This technique is used to retrieve sperms for obstructive azoospermia. It was first described in 1994 by Craft et al. [54]. This SSR technique is the least invasive, easily repeatable, quickest to perform and is the first treatment option for obstructive azoospermia which cannot be surgically corrected. Different techniques can be used to perform PESA. Originally, the use of a larger butterfly needle was described [54] (Fig. 23.1) but currently, most experts use a fine needle (26 gauge) attached to a tuberculin syringe containing sperm washing medium [55, 58].

The technical procedure for percutaneous epididymal sperm aspiration involves (Fig. 23.2), stabilisation of epididymis between the index finger, thumb and a forefinger,and a 26-guage needle which is attached to a 1-ml tuberculin syringe, is inserted into the epididymis by piercing the scrotal skin. After creating negative pressure by pulling the syringe plunger, the tip of the needle is gently and slowly moved in and out inside the epididymis until clear fluid is aspirated and is seen coming in the tuberculin syringe. Minimal amount of fluid is aspirated, usually 0.1 ml except in cases of congenital absence of vas deferens where up to 1.0 ml of fluid is aspirated. Aspirated fluid from the epididymis is flushed into a tube containing warm sperm culture medium. The tube containing the epididymal aspirate is taken to the laboratory for immediate microscopic examination to identify sperm under the microscope. If motile sperm are not obtained, PESA may be repeated at a different site (from the cauda to caput epididymis) until an adequate number of motile sperm is retrieved. Because PESA is a blind procedure, multiple attempts may be needed before high-quality sperm are found.

The disadvantage of this technique is that sometimes an inadequate number of sperm are collected and the surgeon may have to proceed to another approach [29]. If PESA fails to retrieve motile sperm, testicular SSR can be attempted at the same operative time.

This technique is used to retrieve sperms for obstructive azoospermia and was first described by Temple-Smith et al. [59]. It is an alternative to PESA in obstructive azoospermia and involves a 2–3 cm transverse incision through the scrotum into the epididymis so that an operating microscope can be used to extract sperm [55]. As this technique involves exposing the inside of the epididymis, it allows the surgeon to aspirate a much larger amount of sperm compared to PESA [29]. The epididymal tunica is incised, and an enlarged tubule is selected. Then, the epididymal tubule is dissected and opened with sharp microsurgical scissors. The fluid that flows out of the tubule is aspirated with the aid of a silicone tube or a needle attached to a tuberculin syringe (Fig. 23.3). The aspirate is flushed into a tube containing warm sperm culture medium and is transferred to the laboratory for examination. MESA can be repeated at a different site on the same epididymis (from the cauda to caput regions) and/or the contralateral epididymis until an adequate number of motile sperm is retrieved [4].

If MESA fails to retrieve motile sperm, TESA or TESE can be performed as part of the same procedure. However, MESA often provides enough sperm for cryopreservation. A single MESA procedure usually enables the retrieval of a large number of high-quality sperm that can be used for ICSI or intentionally cryopreserved for subsequent ICSI attempts [60, 61].

This technique is used to retrieve sperm for non-obstructive azoospermia or in cases of failed PESA in men with obstructive azoospermia.

In TESA, a needle is inserted through the scrotal skin into the testis (Fig. 23.4). The needle is usually inserted into the antero-medial or antero-lateral portion of the superior testicular pole at an oblique angle toward the medium and lower poles. These areas are the least likely to contain major branches of the testicular artery running superficially underneath the tunica albuginea. These aspirations are usually carried out using either fine (testicular fine-needle aspiration; TEFNA) or large-diameter needles attached to a syringe. The testicular parenchyma is aspirated by creating negative pressure and the specimen is sent to the laboratory for microscopic examination. TESA can be carried out in the contralateral testis if an insufficient number of or no sperm are obtained during the first attempt. Alternatively, testicular parenchyma can be obtained percutaneously using a tissue-cutting biopsy needle (e.g., a Tru-cutTM needle or Biopty TM gun). For this procedure, the needle is placed against the testis and, upon release of the springer; the needle enters the parenchyma, cuts a piece of tissue and withdraws it into a sheath [62].

The technique of testicular fine-needle aspiration (TFNA) of the testis was initially described as a diagnostic procedure in azoospermic men [63]. Subsequently, testicular fine needle aspiration or biopsy for the recovery of spermatozoa has been described [64].

Percutaneous puncture and aspiration of the testis can be performed using a 21–23-gauge needle connected to a 20-cc syringe in a Menghini syringe holder. Percutaneous testicular needle biopsy can be performed with an automatic biopsy gun (Fig. 23.5). The limited published experience to date with TFNA makes critical evaluation of this technique difficult, although it has been shown that SSR is routinely possible with TFNA for men with obstructive azoospermia. SSR rates are much higher in obstructive patients with almost 100 % of procedures being successful compared to around 27 % in non-obstructive azoospermia [29]. However, recently a study has shown that up to four repeat TESA attempts in non-obstructive patients can have a success rate of 67 % [65].

