I friend of mine, a urologist in OH, asked me how I do an epididymal sperm aspiration . Here is what I told him.
First, after taking proper informed consent, I take the patient into the OR and prep and drape the area. Local anesthesia with some light IV sedation is sufficient, typically. I do a perivasal cord block using the 3 finger technique, such as during a vasectomy. Then I wrap a sterile gauze pad around the testicle so that I can easily immobilize it with my left hand while keeping the skin overlying the testicle taught. I then infiltrate local under the scrotal skin and dartos and make a 1-2cm transverse scrotal incision, which I deepen with the knife and cautery until I get to the tunica vaginalis. of the testicle. After opening the tunica vaginalis, I roll the testicle so that the epididymis comes into the field. I then immobilize the epididymis by passing a 5-0 nylon suture through the tunic of the epididymis. At this point I am ready for the sperm retrieval,which is performed as follows.
After inspecting the head, body, and tail of the epididymis, I try to determine which area appears most dilated and which area has dilated tubules that appear full of milky white fluid. I then pass a 26G needle into the tubules at these areas and aspirate back and forth. If you hit sperm filled tubules, some milky white fluid will enter the needle/syringe. You then squirt the aspirate into a media filled petri dish and inspect in the microscope for the presence of sperm, most preferably motile sperm. If you have several million motile sperm, and the patient intends to proceed with IVF or ICSI, you are done. If the patient plans to proceed with IUI only, you'll need at least 5-10 million motile sperm. If you don't get this on the first pass, you continue the procedure by sequentially aspirating various portions of the epididymal head, body, and tail until you either have enough sperm or you can not get enough motile sperm. In cases where 1 side does not yield motile sperm in sufficient quantities, you must proceed to the other side.
That is how I do it. Some urologists do the entire procedure percutaneously, but I have found that sperm yields are not sufficient via the percutaneous approach. Just my own observation. Patients do quite well and do not have more post-op pain than with the percutaneous method. Patients that have the procedure performed on a Friday may return to work by Monday.
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