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Chapter 5 - Epididymal Sperm Retrieval

Indications, Surgical Protocol, and Outcomes

from Part II - Sperm Retrieval

Published online by Cambridge University Press:  09 April 2021

Ashok Agarwal
The Cleveland Clinic Foundation, Cleveland, OH, USA
Ahmad Majzoub
Hamad Medical Corporation, Doha, Qatar
Sandro C. Esteves
Andrology & Human Reproduction Clinic, Sao Paulo, Brazil
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Azoospermia is diagnosed in approximately 1 percent of the general population and in up to 15 percent of infertile men. Of these men, 15–20 percent can be further categorized as having obstructive azoospermia [1]. Men with obstructive azoospermia have preserved spermatogenesis, allowing for either surgical repair of their obstruction or sperm retrieval to be used in conjunction with in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). The obstruction can occur anywhere along the passage of sperm from the efferent ducts within the testis, along the epididymis, through the vas deferens, the ejaculatory ducts, or the distal penile urethra. Causes of obstructive azoospermia can be congenital, acquired, or idiopathic (Table 5.1) [2]. Vasectomy and iatrogenic obstruction to the vas deferens at the time of inguinal hernia repair are the most common causes of acquired obstructive azoospermia. Congenital bilateral absence of the vas deferens (CBAVD) is the most common congenital cause [3,4]. In men with obstruction of the epididymis or vas deferens, microsurgical reanastomosis at the site of obstruction can be done with good fertility-related outcomes. Those who do not wish to undergo surgical repair of their obstruction, have failed surgical repair, have CBAVD, or have an unclear/multifactorial cause of their obstruction can be treated with sperm retrieval and ICSI [5]. Percutaneous epididymal sperm aspiration (PESA), microsurgical epididymal sperm aspiration (MESA), and the recently described minimally invasive epididymal sperm aspiration (MIESA), are all techniques that allow successful retrieval of sperm from the epididymis in men with obstructive azoospermia (Table 5.2).

