MESA/TESE etc
4 Replies
alexis - January 19

We are doing our last IVF attempt. This is after a loss last year at 5 months of identical twins, so there's a lot of emotion and tension riding on this.

Yesterday my husband did a semen analysis/culture, and there were only "rare immotile sperm." In the past he's always had low sperm counts and motility, but enough to do ICSI. The doctor is recommending we do sperm aspiration, and I have lots of question about this.

1) If only "rare immotile" sperm are coming out from ejaculation, are there likely to be good sperm inside? And why don't the good ones come out if they're in there?

2) Based on his past -- low counts -- and now the latest, is aspiration likely to produce good sperm for use in IVF?

3) There seem to be lots of ways of aspirating sperm -- MESA, PESA, TESE, TESA. I think my husband would get either MESA or TESA. Any thoughts?

4) What is the procedure like for the man? What are the risks? How long is the recovery period?

5) And why would a man's sperm change from OK/low to lousy? Also, the volume of semen is very low, and seems to be decreasing with age. Any thoughts on why this occurs? Is either the low semen volume or the bad sperm possibly a sign of larger health problems?

Thank you very much for your help.
Alexis

 

Dr Smith - January 19

All of your questions are good ones, but there's no absolute answers to any of them. I'll try, but its vague at best.

A1. When a MESA or TESE is performed it may be possible to obtain viable sperm when there are none in the ejaculate. It takes 72 days from the time the sperm are made to the time they are ejaculated. During this maturation process, the sperm may die. By going backwards up the track (e.g. epididymal or testicular sources), it may be possible to obtain viable sperm. In a sense, you are turning back the clock.

A2. Sperm from the epididymus or testes are rarely "good". They may be used for fertilization through ICSI, but fertilization rate and pregnancy rates are significanty lower. It is always preferable to use ejaculated, mature sperm, even if they are just weakly motile.

A3. The farther along the track that viable sperm can be found increases the chnces of success. That is, ejaculated is better than epididymal which is better than testicular sperm.

A4. Ouch! Local anesthetic for the aspiration, which wears off in a couple of hours. Cold packs off and on for a couple of days. Tenderness when sitting down. About 1 week for full recovery. About the same as a bad kick in the ba... The docs tend to minimized the discomfort, but then they've never had one, have they? The risks include infection, the testicles falling off (just kidding), etc. The consent form will include all the risks. Ask for a copy before making up your mind.

A5. No one knows. There aren't even theories about it.

 

alexis - January 19

Thanks for your reply. Another question: Everything I have found on the Web seems to apply to men who produce NO sperm. Are the conditions -- and success rates -- different for a case like my husband's? He produces some sperm, although this time they found only "rare immotile" ones.
This seems like it would be different from a blocked tube. Or?

many thanks!

 

alexis - January 19

I just spoke with our IVF clinic, and the dr there says that fertilization/pregnancy rates are not lower using sperm extracted with MESA or PESA. Not at this clnic, he said, "We don't use germ cells." If it's true about the success rates, then it's reassuring. But is it? It contradicts what you said earlier (Dr. Smith), and what I've read elsewhere... What to believe?

(This is in addition to my other added question, in previous post.)

Again, many thanks!
Alexis

 

Dr Smith - January 20

There are two situations that can cause very few or no sperm in the ejaculate. Either no or limited sperm production (non-obstructive azoospermia) or a blockage that prevents or greatly reduces the number of sperm that are ejaculated (obstructive azoospermia). It is generally agreed that the prognosis for obstructive is better than non-obstructive. This is because the sperm that are recoverd from the epididymus or testes in obstructive cases are more plentiful and more mature.
Ref:
Intracytoplasmic sperm injection with testicular spermatozoa is less successful in men with nonobstructive azoospermia than in men with obstructive azoospermia.
Vernaeve V, Tournaye H, Osmanagaoglu K, Verheyen G, Van Steirteghem A, Devroey P. Fertil Steril. 2003 Mar;79(3):529-33.

In your husband's case, there are still a few ejaculated sperm. This is call cryptozoospermia. The following study applies directly to your situation.

Ref:
Very low sperm count affects the result of intracytoplasmic sperm injection.
Strassburger D, Friedler S, Raziel A, Schachter M, Kasterstein E, Ron-el R. J. Assist Reprod Genet. 2000 17:431-6.

PURPOSE: The aim was to examine the influence of extremely low sperm count on intracytoplasmic sperm injection (ICSI) outcome. METHODS: Over 1000 consecutive unselected ICSI cycles were divided into four groups according to sperm concentration of their patients: A, cryptozoospermia, 107 patients; B, sperm concentration of < or = 1 x 10(4), 146 patients; C, sperm count of 1 x 10(4)-1 x 10(5), 135 patients; and concentration of > 1 x 10(5) and < 10 x 10(6)/ml (control group), 688 patients. [b] RESULTS: A significant decrease in pregnancy rate was noticed in the cryptozoospermic group in comparison to the control group (20% vs. 31%). Fertilization rate in group A was significantly lower in comparison to all other groups, respectively (46% vs. 52%, 54%, 61%). Embryo quality was inferior in group A in comparison to the control group. A higher yet not statistically significant abortion rate was observed in the cryptozoospermic group (as well as in group C) (30%, 27%) compared to the control group (15%).[/b] CONCLUSIONS: It seems that an extremely low sperm count has a negative effect on the outcome of ICSI. Nevertheless patients with cryptozoospermia should not be offered ICSI treatment with the ejaculated sperm before karyotype is established.

So, unless you clinic is doing something supercalafragilisticexpialadocious, I think the same outcome can be expected in your case. You can ask you doctor to provide statistics to support his contention that ttere is no difference at his clinic. If he can substantiate his claim with statistical evidence, that's great. Go for it!

 

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