To better answer this dilemma, Hauser and colleagues from Tel Aviv, Israel, compared the results of TESE with those from TESA in the same testis of NOA patients. Three samples by TESE and by TESA were taken in each testis, and the results were compared. The investigators found that TESE was markedly superior to TESA at obtaining sperm and in terms of the quantity and subsequent motility of the sperm found. This meant that there was a better chance of cryopre-servation of sperm obtained by TESE rather than TESA. The import of this is that such cryopre-served sperm can be used in subsequent cycles rather than the patient having to go through another TESE or TESA procedure.One of the “complaints” about TESE by non-urologists is that general anesthesia is necessary for such a procedure. This is not necessarily true: it can be done safely and comfortably with a cord block, as we perform it at the University of California, Los Angeles. Therefore, according to Hauser and colleagues’ data, it seems that TESE is the preferred method of sperm aspiration in men with NOA.

Sperm

It is possible to freeze sperm prior to a treatment cycle, so as to ensure that there is sufficient sperm available at the time of your partners egg collection. Sperm can also be frozen prior to vasectomy or chemotherapy/radiotherapy treatment, so that the opportunity to have children is possible in the future.

Percutaneous Epididymal Sperm Aspiration (PESA), Microsurgical epididymal Sperm aspiration (MESA) and Testicular Sperm Extraction (TESE)

Sperm can be obtained directly from the epididymis (fine ducts that bring the sperm out of the testis before joining to form the main duct) or directly from the seminiferous tubules (very fine ducts in the testis where the sperm is produced by germ cells). This sperm can be used in an ICSI procedure.

At SJUH the cycle is so planned so that the day of egg collection and that of sperm retrieval coincide. The sperm retrieval is performed as a single stage procedure and sperm are obtained by PESA progressing to MESA if unsuccessful and then to TESE if both of the former have failed. The freshly obtained sperm can then be used for ICSI with the eggs that have been obtained on the same day from the female partner. Spare epididymal sperm if adequate can be frozen for use in a new cycle.

At the LGI the sperm are obtained by PESA or MESA in an adjacently located private hospital and are frozen prior to the female partner undergoing a treatment cycle. On the day of egg collection the frozen sperm are thawed and surviving sperm used in treatment. Sperm obtained by TESE are too few for freezing to be successful. Operationally thus the two services are different with their relative advantages and disadvantages which the patients are advised to discuss with their doctors. The costs of the two services however are not different.

In addition to retrieving sperm from the epididymis through open microsurgical techniques, percutaneous epididymal sperm aspiration (PESA) is also possible. The advantages to this technique are that it can be performed without surgical scrotal exploration, it can be repeated easily and at low cost, and it does not require an operating microscope or expertise in microsurgery. The procedure as described by Craft et al. has been performed under local or general anesthesia. After induction of anesthesia, the testis is stabilized and the epididymis is held between the surgeon’s thumb and forefinger.

A 21-gauge butterfly needle attached to a 20 ml syringe is inserted into the caput epididymis and withdrawn gently until fluid can be seen entering the tubing of the aspiration set.

The tubing is clamped, the 20 ml syringe removed, and the tubing is back flushed with medium. The procedure is repeated until adequate amounts of epididymal fluid with motile sperm are retrieved1. If no sperm are retrieved, as occurs in at least 20% of sperm retrieval attempts, then it is necessary to proceed with MESA, testis biopsy or testicular aspiration.

2. Percutaneous testicular sperm aspiration

The procedure for percutaneous testicular sperm aspiration is similar to PESA. The procedure has been performed under general or local anesthesia. After induction of anesthesia, the testis is stabilized between the surgeon’s thumb and forefinger with the epididymis oriented posteriorly. A 22- or 23-gauge one and one half inch needle attached to a 20 ml syringe is inserted along the long axis of the testis from the inferior pole directed toward the superior pole. The needle is withdrawn slightly and redirected several times in order to disrupt the testicular architecture so that seminiferous tubules can be aspirated. The procedure is repeated until adequate amounts of testicular material are retrieved. For optimal retrieval, a syringe holder is used to provide significant negative pressure for the aspiration. The Franzen hand-grip syringe holder accommodates one disposable syringe and allows aspiration to be performed with one hand while the other hand stabilizes the testis.

