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Obstructive azoospermia and results of ART

Azoospermia (total absense of spermatozoa in semen samples) is the cause of about 2% of infertility but it can be found in 10% of male infertility cases. Azoospermia can result from absent sperm production (secretory, non-obstructive azoospermia) or obstruction of the genital tract (obstructive azoospermia). The clinical features of genital tract obstruction are azoospermia, normal-sized testes and normal serum FSH levels. Spermatogenesis is healthy, and patients are well virilized with normal serum testosterone levels. Obstructions can be congenital, infective or the result of surgical trauma. In the case of obstructive azoospermia, it is important to diagnose the sause of obstruction. There are several therapeutic alternatives for man with obstructive azoospermia: corrective surgery, sperm recovery techiques for use in assisted conception and donor insemination. It was demonstrated that sperm derived from either epididymis or testicle was capable of normal fertilization and pregnancy. Than kowledge has stimulated interest in safe, simple and effective methods form sperm retrieval. Fort the case of obstructive azoospermia, there is usually some epididymis present. If it is so Spermatozoa may be retrived using microsurgical epididymal sperm aspiration (MESA), percutaneous retrival of spermatozoa from epididymis (PESA). For cases of obstructive azoospermia where there is no epididymis sperm can be retrived by testicular sperm aspiration (TESA), testicular fine needle aspiration (TFNA), percutaeous testicular sperm aspiration (PTSA) or testicular sperm extraction (TESE). There are still on going debates over which metod should be prefered. During the last ten years 117 males attempted intracytoplasmic cperm injection (ICSI) cycle for treatment of azoospermia. All patients were undergone sperm retrieval by percutaneous epididymal sperm aspiration (PESA) or testicular sperm extraction (TESE) while their wives received standard ovarian hyperstimulation. The sperm retrieval success rates, fertilization rates, pregnancy rates and complication of PESA or TESE were analysed and evaluated. Sperm were retrieved by PESA in 81, 5%, and by TESE in 91, 7% of men with obstructive azoospermia.Testicualr tissue was cyropreserved in 65%, and epididymal spermatozoa in 11, 3% men with obstructive azoospermia. The fertilization rate and clinical pregnancy rate were 60, 7% and 26, 8% in PESA group, and 61, 3% and 27, 2% in respectively TESE group. No surgical and anesthesiological complications were noticed. We conclude that significantly fewer spermatozoa were harvested after PESA than after open biopsy. However but no significant differences in either fertilization rate or pregnancy rate were observed between PESA and TESE group. PESA is simple, easy to learn, safe and well tolerated tecnique which can be performed without need for expensive equpment and specially trained personnel. The main disandvantage of PESA is limited number of retrived cells which does not easily allow cryopreservation. Using TESE technique multiple specimens can be cryopreserved with one surgical procedure. Some patients may therefore prefore to undego a single more invasive open biopsy, so omitting repeated aspiration. We can conclude that in obstructive azoospermia, cryopreservation of testicular tissue at prior biopsy is the method of choice. If no freezing program is available PESA is preferable.

obstructive azoospermia; ART; TESE; PESA

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