What To Do in Cases of No Sperm in the Ejaculate and No Blockage:    A Review of Management Decision

Azoospermia refers to the condition where there are no sperm in the ejaculate.  This occurs in about one percent of the male population and up to ten percent of men undergoing  fertility evaluation, depending on the practice.   Azoospermia can be either obstructive (normal sperm production is present but there is an anatomic blockage preventing the sperm from exiting the body) or non-obstructive (sperm production is severely diminished or altogether absent).   Commonly associated findings include smaller testicular volumes and elevated serum FSH (follicle stimulating hormone) levels.   In many cases, though sperm production is so poor that none enter the ejaculate, it may be possible to surgically retrieve sperm directly from the testicle for use in an in-vitro fertilization setting.   Further refinements in this approach include the use of microdissection techniques for surgery which have improved overall sperm retrieval rates by over 50% according to the article reviewed.     


When performing microdissection Testicular Sperm Extraction aka MTESE, one decision that comes into consideration is the timing of the procedure: Should it be/can it be performed the same day as egg retrieval for the patient’s partner or should it be performed in advance?     


Two major considerations are 1) logistics and 2) overall cost considerations which including chances of successful sperm retrieval in MTESE.    With respect to logistics, the date of timed retrieval may need to be adjusted from day to day as the cycle continues and the egg follicle sizes and counts are monitored.    Therefore, the urologist must have the flexibility to be available for one specific date, but that date may shift one or two days earlier or one or two days later on very short notice.  That means the operative facility must also have similar flexibility.   Furthermore, this may also mean disrupting scheduled procedures for other patients. 


With respect to overall cost considerations, one must be mindful that IVF is expensive.  According to the article reviewed overall chances of success for MTESE are about 50%,  but it is this author’s experience that factors may point to a higher chance of retrieval (eg prior natural fertility) or lower chance retrieval  (eg genetic abnormality).  Therefore, if chances of sperm retrieval success are high, that might seem to argue more for timed retrieval; however,  the chances of recovery of sperm frozen when chances of success are higher tend to also be higher.     If chances of finding sperm are lower, and if sperm are not found in a “freeze ahead” retrieval, then the expense of egg retrieval in an IVF cycle may be avoided.  However, if sperm are found, chances of sperm recovery from the frozen specimen may also be somewhat lower depending on the amount and quality of sperm frozen.


A survey with responses from 54 urologists regarding this type of scenario was reported on  by Asanad et al in the Journal: Urology.   Findings include the following:  Half of the urologists responding to the survey were in private practice vs an academic setting.  Only a third of those surveyed performed more than twenty MTESE per year.    The majority of doctors primarily performed “freeze-ahead” procedures.    Furthermore, the majority of procedures were performed at centers separate from the facilities where IVF egg retrieval was performed. Finally, those urologists that did prefer fresh retrieval tended to be connected to centers that do the IVF egg retrieval and were more likely to charge higher professional fees.


With respect to this author’s experience:  I have performed several hundred MTESE’s in my 25 years of practice and currently perform several dozen procedures per year.   I have privileges at 3 surgery centers and a hospital affording me the flexibility necessary to cover procedures as is necessary.


Certain omissions from the article were striking to me.   One is the lack of mention of the preference of the IVF center.   One group I work with prefers only timed retrieval.   If that offers a higher chance of success to the patient then that is what I will do.  In fact, one center sometimes requests me to do the procedure the day before egg retrieval and incubates the testicular tissue overnight.   Yet other centers prefer “freeze ahead” MTESE so that their personnel can be fully focused on egg retrievals when those are performed.


I have also had the experience where the wife or partner’s eggs were actually retrieved and frozen in advance.  In all of these cases, the couple had been counseled and were ready to proceed with donor sperm as a back up if sperm were not found on MTESE.      


Finally, with respect to cases where I have retrieved sperm with “freeze ahead” MTESE,  viable sperm were recovered in virtually all specimens on thawing, though this very good recovery rate may be attributable to the very good skills of the laboratory personnel of the groups I work with.

Eric K. Seaman MD Dr. Seaman is a urologist specializing in the field of Male Reproductive Medicine and Surgery. Dr. Seaman Completed his Male Infertility Fellowship under the direction of Larry I. Lipshultz MD at Baylor College of Medicine Houston in 1996. Since that time he has focused his practice on the sub-subspecialty focus area of Male fertility and infertility.

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