How PESA and TESE Can Improve Fertility in Men With Azoospermia

In some cases, men may not have sperm in their ejaculate due to vasal obstruction or congenital bilateral absence of the testis (CBAVD). This type of infertility is called azoospermia. Surgical sperm harvesting procedures such as PESA and TESE can help these men improve their fertility.

Studies report high sperm retrieval rates and adequate pregnancy outcomes when both percutaneous epididymal sperm aspiration (PESA) and TESA are used.
Microepidydimal sperm aspiration (MESA)

This sperm retrieval technique involves using a needle to reach into the epididymis, a tube at the back of the testicle that stores and carries sperm. It is often used in cases where a man’s semen is completely sterile because the vas deferens has been blocked or removed (obstructive azoospermia).

This procedure can be performed without general anesthesia and does not require making an incision in the scrotum. After numbing the area with a local anesthetic, the doctor will gently feel the scrotum to locate the epididymis, then use a needle to draw seminal fluid from the epididymis.

The retrieved sperm can be directly fertilized with an egg in the laboratory or frozen for future use. Fresh MESA-retrieved sperm has been shown to produce fertilization and pregnancy rates comparable to those obtained with congenitally obstructive azoospermia in ICSI cycles.
Percutaneous epididymal sperm aspiration (PESA)

PESA is a minimally invasive technique for retrieving spermatozoa from the epididymis, which is used when there are blockages that prevent sperms from moving further from the testes or when sperm count is low. It involves inserting a needle into the epididymis to aspirate fluid and then inspecting it under a microscope for sperm motility. If the sample contains sufficient sperms, they can then be used for Intra Cytoplasmic Sperm Injection (ICSI).

The objective of this study was to evaluate the reproducibility and efficiency of repeated PESA in men with obstructive azoospermia. The study included 79 PESA procedures in 58 patients with vasectomy or congenital absence of the bilateral vas deferens, who had been trying to conceive for at least one year.

The procedure is very simple and quick; it uses local anesthesia and is performed under a microscope. Despite its simplicity, there are some drawbacks to this technique, including the fact that the location of the puncture cannot be precisely controlled and that the sperm-containing ductule may be missed. Also, it is possible to puncture a blood vessel and contaminate the sample with red blood cells.
Testicular sperm extraction (TESE)

TESE is used in men with no sperm present in their semen (obstructive azoospermia) or very low sperm production (non-obstructive azoospermia). It can also be done in conjunction with vasectomy reversal surgery. Using this technique, sperm can be retrieved from the testicle and cryopreserved for future use in fertility treatment.

The procedure is performed under local anesthesia in the operation room by your doctor. It involves making a small incision in the scrotal skin to expose the epididymis. Your doctor uses a microsurgical needle to sample the epididymal fluid for sperms and any motile ones are collected.

A newer technique called multibiopsy TESE has been shown to increase the number of sperms found with this method. This involves performing multiple samples of the testicular tissue under visual guidance. We prefer this approach because it reduces the chance of a mistake that could result in missing important sperms or damage the seminiferous tubules. We can then proceed with ICSI or egg retrieval.
Testicular sperm extraction with a microscope (TESE-M)

The procedure is performed under local anesthesia and mild sedation. A needle is inserted into the testicle or epididymis (an organ that lives behind the testicle). The sample collected is immediately examined under a microscope to look for healthy appearing spermatozoa. This is a very simple and minimally invasive technique that has been used successfully in men with vasectomy, enlarged epididymis due to a blockage or other problems such as Klinefelter syndrome.

The procedure is performed under a surgical microscope. A wide-bore needle is pushed percutaneously into the testicle. After a few samples are taken, a stereomicroscope is used to evaluate the sperm with a fine needle dissection. Using this method, sperm is 1.5-fold more likely to be found in a sample than using conventional TESE. This improvement in sperm identification allows a greater number of spermatozoa to be harvested for ICSI and improves fertilization and pregnancy rates. Moreover, the time frame for the collection of sperm for ICSI and fertilization is shortened.pesa mesa

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