Publisher: Cambridge University Press
Print publication year: 2021

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Jarow, JP, Espeland, MA, Lipshultz, LI. Evaluation of the azoospermic patient. J Urol 1989;142(1):6265.CrossRefGoogle ScholarPubMed
Wosnitzer, MS, Goldstein, M. Obstructive azoospermia. Urol Clin North Am 2014;41(1):8395.CrossRefGoogle ScholarPubMed
Sheynkin, YR, Hendin, BN, Schlegel, PN, Goldstein, M. Microsurgical repair of iatrogenic injury to the vas deferens. J Urol 1998;159:139141.CrossRefGoogle ScholarPubMed
Hussein, TM, Zakaria, NH, Zahran, AM. Clinical, laboratory and genetic assessment of patients with congenital bilateral absent vas deferens. Andrologia 2011. doi:10.1111/j.1439-0272.2009.01001.x.CrossRefGoogle Scholar
Goldstein, M. Surgical management of male infertility. Campbell-Walsh Urology, 11th edn., Elsevier, Amsterdam, 2012, pp. 648687.CrossRefGoogle Scholar
Robaire, B, Hinton, BT. The epididymis. In: Knobil and Neill’s Physiology of Reproduction. Academic Press, New York, 2014, pp. 691771.Google Scholar
Kavoussi, PK. Surgical, radiographic and endoscopic anatomy of the male reproductive system Campbell–Walsh Urology, 11th edn., Elsevier, Amsterdam, 2012, pp. 498–515.e2.Google Scholar
Turner, TT, Johnston, DS, Jelinsky, SA, Tomsig, JL, Finger, JN. Segment boundaries of the adult rat epididymis limit interstitial signaling by potential paracrine factors and segments lose differential gene expression after efferent duct ligation. Asian J Androl 2007;9:565573.CrossRefGoogle ScholarPubMed
Robaire, B, Hamzeh, M. Androgen action in the epididymis. J Androl 2011;32:592599.CrossRefGoogle ScholarPubMed
Agarwal, A, Hoffer, AP. Ultrastructural studies on the development of the blood–epididymis barrier in immature rats. J Androl 1989;10:425431.CrossRefGoogle ScholarPubMed
Macmillan, EW. The blood supply of the epididymis in man. Br J Urol 1954;26:6071.CrossRefGoogle ScholarPubMed
Kormano, M, Reijonen, K. Microvascular structure of the human epididymis. Am J Anat 1976;145:2327.CrossRefGoogle ScholarPubMed
Parez-Clavier, R, Harrison, RG, Macmillan, EW. The pattern of the lymphatic drainage of the rat epididymis. J Anat 1982;134:667675.Google Scholar
Yafi, FA, Zini, A. Percutaneous epididymal sperm aspiration for men with obstructive azoospermia: predictors of successful sperm retrieval. Urology 2013;82:341344.CrossRefGoogle ScholarPubMed
Wood, S, Vang, E, Troup, S, Kingsland, CR, Lewis-Jones, DI. Surgical sperm retrieval after previous vasectomy and failed reversal: clinical implications for in vitro fertilization. BJU Int 2002;90:227281.CrossRefGoogle ScholarPubMed
Palermo, GD, Schlegel, PN, Hariprashad, JJ, et al. Fertilization and pregnancy outcome with intracytoplasmic sperm injection for azoospermic men. Hum Reprod 1999;14:741748.CrossRefGoogle ScholarPubMed
Nicopoullos, JDM, Gilling-Smith, C, Almeida, PA, et al. Use of surgical sperm retrieval in azoospermic men: a meta-analysis. Fertil Steril 2004;82:691701.CrossRefGoogle ScholarPubMed
van Wely, M, Barbey, N, Meissner, A, Repping, S, Silber, SJ. Live birth rates after MESA or TESE in men with obstructive azoospermia: is there a difference? Hum Reprod 2015;30:761766.CrossRefGoogle ScholarPubMed
Morin, SJ, Hanson, BM, Juneau, CR, et al. A comparison of the relative efficiency of ICSI and extended culture with epididymal sperm versus testicular sperm in patients with obstructive azoospermia. Asian J Androl 2020;22:222226.Google ScholarPubMed
Esteves, SC, Lee, W, Benjamin, DJ, et al. Reproductive potential of men with obstructive azoospermia undergoing percutaneous sperm retrieval and intracytoplasmic sperm injection according to the cause of obstruction. J Urol 2013;189:232237.CrossRefGoogle ScholarPubMed
Hammoud, I, Bailly, M, Bergere, M, et al. Testicular spermatozoa are of better quality than epididymal spermatozoa in patients with obstructive azoospermia. Urology 2017;103:106111.CrossRefGoogle ScholarPubMed
Esteves, S, Varghese, A. Laboratory handling of epididymal and testicular spermatozoa: what can be done to improve sperm injections outcome. J Hum Reprod Sci 2012;5:233243.CrossRefGoogle ScholarPubMed
Gangrade, BK. Cryopreservation of testicular and epididymal sperm: techniques and clinical outcomes of assisted conception. Clinics (Sao Paulo) 2013;68(Suppl. 1):131140.CrossRefGoogle ScholarPubMed
Patrizio, P. Cryopreservation of epididymal sperm. Mol Cell Endocrinol 2000;169:1114.CrossRefGoogle ScholarPubMed
Justice, T, Christensen, G. Sperm cryopreservation methods. Methods Mol Biol 2013;927:209215.CrossRefGoogle ScholarPubMed
Anger, JT, Gilbert, BR, Goldstein, M. Cryopreservation of sperm: indications, methods and results. J Urol 2003;170:10791084.CrossRefGoogle ScholarPubMed
Janzen, N, Goldstein, M, Schlegel, PN, Palermo, GD, Rosenwaks, Z. Use of electively cryopreserved microsurgically aspirated epididymal sperm with IVF and intracytoplasmic sperm injection for obstructive azoospermia. Fertil Steril 2000;74:696701.CrossRefGoogle ScholarPubMed
