Approach first line and should only be indicated

 

Approach
towards treatment of male infertility was revolutionised by the introduction of
novel method of ICSI in  1992 . (1 2). The use of surgical sperm retrieval from the
testis or epididymis associated to ICSI has given the chance for azoospermic
patients of fathering their own genetic children.  Asingle embryo can be injected into
an oocyte which resulted in normal fertilization, embryonic development and implantation.
source of sperm can be preferentially by ejaculation or from epididymis or
testis in azoospermic males irrespective of obstructive or non obstructive aetiology.
This process opened up an unique opportunity for azoospermic male for a
successful parenthood putting an end for their never ending agony of being
childless for the rest of their life. Surgical sperm recovery for ICSI has
become an indispensable part of clinical andrology.

Sperms
can still be retrieved in some cases of non obstructive azoospermia as the
testis persists to possess some isolated foci of active spermatogenesis. Pregnancies
resulting from surgically retrieved sperms were first published by 1993 and 1995
(3-4).

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Anejaculation
and azoospermia- A clinical dilemma.

Successful
pregnancy is plausible only when intravaginal ejaculation is successful.
Primarily this is possible by an intact ejaculatory mechanism which is a  neurologic reflex arc  which can be
disrupted through any type of trauma or disease causing damage to the CNS
and/or peripheral nerves. Ejaculation may be psychogenic or may result from spinal
cord injury or retroperitoneal lymph node dissection. These include 95% of
aetiology followed by diabetic neuropathy , multiple sclerosis, Parkinson
disease, bladder neck surgeries are less encountered causes.Ocassionally drugs
such as antidepressants ,antipsychotics and antihypertensive may cause
anejaculation. Since the outcome of medical treatment for anejaculation is
guarded penile vibratory stimulation or electroejaculation is considered the
first line management than offering surgical sperm retrieval since they are non-invasive
and does not require anaesthesia and they are successful ion 80% of the time 5.often epidydimal or
testicular sperm retrieval are offered initially as facilities of EVS or EJ may
not be available at all centres . Scrotal hematoma and risk of iatrogenic epidydimal
obstruction may preclude surgical sperm retrieval being offered as the first
line and should only be indicated when first line non-invasive management fail.
It is reasonably good to refer anejaculatory 
patients especially with spinal cord injuries to tertiary care centres
where assisted ejaculation and semen cryopreservation facilities are present.

Surgical
sperm retrieval may be a treatment option for men with:

Absolute
Indication:

1.     An obstruction preventing sperm
release, due to injury or infection.

2.     Congenital absence of the vas deferens

3.     Vasectomy

4.     Non-obstructive azoospermia – the
testicles are producing such low numbers of sperm that they don’t reach the
vas.