Although only sporadic reports of fertilization and pregnancy rates achieved with percutaneously aspirated testicular sperm exist, there are reports on success rates with sperm retrieved from open testicular biopsy and manipulated with IVF/ICSI. One such study reported fertilization and clinical pregnancy rates of 45 and 62 percent for epididymal sperm compared to 46 and 42 percent for testicular sperm, respectively. The ongoing pregnancy rates were 50 and 43 percent for sperm retrieved from the epididymis and testis, respectively. Testicular sperm can also be recovered using fine needle aspiration ( FNA), percutaneous biopsy, or an open technique of testicular sperm extraction (TESE).

Once incised, fluid spills from the epididymal tubule and pools in the epididymal bed. This pooled fluid is then aspirated. Because the epididymis is richly vascularized, this technique invariably leads to contamination by blood cells that may affect sperm fertilizing capacity in vitro.

Our initial experience with this “pool and aspirate” technique was unsuccessful due to contamination of the aspirated sperm with blood products. This appeared to result in impaired sperm function and the inability to fertilize oocytes in vitro. For this reason we developed a technique of micropuncture of the epididymal tubule to avoid blood product contamination. This technique, combined with improved ovarian stimulation techniques and micromanipulation of retrieved sperm, has resulted in markedly improved fertilization and pregnancy rates in our patients with unreconstructable reproductive tract obstruction. The technique of microsurgical epididymal sperm retrieval offers the advantages of minimizing contamination of epididymal fluid with bloodcells, repeated aspirations can be performed, and aspiration of sufficient quantities of fluid for immediate use as well as for cryopreservation are possible.

1. Aspiration Device

In order to aspirate fluid from within the epididymal tubules a device is needed that is sharp and fine enough to be able to pierce the tubule successfully, and avoid the extensive, delicate network of Vessels that cover the epididymis. To achieve these goals micropipettes with tip widths of 250 to 350 um were hand drawn from glass tubing with an outer diameter of 0.9 mm and inner diameter of 0.6 mm, and then hand sharpened on a grinding wheel. The micropipette is then attached to silicone tubing and a three-way stopcock. Two syringes are attached to the stopcock, a 1 cc tuberculin syringe and a 10 cc glass syringe. The tuberculin syringe collects the epididymal fluid when sufficient fluid is obtained, while the glass syringe provides fine control of the aspiration as well as rapid equilibration of pressure to avoid aspiration of blood outside of the c.

A unique micropuncture pipet holding apparatus, MESA- Holder has been developed and patented (Schlegel, Li and & Goldstein) at Cornell. Its unique 180° angle adjustable pipet holding system simplifies the procedure of micropuncture epididymal sperm retrieval. The micropuncture technique is an atraumatic technique that limits damage to the epididymal tubules and avoids potential blood cell contamination of the epididymal fluid, while yielding high quantities of motile spermatozoa. In this system it is imperative that the epididymal fluid never contact the glass syringe as the sperm may adhere to the glass surface.

2. Operative Procedure

The patient is explored through a midline scrotal incision. The testis is delivered and tunica vaginalis is opened to expose the epididymis.

The operating microscope is brought into the sterile field and the epididymis is examined under 8 to 15X magnification. The obstructed epididymis has a characteristic appearance. The tail of the epididymis has dilated yellow tubules due to the predominance of macrophages and degenerating sperm. The first puncture for aspiration is made proximal to these yellow tubules. If the tubules can be clearly visualized with the epididymal tunic intact, the puncture can be made through the tunic.

If however the tubules are obscured by the tunic, a linear opening in the tunic is made with a 15 degree microknife after coagulating the surface with the bipolar electrocautery. An alternative approach is to incise tubules and gather fluid after it flows out of the tubules.

