Tag: Azoospermia

Azoospermia

  August 9, 2020
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Azoospermia means there’s no sperm in a man’s ejaculate. Its causes include a blockage along the reproductive tract, hormonal problems, ejaculation problems or issues with testicular structure or function. Many causes are treatable and fertility can be restored. For other causes it may be possible to retrieve live sperm to be used in assisted reproductive techniques.

What is azoospermia?

Azoospermia is a condition in which there’s no measurable sperm in a man’s ejaculate (semen). Azoospermia leads to male infertility.

How common is azoospermia?

About 1% of all men and 10% to 15% of infertile men have azoospermia.

What are the parts of the male reproductive system?

The male reproductive system is made up of the following:

Testes, or testicles produce sperm (male reproductive cells) in a process called spermatogenesis.

Seminiferous tubules are tiny tubes that make up most of the tissue of the testes.

Epididymis is the structure on the back of each testicle into which mature sperm are moved and stored.

Vas deferens is the muscular tube that passes from the epididymis into the pelvis then curves around and enters the seminal vesicle.

Seminal vesicle is a tubular gland that produces and stores most of the fluid ingredients of semen. The vesicle narrows to form a straight duct, the seminal duct, which joins with the vas deferens.

Ejaculatory duct is created when the seminal vesicle duct merges with the vas deferens. The ejaculatory duct passes into the prostate gland and connects with the urethra.

Urethra is the tube that runs through the penis to eliminate urine from the bladder and semen from the vas deferens.

During ejaculation, sperm move from the testes and the epididymis into the vas deferens. Tightening (contraction) of the vas deferens moves the sperm along. Secretions from the seminal vesicle are added and the seminal fluid continues to move forward toward the urethra. Before reaching the urethra, the seminal fluid passes by the prostate gland, which adds a milky fluid to the sperm to form semen. Lastly, the semen is ejaculated (released) through the penis through the urethra.

 

A normal sperm count is considered to be 15 million/mL or more. Men with low sperm counts (oligozoospermia or oligospermia) have a sperm concentration of less than 15 million/mL. If you have azoospermia, you have no measurable sperm in your ejaculate.

Are there different types of azoospermia?

There are two main types of azoospermia:

Obstructive azoospermia:

This type of azoospermia means that there is a blockage or missing connection in the epididymis, vas deferens, or elsewhere along your reproductive tract. You are producing sperm but it’s getting blocked from exit so there’s no measurable amount of sperm in your semen.

Nonobstructive azoospermia:

This type of azoospermia means you have poor or no sperm production due to defects in the structure or function of the testicles or other causes.

What are the causes of azoospermia?

The causes of azoospermia relate directly to the types of azoospermia. In other words, causes can be due to an obstruction or nonobstructive sources.

Obstructions that result in azoospermia most commonly occur in the vas deferens, the epididymus or ejaculatory ducts. Problems that can cause blockages in these areas include:

  • Trauma or injury to these areas.
  • Infections.
  • Inflammation.
  • Previous surgeries in the pelvic area.
  • Development of a cyst.
  • Vasectomy (planned permanent contraceptive procedure in which the vas deferens are cut or clamped to prevent the flow of sperm).
  • Cystic fibrosis gene mutation, which causes either the vas deferens not to form or causes abnormal development such that semen gets blocked by a buildup of thick secretions in the vas deferens.

 

Nonobstructive causes of azoospermia include:

  • Genetic causes. Certain genetic mutations can result in infertility, including:
  • Kallmann syndrome: A genetic (inherited) disorder carried on the X chromosome and that if left untreated can result in infertility.
  • Klinefelter’s syndrome: A male carries an extra X chromosome (making his chromosomal makeup XXY instead of XY). The result is often infertility, along with lack of sexual or physical maturity, and learning difficulties.
  • Y chromosome deletion: Critical sections of genes on the Y chromosome (the male chromosome) that are responsible for sperm production are missing, resulting in infertility.
  • Hormone imbalances/endocrine disorders, including hypogonadotropic hypogonadism. hyperprolactinemia and androgen resistance.
  • Ejaculation problems such as retrograde ejaculation where the semen goes in to the bladder
  • Testicular causes include:
  • Anorchia (absence of the testicles).
  • Cyptorchidism (testicles have not dropped into the scrotum).
  • Sertoli cell-only syndrome (testicles fail to produce living sperm cells).
  • Spermatogenic arrest (testicles fail to produce fully mature sperm cells).
  • Mumps orchitis (inflamed testicles caused by mumps in late puberty).
  • Testicular torsion.
  • Tumors.
  • Reactions to certain medications that harm sperm production.
  • Radiation treatments.
  • Diseases such as diabetes, cirrhosis, or kidney failure.
  • Varicocele (veins coming from the testicle are dilated or widened impeding sperm production).

