After the discovery of microinjection for male infertility, the most important improvement is the surgical intervention applied to men who have no sperm in their semen. Thanks to this method, many males who were seen as hopeless cases were able to have children.
Among the assisted-reproduction treatments, the most important development after IVF is microinjection. A few years after the first microinjection and the baby born after this procedure, the revolutionary ‘surgical sperm search’ process began to be used. Finding sperm with surgery in the testicles of a man who had no sperm in his semen and achieving pregnancy after microinjection with this sperm has become a hope for thousands of men all over the world who are unable to have children. Surgical sperm search operations, which started to be applied in our country a few years later, paved the way for many couples to have their own children.
The absence of sperm in a man’s semen can be due to various reasons. Some of these are due to obstruction of the sperm ducts. In such a case, there is no sperm production in the testicles. However, existing sperm cannot be thrown out with semen due to obstruction in the ducts. In this case, it is said that there is no sperm due to obstruction (obstructive azoospermia). In cases of azoospermia due to obstruction, the clogged channels or testicular tissue are entered with a fine needle, small pieces are taken. The rate of finding sperm in these fragments is close to 100%.
In cases not related to obstruction (non-obstructive azoospermia), sperm production in the testicles is either none or very limited in certain areas. While the underlying cause of non-obstructive azoospermia may be genetic, infections during adolescence may also play a role. In such a case, testicular biopsy is very useful in terms of guiding the treatment.
There are thousands of tiny tube-like structures within the testicular tissue. In these structures, sperm production continues at different stages. While some tubules may have no production, others may have few sperm. This is the rationale underlying surgical sperm search methods. When a large number of pieces taken from different parts of the testis are examined, sperm cells can be found. In this method, called TESE, the probability of finding sperm ranges from 25% – 60 depending on the underlying cause. While the highest success is achieved in hypospermatogenesis cases where sperm production is very low, the chance is minimal in cases of genetic defect.
Finding sperm in trials in an azoospermia case does not guarantee that sperm will always be found in subsequent trials. But success is achieved often. Similarly, there is a possibility of finding sperm in a new trial according to the biopsy result in people on whom it was not possible to find sperm before surgery.
Once sperm is found, whether it is found in the testis or semen does not have a significant impact on the success rates of microinjection. In other words, taking the sperm either from the semen, or through the ducts or directly from the testis does not change the pregnancy rates and results.
This procedure is called percutaneous epididymal sperm aspiration (PESA) when sperm is taken from the canals with a needle. Taking it within the testicle with a needle is percutaneous testicular sperm aspiration (PTSA). Extracting it within the testicle by direct surgery is called testicular sperm extraction (TESE). While PESA and PTSA can be performed under local anaesthesia, TESE is usually performed under general anaesthesia.
The process takes about 15 – 45 minutes and the person can largely return to his normal life the next day.
If sperm cannot be found by surgery, the procedure to be followed depends on the biopsy result. If there is no chance of finding sperm in a new trial, then, applying to sperm banks is the only valid method, at present. However, since this practice is not legal in our country, couples should apply to centers abroad. On the other hand, it is possible to obtain promising results for retry in a significant number of patients. In such a case, a new trial can be made after a few months.