Many people think that infertility is a woman’s problem. But this is not true. Infertility is caused by factors that affect both men and women. In fact, up to 50% of infertility cases are due to health conditions that cause male infertility.¹

What are the causes of male infertility?

Male infertility can be due to different health conditions that affect sperm quality and sperm count. Problems in the genitals, such as infection, previous vasectomy, or abnormal structure can cause poor sperm quality, low sperm count, and a condition known as azoospermia.

Azoospermia is the absence of sperm in the semen.³ This is the most severe type of infertility in males. About 5% of cases of infertility are due to azoospermia.⁴

The following circumstances can cause male infertility²:

• Dysfunction of the testes can cause abnormal ejaculation.
• Blockage in the male genital tract can cause azoospermia.
• Impaired response of the normal testes to hormonal signals can cause abnormal development of the testes. This could then impair sperm development, resulting in non-obstructive azoospermia.³
• Infections of the male reproductive organs, such as prostatitis, can cause poor sperm quality.
• Inflammation can cause damage to sperm structure.
• Failure of ejaculation due to erectile dysfunction can also contribute to male infertility.
• Genetic and chromosome disorder that affect the development of the genitals have also been associated with male infertility.
• Trauma to the penis and testes can damage the genital tract, which may result in infertility.
• Other factors such as long-term illnesses, obesity, and nutritional deficiencies have also been identified as possible causes of male infertility.

Most males with infertility do not have any symptoms. Because of this, couples are often unaware of the condition until the male partner undergoes laboratory tests for infertility. Semen analysis is the main diagnostic test used to assess the quality, appearance, and volume of sperm.² The results of semen analysis can be used to determine whether male infertility is due to azoospermia or poor sperm quality.

Fortunately, several surgical procedures are now available to address male infertility, specifically for cases of azoospermia.³ These surgical options include TESE, TESA, micro-TESE, MESA, and PESA. These procedures help couples increase their chances of conceiving their little one.

Surgical Options for Male Infertility

Testicular Sperm Extraction (TESE)

TESE is the most commonly used surgical technique for men with very low sperm count in the semen. The doctor will make a small cut on the scrotum and testes to remove the testicular tubules. Once the tubules are removed, the tissues will be examined for the presence of viable sperm. Sperm will then be extracted for subsequent injection to the female’s eggs. TESE can be thought of as directly “harvesting” sperm from the testes.^5,6

TESE is done together with a procedure known as intracytoplasmic sperm injection (ICSI). During ICSI, the extracted sperm from TESE is injected to the female’s eggs. Hence, the schedule of TESE should be precisely coordinated with the retrieval of eggs from the female partner.

TESE is usually done in the operating room with general anesthesia, but it can also be performed with local anesthesia in fertility clinics. The extracted sperm can be stored through cryopreservation for future cycles of IVF. Reports show that TESE has a 17-45% success rate for men with low sperm count.⁶

Testicular Sperm Aspiration (TESA)

The TESA technique is closely similar to the TESE as viable sperm are collected from the testicular tubules. The main difference is the manner of collection. While TESE is done through a small cut on the scrotum, TESA involves the insertion of a thin tube, or catheter, through the skin. Through this tube, testicular tissue is suctioned and collected. TESA is minimally invasive and better patient recovery compared to TESE. Similar to TESE, TESA is followed by ICSI.⁶

Microdissection Testicular Sperm Extraction (micro-TESE)

Micro-TESE is recommended for men who have problems with sperm production and have very low sperm count in their semen. Similar to TESE, micro-TESE also involves retrieval of sperm from the testicular tubules. Micro-TESE, however, can be considered as a more precise method because it first identifies specific regions in the testicular tubules that contain numerous sperm prior to extraction. ICSI is then performed after sperm extraction.⁶

Micro-TESE is performed in the operating room with general anesthesia. An operative microscope is used to examine and select the viable testicular tubules.⁶ The extracted sperm can also be stored through cryopreservation for future cycles of IVF.⁶ Compared with TESE, the use of micro-TESE in IVF cycles resulted in higher sperm retrieval rates in men with very low sperm count.⁷

Microsurgical Epididymal Sperm Aspiration (MESA)

MESA is recommended for men with azoospermia due to an obstruction or abnormality in their genital tract. MESA is another sperm retrieval technique that is performed in the operating room with an operative microscope.

In this procedure, a cut is made through the layers of the scrotum, to reach the epididymis. The epididymis is a long, coiled tube that functions as a passageway and maturation site for sperm as it travels from the testes. During MESA, the epididymis is visualized under the microscope to identify tubules that contain sperm.⁵ Compared to other techniques, MESA allows thorough collection of mature sperm that can be used for ICSI and future IVF cycles.

Percutaneous Epididymal Sperm Aspiration (PESA)

PESA is a procedure that is recommended for men who have azoospermia because they underwent a previous vasectomy or had a previous infection. PESA is similar to MESA in that it is also used to retrieve sperm from the epididymis. However, compared to MESA, PESA is less invasive, does not require special equipment, and can be done in the clinic with local anesthesia.⁸

During the procedure, a small needle is inserted through the skin of the scrotum until it reaches the epididymis. A gentle suction is then applied, and fluid of the epididymis is collected. The fluid is then examined for the presence of viable sperm that could be used for ICSI. Studies have reported an 80-100% successful retrieval of sperm via the PESA procedure.⁶

Which procedure for male infertility should I go through?

Several factors should be considered when choosing which treatment to go through for male infertility. The most appropriate procedure depends on the specific cause of your infertility, whether you prefer going through general or local anesthesia, and your general health condition. The cost of the treatment may also be a point of consideration. To know which procedure is best for you, consult your fertility doctor and inquire about your options.

If you need help in making decisions about treatment and navigating your IVF journey, you can consult a reliable fertility expert who will guide and support you throughout your personal IVF journey.

References

• Dohle, G. R., Colpi, G. M., Hargreave, T. B., Papp, G. K., Jungwirth, A., & Weidner, W. (2005). EAU Guidelines on Male Infertility. European Urology, 48(5), 703–711. https://doi.org/10.1016/j.eururo.2005.06.002
• Iammarrone, E., Balet, R., Lower, A. M., Gillott, C., & Grudzinskas, J. G. (2003). Male infertility. Best Practice & Research Clinical Obstetrics & Gynecology, 17(2), 211–229. https://doi.org/10.1053/ybeog.2003.359
• Wosnitzer, M., Goldstein, M., & Hardy, M. P. (2014). Review of Azoospermia. Spermatogenesis, e28218(March), 1–7.
• Irvine, D. S. (1998). Epidemiology and aetiology of male infertility. Human Reproduction, 13(1), 33–44.
• Craft, I., Bennett, V., & Nicholson, N. (1993). Fertilising ability of testicular spermatozoa. The Lancet, 342(8875), 864. https://doi.org/10.1016/0140-6736(93)92722-6
• Ostrowski, K. A. (2018). Treatment: Surgical-current tools. In Encyclopedia of Reproduction (Vol. 4, pp. 358–362). https://doi.org/10.1016/B978-0-12-801238-3.64793-1
• Schlegel, P. N. (1999). Testicular sperm extraction: Microdissection improves sperm yield with minimal tissue excision. Human Reproduction, 14(1), 131–135. https://doi.org/10.1093/humrep/14.1.131
• Proctor, M., Johnson, N., Van Peperstraten, A., & Phillipson, G. (2010). Techniques for surgical retrieval of sperm prior to intra- cytoplasmic sperm injection (ICSI) for azoospermia (Review). Cochrane Database Syst Rev, 2.