Male fertility treatments

Vasectomy reversal surgery is a delicate procedure to rejoin these tubes and allow sperm to flow through them, reversing the actions of the original vasectomy procedure.

It's not always possible for a vasectomy reversal to fully restore your fertility. If you and your partner find it difficult to conceive, it may be possible to retrieve sperm directly from your testicles for IVF treatment. 

More about vasectomy reversal

Men who are unable to produce sperm because of an obstruction between the testicles and penis or the testicles may not be working properly can be helped by various techniques of collecting sperm from the testicles or epididymis eg sperm retrieval. The aim is to collect enough sperm to carry out ICSI. Sperm retrieval techniques commonly used are MESA (microepididymal sperm aspiration) or PESA (percutaneous epididymal sperm aspiration) which are both used for removing sperm from the epididymis in patients diagnosed with an obstruction or blockage.

1% of men suffer from azoospermia (a condition diagnosed when there is no sperm in the ejaculate) and will require sperm to be surgically retrieved for use in a cycle of ICSI to allow a chance of successful conception. 

Azoospermia can be divided into either "obstructive" or "non-obstructive" and patients will undergo thorough investigation before a decision is made to proceed with surgery. 

How does surgical sperm retrieval work? 

Sperm can be retrieved from two areas: 

1. The epididymis (the structure next to the testicle where sperm are stored and mature prior to ejaculation) 

• PESA (Percutaneous epididymal sperm aspiration): The simplest procedure, performed under local anaesthetic where sperm is aspirated using a fine needle and syringe. This is usually performed for obstructions or blockages of the testicle. 
• MESA (Microsurgical epididymal sperm aspiration): This procedure requires a general anaesthetic to allow direct microscopic visualisation of the epididymis for sperm aspiration. This is required when PESA is not possible or successful and may also allow an attempt to surgically correct any obstruction at the same time. 

2. The testicle

• Micro-TESE (Testicular sperm extraction): This more invasive procedure is required in those where epididymal retrieval has failed or with a non-obstructive cause of azoospermia. Under general anaesthetic, small biopsies are taken directly from the testicle under microscopic visualization which is then examined to find small numbers of sperm that can be used for treatment. 
• Results; our team have extensively published their results from mTESE and sperm can be found in up to 50% of patients. Our male fertility team are highly experienced in this surgery. See link 1,2,3 

The retrieval may be planned in advance and the sperm frozen, or on occasion timed to coincide with ovarian stimulation with a urologist on stand-by on the day of egg collection.

Our team has shown that frozen sperm has been shown to be as effective as fresh, in men with a non-obstructive cause where minimal sperm numbers may be retrieved, there may be a concern that insufficient quantities would survive the freeze / thaw process (see link 4) 

The final decision on the type and timing of the retrieval will be made by our expert male fertility team. 

In some men with recurrent failure from IVF treatments in whom sperm DNA fragmentation is raised and treatments have not been successful, TESE-ICSI may be offered. However, this is not undertaken unless there has been a discussion at our MDT where all members of our specialist team will discuss your case in depth and advise the best treatment for you 

More about surgical sperm retrieval

Sperm freezing may be performed in men for a variety of reasons. Some men may prefer to freeze sperm as a personal preference and future back up.

The commonest reasons sperm is at the time of surgical sperm retrieval and in those men who have very low sperm counts, who may wish to cryopreserve sperm as a back-up before ICSI. 

In men with testicular cancer, it is now clear that almost 50% of men will have sperm counts that may be low and in 10% will have no sperm in the ejaculate at the time of presentation. Our male fertility experts can offer sperm cryopreservation or freezing prior to surgery or chemotherapy treatments. 

Various sperm separation or isolation methods exist to select better quality sperm cells to potentially improve ART outcomes. Conventional techniques such as simple wash method, density gradient centrifugation (DGC), swim-up, swim-down and the glass wool filtration techniques, select sperm cells based on their motility and morphology.

However, the important factors that affect the sperms’ fertilization potential such as oxidative stress and DNA integrity cannot be assessed by any of these conventional methods.

Hence, several advanced sperm selection techniques were introduced to select spermatozoa with lower sperm DNA fragmentation to increase the success rate of ART, each relying on slightly different ways to select the optimal sperm.

• Physiological intracytoplasmic sperm injection (PICSI)
  This technique is based on the fact that the chemical hyaluronic acid (HA) plays an important role in selecting good sperm during in vivo fertilization. Not only HA is the main chemical surrounding the egg, but also a natural selector of developmentally mature sperm. Currently, there are two options available to perform this technique: either by using plastic culture dishes with HA hydrogel microdots or by using an alternate HA-containing viscous medium known as “Sperm Slow”.
• ZyMot microfluidic sperm separation technique
  The ZyMot sperm separation technique uses a ZyMot sperm separation device which replicates both the uterine and cervical pathway that sperms navigate to fertilize the egg. It uses a microfluidic technique to select the healthy sperm and involves collecting fresh semen samples and gently inserting them into the ZyMot device chamber. The sperm swim through a filter membrane containing micropores which create the uterine and cervical path. In the end, the sperm emerging through the membrane is collected and used to fertilize the egg. ZyMot sperm separation devices are used to select healthy sperm with high motility, good morphology, and lower DNA fragmentation.
• TESE-ICSI
  As discussed previously, TESE-ICSI (testicular sperm extraction associated with intracytoplasmic sperm injection) can be used in couples with elevated sperm DNA fragmentation as testicular sperm is reported to have lower levels of sperm DFI when compared to ejaculated sperm. However, as it is more invasive and will need an anaesthetic, only in select cases approved by the MDT team for TESE-ICSI. TESE-ICSI procedures can be synchronised so that fresh sperm (that is not frozen, although this can be a back-up) is used to inject into eggs harvested on the same day (a ‘fresh/fresh’ cycle) which may be of benefit in some couples.

In summary, several sperm preparation methods are available to process sperm for use in ART. Each infertile couple must be carefully examined to determine the best sperm preparation method. It is the responsibility of the IVF clinic to select the appropriate cases that will be benefited from these methods as their routine use to all cases might lead to an adverse outcome.