Procedures and operations for men as part of a fertility treatment

Whether or not a man is fertile depends largely on his sperm production. This is controlled and regulated hormonally, but not all problems can be blamed on hormonal imbalance. Sometimes psychological factors are the reason, or else an obstruction somewhere along the sperm's journey both in the man's and woman's body.
See also the sperm quality for the requirements a sperm sample needs to meet for 'normal' fertility.

TESE and other sperm extraction procedures for ICSI

A man's contribution to an ART treatment is to provide a fresh sperm sample through masturbation.
This is usually the case:
  • for artificial insemination with own sperm,
  • for 'classic' IVF, and

IVF with ICSI (fertilisation of an egg via the injection of one sperm).

In this last procedure a man may require some form of procedure specifically aimed at collecting sperm. In some men, the ejaculated semen contains no or insufficient numbers of motile sperm. However, they can be collected with a small operative procedure.
Thanks to the ICSI technique, only a few sperm will be needed. They don't even have to be fully mature. From the moment they are produced in the testicles, they contain all of the man's genetic information and can be used in the laboratory for injection into the egg.
The procedure is normally performed on the same day as your partner's egg retrieval, so that we can use a fresh sample.


Procedure anaesthetic

How does the UZ Brussel go about examinations or operations under anaesthetic?

Sperm extraction procedures have a number of things in common:
  • they can be performed either under local or general anaesthetic;
  • you may go home later on the same day (outpatient), a night in the hospital is not necessary;
  • the different options - both the procedure and the anaesthetic - will be discussed with you. Obviously, the decision will depend on the results of the preliminary tests, but also according to what is most feasible in practice in your situation; 
  • in the planning of the IVF treatment your procedure will usually take place on the same day as your partner's egg retrieval. For ICSI we prefer to use the freshest material possible.

To perform a procedure we need your consent. You need to sign a contract which contains all the information about the procedure and the possible side effects.
You will receive the same information from the CRG doctor.

Frozen storage   

The procedure often provides enough sperm for three or four ICSI sessions. When ICSI has been performed on all your partner's ripe eggs, the remaining sperm can be frozen and stored for a possible next treatment.
  • However, for this we need your consent. To do so, fill out and sign the "Consent for the frozen storage of sperm" contract and return it to us before the procedure. This contract lays down what you want done with the frozen material when you can't use it anymore.
  • The fact that you give your consent of course does not mean that frozen storage is possible.
  • Nor is storage free of charge. It is free the year of your treatment, but afterwards an annual storage cost is payable.
  • The maximum storage period is ten years.
Which extraction procedure is used in your case depends on the nature of the problem (see Looking for the cause).

For anejaculation, vibro- and electrostimulation are recommended.
Anejaculation means you produce sufficient sperm, but you are unable to ejaculate, even though you are able to get an erection. It is more common than one would think. Below is a list of the major causes:
  • neurological damage through trauma to the spinal column (e.g. men whose lower body is paralysed);
  • after surgery for testicular cancer;
  • as a result of multiple sclerosis;
  • as a result of diabetes with nerve damage;
  • unexplained anejaculation, be it physical or psychological.

For azoospermia the four other techniques are used.
Azoospermia means there are no (or only dead) sperm in the ejaculate.
Which of the four extraction techniques is used, depends on the nature of the cause.
Please understand the following: even in normal healthy sperm production, not all the sperm which are produced make it into the ejaculate. A small percentage is always lost along the way.
But if there are no sperm at all in the ejaculate this can be the result of:
  • a blockage somewhere along the sperms' journey: this is known as obstructive azoospermia. Sperm production is normal, but they cannot get out. In this case, all four procedures come into consideration;
  • a problem with the production of sperm: too few are produced or they don't mature. This is known as non-obstructive azoospermia. TESE is the only option;
  • a hormonal disorder (this is unusual). In this case no operative procedure is needed. If possible the problem is solved with medication. See hormone treatment.

As previously discussed, obstructive azoospermia is the condition whereby normal healthy sperm cannot get out of the epididymis, e.g. due to a blockage of the vas deferentia or because they are missing.
During a MESA or PESA procedure, the lab checks whether sufficient amounts of sperm have been extracted. The procedure may be repeated on the other epididymis.

MESA or microsurgical epididymal sperm aspiration

In this procedure sperm are surgically extracted from one of the epididymis:
  • under general anaesthetic
  • an incision is made in the scrotum, and
  • a special microscope is used to select a suitable area of an epididymis,
  • from which the sperm are aspirated.

PESA or percutaneous epididymal sperm aspiration.

This procedure does not involve an incision:
  • under local anaesthetic
  • we puncture an area of the epididymis through the skin, and
  • the sperm is aspirated.
This is a very simple technique, but does not always result in sufficient sperm collection.

In some cases, the only option is to find sperm in the testicles themselves, before they go to the epididymis to ripen. TESE and FNA are an alternative to MESA and PESA, but usually result in less sperm.

FNA or fine needle aspiration

  • Under local (or sometimes general) anaesthetic
  • the testicle is punctured with a fine needle,
  • to try to aspirate sufficient sperm.
It is a simple technique, which not always achieves the envisaged result.
FNA is an option if you have a normal sperm production but no sperm in your ejaculate due to a blockage.
The procedure results in too few sperm to freeze though.

TESE or testicular sperm extraction 

TESE is recommended:
  • for obstructive azoospermia
    • if the FNA procedure does not achieve the envisaged result or
    • if you want to freeze sperm.
    One small biopsy, taken under local anaesthetic, is usually enough to provide the sperm required to perform ICSI and to freeze for later;
  • for non-obstructive azoospermia. TESE is the only possible option:
    • the procedure is done via micro surgery, and
    • under general anaesthetic.
      Often, multiple biopsies need to be taken from both testicles.

A small bit of tissue is surgically removed from a testicle. It is prepared and examined for the presence and the quality of sperm in the lab. Depending on the findings more tissue is removed from the same testicle or a piece is removed from the other testicle.
Although the cause of non-obstructive azoospermia is that sperm production in the testicle is minimal or absent, in half of the cases TESE results in enough sperm for ICSI.
In some cases sperm can also be frozen (if we have your consent for this).
After the procedure, the surgeon will inform you as to whether sufficient sperm was found for the ICSI procedure and/or for the purposes of storage.

Menwho are unable to ejaculate, either due to psychological or physical reasons, can be helped with vibro or electrical stimulation
Unfortunately these two methods are not covered by health insurance.

Before the procedure a number of tests need to be performed:
  • a blood test
    • for your hormonal profile, and
    • a test for infectious diseases; and
  • a urine culture to check for urinary tract infections.
    If positive, they are treated first.

Most sperm samples obtained after months of inactivity are of poor quality. The chances of success of an ART treatment naturally depend on the sperm quality. This is why ICSI may offer a solution: the best sperm are selected from the obtained sample to inject in the eggs.
Because ICSI is best performed with fresh sperm, the procedure will be performed on the same day as your partners' egg retrieval.
But the collected sperm can of course also be frozen for later use. For this you need to sign a consent form.

Vibratory stimulation

A vibrating apparatus is held to the penis, which causes a reflex leading to ejaculation. A reflex is something you cannot control, like the heave reflex when you stick your finger down your throat.

Electrostimulation

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