Page Title

Microsurgical Epididymal Sperm Aspiration (MESA): Microsurgical epididymal
sperm aspiration is performed as open operation under the operating microscope.
Individual tubules of the epididymis are isolated and micropuncture aspiration is taken.
This approach has the advantages of reliable retrieval of large numbers of epididymal
spermatozoa that can be readily frozen and thawed for subsequent attempts at fertility.
Since MESA involves direct retrieval of spermatozoa from epididymal tubule, it minimizes
contamination of the epididymal fluid by blood cells, which may affect spermatozoa
fertilizing capacity during the IVF.
MESA is performed with a micropuncture siliconized glass pipette connected to sterile
medical grade silicone tubing that is attached to an aspiration device consisting of a 1-ml
plastic tuberculin syringe and a 10-ml glass syringe. The tip size of micropuncture pipette
is about 250 to 350 µm sharpened on a fine grinding wheel to facilitate puncture of the
epididymal tubule.9,12,14 A unique micropuncture pipet holding apparatus, MESA- Holder
(Patent pending, Cornell Research Foundation, 1997) has been developed at Cornell. Its
unique 180o angle adjustable pipet holding system simplifies the procedure of
micropuncture epididymal sperm retrieval. With gentle aspiration, epididymal fluid passes
into the micropipet, through the silicone tubing, and into a plastic syringe. Sequentially
more proximal punctures are performed until optimal sperm quality has been obtained.
Puncture sites are then closed with interrupted 9-0 Nylon suture, or cauterized and the
epididymal tunic closed with 6-0 polypropylene suture. This sperm retrieval method is the
most effective known for men with CBAVD.

Testicular Fine Needle Aspiration (TFNA): The technique of testicular fine-needle aspiration (TFNA) of the testis was initially
described as a diagnostic procedure in azoospermic men. Subsequently, testicular fine needle aspiration or biopsy for the
recovery of spermatozoa has been described12, 14. Percutaneous puncture and aspiration of the testis can be performed
using a 21-23-gauge needle connected to a 20cc syringe in a Menghini syringe holder. Percutaneous testicular needle
biopsy can be performed with an automatic biopsy gun. The limited published experience to date with TFNA makes critical
evaluation of this technique difficult, although it is evident from our experience that 1) sperm retrieval is routinely possible
with TFNA for men with obstructive azoospermia, 2) occasional hematoceles and hematomas are possible with this
technique. The advantages of percutaneous aspiration techniques are that they can be performed with local anesthesia,
without open scrotal exploration and its attendant postoperative discomfort, and without microsurgical expertise.

Percutaneous Epididymal Sperm Aspiration (PESA): PESA has been advocated because it can be performed without
surgical scrotal exploration, it is repeated easily at low cost, and it does not require an operating microscope or expertise in
microsurgery. The procedure can be performed under local or general anesthesia. The testis is stabilized and the
epididymis is held between the surgeon's thumb and forefinger. A 21-gauge butterfly needle attached to a 20-ml syringe is
inserted into the caput epididymis and withdrawn gently until fluid can be seen entering the butterfly needle tubing. The
procedure is repeated until adequate numbers of sperm are retrieved. PESA yields very small amount of epididymal fluid
and contamination with blood cells is frequent. For the 10-20% of attempts where sperm are not retrieved with PESA, open
sperm retrieval or percutaneous testicular aspiration is possible.