Tests and Investigations
We always like to have more than one semen analysis. This is because there is much biological variation in sperm production, and we cannot be sure that one or even two semen analyses reflect the real situation.
Hormonal blood tests (FSH, LH, Testosterone) are usually helpful.
In cases where there is either azoospermia (no sperm) or severe oligospermia (less than 5 million sperm), we usually advise genetic blood tests (known as the karyotype and Y-micro-deletion studies, which look specifically at the “Y” or male chromosome).
What about more sophisticated or unusual tests?
Over the past three years, we have been looking very carefully for signs of infection and inflammation in the male genital tract (this is the pathway that the sperm take from the testicles, all the way to the urethra tube in the penis). We will often do a test for reactive oxygen species (ROS) chemicals, and a special urine test looking for low levels of bacteria (a PCR test).
In some, but by no means all cases, we can look more closely at the DNA and chromosomes in the sperm themselves (DNA fragmentation and aneuploidy tests).
We have also started to look at novel hormone tests (the Anti Mullerian Hormone or AMH) in men with Azoospermia, which might help to predict positive sperm retrieval.
Finally, because we believe that treating varicocele (distended veins, like varicose veins, in the scrotum) is helpful, we may request an ultrasound scan of the testicles.
Male Fertility Testing
Appropriate testing and accurate interpretation of semen analysis results is vital to achieve a reliable diagnosis for male factor infertility. A fully comprehensive semen analysis is performed by an experienced embryologist with a fertility background.
- The number of sperm present. This is important as sperm have to travel an exceptionally long and convoluted distance from the vagina into the Fallopian tubes to meet the egg. If the count is too low, the chances of even one sperm finding the egg is going to be very much reduced
- The percentage of sperm that are moving and analysis of how progressively motile these sperm are (motility). Sperm have to be good swimmers, moving rapidly and in straight lines if they are to be successful in reaching the egg
- The shape of the sperm (morphology) with a detailed breakdown of defects. If sperm are an abnormal shape this can decrease their ability to fertilise an egg
- MAR antibody test (IgA/IgG). If antibodies are present this can cause the sperm to stick together and reduce the ability of the sperm to fertilise an egg
- Presence of other cells as a marker of inflammation or infection as this may reduce fertility
Testicular Mapping Procedure
This is also known as the fine-needle technique and I believe that it has an important place in diagnosis before the more invasive microdissection treatment is undertaken.
It is a non-surgical, minimally invasive procedure that can accurately diagnose.
The fine-needle testicular mapping procedure (FNA) was described by Paul Turek, from San Francisco, nearly 20 years ago. Most North American Urologists, and nearly all those from Europe, have not perceived much benefit, and tend to recommend micro-TESE in all cases.
We have taken a different approach, particularly in critical cases (low levels of Testosterone and hypogonadism, testicles which have previously been operated upon, and men who have failed to produce any sperm after medical treatment). We recommend FNA as a diagnostic procedure before committing to a micro-TESE.
By taking this approach, we can more confidently predict a successful micro-TESE with fewer complications. We can also time the sperm retrieval (micro-TESE) to be synchronised with egg collection, because we can be more certain that we will retrieve sperm.
The Fine-Needle Aspiration (FNA) procedure is not a sperm retrieval; it is designed to tell us whether or not there are any areas of sperm production in either testicle (spermatogenesis) and, if such areas exist, their precise location.
The procedure usually requires a light general anaesthetic, or sedation, in combination with generous amounts of local anaesthesia. 18 separate specimens are taken through a narrow-gauge needle from 18 different sites in each testicle.
Recovery is surprisingly quick. Most men feel little pain and are able to return to work in 2-3 days. In the first 150 cases undertaken in the past three years, only one patient had pain and discomfort for more than two weeks, and fortunately these symptoms eventually subsided. An analysis of our presentation of the first 72 cases can be found in the information section.
Although the FNA procedure itself is relatively straightforward, the majority of the ‘work’ associated with it is the highly technical assessment of the 36 slides, or samples, which require expert and time-consuming scrutiny by a Consultant skilled in Cytopathology. Results may take up to 6 weeks.
