The primary
treatment option for infertile men with obstructive azoospermia was
vasovasostomy or vasoepididymostomy for reconstruct able causes, or implantation
of an alloplastic artificial spermatocele for subsequent percutaneous retrieval
of sperm for unreconstructed able causes, such as congenital absence of the vas
deferens.
Since the first US
report of a successful delivery from in vitro fertilization (IVF)
in 1982, progress in the field of assisted reproduction and micromanipulation
has been truly dramatic, particularly in the area of male factor infertility,
offering couples considered irreversibly infertile,
Results:
The consequences of ICSI are being used
increasingly in the absence of abnormal semen parameters or male factors the
role of male infertility per se in the analysis of outcomes has
become less evident. There is often a masking of data pertaining to male-factor
infertility as ICSI is being used to increase the odds of successful live birth
in couples with not only male causes of infertility, but also cervical causes,
or combined causes. The origin of the sperm and type of infertility are seldom
examined and the results are not stratified according to these important
exposures.
Obstructive & Non-obstructive Azoospermia:
The major subgroups of male infertility,
obstructive azoospermia (OA), non-obstructive azoospermia (NOA) and severe Oligozoospermia (SO) seem likely to have different implications in terms of
outcomes for the offspring. In the case of Oligozoospermia there will be a normal
spermatogenesis but some mechanical problem preventing passage of the sperm
such as in men who have damage to the epididymis because of infection or
inflammation or have had vasectomies. Oligozoospermia can be the result of congenital
bilateral absence of the vas deferens in men with or without clinically evident
cystic fibrosis. With non-obstructive azoospermia. This is often due to genetic
defects.
Testicular sperm extraction: (TESE)
TESE is a surgical sperm retrieval procedure used in subfertility
treatment for men who have no sperm in their ejaculate.
TESE suitable for:
TESE is used for male with both obstructive &
non-obstructive Azoospermia. These men have no sperm in their ejaculate because
either there is a blockage in the route between the site of sperm production
(the testes) and ejaculation or because there is a partial or complete failure
in sperm production in the testes.
Conventional TESE is usually performed under local, or
sometimes spinal or general, anesthesia. An incision in the median raphe of the scrotum is made. The testicle and epididymis are then
visible. From here incisions are through the outer covering of the testis to
retrieve biopsies of seminiferous tubules, the structures which
contain sperm. The incision is closed with sutures and each sample is assessed
under a microscope to confirm the presence of sperm. Following extraction,
sperm is often cryogenically preserved for future use,
but can also be used fresh.
When TESE is done:
The consultant may advise that TESE is carried out in
advance of any fertility treatment to confirm that sperm
production is occurring. If suitable numbers of sperm are identified on this
occasion, it is sometimes possible to freeze the testicular extract and to thaw
and use this sample for subsequent treatment. More commonly however, once it
has been confirmed that sperm production is occurring, the TESE procedure is
repeated on the day of the egg retrieval and the fresh sample used for ICSI.
Again, providing that there are suitable numbers of sperm present, the sample
can sometimes be frozen for use in future treatment cycles
Micro-TESE:
Micro-TESE, or micro
dissection testicular sperm extraction, includes the use of an operating microscope. This allows the
surgeon to observe regions of seminiferous tubules of the testes that have more
chance of containing spermatozoa. The procedure is more invasive than
conventional TESE, requiring general anesthetic, and usually used only in
patients with non-obstructive azoospermia. Similarly to TESE, an incision is
made in the scrotum and surface of the testicle to expose seminiferous tubules.
However, this exposure is much wider in micro-TESE.
This allows exploration of the incision under the
microscope to identify areas of tubules more likely to contain more sperm. If
none can be identified, biopsies are instead taken at random from a wide range
of locations. The incision is closed with sutures. Samples are re-examined
post-surgery to locate and then purify sperm.
When compared with conventional TESE, micro-TESE
generally has higher success in extracting sperm; as such, micro-TESE is
preferable in cases of non-obstructive azoospermia, where infertility is caused
by a lack of sperm production rather than a blockage. In these cases,
micro-TESE is more likely to yield sufficient sperm for use in ICSI.
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