Occasional haematoceles and hematomas are possible with this technique. The advantages of percutaneous aspiration techniques are that they can be performed with local anaesthesia, without open scrotal exploration and its attendant postoperative discomfort, and without microsurgical expertise.

This technique is used to retrieve sperms for non-obstructive azoospermia, failed PESA or TESA in men with obstructive azoospermia. Testicular sperm extraction (TESE) is the most commonly employed SSR technique in men with non-obstructive azoospermia and has much higher success rates in this group of patients compared to TESA. Systematic review reported the 49.5 % success of TESE in this group of patients [66]. The difference between TESE and TESA is that this technique involves an incision into the testes to remove a testicular tissue.

TESE can be used to assess the degree of sperm production in the setting of azoospermia as well as to obtain sufficient tissue for sperm extraction, either for immediate use or to be preserved as a frozen specimen for IVF with ICSI. The procedure can be performed with unifocal biopsies from both testicles and open scrotal exploration for obtaining multifocal testicular biopsies.

Through a scrotal incision the testis is exposed after opening the tunica vaginalis layer. The tunica albuginea is incised, and a piece of protruding testicular tissue is excised. The tunica albuginea and vaginalis is sutured in separate layers and the skin incision is closed (Fig. 23.6a–c). It is an easy method and yields a good amount of tissue. But the drawback is that it is an open surgical procedure and there is risk of damage to the testicular vessels whilst excising the testicular tissue and during incision and closure of the tunica albuginea. Testicular arteries are end-arteries, and hence multiple, conventional biopsies in men with testicular failure can demonstrably impair testicular function [67, 68].

Multifocal TESE can be performed under spinal/ general anaesthesia. A small either vertical incision in the median scrotal raphe or a transverse 2–3 cm incision is given after the scrotal skin is stretched over the anterior surface of the testis. The skin, dartos muscle and tunica vaginalis is opened to expose the tunica albuginea. Testes are exteriorised. The tunica albuginea is incised for up to 4 mm at multifocal sites representing all areas of the testicle. Gentle pressure is applied to the testis to extrude a sufficient tissue volume, which is excised with sharp scissors. The same procedure is subsequently repeated on the contralateral testis. The tunica albuginea is closed with 3-0 Vicryl, and then the scrotal skin is closed separately using a continuous subcuticular 4-0 vicryl suture (Fig. 23.7a–k). Scrotal dressing and scrotal supporter are placed. Pain relief is given in the form of local infiltration with bilateral nerve block to the genital region.

This technique is used in order to increase the success of SSR as often only a few areas within the testes are producing sperm in non-obstructive azoospermic males [29]. As a significant amount of the seminiferous tubules are removed in the procedure, studies have shown there to be an adverse effect on spermatogenesis temporarily and potentially in the long term too. As a result, repeat sampling is much more difficult [69]. Therefore surgeons are recommended to wait around 3–6 months for any repeat procedure in order to give the testes time to resume spermatogenesis [4].

Micro TESE involves testicular sperm extraction, involving micro-dissection with the help of operating microscope. This technique was first described by Schlegel in 1999 and is used to retrieve sperms for non-obstructive azoospermia [61, 70, 71].

Micro-TESE is performed under general or regional anaesthesia. The scrotal skin is stretched over the anterior surface of the testis after which a 2–3-cm transverse incision is made [4]. Alternatively, a single midline scrotal incision can be used [70]. The incision extends through the dartos muscle and the tunica vaginalis. The tunica is opened, and identifiable bleeders are cauterized. The testis is delivered externally, and the tunica albuginea is examined. Then, a single, large, mid-portion incision is made in an avascular area of the tunica albuginea under 6–86 magnification, and the testicular parenchyma is widely exposed in its equatorial plane. The testicular parenchyma is dissected at 16–256 magnification to enable the search and isolation of seminiferous tubules that exhibit larger diameters (which are more likely to contain germ cells and eventually normal sperm production) in comparison to non-enlarged or collapsed counterparts. If needed, the superficial and deep testicular regions can be examined, and microsurgical-guided testicular biopsies are performed by carefully removing enlarged tubules using microsurgical forceps. If enlarged tubules are not observed, any tubule that differs from the remaining tubules in size is excised [4]. The excised testicular tissue specimens are placed into the inner well of a Petri dish containing sperm media, and are sent to the laboratory for processing and sperm search [4]. The tunicas albuginea and vaginalis are then closed in a running fashion using non-absorbable and absorbable sutures; dartos muscle is closed with interrupted absorbable sutures, respectively. Immediately prior to complete closure, 3 cc of 1 % xylocaine solution may be injected into the subcuticular layers. The skin is closed using a continuous subcuticular 4-0 vicryl suture. Scrotal dressing and scrotal supporter are placed.

Direct vision with the operating microscope in microdissection TESE is of great advantage, since larger, more opaque, whitish tubules, presumably containing more intra-tubular germ cells with active spermatogenesis, can be identified. Generally, the testis is small in patients with NOA involving severely impaired spermatogenesis, such as in Sertoli cell only syndrome (SCOS) and Klinefelter syndrome. Minute foci of normal spermatogenesis in the small testis can be detected under the operating microscope; only tiny portions need to be removed, minimizing operative damage.

