Some men may have conditions that make it hard for them to give a sperm sample.

If you’re having problems giving a sperm sample, there are other ways to get sperm that require surgical tools or instruments. These procedures are especially useful for men who have neurological or spinal cord injuries. Sometimes these procedures are also used if there is no sperm in the sample you’ve given due to a blockage or other reason.

In some cases, specific procedures are needed to obtain a sperm sample. It is important to note that clinics may differ in how they decide who might require each procedure. It is important to know that even if sperm are retrieved, this does not guarantee a successful pregnancy. The success rates of each procedure (likelihood of retrieving sperm) is also variable depending on the clinic, your underlying cause of infertility, female partner’s age and reproductive health, response to treatment, and many other factors.

It is also important to note that, in Canada, most of these treatments are not covered by provincial health care plans. The costs of each treatment vary highly based on geographic location, the experience of your clinic, and the complexity of the treatment. Talk to your doctor for more information and to learn what approach they would recommend for your specific case.

Penile Vibratory Stimulation (PVS) / Electroejaculation (EEJ)

Who might need it?

Men with:

  • Spinal cord/neurological injuries
  • Anejaculation
  • Retrograde ejaculation
  • Erectile dysfunction

Penile Vibratory Stimulation (PVS) and Electroejaculation (EEJ) are generally used to retrieve sperm from men with spinal cord injuries or other neurological injuries that prevent them from ejaculating. These treatments can also be used in men who are unable to ejaculate (anejaculation), unable to ejaculate outwards (retrograde ejaculation) or have erectile dysfunction.

What is it?

PVS and EEJ are procedures that stimulate the male reproductive organs through penile vibration or electrical stimulation of the prostate.

PVS is the easier of the two procedures and will usually be tried first as it is non-invasive and less expensive than EEJ. PVS is performed using a medical vibrator to stimulate the glans of the penis.

EEJ is a more complex procedure. You will first be put to sleep with general anesthesia, unless you have no pain sensation in your genital organs. Then a special probe will be inserted into your rectum to stimulate the nerve to provide ejaculation for a sperm sample.

What to expect?

PVS usually involves stimulation of the penis glans for repeated periods of 2 minutes, with a rest period of 30 seconds in between. When ejaculation occurs, the vibrator is removed, and the ejaculate is collected. To maximize the amount of sperm collected, the urethra will be manually milked to collect more semen. More than one PVS attempt may be required to induce complete ejaculation.

To perform EEJ, several steps are necessary to ensure a safe procedure, including general anesthesia, when it is indicated. A proctoscopy will be performed to check for pre-existing damage in the area. The bladder will be emptied as EEJ can lead to retrograde ejaculation which may require sperm collection from the bladder by catheterization. A probe is inserted into the rectum while the man is lying down on his side. An electrical current is delivered in waves with 5 seconds of stimulation followed by a 20-second pause. Stimulation is repeated at increased voltages at every wave until ejaculation occurs. Ejaculation will only occur during the periods of rest during which the ejaculate is collected. As with PVS, the urethra will be milked manually to collect as much semen as possible. Finally, a proctoscopy is repeated to make sure the procedure did not cause any damage in the area.

Pros:

  • Compared to EEJ, PVS is non-invasive and inexpensive.
  • EEJ is generally safe and has high success rates of sperm retrieval (95%). It is important to know that even if sperm are retrieved, this does not guarantee a successful pregnancy. The success rate of having a successful pregnancy will also depend on egg quality, embryo development, maternal age and many other factors.
  • You won’t need surgery and can be back to your daily routine after 1–2 days.

Cons:

  • PVS may cause your penis to become irritated and you may notice little cuts. These will heal on their own.
  • If your doctor recommends EEJ, you’ll have to go under general anesthesia. Before this procedure, your doctor will perform blood pressure tests and ask about medical history (e.g., prior heart complications) since stimulation will lead to an increase in blood pressure.
  • The sperm retrieved during these procedures may not be as high quality (lower motility, viability and count) as sperm retrieved through masturbation. If your sperm isn’t of good enough quality, your doctors may recommend that IVF/ICSI is used to help increase the chances of pregnancy.

Percutaneous Epididymal Sperm Aspiration (PESA)

Who might need it?

PESA is a procedure used for men who don’t have problems creating sperm, but the sperm has problems getting out (obstructive azoospermia).

What is it?

Sperm is retrieved directly from the epididymis, the area where sperm is stored.

What to expect?

PESA is performed under local anesthesia and generally causes little pain. For this procedure, a needle is inserted through the skin of the scrotum into the epididymis and then slowly removed until milky white fluid is collected. PESA may be done a few times until enough sperm is collected. The procedure can be done fairly quickly (10–20 minutes).

Pros:

  • Fast and minimally invasive.
  • It is a simple procedure that only requires your private parts to be numbed.
  • The recovery is easy and takes about 1–3 days.
  • More than 80% of men with obstructive azoospermia can have sperm found with PESA. Even if sperm are retrieved, this does not guarantee a successful pregnancy. The pregnancy success rate will also depend on egg quality, embryo development, maternal age, and many other factors.

Cons:

  • Due to the limited quantity of sperm that can be collected, they can only be used for IVF/ICSI.
  • The procedure can cause damage to the epididymis, meaning that the next time your sperm are retrieved, there may be less sperm found.
  • Sometimes, this procedure can damage the testicular artery, contaminating the sample with blood and causing complications such as pain, swelling, or damage to testis function.

Microsurgical Epididymal Sperm Aspiration (MESA)

Who might need it?

MESA may be used if there is a problem with sperm count that is due to a blockage (obstructive azoospermia).

