How Is the Retrieved Sperm Used?

The collected sperm is generally used in assisted reproductive technology (ART); most commonly, ICSI is used. The surgically collected sperm may be:

• Used immediately in IVF: The collected fresh sperm can be immediately used for egg fertilisation in an IVF cycle.
• Fertilisation using ICSI: ICSI involves directly injecting a healthy sperm into the egg to achieve fertilisation. It is recommended that surgically retrieved sperm are generally less and cannot fertilise eggs on their own.
• Frozen for future use: If appropriate sperm are collected, they can be cryopreserved and stored. Cryopreserved sperm can be used in future cycles of IVF or ICSI after thawing, avoiding further retrieval surgery.

Benefits of Surgical Sperm Retrieval

Depending on the cause of the male infertility, surgical sperm retrieval provides various benefits, including:

• Allows many males who suffer from either obstructive or non-obstructive (selected cases) azoospermia to use their own sperm for assisted reproduction rather than donor sperm.
• Sperm retrieved by surgery can be used for IVF and ICSI procedures to achieve fertilisation even when there is a small amount of viable sperm.
• Methods like PESA, MESA, TESA, TESE, and Micro-TESE provide the possibility to use a proper technique depending on the cause of infertility and localisation of the sperm.
• If adequate viable sperm are present after retrieval, they can be preserved by cryopreservation for later use in IVF or ICSI cycles without additional retrieval surgery.

Risks and Possible Complications

Surgical sperm retrieval is usually regarded as a relatively safe procedure, especially when it is done by a highly skilled surgeon. However, like any other surgery, there are certain risks associated with it, which include:

• Pain or discomfort that improves within a few days with medications.
• Temporary swelling and bruising of the scrotum that resolves on its own
• Collection of blood in the scrotum resulting in a haematoma, which is usually uncommon.
• Possibility of infections that can be minimised using proper medications and post-operation care.
• TESE and micro-TESE may temporarily impact testosterone production.
• In certain cases of non-obstructive azoospermia, sperm retrieval is not always successful.

Recovery After Surgical Sperm Retrieval

The surgical sperm retrieval procedure usually has a fast recovery, with most men returning to their routine activities within a few days. However, recovery can be delayed in some advanced procedures like TESE and micro-TESE. Pain, swelling, and bruises are common and can be relieved using proper medications and rest. Physical activities like strenuous exercise, heavy lifting, and sexual activity are usually advised to be avoided for a certain period to allow proper healing. The research in reproductive medicine and biology states that most patients recover successfully with appropriate postoperative care and proper follow-up.

Conclusion

Surgical sperm retrieval can be considered a valuable option for males who are unable to produce sperm but want to use their own sperm in the process of fertilisation. Different approaches to retrieval exist, and the choice of the appropriate technique is dependent on the cause of male infertility and the patient’s health condition. The knowledge of the procedure, the process of how the retrieved sperm is used in IVF with ICSI, benefits, risks, and recovery from the operation should be considered. Consulting a fertility specialist is important to determine if the surgical sperm retrieval procedure is the right approach for your reproductive goals.