With the assistant stabilizing the testicle, a suitable tubule is punctured by the operating surgeon and fluid is gently aspirated (Figure 6). The assistant can facilitate retrieval by gently compressing the testis and epididymis. When there is no longer flow, the retrieved fluid is back flushed through the system using 0.5 cc of human tubal fluid and handed to the in vitro fertilization team who are standing by in the operating room.

They examine the fluid immediately under the microscope to assess sperm count and motility. Sequential micropunctures can be performed until optimal sperm quality has been obtained. Typically approximately 100 x 106 sperm with good motility are retrieved using this MESA approach. Because sperm in the epididymal fluid are highly concentrated (roughly 1 x 106 /ul), only microliters quantities of epididymal fluid are needed to be retrieved. In this way, MESA provides for more than adequate numbers of sperm for immediate use with ICSI, as well as for sperm cryopreservation.

If optimal sperm quality has not been found in the caput or body of the epididymis, fluid can be retrieved from the efferent ductules with the micropuncture technique. The efferent ductules arise from the superior pole of the testis, just superior to the testicular vessels. Therefore, with the assistant orienting the testicle properly, the operating surgeon can expose the efferent ductules by incising the tunic at the junction of the epididymis and testis. In this way the caput epididymis is dissected bluntly off of the testis. After adequate fluid has been retrieved the puncture sites are closed with 10-0 monofilament nylon sutures. The tunic incisions are closed with 6-0 polypropylene or larger. The tunica vaginalis is closed in a water tight fashion to avoid inflammation and adhesions that could complicate future explorations. Epididymal fluid samples are taken from the operating room to the in vitro fertilization laboratory where they are subjected to mini-Percoll discontinuous gradient centrifugation, swim-up, and/or sedimentation to remove debris, macrophages and blood products.

In general, artificial insemination is used when:

A woman’s cervical mucus is scant or hostile to sperm. Through IUI, sperm directly reaches the uterus, bypassing the cervix and the cervical mucus.
The man has a low sperm count, though the sperm should be healthy.
Male infertility due to antibodies to his own sperm. Sperm not damaged by the antibodies will be separated and used in the IUI process.
Ejaculation issues due to vaginal muscle contractions or psychological problems.
Retrograde ejaculation, a condition where the semen goes back into the bladder rather than being expelled from the body.
Couples who cannot naturally have intercourse due to disability, injury or premature ejaculation.
In the process of iui, the fertilisation of the egg and sperm occurs naturally, although the sperm is given a kind of “push” into the uterus. For this reason, both partners must meet certain criteria in order to have the best chances at success with IUI.

Male Partner Requirements

Tests down on sperm prior to IUI must reveal normal functioning in terms of:

• Sperm count
• Mobility (movement of sperm)
• Sperm morphology (shape of sperm)

If sperm are naturally not healthy or they are misshaped, even the use of artificial insemination cannot induce fertilisation. Under some circumstances, the treatment may also be done using donor sperms. This is called AID (Artificial Insemination by Donor) or TDI (Therapeutic Donor Insemination). If using donor sperm, make sure it is tested for mobility, shape as well as quarantined for 180 days before use. Tests for infectious diseases and disorders, including HIV, must be performed on the semen sample before it can be used.

Female Partner Requirements

Because fertilisation and conception are still expected to take place as normal, the female partner will be tested to ensure that she has:

• A normal ovulation cycle
• Open fallopian tubes
• A normal uterine cavity

Sometimes, woman with ovulatory disorders or those who ovulate irregularly can undergo IUI with the help of fertility drugs. These drugs stimulate the brain to produce hormones that in turn induce the ovary follicles to mature into eggs. Once the eggs mature, IUI can be used to introduce the sperm inside the uterus. The timing of this particular procedure is important, as it is only when the egg and sperm are both present that fertilisation will occur.

Woman suffering from endometriosis but who have a healthy pelvic structure may also benefit from IUI.

Unfortunately, those with damaged fallopian tubes, poor egg quality, are over the age of 40, or who are menopausal are not candidates for IUI, as the chances of conceiving are too low.

