postoperative pain, complications, and satisfaction rates in patients who undergo surgical sperm...

Postoperative pain, complications, andsatisfaction rates in patients who undergosurgical sperm retrieval

Simon Wood, M.D.,a Kevin Thomas, M.D.,a,b Vicky Sephton, M.D.,a

Stephen Troup, Ph.D.,a Charles Kingsland, M.D.,a and Iwan Lewis-Jones, M.D.a,b

Reproductive Medicine Unit, Liverpool Women’s Hospital, Liverpool, England

Objective: To determine patients’ experiences with surgical sperm retrieval and its common complications.

Design: A questionnaire based survey using visual analogue scales (VAS) and closed questions to analyzecomplication, pain, and satisfaction rates.

Setting: Tertiary care university hospital.

Patient(s): One hundred consecutive males undergoing surgical sperm retrieval by percutaneous epididymalsperm aspiration (PESA) or testicular sperm extraction (TESE).

Intervention(s): None.

Main Outcome Measure(s): We surveyed for pain perception complication rates and satisfaction scores.

Result(s): Of the 85 patients who replied, 21 underwent retrieval for nonobstructive causes, 37 followingfailed reversal of vasectomy, and 27 for other obstructive causes. Retrieval was successful in 100% ofobstructive causes and in 61% for nonobstructive azoospermia. Epididymal retrieval was successful in 23patients, 30 patients underwent TESE after failed PESA, and 23 had TESE only. There were significantincreases in pain perception scores and reported complications with TESE over PESA (31 vs. 16; and 21 outof 63 vs. 2 out of 22, respectively), but no difference in satisfaction rate. The cause of azoospermia did notaffect pain perception or satisfaction in TESE. Complication rates were increased in larger testes (3 out of 22vs. 24 out of 63). Unsuccessful sperm retrieval did not significantly affect patients’ pain perception orsatisfaction. Surgical sperm retrieval was rated as significantly less painful than both vasectomy and reversal(21% vs. 42% vs. 57%, respectively) and was associated with significantly fewer days absent from work (3.0vs. 8.5).Conclusion(s): Surgical sperm retrieval by PESA or TESE is a safe procedure with only minor complicationsthat is tolerated well by patients. (Fertil Steril� 2003;79:56–62. ©2003 by American Society for ReproductiveMedicine.)

Key Words: Sperm retrieval, pain, satisfaction

For men with uncorrectable obstructiveazoospermia or nonobstructive azoospermia,their partner’s only hope of achieving a preg-nancy using the men’s own spermatozoa viawith surgical sperm retrieval. Although the firstpregnancy reported following in vitro fertiliza-tion (IVF) with spermatozoa retrieved from theepididymis was reported in 1985 (1), the fer-tilization potential and subsequent pregnancyrates of retrieved epididymal spermatozoa re-mained low (2, 3). For testicular sperm, al-though fertilization was reported (4), no preg-nancy resulted.

With the introduction of intracytoplasmicsperm injection (ICSI) in 1993 (5), the use ofsurgically retrieved spermatozoa became a

more realistic option for couples. The firstpregnancies with testicular sperm soon fol-lowed (6, 7), and rapidly the success rates withboth epididymal and testicular retrieved sper-matozoa matched those achieved with ejacu-lated spermatozoa (8–10).

After the demonstration of the high fertiliz-ing potential of testicular spermatozoa, manycenters began retrieving spermatozoa from pa-tients with nonobstructive azoospermia and us-ing this for ICSI (11, 12). Many investigatorshave described ways of increasing both thefrequency of successful retrieval and the yieldof spermatozoa from each attempt. Most cen-ters quote retrieval rates for nonobstructiveazoospermia of around 50% for open extrac-

Received January 24,2002; revised andaccepted May 8, 2002.Reprint requests: SimonWood, M.D., ReproductiveMedicine Unit, LiverpoolWomen’s Hospital, CrownStreet, Liverpool L8 7SS,England (FAX:00441517024042; E-mail:[email protected]).a Reproductive MedicineUnit.b Department of Obstetricsand Gynaecology,University of Liverpool,Liverpool Women’sHospital.

FERTILITY AND STERILITY�VOL. 79, NO. 1, JANUARY 2003

Copyright ©2003 American Society for Reproductive MedicinePublished by Elsevier Science Inc.

Printed on acid-free paper in U.S.A.

