Sperm Extraction

Sperm Extraction

It is now fairly routine to extract sperm from men. The procedure can offer hope to many couples who
otherwise have no other options for a biological child. There are two types of procedures to extract sperm
from the testis and/or epididymis:

1) Percutaneous (meaning "across the skin") Sperm Extraction (PSE), which involves obtaining sperm by
passing a needle through the scrotal skin and into the testis or epididymis (also referred to as percutaneous
sperm aspiration - PESA or testicular sperm extraction - TESE, TSE)

2) Open Sperm Extraction (OSE) in which one or two small incisions are made in the scrotum and sperm
are obtained under direct vision, often with an operative microscope (also referred to as microsurgical
sperm aspiration - MESA).

Both techniques are done under some sort form of anesthesia, which will be discussed later.

It is important to understand that PSE and OSE almost never yield enough sperm for insemination. In
other words, we usually obtain too few sperm to expect success by putting them into the woman's cervix
or uterus. Instead, we must combine the extracted sperm with eggs in the laboratory (in vitro fertilization)
and most often, we need to assist the process of fertilization with injection of individual sperm into each
egg (intracytoplasmic sperm injection).

Who needs sperm extraction?

There are many reasons why some men need to undergo sperm extraction. The following are the most
common reasons:

1) Absent vas deferens - Some men are born without a tube called the vas deferens, which transports
sperm from the testis to the urethra in the penis. In simple terms, the "sperm factory" has no highway
leading away from it. Thus, sperm extraction offers the only hope for a biological child.

2) Spinal cord injury - Some paraplegics and quadriplegics can achieve a pregnancy with their partners
using vibratory and electrical techniques to stimulate ejaculation. When these techniques fail or when they
result in very poor quality sperm, sperm extraction may be considered.

3) Testis cancer - Men who have had cancer of the testicle and who have had major abdominal surgery to
remove lymph nodes may develop fertility problems. If standard solutions fail or result in very poor
quality sperm, sperm extraction may be necessary.

4) Failed vasectomy reversal - Men who have undergone vasectomy reversal and who subsequently have
no sperm in the ejaculate can consider having a repeat vasectomy reversal, another surgical procedure
known as vasoepididymostomy, or sperm extraction.

5) Alternative to vasectomy reversal - Since sperm can be extracted from the epididymis after a
vasectomy, it is not absolutely necessary to undergo a vasectomy reversal if a pregnancy is desired.
However, the cost of sperm extraction in conjunction with in vitro fertilization is considerably higher than
a reversal. Therefore, very few "vasectomized" men will choose sperm extraction as the first procedure to
restore their fertility unless there is another indication for in vitro fertilization such as blockage of their
partner's fallopian tubes (refer to "Indications for treatment with ART").

6) Blocked epididymis - Some men are born with or develop a blockage in the epididymis (tube
connecting the testis and vas deferens). This blockage may be surgically corrected (vasoepididymostomy)
or sperm extraction may be performed.

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7) Ejaculatory problems - Diseases that interfere with nerve functions (such as diabetes or multiple
sclerosis) can lead to ejaculatory problems. Men with these conditions sometimes require sperm
extraction.

Percutaneous Sperm Extraction (PSE)

PSE involves putting a needle through the scrotal skin and into the epididymis and/or testis. Suction is
applied to the needle to extract the sperm. The advantages of PSE include lower cost and avoidance of a
surgical incision.

However, there are clearly some disadvantages to PSE. First, the number of sperm recovered tends to be
lower than with OSE. Second, the risk of damaging the testis or epididymis tends to be higher with PSE
than with OSE. Neither technique carries a high risk of complications but the multiple, blind passes of the
needle with PSE increases the risk of damage to blood vessels supplying the testicle and may cause injury
to the epididymal tubules thus jeopardizing subsequent attempts at sperm extraction or surgical correction.

The length of time required to perform PSE is not necessarily shorter than OSE and in fact, OSE is
sometimes quicker than PSE.

Open Sperm Extraction (OSE)

OSE involves making one or two small incisions in the scrotum to expose the testis and/or epididymis.
Sperm extraction is then usually done using an operative microscope. The epididymis is the preferred site
for obtaining sperm, but microdissection of the testicular tubules can be performed if necessary. The
advantages of OSE (as compared with PSE) include the following:

1) the recovery of more sperm

2) a lower risk of injury to the delicate tubules of the epididymis and the testicular blood vessels.

The disadvantages of OSE are the cost (higher than with PSE) and the requirement for a small incision in
the scrotum.

Timing of Sperm Extraction

Sperm extraction can be done at the same time the woman's eggs are being retrieved during an in vitro
fertilization cycle. In most cases, however, the sperm extraction is performed as an independent procedure
prior to the woman's treatment cycle, and the recovered sperm are cryopreserved (frozen). There are two
significant advantages to this approach including the following:

1) If the sperm extraction is not successful, significant expense may be averted because the female partner
has not yet begun the treatment cycle. Remember that the process of stimulating a woman's ovaries and
then removing eggs is costly.

2) It is more convenient for both the patient and physician to schedule the sperm extraction as opposed to
doing it on short notice once the eggs are ready to be retrieved.

It is important to note that in most cases, frozen sperm appear to be as fertile as fresh sperm for in vitro
fertilization. It is also often possible to recover enough sperm during one sperm extraction (especially
with OSE) for more than one in vitro fertilization procedure.

Anesthesia

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OSE and PSE are always done under some form of anesthesia so that you will not feel pain. Afterwards,
the pain is usually mild. Most commonly, a local anesthetic is used in combination with I.V. (intravenous)
sedation. Occasionally, local anesthesia alone is all that is necessary. General anesthesia (heavy sedation
putting you to sleep) can be performed but the risks are slightly higher with this kind of anesthesia.

Costs

Currently, the total cost for PSE is approximately $1,750.00. and OSE is approximately $3,200.00. These
costs include the surgeon's fee, the anesthesia fee, and the fees for the facility/operating room. The only
costs not included are those associated with the initial consultation visit ($100) and the fee for sperm
freezing ($250).

Risks

The risks associated with sperm extraction are quite low. Mild bruising is common but bleeding more
than a small amount is very unusual. Infection and/or nerve damage, though possible, are also very
unlikely. As previously discussed, damage to blood vessels and/or epididymal tubules are uncommon
with OSE. Testicular atrophy (shrinking of the testicle with loss of function) is very rare.

Summary

Sperm extraction, coupled with in vitro fertilization and often with intracytoplasmic sperm injection,
offers hope for some couples who previously have had no chance of conceiving. We are pleased to be
able to offer these procedures and invite you to contact us for more information.

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