Sperm retrieval is a broad term describing a variety of modern surgical techniques used to obtain sperm without ejaculation. Depending on your circumstances it may be used as an alternative to, or in conjunction with corrective surgery to maximise the chances of achieving a successful pregnancy.
The procedure used will depend on the outcome of your tests and the nature of exploration. Testicular Sperm Aspiration (TESA) is a simple procedure to extract some of the substance of one (or preferably both) testes for further analysis (e.g. with Obstructive Azoospermia). At the same time, testicular tissue is frozen so that any sperm present can be subsequently used.
There is increasing evidence that whilst testicular exploration, biopsy and sperm extraction should be as thorough as possible, it should also be limited in order to reduce the chance of subsequent testicular failure and low androgen levels.
It is our practice for the surgeon undertaking surgical sperm retrieval to be accompanied in the operating theatre by an embryologist experienced in the use of high quality microscopes. In this way optimal tissue extraction can be maximised without removing excessive non-sperm producing testicular tissue.
Over the past year, we have been looking more closely at the DNA quality of surgically retrieved sperm. At present, our preliminary results are suggesting that in some cases, the DNA quality of testicular sperm may be better than in "ordinary" sperm samples.
Microdissection Sperm Retrieval
When no obstruction of the testes is suspected (Non-Obstructive Azoospermia), the attempt to find and store sperm is more thorough, and involves the extraction of multiple small testicular specimens taken from different sites in each testicle. This is a micro TESE and can only be undertaken using an operating microscope.
This surgical technique has been developed to detect sperm in the testicles of men who have poor sperm production.
Occasionally in non-obstructive azoospermia (NOA) non- surgical treatment may be effective, but this can only be expected in 10% of cases.
When the (non-obstructive) azoospermia persists despite medical treatments, there are two options for the men: The traditional and accepted route is to suggest a ‘micro-TESE’ (testicular micro-dissection), or microsurgical testicular sperm extraction.
This important daycare procedure requires a light general anaesthetic and recovery is swift, but we recommend that men take one week away from work to ensure comfortable recovery, and to minimise complications.
The operation (m-TESE) requires a small (2 cm) cut on the front of the scrotum (sac). This incision is closed with stitches which are under the skin, and which dissolve without the need for removal or other post-operative care.
When the azoospermia is ‘obstructive’ (OA), a sperm retrieval procedure is inevitable, to allow sperm to be stored or used on the same day as the retrieval for IVF using Intracytoplasmic Sperm Injection (ICSI). Medical treatment is not helpful.
Sometimes, the sperm retrieval can be done without a general anaesthetic by percutaneous epididymal sperm aspiration (PESA). It is, however, more likely that we would advise a micro-epididymal sperm aspiration (MESA) under a light general anaesthetic, which gives the opportunity for reconstructive surgery, when it is possible and advisable to bypass an obstruction by a microsurgical epididymovasostomy. The MESA procedure (as opposed to the PESA) allows scope to extend the search for "best quality" sperm to the testicle itself, and also in our most recent practice to send the retrieved sperm for DNA fragmentation studies, to further refine our decision making when it comes to ICSI.
Even when obstructive azoospermia has been diagnosed, or is the likely diagnosis, we sometimes find that there are no motile, or normal, sperm in either of the epididymides and that therefore we need to proceed to a micro-TESE straight away, at the same time, and under the same general anaesthetic. It is therefore only the most ‘obvious’ cases of obstructive azoospermia in which we are ‘sure’ to find sperm in the epididymis, and when we are not proposing any other micro or reconstructive surgery, which are suitable for a PESA procedure under local anaesthesia.
The operative and post-operative descriptions and instructions are similar for both micro-TESE and MESA.
What about complications?
Fortunately there are very few. Wherever an incision is made, infections under the skin (abscesses) and localised blood clots (haematomas, usually the size of a cherry) may occur. However, the incidence of such eventualities which either require treatment or which significantly alter the recovery trajectory are rare, occurring in less than 5% of all cases.
