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University Hospital Brussels- UZ Brussel

Male Intervention

Sperm Extraction Techniques for ICSI

As part of the treatment for IVF or ICSI (fertilisation of an egg via the injection of one sperm), it is possible that the man may require some form of intervention to be performed, to collect sperm for the procedure.
In some men, the ejaculated semen contains insufficient numbers of sperm, but, there may be sperm present in the testicles, which can be obtained by means of a small operative procedure.
Thanks to the nature of the ICSI technique, only a few sperm will be needed, nor do they require to be fully mature, because as of the moment they are produced in the testicles, they contain all of the genetic information from the man and can be directly used in the laboratory, to fertilise the egg.
The procedure to obtain the sperm from the man is normally performed on the same day as the womans' Pick up, so that we can have as fresh a sample as possible.
 

Procedure

General principles for sperm extraction procedures:

  • they can take place either under local or general anaesthesia;
  • only MESA is carried out only under general anaesthesia;
  • vibrostimulation is performed without any form of anaesthesia;
  • electro-ejaculation takes place under general anaesthesia, or should the man be paralyzed, without anaesthesia;
  • you may go home later on the same day, a night in the hospital is not necessary.

The different options and types of procedure will be discussed beforehand.
The procedure usually takes place on the same day as the pick up of your partner.

Surplus sperms may be frozen and used at a later date in a subsequent treatment. 

 

Indications
Which extraction procedure is implemented depends on the nature of the fertility problem.

ANEJACULATION: method of vibro- and electrostimulation.

Anejaculation, means that you do produce sufficient sperm, but that you are unable to ejaculate, even though you are able to get an erection. The problem is more common than you might think. There are a number of reasons:

  • neurological damage through trauma to the spinal column (e.g. in men who are partially paralyzed);
  • as a result of surgery for testicular cancer;
  • as a result of multiple sclerosis;
  • as a result of diabetes with nerve involvement;
  • unexplained anejaculation, whether they be physical or psychological.

AZOSPERMIA:

Azospermia means that there are no (or only dead) sperm present in the ejaculate. Even in normal healthy sperm production, not all the sperms which are produced make it into the ejaculate. A small percentage is always lost along the way. But when there are no sperms at all in the ejaculate,

- it can be due to a blockage somewhere along the sperms' journey, it is known as obstructive azospermia. The sperm production is normal, but they cannot get out. In this case all four methods of sperm retrieval can be considered;

- it can be due to an insufficient production of sperm cells in the testicles, or they do not ripen properly. This is known as non obstructive azospermia and TESE is the only considerable option;

- it can be due to a hormonal imbalance (this is unusual), in which case the problem must be rectified with medication. 

MESA & PESA: sperm from the epididymis.

Obstructive azospermia is the condition whereby the normal healthy sperm cannot get out due to a blockage somewhere along the way. During a MESA or PESA operation, the lab checks whether sufficient amounts of sperm have been extracted. The procedure can be carried out on both sides.   

MESA (microsurgical epididymal sperm aspiration)
Sperm cells are surgically extracted from the epididymis. Under general anaesthesia a small incision is made in the scrotum and a special microscope is used to select a suitable area from which the sperm cells are then aspirated.

 

PESA (percutaneous epididymal sperm extraction)
This procedure does not involve an incision. Under local anaesthesia, the epididymis is punctured through the skin and aspirated. This is a very simple technique, but does not always result in sufficient sperm retrieval. 

FNA & TESE: sperm from the testicle

In certain cases, sperm has to be extracted from the testicle itself, before they go to the epididymis to ripen. These two procedures usually result in less sperm retrieval than the other techniques.

 
FNA (fine needle aspiration)
With a fine needle, the testicle is punctured and aspirated. It is a simple technique but it does not always result in sufficient sperm retrieval. 

TESE (testicular sperm extraction)
If FNA does not result in sufficient sperm, or if you wish to have sperm banked and stored, then TESE is the procedure of choice. One small biopsy, taken under local anaesthesia is usually enough to provide the sperm required to perform ICSI and to freeze for later.
In the case of non obstructive azospermia, TESE is the only option and is best performed under general anaesthesia.
Even in cases where only small numbers of sperm are produced, TESE can usually provide enough sperm for ICSI in about half of the cases and even provide enough for freezing and storage.
Even in cases where only small numbers of sperm are produced, TESE can usually provide enough sperm for ICSI in about half of the cases and even provide enough for freezing and storage.

The tubules are pulled apart to free up the sperm producing cells.
Under the microscope, between the sperm producing cells, actual sperms can be seen, recognizable by their tales.
 

Vibro- and electrostimulation

For some men it is physically impossible to ejaculate due to psychological or physical reasons. In these cases, ejaculation can be achieved using vibro or electrical stimulation.
Before the procedure, there will be a number of investigations performed: the hormonal profile and infection status will be determined via blood and urine tests. If there are any infections, these will be treated before the procedure can be performed.
Most sperm samples obtained after a period of inactivity are of poor quality. The very best sperms will be selected from the sample for use in the fertilisation of the partners' eggs.

Electrical impulses are administered via the rectum.

Because ICSI is best performed with fresh sperm, the procedure is done on the same day on which the partners' Pick up is scheduled. 

 
VIBRO STIMULATION (day case procedure)
A vibrating apparatus is held to the penis, with which a possible reflex leading to ejaculation may occur. 


ELECTRO STIMULATION (day case procedure)
During this procedure, a special probe is inserted into the rectum. Via electrical impulses, certain nerves are stimulated, causing an erection and subsequently, ejaculation.

Read the Guide

The guide is available as downloadable PDF documents.

Click on the chapters to view the PDF's.

  • More than medical. Ethical, social and health aspects of IVF. Possible consequences for the child; the ethical implications of a prenatal diagnosis; how to deal with treatment with regards to your friends and family; what happens with the frozen material...