 

How is azoospermia diagnosed?

Azoospermia is diagnosed when, on two separate occasions, your sperm sample reveals no sperm when examined under a high-powered microscope following a spin in a centrifuge. A centrifuge is a laboratory instrument that spins a test sample at a high speed to separate it into its various parts. In the case of centrifuged seminal fluid, if sperm cells are present, they separate from the fluid around them and can be viewed under a microscope.

As part of the diagnosis, your healthcare provider will take your medical history, including asking you about the following:

  • Fertility success or failure in the past (your ability to have children).

  • Childhood illnesses.
  • Injuries or surgeries in the pelvic area (these could cause duct blockage or poor blood supply to the testicles).
  • Urinary or reproductive tract infections.
  • History of sexually transmitted diseases.
  • Exposure to radiation or chemotherapy.
  • Your current and past medications.
  • Any abuse of alcohol, marijuana or other drugs.
  • Recent fevers or exposure to heat, including frequent saunas or steam baths (heat kills sperm cells).
  • Family history of birth defects, mental retardation, reproductive failure or cystic fibrosis.

 

Your healthcare provider will also conduct a physical examination, and will check:

  • Your entire body in terms of signs of/lack of maturation of your body and reproductive organs.

  • Your penis and scrotum, checking for the presence of your vas deferens, tenderness or swelling of your epididymis, size of the testicles, the presence or absence of a varicocele, and any blockage of the ejaculatory duct (via exam through the rectum) as evidenced by enlarged seminal vesicles.

Your healthcare provider may also order the following tests:

  • Measurement of testosterone and follicle-stimulating hormone (FSH) levels.
  • Genetic testing.
  • X-rays or ultrasound of the reproductive organs to see if there are any problems with the shape and size, and to see if there are tumors, blockages or an inadequate blood supply.
  • Imaging of the brain to identify disorders of the hypothalamus or pituitary gland.
  • Biopsy (tissue sampling) of the testes. A normal biopsy would mean a blockage is probable at some point in the sperm transport system. Sometimes, any sperm found in the testes is frozen for future analysis or can be used in assisted pregnancy.

 

How is azoospermia treated?

Treatment of azoospermia depends on the cause. Genetic testing and counseling are often an important part of understanding and treating azoospermia. Treatment approaches include:

  • If a blockage is the cause of your azoospermia, surgery can unblock tubes or reconstruct and connect abnormal or never developed tubes.
  • If low hormone production is the main cause, you may be given hormone treatments. Hormones include follicle-stimulating hormone (FSH), human chorionic gonadotropin (HCG), clomiphene, anastrazole and letrozole.
  •  
  • If a varicocele is the cause of poor sperm production, the problem veins can be tied off in a surgical procedure, keeping surrounding structures preserved.
  • Sperm can be retrieved directly from the testicle with an extensive biopsy in some men

If living sperm are present, they can be retrieved from the testes, epididymis or vas deferens for assisted pregnancy procedures such as in vitro fertilization or intracytoplasmic sperm injection (the injection of one sperm into one egg). If the cause of azoospermia is thought to be something that could be passed on to children, your healthcare provider may recommend genetic analysis of your sperm before assisted fertilization procedures are considered.

How can azoospermia be prevented?

There is no known way to prevent the genetic problems that cause azoospermia. If your azoospermia is not a genetic problem, doing the following can help lessen the chance of azoospermia:

  • Avoid activities that could injure the reproductive organs.
  • Avoid exposure to radiation.
  • Know the risks and benefits of medications that could harm sperm production.
  • Avoid lengthy exposure of your testes to hot temperatures.

 

What is the long-term outlook for those with azoospermia?

Every cause of azoospermia has a different prognosis. Many causes of azoospermia can be reversed. You and your healthcare team will work together to determine the cause of your azoospermia and treatment options. Hormonal problems and obstructive causes of azoospermia are usually treatable and fertility can potentially be restored. If testicular disorders are the cause, it’s still possible to retrieve live sperm to be used in assisted reproductive techniques.

