There are multiple reasons that men may have little (oligospermia) or no sperm (azoospermia). They could have an intrinsic production problem (NOA) or an obstruction that is preventing the flow of sperm from the testicle (OA). There are various tools that can be used to figure out the cause including:
- Hormonal evaluation through a blood test
- Testicular aspiration or core biopsy
The testicular aspiration or core biopsy is a procedure that not only distinguishes production problems from obstruction problems, but also leads to the next steps for a man’s reproductive treatment. During TESA, a local anesthetic is used to numb the nerves in the testicle and a small aspirating syringe obtains a seminiferous tubule from the testicle.
If the result of the TESA determines there is no sperm in the man’s ejaculate, but sperm is found on the aspiration, he may also have a testicular sperm extraction (TESE) when his partner’s egg is extracted or cryopreserve the sperm for the future.
If no sperm at all is found, a more in-depth procedure using a surgical microscope maybe performed in the operating room.
Testicular Sperm Extraction (TESE) is a procedure that may be performed for a number of reasons:
- Obstructive azoospermia (absence of sperm)
- Spermatogenic failure (low or absence production of sperm)
- Cancer patient for cryopreservation
There is a high rate of success for TESE for men that has a problem in regards to the transport of sperm, such as a previous vasectomy or congenital absence of the tube (vas deferens) that transports sperm from to the urethra.
For men with spermatogenic failure, reproduction is possible with the help of in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). TESE can also give men with cancer the potential to preserve sperm for future use.
TESE can be done as an in-office procedure with local anesthetic or may be done in the operating room. Because of the low amount of sperm that is obtained through TESE, the sperm is combined with eggs from the male’s partner through ICSI.
Testicular Sperm Extraction Resources:
Microscopic testicular sperm extraction (microTESE) is a similar procedure to TESE, however it is more complex and requires to be performed in an operating room under general anesthetic. In microTESE a surgical microscope helps determine which seminiferous tubules within the testicle are likely to contain sperm.
Many samples are extracted from each testicle in microTESE and evaluated for the presence of sperm by an andrologist using a powerful microscope while in the operating room. The procedure has a 50% change of finding sperm and will last until enough tissue is obtained to use for assisted reproduction. Men can even have extra sperm cryopreserved for future IVF/ICSI treatments.
Microscopic Testicular Sperm Extraction Resources
- Retrieval Outcomes with MicroTESE
- Considerations and Technique of MicroTESE
- Video of MicroTESE Performed by Dr. Peter Schlegel
Microscopic epididymal sperm aspiration (MESA) is used for men who do not have a sperm drainage system or are not able to have a reconstruction procedure. It is a technique that helps extract sperm from the epididymis (a duct behind the testis that sperm passes through) of men.
This is a common problem for men with a congenital condition called vasal agenesis in which the sperm drainage system (vas deferens) does not form. MESA might also be used for men who had a vasectomy or blockage that might have occurred after an infection. MESA is performed using an operating microscope; sperm are located in the epididymis from an isolated tubule and aspirated until enough sperm is collected. After the sperm is processed, it can be used for IVF/ICSI or preserved for future use.
Microscopic Epididymal Sperm Aspiration Resources
- MESA Procedural Steps with Video:
- Sperm Retrieval and Diagnosis Techniques from the Urology Care Foundation
Seminal vehicle ultrasound and aspiration is used for men with little to no sperm in the ejaculate and overall low semen volume. In these cases, there may be an obstruction where the ejaculatory ducts empty into the urethra. An obstruction could be caused by:
- Scarring of the ducts
- Ejaculatory duct cysts
First, a transrectal ultrasound test will show an image of the seminal vesicles and ejaculatory ducts. Then, in this procedure the seminal vesicles that are potentially obstructed are dilated, and aspiration of the obstructed fluid is done to find sperm. If the sperm is present, it suggests there is an obstruction.
Seminal Vesicle Aspiration Resources
- An Update on the Diagnosis and Management of Ejaculatory Duct Obstruction
- SVA Technique and Ultrasound Images
Penile vibratory stimulation (PVS) is normally the first treatment option for men that have an absence of ejaculation during orgasms. Common causes can include:
- Spinal cord injuries
- Diabetes mellitus
- Medication-related dysfunction
The procedure includes placing a vibrating stimulator on the dorsum or frenulum of the glans penis (head of the penis), which causes a reflex to induce ejaculation.
Penile Vibratory Stimulation Resources
Electroejaculation (EEJ) is considered as a treatment option for men who do not respond to penile vibratory stimulation (PVS). During this procedure, a current is delivered via a probe that stimulates the nerves that cause the emission of semen.
EEJ is much more invasive than PVS and only used once PVS fails. The procedure requires general anesthesia for men who have their pelvic sensation intact.