Has it really been over three months since my last post? Between becoming one of the next Co-Editors in Chief of Fertility and Sterility, preparing for a review of our urology training program and finishing my latest book (Thank You, Chapter Authors!) I guess that I’ve let my blogging slip a bit. Fortunately, thanks to my Italian co-faculty’s discovery of the Saeco Vienna Plus espresso maker at Costco, I’m back at the keyboard.
I turned off the two-week limit for comments, and so far, that’s been a good idea. People are commenting on older posts (like How Clomid Works in Men) with good questions and thoughtful points. For new commenters, please read the FAQ. I can’t answer questions about specific patients. Those are best left to a live visit with a doctor with an interest in male reproductive medicine. One great resource is the American Society for Reproductive Medicine’s Society for Male Reproduction and Urology page and the ASRM’s find a doctor search page, (just click on the “Society for Male Reproduction and Urology (SMRU)” button in the “Find Member by Affiliated Society:” section.) Another excellent way to find a specialist who treats men with reproductive issues is to use the American Urological Association’s Society for the Study of Male Reproduction’s search engine.
This blog post was inspired by several patients who asked after I explained surgical sperm retrieval, if there was somewhere they could go for more information. I realized that I hadn’t written about such a common issue.
Just as a carpenter has many ways to make a cabinet, a surgeon can tackle a problem in a number of ways. And just as two cabinets may differ, different surgical problems demand different approaches. Such is the case in retrieving sperm from the testis.
Most of the time, taking sperm directly from the testis is necessary when a man has azoospermia, where no sperm is found in the ejaculate. Azoospermia takes two basic forms, obstructive and non-obstructive. As the name implies, obstructive azoospermia is due to a blockage in the tubes and structures that convey sperm from the testis to the outside world. In the best case, a surgeon can fix the errant anatomy, allowing a couple to conceive children without further ado. But because the tubes are so tiny, sometimes the tubes can’t be reconnected with surgery, and the alternative is to take sperm from the testis for it to be used in in-vitro fertilization.
The other form of azoospermia, non-obstructive, arises when the factory making sperm in the testis isn’t working quite right. Sometimes, the cells starting sperm are missing entirely, a condition known as “Sertoli cell only syndrome”. Occasionally, sperm may be rolling along their assembly line, a process that takes two to three months to complete, and stop mid-production. When that happens, it’s called “maturation arrest“. But frequently, sperm can be found in small amounts in the testis and can be retrieved using surgery.
Because it isn’t mature, sperm from the testis can only be used with in-vitro fertilization and intra-cytoplasmic sperm injection.
How can a surgeon remove sperm? He or she can take it from the testis itself, or the epididymis, the tiny coiled tube lying on the back of the testis where sperm mature. The surgeon can insert a needle into the testis or epididymis, he or she may make one or several small incisions into the testis or use microsurgery to retrieve sperm from either the testis or epididymis. In the case of obstructive azoospermia, it doesn’t seem to matter which technique is used. There’s plenty of sperm wherever it’s sought, and any method will do to retrieve it. When a man has obstructive azoospermia, I usually recommend taking a small piece from the testis, as the sperm may be frozen and is good for a number of in-vitro fertilization cycles so that the man doesn’t need to go through a procedure for every cycle, and can be there for his wife during her procedures.
We’ve found that frozen sperm is just as good as fresh. in fact, the chances for fertilization are the same for fresh and frozen sperm, and the chance for pregnancy may even be a little better for frozen sperm than for fresh.
Frozen sperm should literally last forever. It’s in liquid nitrogen, which is so cold that the building blocks making sperm don’t decay. Freezing sperm gives a couple time to plan when in-vitro fertilization is done.
When he has non-obstructive azoospermia, a man’s options are more limited. A surgeon can use the operating microscope to comb through the testis looking for areas that may contain sperm, a procedure known as “microsurgical testis sperm extraction“. Other techniques include making several small incisions in the testis or piercing the testis with a needle in a dozen or so different spots. When a man has non-obstructive azoospermia, I usually recommend microsurgical testis sperm extraction. More areas of the testis can be examined, and I can see the places that most likely contain sperm.
We’ve observed that prescribing a man with non-obstructive azoospermia clomiphene citrate for a few months before surgical retrieval seems to increase the chance to retrieve sperm. In many men, sperm appears in the ejaculate and surgery isn’t needed. If a couple has a few months, taking clomiphene before surgical sperm retrieval might be a good idea.
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How has your success been with this method for patients who have had agressive chemo therapy befor puberty (age 11 treated for NHL)? My son has azoospermia-no sperm- and we wonder if there is a small ray of hope for paternity.
Good question Jo. My husband had aggressive chemo at age 14 for NHL and is now azoospermic. We go for the biopsy in 2 months after he finishes 3 months of clomid. Keeping our fingers crossed. Thank you MaleDoc for all of this info..I have been reading your blogs / comments for nearly two hours now.
He also has a lung disease called primary ciliary dyskensia that cause poor motility in sperm. Just wanted to throw that out there to spread awareness of PCD in case there are readers out there with poor motility AND chronic lung/ sinus issues. Email me if you’d like: carty.julie@yahoo.com
Hi Jo, microsurgical testicular sperm extraction can be successful in a variety of circumstances in which a man is azoospermic, including for those who have had chemotherapy. But you’re asking about a specific patient, and I can’t answer personal medical questions. (See the FAQ.) I recommend that you see an expert in your area. “Find a Doc” on the SSMR site (http://www.ssmr.org/doctors/locate.aspx) can help you.