 

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Microsurgical Testicular Sperm Extraction (Micro-TESE)

  April 4, 2018
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Microsurgical Testicular Sperm Extraction (Micro-TESE)

Advances in reproductive medicine over the last 10 years have allowed men who were previously considered absolutely sterile to father biological children.

Those advances have come on two fronts. The first was the advent of In-Vitro Fertilization (IVF) with Intra-Cytoplasmic Sperm Injection (ICSI).

This technological breakthrough reduced the requirement of the number of sperm needed to fertilize an egg from millions to just one sperm per egg. It meant that men with very low sperm counts who could not be improved with other means had a new way of effectively conceiving. It also led us to reexamine our understanding how the testicles function.

It turns out that men who have no sperm in the ejaculate because of problems with sperm production, a condition called Non-Obstructive Azoospermia (NOA), actually may have small pockets of sperm production within the testicle. In fact, greater than 60% of men with NOA actually do produce small amounts of sperm inside the testicle that can be used with IVF/ICSI to create a baby.

Sounds like great news all around, right? Well, the challenge for experts has been to develop techniques that improve the chances of finding sperm inside the testicle and then to create effective strategies to best harvest that sperm IN THE SAME PROCEDURE, for use with IVF.

 

Extracting that single sperm takes skill and technology

A new surgical technique, called Microsurgical Testicular Sperm Extraction or “Micro-TESE” has been developed to detect sperm in the testicles of men who have poor sperm production.

Because the testicular tubules are microscopic structures, they cannot be distinguished by the naked eye. However, by using an operating microscope to examine the tubules at the time of testicular biopsy, So that the Andrologist can selectively remove the “better” or more normal appearing tubules. He is very aware that there is a higher chance that he will find sperm in “fuller,” more normal tubules than in scarred or fibrotic tubules.

Once the specimens are removed, the tubules are opened in a Petri dish containing sperm wash media and the search for sperm begins by examining the specimens under the microscope. It can take up to five hours to search for sperm in the specimens. This is a very involved and tedious process, but very thorough and important. Once they are found, the sperm are then either incubated and injected into awaiting eggs or frozen for future injection.

This advanced technique allows us to direct the biopsy to the best areas and increase the chance of finding sperm while removing smaller amounts of tissue then a random biopsy, causing less damage.

Micro-TESE can be performed as a diagnostic procedure and if usable sperm are found, then they can be frozen and the couple is recommended to proceed with ICSI. It can also be performed and timed with an egg retrieval/IVF cycle so that the sperm are injected into the eggs without freezing. Freezing the sperm from men with sperm production problems can be difficult since these sperm are usually few in number and don’t thaw well. Therefore the best chance of pregnancy is to use fresh sperm obtained just prior to IVF.

The chance of finding sperm with Micro-TESE is better than 60%. This is twice the chances of finding sperm by non-microsurgical or needle biopsies taken by general urologists.

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Male Infertility

  December 20, 2017
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Male Infertility

Definition

Up to 15 percent of couples are infertile. This means they aren't able to conceive a child even though they've had frequent, unprotected sexual intercourse for a year or longer. In up to half of these couples, male infertility plays a role.

Male infertility is due to low sperm production, abnormal sperm function or blockages that prevent the delivery of sperm. Illnesses, injuries, chronic health problems, lifestyle choices and other factors can play a role in causing male infertility.

Not being able to conceive a child can be stressful and frustrating, but a number of male infertility treatments are available.

Symptoms

The main sign of male infertility is the inability to conceive a child. There may be no other obvious signs or symptoms. In some cases, however, an underlying problem such as an inherited disorder, hormonal imbalance, dilated veins around the testicle, or a condition that blocks the passage of sperm causes signs and symptoms.