What is it?

MESA is a microsurgical procedure where doctors try to find sperm in the epididymis, the area where your sperm is stored. The procedure is usually done under general anesthesia where you will be fully asleep; however, sometimes only your private parts will be numbed. You and your doctor may prefer general anesthesia to prevent you from moving during the procedure.

Pros:

  • You’ll probably get a lot of sperm. This is a real advantage as the sperm can be frozen and used later during IVF/ICSI. This means that you may have enough sperm for more than one round of treatment with IVF/ICSI.
  • The recovery is simple, and you’ll be back at it in 1–3 days.
  • More than 90% of men with obstructive azoospermia can have sperm found with MESA. Even if sperm are retrieved, this does not guarantee a successful pregnancy. The pregnancy success rate will also depend on egg quality, embryo development, maternal age, and many other factors. The success rate of sperm retrieval using MESA is slightly higher than PESA for men with obstructive azoospermia.

Cons:

  • It is a complex surgery that is done under a microscope by a specially trained surgeon.
  • A more invasive procedure compared to PESA.

Testicular Sperm Aspiration (TESA)

Who might need it?

This procedure is for men who don’t have any sperm in their ejaculate (obstructive azoospermia or non-obstructive azoospermia), or those who have sperm in the ejaculate that aren’t of good quality and fail ICSI.

What is it?

Sperm is taken from your testicles with a needle (medical speak: testicular aspiration).

What to expect?

Local anesthesia is used to reduce the pain from the procedure. A needle is slightly inserted and withdrawn from the testis until enough sperm is retrieved. No incision is required in this procedure. This procedure can be done in an office without an operating room.

Pros:

  • For obstructive azoospermia, TESA requires no microsurgical skills, is fast, minimally invasive and successful most of the time.
  • For men who have sperm that aren’t good swimmers, with TESA sperm can be found most of the time.
  • The recovery is easy, and you’ll be back at it in 1–3 days.

Cons:

  • There is a small risk of side effects, such as pain, bleeding, swelling, bruising, or infection in the testicles.

Percutaneous Testicular Biopsy

Who might need it?

This procedure may be an option for you if you ejaculate, but there’s no sperm in there (azoospermia), or your sperm are of poor quality that fail ICSI. You may have a block in your reproductive tract and sperm don’t come out, even though you have no trouble making sperm inside your testes (obstructive azoospermia). Alternatively, you may have no block in the reproductive tract, and you just do not make enough or any sperm to flow to semen (non-obstructive azoospermia). In either case, it is necessary to take testicular tissue to look for sperm is needed.

What is it?

A small amount of testicular tissue is removed (biopsy) with a special needle that can find sperm.

What to expect?

A thin needle is inserted through the scrotal skin to collect testicular tissue. Your surgeon may sometimes make an incision in the scrotum to obtain enough testicular tissue to look for sperm. The procedure requires your private parts to be numbed, using local anesthesia.

Pros:

  • Minimally invasive.
  • The procedure can be performed on an outpatient basis.
  • The recovery is easy, and you’ll be back at it in 1–3 days.

Cons:

  • You probably won’t find a lot of sperm this way; the sperm that is collected can only be used for ICSI.
  • There is a risk of testicular swelling, bleeding, pain, infection and loss of testicular function. However, the risks associated with Percutaneous Testicular Biopsy are less than those for TESE and microTESE since it is less invasive.

Testicular/Epididymal Sperm Extraction (TESE)

Who might need it?

This procedure may be for you, if you have no sperm in the semen due to either a blockage (obstructive azoospermia) or problems with sperm production (non-obstructive azoospermia).

What is it?

TESE is a procedure where tissue containing sperm is removed from your testicles to use later for sperm retrieval. 

What to expect?

TESE is usually performed under local anesthesia to reduce pain. The procedure is done through a small window in the scrotal skin. An incision is made with a scalpel to retrieve a small amount of testicular tissue. The skin is then closed with stitches and the scrotum returns to its original state.

Pros:

  • In obstructive azoospermia, no microsurgical skills are needed and TESE is a reliable procedure to acquire sperm.

Cons:

  • There is a risk of testicular swelling, bleeding, pain, infection, and loss of testicular function.
  • The procedure may require a longer recovery time (1-2 weeks) compared to other sperm retrieval procedures.

(Micro) Testicular Sperm Extraction (microTESE)

Who might need it?

You may be offered microTESE if you have no sperm in the semen due to problems with sperm production (non-obstructive azoospermia).

What is it?

MicroTESE is usually performed under a general anesthetic. An operating microscope is used to find where in your testicles there is tissue that may have the best chance of containing sperm. When they are found, this testicular tissue is removed to look for sperm.

What to expect?

In microTESE, testicular vessels can be visualized using magnification and preserved. An incision is made and the surgeon separates and examines each seminiferous tubule for the likelihood of sperm production. A small amount of testicular tissue is collected from these areas to look for sperm. This procedure can take 1–2 hours. This procedure is more invasive than TESE, but is also more precise since it uses magnification.

Pros:

  • MicroTESE is the primary sperm retrieval method used in men with non-obstructive azoospermia, with a success rate of up to 50%. 
  • The sperm can then be used in an IVF/ICSI cycle or frozen for future cycles. 
  • Even if sperm are retrieved, this does not guarantee a successful pregnancy. Success rates of live birth will also depend on egg quality, embryo development, maternal age, and other factors.

Cons:

  • This is an invasive and complex procedure.
  • There is a risk of testicular swelling, bleeding, pain, infection, and loss of testicular function.
  • MicroTESE may require a longer recovery time compared to other sperm retrieval procedures, requiring about a week off work.