Generally, how successful is sperm extraction in patients with non-motile sperm cells and very low sperm count?
I believe that you’re asking about surgical extraction from the testis in cases where there’s actually sperm in the ejaculate, just very few and not wiggling. We refer to that as “cryptozoospermia.” Microsurgical testis sperm extraction can very often yield sperm in that circumstance.
Thanks, Maledoc. You also mentioned in an other post that even dead sperm cells can be used in IVF with ICSI. Although the practice is that in that case they recommend the patient the sperm extraction directly from the testis. Why is this?
Some limited evidence suggests that in cases of very few sperm in the ejaculate, sperm from the testis has better overall DNA quality, which can serve as an argument for getting sperm directly from the testis. But it’s not proven, so it’s a judgement best made between doctor and patient.
Thanks, Maledoc! In your other blog you mention that they can use not moving even dead sperm cells in IVF with ICSI. In practice in that case they recommend you to do surgical sperm extraction directly from the testis. Why is that?
Thanks!
We have recently been told by a urologist that sperm extracted from the epididymis is “a” quality sperm and freezes/thaws well for use in IVF and that sperm extracted from the testis is “b” quality sperm and is best used fresh in IVF (does not thaw well). Is there any research or data indicating that sperm extracted either way is of different quality?
A substantial body of evidence suggests otherwise. In a study published in the British Journal of Urology in April of this year comparing fresh and frozen sperm from the testis and epididymis, frozen sperm from the testis did best in IVF. It may be counterintuitive, but most studies support that testis sperm works better in IVF than does epididymal sperm. I was surprised when I saw the first set of reports observing that testis sperm had generally better outcomes, but study after study supports that finding.
What are your thoughts on alternate medication choices (HCG injections) for patients who are unresponsive to clomid? Are you aware of any research that suggests other medications are effective in increasing sperm production prior to mTESE in males with non-obstructive azoospermia?
Koji Shiraishi just published on the use of HCG prior to micro-dissection testis sperm extraction: see the abstract here. Unfortunately, it looks like they didn’t try clomiphene prior to the testis extraction procedures, so they may have had the same results with a simpler, oral, less expensive medication.
I had an incident by which my one testie remained of the size of a samll grain from the age of 6 and the second one at the age of 18 due some infection got damaged and slowly with passage of time it become almost of same size just like a small grain. To check reproductivity TESEA was done but nothing is found. Pleae advise what are the chancs of finding sperms in such cases.
I’m sorry, Platia, but I can’t answer personal questions about your own health. Please read the FAQ.
Dr. Craig please advice:
I have obs. azoosperia, I had my TESE done exactly one year ago, the urologist tried to repair the vas deferral and he found good amount of sperm to be use for IVF with ICSI. I did a SA test 3 months/6 months/9 months after surgery and no sperm coming out. Does it mean the surgery was unsuccessful in regards of the blockage? Do we have a chance of success if we redo the surgery? What about the use of Clomid, will that help in any way? Thank you..
I’m sorry, George, but I can’t answer personal questions about your own health. Please read the FAQ.
generally in maturation arrest what is the success rate in using clomiphene citrate before IVF. may i know its role in developing the sperm and do it create any side effects as such. which one among Clomiphene citrata and HCG is better?
Good questions. I prescribe clomiphene first and depending on the man’s individual response, hCG only if necessary, as it’s more expensive and requires injections. We don’t know the exact improvement in maturation arrest as the study wasn’t designed to precisely assess that. See this paper and this paper for more details.
thank you sir for the information you have provided here. it brought new ray of hope in our married life
The only way to diagnose maturation arrest is with a biopsy, right? So, if I’m understanding your answer to the previous comment, in the hypothetical situation of a patient with normal testosterone and NOA you wouldn’t prescribe clomid prior to the first mTESE but possibly for a follow-up mTESE. Is that correct?
Hi Kate, we don’t do biopsies any more just to do them: we do them at the same time as a microsurgical testis sperm extraction to “see what’s up.”
Is there any evidence that clomid, hcg, or hmg could have a negative effect on sperm production? In other words, maybe it helps most patients, has no effect on some, and has a negative effect on the rest?
As I’ve written many times in the comments on posts on this blog, anything’s possible when it comes to humans 🙂 That’s why a man needs to see his doctor for individualized care.
It’s been many years, and I’ve finally turned off comments for this WordPress blog. Why? Although it’s the first question in the FAQ, I still get comments (a bunch a day!) asking personal medical questions that I can’t answer. That’s sad and frustrating for me, because as a doctor, I really like to help patients. But this WordPress site was never meant to deliver personal medical care, and the University lawyers tell me that doing so would run afoul of State and Federal laws.
If you have specific questions about your own personal care, I urge you as outlined in the FAQ to use the American Urological Association’s Society for the Study of Male Reproduction’s search engine
I also urge you to read through all of Maledoc.com and especially the comments. For the five or so years that it was active, A lot of excellent questions were asked, including by other healthcare providers. Chances are, if you have a general question, it’s been answered here and more than once.