The use of microsurgical techniques in sperm extraction represent a newer approach to retrieval and appear to have a higher success rate and a lower risk of reducing spermatogenesis following the procedure as less tissue is removed. These may form the future of SSR [29].

Percutaneous SSR is an effective method to retrieve sperm in men with obstructive azoospermia irrespective of the cause of obstruction but chance of achieving a live birth and the after sperm injection is not related to the cause of obstruction [61]. Cochrane review [61] showed that no specific SSR technique for azoospermic men is preferable to achieve better outcome undergoing ICSI. In the absence of robust evidence it is recommended to use the least invasive and simplest technique available.

The number of spermatozoa collected with testicular sperm extraction is linked to the number of clinical pregnancies, independent of the number of ICSI cycles and the number of oocytes collected/injected. FSH level and testicular volume are also linked to ICSI success [72].

Carefully performed testicular biopsy is associated with few complications. Postoperative complications of SSR techniques include persistent pain, swelling, infection, hydrocele and hematoma formation [71, 73]. The complication rates vary depending on the SSR technique. Percutaneous retrievals have an increased risk of hematoma compared with open techniques [45, 74]. Nevertheless, except for minor pain and local swelling, there have been no reports of clinically significant intra- or postoperative complications with PESA [56].

The incidence of complications after SSR, including persistent pain, swelling, infection, hydrocele, and hematoma, ranges from 0 to 70 % [71, 73]. Patients who undergo TESE, with single or multiple biopsies have increased risk of intra-testicular hematoma formation and therefore scrotal support is given at least 24 h after surgery. Large-volume conventional TESE has been associated with a higher risk of a transient or even permanent decrease in serum testosterone levels due to testicular devascularisation and excessive tissue removal [75, 76]. On the other hand, the incidence of complications is lower following micro-TESE compared to conventional TESE [66, 70, 77].

In micro-TESE, the testicular vessels under the tunica albuginea are identified prior to the placement of an incision in the testis. In addition, the use of optical magnification and microsurgical techniques allows the preservation of the intra-testicular blood supply [56]. But the risk of serum testosterone insufficiency has been documented following micro-TESE in patients with Klinefelter syndrome who already have diminished androgen production due to small atrophic testicular volume [73]. Nonetheless, it has been observed that serum testosterone levels returns to pre-surgical values in most individuals within 12 months following surgery [76]. Any procedure that requires a general anaesthetic also carries an increased risk of complications.

Given the potential serious postoperative complications of SSR, it is recommended that these procedures be performed by surgeons who have specific training in the above-mentioned techniques [76].

SSR is a relatively low risk procedure and is performed as a day case procedure, with patients being discharged 4–5 h after surgery. The patient should not be allowed to leave for home without an accompanying person. The recovery time depends on what technique was used and can range from a few days to a couple of weeks. Most patients can return to light office work in 24–48 h after percutaneous retrievals. Bed rest is recommended for the first 48 h, especially following open retrievals. The patients are instructed to keep the pressure dressing and scrotal support on for at least 24 h to reduce the risk of testicular haematoma formation and bruising that can happen in the immediate postoperative period (Fig. 23.8). They are encouraged to take warm showers and wash the incision area with soap and water after 24 h and keep the area dry, but to avoid hot baths to prevent infection. Most men will be instructed to avoid strenuous activity and use a scrotal or athletic supporter, for approximately 1 week after the procedure or until they are fully recovered. This reduces the risk of chronic testicular pain in the long run. Oral analgesia is generally prescribed for 3–5 days. Postoperative antibiotics are not routinely prescribed but just given as a single dose of antibiotic peri-operatively. Patients are instructed to resume a normal diet and increase their daily activities to a normal level over a 3–4-day period. The patient should abstain from sports activities, heavy lifting and sexual intercourse for approximately 10 days [56]. Moreover, patients should be informed of the likelihood of scrotal swelling and ecchymosis at the wound site, as well as mild discomfort that should subside in approximately 1 week [4].

A follow up appointment in the clinic is arranged in 2 weeks to assess the postoperative recovery and to discuss the results. If sperms are successfully cryosperserved then discussion of IVF with ICSI treatment is taken place. Failing that, option of donor sperm and adoption is discussed. A scrotal ultrasound may be indicated in cases with any complications after surgery or where repeat surgery is required; In that case determination of hormone levels, including total and free testosterone, FSH and LH level, is also recommended in 6 months. The author suggests that patient selection should be done appropriately and the right procedure is selected in order to avoid repeat procedure and reduce morbidity associated with repeat testicular biopsies.

The number of men undergoing vasectomy has not changed over years. Up to 6 % of men (approximately 30,000 men each year), change their minds after vasectomy and wish to father children again. Although intended for permanent sterilization, vasectomy can be reversed in most men seeking to restore their fertility due to a change in marital status or reproductive goals. Furthermore, obstructive azoospermia can be the result of iatrogenic injuries to the vas deferens, usually from hernia repair [88] in 6 % of azoospermic men [89].