Although most men with male infertility do not notice symptoms other than inability to conceive a child, signs and symptoms associated with male infertility include:

  • Problems with sexual function — for example, difficulty with ejaculation or small volumes of fluid ejaculated, reduced sexual desire or difficulty maintaining an erection (erectile dysfunction)
  • Pain, swelling or a lump in the testicle area
  • Recurrent respiratory infections
  • Inability to smell
  • Abnormal breast growth (gynecomastia)
  • Decreased facial or body hair or other signs of a chromosomal or hormonal abnormality
  • Having a lower than normal sperm count (fewer than 15 million sperm per milliliter of semen or a total sperm count of less than 39 million per ejaculate)

 

When to see a doctor

See a doctor if you have been unable to conceive a child after a year of regular, unprotected intercourse or sooner if you have any of the following:

  • Have erection or ejaculation problems, low sex drive, or other problems with sexual function
  • Have pain, discomfort, a lump or swelling in the testicle area
  • Have a history of testicle, prostate or sexual problems
  • Have had groin, testicle, penis or scrotum surgery

Causes

Male fertility is a complex process. To get your partner pregnant, the following must occur:

  • You must produce healthy sperm.Initially, this involves the growth and formation of the male reproductive organs during puberty. At least one of your testicles must be functioning correctly, and your body must produce testosterone and other hormones to trigger and maintain sperm production.
  • Sperm have to be carried into the semen.Once sperm are produced in the testicles, delicate tubes transport them until they mix with semen and are ejaculated out of the penis.
  • There needs to be enough sperm in the semen.If the number of sperm in your semen (sperm count) is low, it decreases the odds that one of your sperm will fertilize your partner's egg. A low sperm count is fewer than 15 million sperm per milliliter of semen or fewer than 39 million per ejaculate.
  • Sperm must be functional and able to move.If the movement (motility) or function of your sperm is abnormal, the sperm may not be able to reach or penetrate your partner's egg.

Medical causes

Problems with male fertility can be caused by a number of health issues and medical treatments. Some of these include:

  • A varicocele is a swelling of the veins that drain the testicle. It's the most common reversible cause of male infertility. Although the exact reason that varicoceles cause infertility is unknown, it may be related to abnormal testicular temperature regulation. Varicoceles result in reduced quality of the sperm.

Treating the varicocele can improve sperm numbers and function, and may potentially improve outcomes when using assisted reproductive techniques such as in vitro fertilization.

  • Some infections can interfere with sperm production or sperm health or can cause scarring that blocks the passage of sperm. These include inflammation of the epididymis (epididymitis) or testicles (orchitis) and some sexually transmitted infections, including gonorrhea or HIV. Although some infections can result in permanent testicular damage, most often sperm can still be retrieved.
  • Ejaculation issues.Retrograde ejaculation occurs when semen enters the bladder during orgasm instead of emerging out the tip of the penis. Various health conditions can cause retrograde ejaculation, including diabetes, spinal injuries, medications, and surgery of the bladder, prostate or urethra.

Some men with spinal cord injuries or certain diseases can't ejaculate semen, even though they still produce sperm. Often in these cases sperm can still be retrieved for use in assisted reproductive techniques.

  • Antibodies that attack sperm.Anti-sperm antibodies are immune system cells that mistakenly identify sperm as harmful invaders and attempt to eliminate them.
  • Cancers and nonmalignant tumors can affect the male reproductive organs directly, through the glands that release hormones related to reproduction, such as the pituitary gland, or through unknown causes. In some cases, surgery, radiation or chemotherapy to treat tumors can affect male fertility.
  • Undescended testicles.In some males, during fetal development one or both testicles fail to descend from the abdomen into the sac that normally contains the testicles (scrotum). Decreased fertility is more likely in men who have had this condition.
  • Hormone imbalances.Infertility can result from disorders of the testicles themselves or an abnormality affecting other hormonal systems including the hypothalamus, pituitary, thyroid and adrenal glands. Low testosterone (male hypogonadism) and other hormonal problems have a number of possible underlying causes.
  • Defects of tubules that transport sperm.Many different tubes carry sperm. They can be blocked due to various causes, including inadvertent injury from surgery, prior infections, trauma or abnormal development, such as with cystic fibrosis or similar inherited conditions.

Blockage can occur at any level, including within the testicle, in the tubes that drain the testicle, in the epididymis, in the vas deferens, near the ejaculatory ducts or in the urethra.