Devroey, P, Silber, S, Nagy, Z, et al. Ongoing pregnancies and birth after intracytoplasmic sperm injection with frozen–thawed epididymal spermatozoa. Hum Reprod 1995;10:903906.CrossRefGoogle ScholarPubMed
Nudell, DM, Conaghan, J, Pedersen, RA, et al. The mini-micro-epididymal sperm aspiration for sperm retrieval: a study of urological outcomes. Hum Reprod 1998;13:12601265.CrossRefGoogle ScholarPubMed
Oates, RD, Lobel, SM, Harris, DH, et al. Efficacy of intracytoplasmic sperm injection using intentionally cryopreserved epididymal spermatozoa. Hum Reprod 1996;11:133138.CrossRefGoogle ScholarPubMed
Wood, S, Thomas, K, Schnauffer, K, et al. Reproductive potential of fresh and cryopreserved epididymal and testicular spermatozoa in consecutive intracytoplasmic sperm injection cycles in the same patients. Fertil Steril 2002;77:11621166.CrossRefGoogle ScholarPubMed
Friedler, S, Raziel, A, Soffer, Y, et al. The outcome of intracytoplasmic injection of fresh and cryopreserved epididymal spermatozoa from patients with obstructive azoospermia: a comparative study. Hum Reprod 1998;13:18721877.CrossRefGoogle ScholarPubMed
Hutchon, S, Thornton, S, Hall, J, Bishop, M. Frozen–thawed epididymal sperm is effective for intracytoplasmic sperm injection: implications for the urologist. Br J Urol 1998;81:607611.CrossRefGoogle ScholarPubMed
Madgar, I, Hourvitz, A, Levron, J, et al. Outcome of in vitro fertilization and intracytoplasmic injection of epididymal and testicular sperm extracted from patients with obstructive and nonobstructive azoospermia. Fertil Steril 1998;69:10801084.CrossRefGoogle ScholarPubMed
Cayan, S, Lee, D, Conaghan, J, et al. A comparison of ICSI outcomes with fresh and cryopreserved epididymal spermatozoa from the same couples. Hum Reprod 2001;16:495499.CrossRefGoogle ScholarPubMed
Moomjy, M, Scott Sills, E, Rosenwaks, Z, Palermo, GD. Implications of complete fertilization failure after intracytoplasmic sperm injection for subsequent fertilization and reproductive outcome. Hum Reprod 1998;13:22122216.CrossRefGoogle ScholarPubMed
Temple-Smith, PD, Southwick, GJ, Yates, CA, Trounson, AO, de Kretser, DM. Human pregnancy by in vitro fertilization (IVF) using sperm aspirated from the epididymis. J Vitr Fertil Embryo Transf 1985;2:119122.CrossRefGoogle ScholarPubMed
Craft, I, Shrivastav, P, Quinton, R, et al. Treatment of male infertility. Lancet 1994;344:191192.CrossRefGoogle ScholarPubMed
Coward, RM, Mills, JN. A step-by-step guide to office-based sperm retrieval for obstructive azoospermia. Transl Androl Urol 2017;6:730744.CrossRefGoogle ScholarPubMed
Collins, GN, Critchlow, JD, Lau, MW, Payne, SR. Open versus closed epididymal sperm retrieval in men with secondarily obstructed vasal systems: a preliminary report. Br J Urol 1996;78:437439.CrossRefGoogle ScholarPubMed
Wakefield, SE, Elewa, AA. Spermatic cord block: a safe technique for intrascrotal surgery. Ann R Coll Surg Engl 1994;76:401402.Google ScholarPubMed
Chiles, KA, Schlegel, PN. Sperm retrieval. In Smith, JAJ, Howards, SS, Preminger, GM, Dmochowski, RR (eds.) Hinman’s Atlas of Urologic Surgery, 4th edn., Elsevier, Amsterdam, 2018, pp. 791793.Google Scholar
Silber, SJ, Balmaceda, J, Borrero, C, Ord, T, Asch, R. Pregnancy with sperm aspiration from the proximal head of the epididymis: a new treatment for congenital absence of the vas deferens. Fertil Steril 1988;50:525528.CrossRefGoogle ScholarPubMed
Silber, SJ, Nagy, Z, Liu, J, et al. The use of epididymal and testicular spermatozoa for intracytoplasmic sperm injection: the genetic implications for male infertility. Hum Reprod 1995;10:20312043.CrossRefGoogle ScholarPubMed
Bernie, AM, Ramasamy, R, Stember, DS, Stahl, PJ. Microsurgical epididymal sperm aspiration: indications, techniques and outcomes. Asian J Androl 2013;15:4043.CrossRefGoogle ScholarPubMed
Hibi, H, Sumitomo, M, Fukunaga, N, Sonohara, M, Asada, Y. Superior clinical pregnancy rates after microsurgical epididymal sperm aspiration. Reprod Med Biol 2018;17:5963.CrossRefGoogle ScholarPubMed
Bromage, SJ, Falconer, DA, Lieberman, BA, Sangar, V, Payne, SR. Sperm retrieval rates in subgroups of primary azoospermic males. Eur Urol 2007;51:534539.CrossRefGoogle ScholarPubMed
Karpman, E, Williams, D. Techniques of sperm retrieval. In Lipshultz, LI, Howard, SS, Niederberger, CS (eds.) Infertility in the Male, 4th edn., Cambridge University Press, New York, 2009. pp. 407420.CrossRefGoogle Scholar
Shin, DH, Turek, PJ. Sperm retrieval techniques. Nat Rev Urol 2013;10:723730.CrossRefGoogle ScholarPubMed
Heidenreich, A, Altmann, P, Engelmann, UH. Microsurgical vasovasostomy versus microsurgical epididymal sperm aspiration/testicular extraction of sperm combined with intracytoplasmic sperm injection: a cost–benefit analysis. Eur Urol 2000;37:609614.CrossRefGoogle ScholarPubMed

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