In absence of the vasdeference. They can still ejaculate

In the first three conditions, sperm are  produced by the testes, but are unable to be
ejaculated primarily due to obstruction of transport  or congenital absence of the vasdeference.
They  can still ejaculate seminal fluid
but this fluid will not contain any sperm. It is possible to collect sperm
directly from the epididymis. most azoospermic patients suffer from primary
testicular ailure(60%).because these subset of patients do not show any clinical
signs of obstruction and they are often referred to as non obstructive
azoospermia NOA. However in few cases of azoospermia ensues due to hypogonadotropic
hypogonadism and not due to obstruction. These patients have an early
maturation arrest in spermatogenesis and adequate treatment with FSH and human
chorionic gonadotrophins might restore spermatogenesis.

Different types of SSR

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1.     Percutaneous epididymal sperm
aspiration (PESA).

2.     Microsurgical epididymal sperm
aspiration (MESA).

3.     Testicular sperm aspiration (TESA).

4.     Testicular sperm extraction (TESE) –
single or multi-site.

5.     Microscope-assisted testicular sperm
extraction (MicroTESE).

All these
procedures can be safely  performed  as an outpatient basis with effective
preparation by local anesthesia or under general anesthesia.

 

Preoperative assessment.Pre-operative evaluation consists of recording   the
patient’s health and social history, conducting a physical examination,
developing a plan of anesthesia care and developing a safe plan for discharge
to home from the practice after recovery from the procedure.

1.Percutaneous approaches-(PESA / TESA).

Advantages

1.Minimal training

2. No need for microscopic instruments

3.Percutaneous route more approachable

4.No need for sedation.

5.Lower complication rate

 

Disadvantages

 

1.    
Low yield of sperm retrieved compared with open
approaches. 

1. Percutaneous epididymal sperm
aspiration (PESA)

PESA is a needle aspirate of the head of the
epididymis for attempted retrieval of more mature, motile sperm. Glina and
colleagues reported a sperm retrieval rate of 82% patients who underwent PESA,
while no complications were reported 6, while
the  complication rate of PESA was 3.4%
and included pain, hydrocele, infection, and swelling.(7)

 

 

 

Technique:

 

Under local anaesthesia
scrotum is initially painted with antibiotic solution followed by repeat
painting with normal saline to remove any residual antibiotic solution. On
dependant hand supports the testis and the head of the epididymis is palpated
and stabilised with thumb and forefinger. Aspiration of epididymis is performed with a 27. G needle
mounted with tuberculin syringe containing culture medium. With the needle still
within the epididymis the syringe is advanced in different direction while
maintaining continuous suction. The needle is gently withdrawn from the
epididymis while the suction is released. The aspirate is then emptied into the
dish containing the sperm wash media to be examined under microscope for the
presence of any sperms which can be eventually cryopreserved for future use
during an ICSI. A repeat attempt at an aspiate is made in case of negative
aspiration but at a different location along the epididymal head and repeated
on the contralateral testis. Since this is a blind procedure sometimes several
attempts are required before good quality sperm are found.

 

Advantages

Disadvantages

·      
Fast
and low cost.
·      
Minimal
morbidity, repeatable.
·      
No
microsurgical expertise required.
·      
Few
instruments and materials.
·      
No
open surgical exploration.

·      
Few
sperm retrieved.
·      
Limited
number of sperm for cryopreservation.
·      
Fibrosis
and obstruction at the aspiration site.
·      
Risk
of hematoma/spermatocele .

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