  • Chromosome defects.Inherited disorders such as Klinefelter's syndrome — in which a male is born with two X chromosomes and one Y chromosome (instead of one X and one Y) — cause abnormal development of the male reproductive organs. Other genetic syndromes associated with infertility include cystic fibrosis, Kallmann's syndrome and Kartagener's syndrome.
  • Problems with sexual intercourse.These can include trouble keeping or maintaining an erection sufficient for sex (erectile dysfunction), premature ejaculation, painful intercourse, anatomical abnormalities such as having a urethral opening beneath the penis (hypospadias), or psychological or relationship problems that interfere with sex.
  • Celiac disease.A digestive disorder caused by sensitivity to gluten, celiac disease can cause male infertility. Fertility may improve after adopting a gluten-free diet.
  • Certain medications.Testosterone replacement therapy, long-term anabolic steroid use, cancer medications (chemotherapy), certain antifungal medications, some ulcer drugs and certain other medications can impair sperm production and decrease male fertility.
  • Prior surgeries.Certain surgeries may prevent you from having sperm in your ejaculate, including vasectomy, inguinal hernia repairs, scrotal or testicular surgeries, prostate surgeries, and large abdominal surgeries performed for testicular and rectal cancers, among others. In most cases, surgery can be performed to either reverse these blockage or to retrieve sperm directly from the epididymis and testicles.

 

Environmental causes

Overexposure to certain environmental elements such as heat, toxins and chemicals can reduce sperm production or sperm function. Specific causes include:

  • Industrial chemicals.Extended exposure to benzenes, toluene, xylene, pesticides, herbicides, organic solvents, painting materials and lead may contribute to low sperm counts.
  • Heavy metal exposure.Exposure to lead or other heavy metals also may cause infertility.
  • Radiation or X-rays.Exposure to radiation can reduce sperm production, though it will often eventually return to normal. With high doses of radiation, sperm production can be permanently reduced.
  • Overheating the testicles.Elevated temperatures impair sperm production and function. Although studies are limited and are inconclusive, frequent use of saunas or hot tubs may temporarily impair your sperm count.

Sitting for long periods, wearing tight clothing or working on a laptop computer for long stretches of time also may increase the temperature in your scrotum and may slightly reduce sperm production.

Health, lifestyle and other causes

Some other causes of male infertility include:

  • Illicit drug use.Anabolic steroids taken to stimulate muscle strength and growth can cause the testicles to shrink and sperm production to decrease. Use of cocaine or marijuana may temporarily reduce the number and quality of your sperm as well.
  • Alcohol use.Drinking alcohol can lower testosterone levels, cause erectile dysfunction and decrease sperm production. Liver disease caused by excessive drinking also may lead to fertility problems.
  • Tobacco smoking.Men who smoke may have a lower sperm count than do those who don't smoke. Secondhand smoke also may affect male fertility.
  • Emotional stress.Stress can interfere with certain hormones needed to produce sperm. Severe or prolonged emotional stress, including problems with fertility, can affect your sperm count.
  • Obesity can impair fertility in several ways, including directly impacting sperm themselves as well as by causing hormone changes that reduce male fertility.

Certain occupations including welding or those involving prolonged sitting, such as truck driving, may be associated with a risk of infertility. However, the research to support these links is mixed.

 

 

Risk factors

Risk factors linked to male infertility include:

  • Smoking tobacco
  • Using alcohol
  • Using certain illicit drugs
  • Being overweight
  • Having certain past or present infections
  • Being exposed to toxins
  • Overheating the testicles
  • Having experienced trauma to the testicles
  • Having a prior vasectomy or major abdominal or pelvic surgery
  • Having a history of undescended testicles
  • Being born with a fertility disorder or having a blood relative with a fertility disorder
  • Having certain medical conditions, including tumors and chronic illnesses, such as sickle cell disease
  • Taking certain medications or undergoing medical treatments, such as surgery or radiation used for treating cancer

Tests and diagnosis

Many infertile couples have more than one cause of infertility, so it's likely you will both need to see a doctor. It might take a number of tests to determine the cause of infertility. In some cases, a cause is never identified.

Infertility tests can be expensive and might not be covered by insurance — find out what your medical plan covers ahead of time.

Diagnosing male infertility problems usually involves:

  • General physical examination and medical history.This includes examining your genitals and asking questions about any inherited conditions, chronic health problems, illnesses, injuries or surgeries that could affect fertility. Your doctor might also ask about your sexual habits and about your sexual development during puberty.
  • Semen analysis.You can provide a semen sample by masturbating and ejaculating into a special container at the doctor's office or by using a special condom to collect semen during intercourse.

Your semen is then sent to a laboratory to measure the number of sperm present and look for any abnormalities in the shape (morphology) and movement (motility) of the sperm. The lab will also check your semen for signs of problems such as infections.

Often sperm counts fluctuate significantly from one specimen to the next. In most cases, several semen analysis tests are done over a period of time to ensure accurate results. If your sperm analysis is normal, your doctor will likely recommend thorough testing of your female partner before conducting any more male infertility tests.