When timing of the IUI is based on and HCG injection, the IUI is usually done between 24 and 48 hours later. Average timing is to have a single IUI at about 36 hours post hCG though some doctors do it more around 24 hours, and other are reporting that doing the IUI at 40-42 hours yields the best results. If you are having two IUI’s schedules, you’ll find that they are usually done 12 hours apart and are usually done between 24 and 48 hours after the hCG. Although some experts believe that there is not an increased chance of a resulting pregnancy with two IUI’s, others report it may increase chances of success by 6%.

Some doctors base the timing of a IUI on a natural LH surge. In cases where a natural surge is used for timing a single IUI at 36 hours is typical, but doing them around 24 hours is also very common since ovulation may have actually occurred earlier. It’s important to remember during this timing that the egg is only viable for twenty four hours after it’s been released.

The success rate of a IUI varies from clinic to clinic as well as when you break up the type of infertility issue at hand. But, success rates vary from about 6% to 26% chance per cycle, which is a promising success rate. The higher the sperm count, the higher the chance of success goes. It’s also worth noting that 23-30% of successful IUI pregnancies results in a multiple birth, too.

IUI is not for everyone, and you and your doctor can work together to determine if this procedure is right for you. The procedure itself is fairly painless, almost like having a pap smear. A well-timed IUI will mean that your cervix is already open for ovulation, easing the process. Many women have to go through a couple IUI procedures before they experience success, but the procedure is well worth it.

IUIs can be performed either with the partner’s sperm or with donor sperm. It is recommended that the patient abstain from sexual intercourse for two to three days before the procedure. The male partner is asked to produce a semen sample by masturbation, one to two hours before the procedure is to be performed or a prior collected frozen semen sample is thawed. Only washed and prepared sperm are used for intrauterine insemination because untreated semen may cause severe uterine contractions, pain, cramps and may even faint or collapse.

This insemination procedure is simple and takes about 5-10 minutes, usually being painless. It involves insertion of a speculum into the vagina to visualize the cervix. The cervix is then cleaned with a little culture medium. The prepared sperm is then injected into the cavity of the womb using a fine plastic catheter. After insemination, the patient may be asked to rest for a short period of time, approx 10 mins. There are no restrictions thereafter.

Indications for IUI:

1. Cervical hostility: when the mucus in the mouth of the uterus is not permeable to the sperm confirmed by the post coital test. IUI can be performed in a spontaneous ovulatory cycle.

2. In a cycle where drugs are being used for ovarian stimulation for unexplained infertility and male subfertility. Every clinic has different cut off values for sperm count after preparation, which they will use to perform an IUI.

3. Inability for vaginal ejaculation as in men with retrograde ejaculation or spinal cord injury

4. Donor Sperm insemination

The washing technique for near normal specimens is mixing the ejaculate after liquefaction with the appropriate washing medium followed by centrifugation. (A centrifuge is a machine that separates materials with different densities by spinning them at high speed.) The supernatant is discarded and the sediment (sperm rich fraction) is re-suspended in more washing medium. This process is repeated 2-3 times maximum. In the final wash, the sediment is re-suspended in 0.5 cc of medium, loaded into a syringe and deposited in the uterus.

The “Sperm Rise” or “Swim-up” technique is one in which two to five cc of medium are carefully layered on top of 0.2-0.5 cc of semen. Motile sperm cells “swim-up” into the culture medium. After some time (30-90 minutes) the medium (containing motile sperm cells) is carefully harvested and centrifuged. If necessary, fresh medium is layered on top of the seminal fluid again to harvest more sperm cells.

The discontinuous gradient centrifugation technique utilizes a dense liquid phase to separate sperm cells from seminal fluid and debris. There are different compounds commercially available that may be used. Semen is deposited on top of this fluid and subjected to centrifugation. Motile sperm cells migrate to the bottom of the tube, which are used for IUI after further washing.

During an intrauterine insemination, the sperm are released into the uterus. The sperm do not remain viable for as long a period of time. Consequently, the sperm must be inseminated close to the time of ovulation.

One method to time an IUI is with an ovulation predictor kit. The kit measure a woman’s LH surge. The surge peaks about 12-24 hours before the egg is released. A woman will test her urin in the morning. If the test is positive, she whould have the intrauterine insemination the next day.

