There are many options available for males with a previous vasectomy or other cause of abnormal sperm production. You will need to discuss the options in detail with an experienced physician. This page will outline information that may be helpful to you, but in no way is meant to replace expert advise from a male fertility specialist.
The most common techniques for extracting the sperm are PESA, or percutaneous sperm extraction, and MESA, or microsurgical sperm extraction. TESA and TESE may also be used. The level of anesthesia and amount of recovery will vary with the different procedures. The consulting physician will be able to give you a much better idea of the anticipated type of procedure and estimated recovery.
MESA – Microscopic Epididymal Sperm Extraction
During a MESA procedure, small incisions are made into the scrotum under anesthesia. The sperm is extracted under direct visualization using a microscope. The sperm is retrieved from the epididymis (storage of sperm before ejaculation). A TESE procedure is similar except the sperm is removed from the testicle. The sperm collected from the testis are often more immature, harder to isolate, and may not be very motile. For this reason, it is preferable to have sperm from the epididymis when possible. Men with previous vasectomies or problems having an ejaculation will most often have sperm available in the epididymis for collection. Men with hormonal causes or defects in sperm production may not have sperm in the epididymis and a search for sperm within the testis may be necessary.
PESA – Percutaneous Sperm Extraction
PESA procedures involve passing a needle directly through the skin of the scrotum and into the epididymis or testicle. This is an easier procedure than a MESA and is usually cheaper. The biggest disadvantage is that it is not as efficient at collecting enough sperm for treatment as a MESA procedure. The risk of injury and bleeding is also higher. For these reasons, MESA procedures are performed in most cases.
TESE / TESA – Testicular Sperm Extraction and Aspiration
The TESE procedure involves making an incision in the Scrotum and removing the sperm from the testicle. A TESA procedure uses a biopsy needle to remove sperm by extracting sperm from the testicular tissue. Since the sperm may be immature and less motile, it is generally preferable to extract sperm from the epididymis when possible.
Once the sperm is collected, it will be sent to the laboratory for processing, evaluation, and storage. Evaluating the sperm count, motility, and other parameters will help determine how to best store, or freeze the sperm. The sperm are usually stored in aliquots, or portions, that will allow for multiple treatments. The amount of sperm collected is usually not enough to allow for an intrauterine insemination (IUI – sperm are placed into the uterus using a small catheter. Also referred to as artificial insemination). The sperm collected by the various extraction procedures such as MESA and PESA are usually used in conjunction with in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). The surgeon will attempt to obtain enough sperm to store for multiple treatments.
IVF and ICSI are procedures performed in a fertility clinic where eggs are collected from a woman and placed with the sperm from a man. The sperm are injected into the cytoplasm of the egg to make certain the sperm enter the egg. This procedure is called intracytoplasmic sperm injection (ICSI). The embryos that result from putting the sperm and eggs together can be placed back into the uterus of a woman 3 to 5 days later. After this procedure is performed, a pregnancy test is done 8-10 days later to see if the procedure worked. Newer approaches have resulted in much higher rates of success if the resulting embryos are frozen 5-6 days after fertilization. This allows time for the ovaries to recover and avoids excessive hormone stimulation of the uterine lining. By utilizing the frozen embryo approach, IVF pregnancy success has increased up to 20% over what has been seen with fresh transfers.
Men with a previous history of having a vasectomy may be candidates for a vasectomy reversal. This procedure involves reconnecting the ends of the vas deferens; which is the tube that carries sperm from the testis and epididymis to the outside during an ejaculation. The vas deferens is cut and tied during a vasectomy procedure.
The vasectomy reversal can be affected by the length of time that has passed since the vasectomy was performed. Vasectomy reversals are more successful the closer they are performed to the actual time of the vasectomy. A vasectomy reversal performed in less than 10 years from the original procedure would have a 60-80% chance of success if there are not other factors affecting fertility. This estimate can drop to 10 to 40% if the vasectomy was performed more than 10 years ago. The main reasons for the decline in fertility is related to a vasectomy reversal are from obstruction of the epididymis and from antisperm antibodies. Obstruction of the epididymis can usually be identified and corrected at the time of surgery. This is an important reason to use a skilled and experienced surgeon if you are considering this option. If this is not properly corrected, the pregnancy rates can drop as low as 10%.
Antisperm antibodies are antibodies produced by the male that attach to sperm. The antibodies act as a signal to white blood cells to attack and kill the sperm since they have no where to go. These antibodies also cause sperm to cluster together, or agglutinate. There have been several proposed treatments for antisperm antibodies but intracytoplasmic sperm injection (ICSI) seems to be the most effective.
Cryopreservation (Freezing and Storing) of Sperm
Sperm have been successfully frozen and thawed for use with fertility treatments for many decades. Modern procedures for freezing and thawing of sperm will decrease the number and motility of sperm. Since ICSI is the most commonly recommended treatment when sperm are extracted, only one motile sperm is needed for each egg that is going to be fertilized. Once frozen, the sperm can remain in storage without affecting the quality of the sperm. The freezing and thawing process can affect sperm and since many of the living sperm may be abnormal, it is still best to have the most amount of sperm possible. An experienced male fertility surgeon can improve the chances of giving the IVF laboratory a high quality sample. Laboratory processing and yearly storage fees will apply to cryopreservation specimens.
Because fertility clinics store sperm from many individuals, there are state and federal guidelines governing the storage of sperm. For this reason, it will be necessary to have an infectious disease evaluation completed before storing sperm. The following 5 tests are needed.
- Hepatitis B Surface Antigen (Hep BsAg)
- Hepatitis C Antibody (Anti-HepC Ab)
- Syphilis testing (RPR, VRDL, or equivalent)
- HTLV I&II (Human T-Cell Lymphocyte Virus)