Your doctor might recommend additional tests to help identify the cause of your infertility. These can include:

  • Scrotal ultrasound.This test uses high-frequency sound waves to produce images inside your body. A scrotal ultrasound can help your doctor see if there is a varicocele or other problems in the testicles and supporting structures.
  • Hormone testing.Hormones produced by the pituitary gland, hypothalamus and testicles play a key role in sexual development and sperm production. Abnormalities in other hormonal or organ systems might also contribute to infertility. A blood test measures the level of testosterone and other hormones.
  • Post-ejaculation urinalysis.Sperm in your urine can indicate your sperm are traveling backward into the bladder instead of out your penis during ejaculation (retrograde ejaculation).
  • Genetic tests.When sperm concentration is extremely low, there could be a genetic cause. A blood test can reveal whether there are subtle changes in the Y chromosome — signs of a genetic abnormality. Genetic testing might be ordered to diagnose various congenital or inherited syndromes.
  • Testicular biopsy.This test involves removing samples from the testicle with a needle. If the results of the testicular biopsy show that sperm production is normal your problem is likely caused by a blockage or another problem with sperm transport.

However, this test is not commonly used to diagnose the cause of infertility.

  • Specialized sperm function tests.A number of tests can be used to check how well your sperm survive after ejaculation, how well they can penetrate an egg, and whether there's any problem attaching to the egg. Generally, these tests are rarely performed and often do not significantly change recommendations for treatment.
  • Transrectal ultrasound.A small, lubricated wand is inserted into your rectum. It allows your doctor to check your prostate, and look for blockages of the tubes that carry semen (ejaculatory ducts and seminal vesicles).

Treatments and drugs

Often, an exact cause of infertility can't be identified. Even if an exact cause isn't clear, your doctor might be able to recommend treatments or procedures that will result in conception.

In cases of infertility, the female partner is also recommended to be checked. This can help to determine if she will require any specific treatments or if proceeding with assisted reproductive techniques is appropriate.

Treatments for male infertility include:

  • For example, a varicocele can often be surgically corrected or an obstructed vas deferens repaired. Prior vasectomies can be reversed. In cases where no sperm are present in the ejaculate, sperm can often be retrieved directly from the testicles or epididymis using sperm retrieval techniques.
  • Treating infections.Antibiotic treatment might cure an infection of the reproductive tract, but doesn't always restore fertility.
  • Treatments for sexual intercourse problems.Medication or counseling can help improve fertility in conditions such as erectile dysfunction or premature ejaculation.
  • Hormone treatments and medications.Your doctor might recommend hormone replacement or medications in cases where infertility is caused by high or low levels of certain hormones or problems with the way the body uses hormones.
  • Assisted reproductive technology (ART).ART treatments involve obtaining sperm through normal ejaculation, surgical extraction or from donor individuals, depending on your specific case and wishes. The sperm are then inserted into the female genital tract, or used to perform in vitro fertilization or intracytoplasmic sperm injection.

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Sperm Retrieval Procedures

  November 26, 2017
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Sperm Retrieval Procedures