Another method for timing an insemination is to artificially trigger ovulation. A medication called hCG can be injected by a woman when ultrasound determines that the egg or eggs developing in her ovaries are mature enough to be released. Ovulation will occur approximately 36 hours later. The hCG trigger injection is given in the evening and the IUI can be performed two morning later.

It is not necessary to abstain from intercourse before doing an IUI. Sperm counts vary in all men. The frequency of ejaculation does not have any consistent effect on sperm numbers. sometimes there will be more sperm on a second or third ejaculate and sometimes there will be less sperm.

Our recommendation is to have intercourse on the day that an ovulation kit turns positive or on the day that an hCG trigger injection is given. The IUI is then timed as indicated above.

The semen sample is collected through ejaculation into a sterile collection cup that we provide in the office. The specimen is usually collected in the office in a specially designated private room. The man’s partner may be in the room to help him collect. On occasion, a man will for various reasons, be unable to collect a sperm specimen in the office. In those situations, we will let him collect at home and bring the sepcimen in. It is important to get the specimen to the office within a half hour or so and it should be kept warm. It is also possible to use a specialized nontoxic collection condom. Important! Ordinary condoms cannot be used for IUI.

We will schedule the male for collection approximately one hour before we schedule the woman for the IUI. This allows time for the sperm to liquefy in our incubator and time for preparation for the IUI.

Sperm wash for IUI

Before sperm can be placed into a woman’s uterus, it must first be prepared. When a man ejaculates, the fluid that is emitted is composed of two main components: seminal fluid and sperm. Seminal fluid contains many types of hormones and chemicals. One group of chemicals in particular can cause problems and are known as prostaglandins.

Prostaglandins are responsible for many bodily functions. If high levels of certain types of prostaglandins are placed directly into the uterus, they can cause a woman to become very sick. The symptoms of prostaglandin absorption during intrauterine insemination - IUI, are nausea and vomiting, fever, diarrhea and cramping. The symptoms usually begin within a few minutes of performing the IUI.

Preparation for an IUI involves separation of the sperm from the seminal fluid and is known as a sperm wash. Sperm was for IUI is actually a bad term because the sperm are not actually being washed or cleaned.

There are several methods for performing a sperm wash for an intrauterine insemination. The medical literature does not clearly indicate that any method is any better than any other. It is therefore up to the personal preference of the physician performing the IUI.

Once the semen is collected it must sit for a while to allow it to liquefy. The consistency of the semen will still be thick at this point. Next the semen is mixed with a chemical solution called sperm wash media. This solution is specially designed to not harm sperm. The semen and the media are thoroughly mixed.

Next, the semen and media mixture is placed into an instrument called a centrifuge. The centrifuge will rapidly spin the test tube containing the mixture. This causes the sperm to settle at the bottom in a small pellet. The fluid above the pellet contains the seminal fluid and can be poured out.

Finally, the sperm pellet is dissolved by adding some fresh sperm wash media and mixing thoroughly. The specimen is now ready for insemination.

One important factor that is specific to intrauterine insemination is the amount of motile sperm that is inserted into the uterus. Several studies have indicated that if a man has a low number of progressively motile sperm after the sperm wash, that the chance for pregnancy is lowered. The lower the number, the lower the chances for pregnancy.

If a man has a high percentage of abnormal appearing sperm on a semen test, that will also lower the chances for success.

Timing of the intrauterine insemination is also very important. In order to maximize the chance for pregnancy, sperm must be inseminated on the same day as ovulation. Performing the IUI the day before or day after will lower the chance for IUI success. This is an important point, it is not acceptable for a provider of intrauterine inseminations to tell a patient who is ovulating on a Sunday, that she must wait until Monday when the office is open. This will severely compromise the chances for success.

On the other hand, there does not seem to be any advantage to performing an intrauterine insemination twice. Several well done studies comparing the pregnancy rates between couples having a single insemination to those having two inseminations have found no significant difference in the pregnancy rates.