Read recent reports for more information on our GP page
Are there any serious or long-lasting complications?
Much has been written about possible damage to the Testosterone-producing parts of the testicles. This sort of damage only occurs after a micro-TESE procedure, and not after a MESA, nor after epididymovasostomy, or vasectomy reversal.
The most favourable clinical reviews quote a 10% incidence of significant reduction in Testosterone production after micro-TESE. By ‘significant’, we mean that there is a need for Testosterone replacement therapy, because the damaged testicles cannot produce sufficient Testosterone for normal physiological functions.
The least favourable reviews quote incidences of low Testosterone (hypogonadism) in up to 25% of micro-TESE cases.
The real figure, in our experience, lies somewhere between the two; principally because the selective use of the FNA (mapping) procedure prior to micro-TESE means that we seldom need to operate on both testicles at the same time, thus preserving the hormonal (or endocrine) function at least one of the testes.
The risk of low Testosterone levels after micro-TESE is greatly increased when the micro-TESE has to be repeated. Therefore, when patients are seeking a second micro-TESE, or indeed a micro-TESE after previous multiple biopsies, we tend to offer a preliminary FNA mapping procedure, so that we will only be undertaking a micro-TESE when we know that sperm are present. It is rare in these cases to have to explore (and therefore potentially damage) both testes.
Finally, we may undertake a sperm retrieval (that is a micro epididymal sperm aspiration, or MESA) as part of a vasectomy reversal. The MESA adds very little time, and certainly no extra complications to the vasectomy reversal, and may help to indicate (by the quality and location of the sperm retrieved) what type of reconstruction might best suit the individual patient.
Recovery from vasectomy reversal operation (with or without a MESA procedure) often takes a little longer than from the other scrotal operation for sperm retrieval. Re-joining the vas tubes on both sides requires more dissection, and so the tissues in the scrotal sac and those surrounding the spermatic cords are necessarily more disturbed and will take more time to heal. The position of the testicles within the scrotal sac may also be altered.
Overall, we recommend 10 days off work, travelling and holidays following a reversal. Strenuous activity, including running and working out in the gym, should be avoided for at least one month post-operatively.
Whenever a surgical procedure is undertaken for the diagnosis or treatment of male factor infertility, it is advisable and often mandatory to consider sperm storage. We are never sure whether we are going to find sperm. Thus having an experienced embryologist on site and access to sperm freezing and storage facilities is a vital part of maximising a successful outcome. In our practice an experienced embryologist is always present in the operating theatre. Our network of fertility units associated with each hospital includes:
- Hammersmith Fertility Unit (London)
- Chelsea and Westminster Assisted Conception Unit (London)
- The Agora Clinic (Hove)
- The Lister Hospital Fertility Unit (London)
- Andrology Solutions (London)
- Fertility Solutions (Windsor)
- Boston Place (near Marylebone Station)
Sperm are always stored under the Human Embryology and Fertility Association (HEFA) guidelines and consent for an initial period of storage of 5 years is typical. All men considering sperm storage need to have screening blood tests for Hepatitis B Core Antibodies and Surface Antigen, Hepatitis C and HIV. Couples are contacted on an annual basis to confirm their intentions to continue sperm storage.
Vasectomy reversal success can be measured in two ways:
- The most important relates to the chance of a successful pregnancy following the surgery and this figure is very much dependent upon the age of the female and to a lesser extent the age of the male partner. In general terms for female partners of 35 years or less a 40% pregnancy rate should be expected.
- The other rather more optimistic way of measuring success is on the basis of the return of sperm to the ejaculate. This really depends upon surgical technique rather than physiology (although it is slightly influenced by age) and we should expect success in 80% of cases measured in this way.
The interval between the original vasectomy and the time of reversal does seem significant in most studies, however results seem less favourable when the interval is more than eight years.
Even if the odds are against you, we use all the skills, experience, techniques, and technology available to seek to maximise your chances of achieving a pregnancy.