Sperm harvesting is entirely different from a diagnostic testicular biopsy since in this setting the goal is not to identify what is happening in the testis but instead it is to find sperm.  Only men with no sperm in their ejaculate (azoospermia) need to have sperm retrieved directly from the testis or epididymis.
This may involve a simple aspiration for men who have a blockage or require much more extensive sampling of the testis for men who have a sperm production problem. As a result, there is a significant difference in the amount of time it takes, the need for anesthesia and the equipment utilized.
Very few tests allow for an accurate prediction of whether or not sperm will be found in the testes of men with testicular problems. Genetic testing may give insight into the chance of finding sperm but are not absolute. The pattern of the problem of the testis found at the time of a diagnostic testicular biopsy may be slightly predictive but again there is no finding that absolutely predicts the presence or absence of sperm. Other blood tests including hormonal studies are not predictive.
Finally, even having sperm found on previous harvesting session does not guarantee that sperm will be found on future harvesting attempts. Thus, diagnostic testicular biopsy is not routinely performed in patients who are to undergo testicular harvesting of sperm when the cause of their zero sperm count is already established through other means.
The Timing of Sperm Retrieval
The timing of sperm harvesting in conjunction with the IVF cycle is a difficult matter to resolve. There are advantages for and against doing the sperm harvesting prior to the IVF cycle or in conjunction with the harvesting of the female partner’s eggs. The ultimate decision is made by the preference of the IVF program. Performing the harvesting in advance and freezing the sperm until the eggs are harvested allows the couple to make an informed decision whether to go forward with IVF since in most circumstances the chance of finding sperm may be only 60% or less.
Moreover, it is difficult for many couples to undergo operative procedures the same day since it requires their enlisting other resources to help them get to and from the hospital and assistance at home. IVF laboratories frequently prefer to work with fresh rather than frozen sperm and thus their desire to have fresh sperm trumps any other consideration.
As a result, simple sperm retrievals are typically performed the day of egg retrieval.  Simple sperm retrievals are procedures performed in men with known obstruction who make sperm without a problem.  These procedures are summarized below, and include Testicular Sperm Aspiration (TESA), Percutaneous Sperm Aspiration (PESA), and Testicular Sperm Extraction (TESE).
Microdissection TESE is a much more involved procedure and is performed the day before the female partner’s egg retrieval. Microdissection TESE is carefully coordinated with the reproductive endocrinologist and is performed at designated times on a quarterly basis.
Which Sperm Retrieval Procedure is Recommended?
There are numerous ways to harvest sperm from a man with normal sperm production and a blockage. The simplest and most cost-effective is an aspiration of sperm. This is routinely performed under local anesthesia and takes approximately ten minutes.
Harvesting sperm from a man with a testicular problem is much more difficult and often takes several hours. The ideal procedure, Microdissection Testicular Sperm Extraction, is performed with the aid of a surgical microscope whereby the chances of finding sperm are increased and the amount of tissue taken out of the testis can be minimized.
It is important to understand that the microscope utilized in the operating room does not have sufficient magnification to see sperm but instead just helps sort out which tubules within the testis are more likely to contain sperm. Small amounts of tissue are sent to the IVF laboratory during the course of the procedure so that they can assess whether sufficient numbers of sperm have been harvested. A more powerful microscope is used by the IVF laboratory to evaluate this tissue. Repeated biopsies from one or both testes are obtained until sufficient sperm has been harvested for that IVF cycle. Extra sperm may be harvested to preserve for future cycles of IVF in case the current cycle is unsuccessful or the couple desires more children in the future. This procedure can take as long as four hours depending upon how quickly sperm are found.
Here is a summary of the procedures available for sperm harvesting:
Testicular sperm aspiration (TESA)
Testicular sperm aspiration (TESA) is a procedure performed for men who are having sperm retrieved for in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI).  It is done with local anesthesia in the operating room or office and is coordinated with their female partner’s egg retrieval.  A needle is inserted in the testicle and tissue/sperm are aspirated.  TESA is performed for men with obstructive azoospermia (s/p vasectomy).  Occasionally, TESA doesn’t provide enough tissue/sperm and an open testis biopsy is needed.
Percutaneous Epididymal Sperm Aspiration (PESA)
PESA is a procedure performed for men who are having sperm retrieved for in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) who have obstructive azoospermia from either a prior vasectomy or infection.  It is done with local anesthesia in the operating room or office and is coordinated with their female partner’s egg retrieval.
Testicular sperm extraction (TESE)
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.  Patients usually cryopreserve sperm during this procedure for future IVF/ICSI.  Microdissection TESE has replaced this as the optimal form of retrieval for men with no sperm in their ejaculate (azoospemia) from a problem with production.
Microepididymal Sperm Aspiration (MESA)
MESA is a procedure performed for men who have vasal or epididymal obstruction (s/p vasectomy, congenital bilateral absence of the vas deferens).  It is either done as a scheduled procedure or is coordinated with their female partner’s egg retrieval.  MESA is performed in the operating room with general anesthesia utilizing the operating microscope.  Patients usually cryopreserve sperm during this procedure for future IVF/ICSI.  MESA allows for an extensive collection of sperm as compared to aspiration techniques, and is the preferred method of retrieval for men with congenital bilateral absence of the vas deferens (CBAVD).
Microdissection TESE (microdissection testicular sperm extraction)
Microdissection TESE is a procedure performed for men who have a sperm production problem and are azoospermic.  Microdissection TESE is performed in the operating room with general anesthesia under the operating microscope.  Micro TESE 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 the case that sperm are not found in the male partner.  Micro TESE 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.

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