0015-0282/03/$30.00PII S0015-0282(02)04553-3

56

tion techniques (13) compared with 12% for a closed aspi-ration technique (14). Some studies also have shown im-proved recovery rates from multiple open or closed biopsies,either unilaterally or bilaterally (15, 16). Others have sug-gested that using a microsurgical technique for identificationof distended and potentially sperm yielding seminiferoustubules may improve successful retrieval and reduce thevolume of tissue samples removed (17).

Following the introduction of a simplified blind aspira-tional technique, percutaneous epididymal sperm aspiration(PESA) (18, 19), most units switched to PESA from themore invasive open microsurgical epididymal sperm aspira-tion (MESA). The simplicity of PESA and the ability toperform it under local or no anesthesia (20) were benefits.However, some proponents of MESA still use this as afirst-line option because of the reported increased successrate in retrieval (21), increased harvest of spermatozoa fortreatment and cryopreservation, and the increased diagnosticinformation (22). Others have suggested that a mini-micro-epididymal sperm aspiration under local anesthesia reducesboth morbidity and costs (23).

Many studies have looked at recovery rates and fertiliza-tion potential of fresh and cryopreserved surgically retrievedspermatozoa, but fewer studies have looked at the painperception and complication rates with surgical sperm re-trieval. Studies that have looked at pain perception have beenmostly concerned with the ability to perform these proce-dures under local anesthetic (20, 23–25). Most data withregards to complications are concerned with postoperativeultrasound (26, 27) and biochemical complications (28).

In the present study, all patients underwent surgical spermretrieval under general anesthesia, and those with unsuccess-ful PESA underwent TESE using an open method during thesame operation. Although spermatozoa can be retrieved in96% to 100% of patients with obstructive azoospermia byaspirational techniques with a 21-gauge needle (29) theretrieval rates for nonobstructive azoospermia fall to only12% (14). The quantity of recovered spermatozoa is ofteninadequate for cryopreservation or histologic assessment(14). With the use of larger 19-gauge needles, clinics canusually obtain excess spermatozoa for cryopreservation, butgeneral anesthesia is often required (30).

MATERIALS AND METHODS

Patient PopulationInstitutional review board approval was sought and ap-

proved for a prospective questionnaire study of patientsundergoing surgical sperm retrieval. Power calculation couldnot be calculated, as there were no previous data with regardto pain perception or satisfaction and complication rates.Thus, a sample size of 100 patients was selected to give anadequate representation of patients.

Between August 1999 and March 2000, 100 consecutivepatients undergoing surgical sperm retrieval for azoospermiawere asked to complete a questionnaire 2 to 3 weeks aftertheir operation. All patients were included, regardless of thecause of their azoospermia or whether they had undergoneprevious surgical sperm retrieval. Of these 100 question-naires, 85 were returned and the data analyzed.

Of the returned questionnaires, 51 (60%) patients hadtheir surgical sperm retrieval performed in conjunction withan oocyte retrieval and ICSI in the female partner; 34 (40%)were performed electively with cryopreservation of retrievedspermatozoa before an IVF/ICSI cycle in the female. Thedecision to perform an elective procedure was made betweenthe clinician and patient as the unit began an audit of the useof cryopreserved spermatozoa. Which patients had an elec-tive rather than coordinated cycle was evenly divided be-tween obstructive and nonobstructive patients. Thirty (35%)patients underwent planned TESE either due to a diagnosisof nonobstructive azoospermia (as determined by elevatedFSH levels �16, small volume testes �9 mL, or histology),previous failed PESA, or a nonpalpable epididymis. Of the55 patients who underwent planned PESA, 22 (43%) hadsuccessful epididymal retrieval, and 33 (57%) underwent anadditional TESE procedure. Of the 37 patients who wereazoospermic following a previous vasectomy, 30 (81%) hadhad a previous failed reversal.

Questionnaires were completed and returned after thepatient’s partner had undergone a urinary hCG pregnancytest to establish pregnancy but before an ultrasound scan toconfirm fetal numbers and viability.

QuestionnaireThe questionnaire was sent out 2 weeks after the proce-

dure to ensure as accurate a reflection of the true pain andsatisfaction scores while allowing a true assessment of com-plications with regard to pain, bruising, and scarring over theintervening weeks.

Complications were assessed by means of closed ques-tions with regard to bleeding, bruising, pain, and scarring.Each category had four possible responses scored from 0 forno complication, 1 for mild/minimal, 2 for moderate, and 3for severe. A score of 2 in any category was arbitrarily takento indicate a complication had occurred rather than a naturalsequela of surgery. Complication rates were established forthe occurrence of at least one positive complication. Acomplications score was also established by adding thescores for each of the four categories.

Pain and satisfaction scores with regard to the treatmentas well as previous vasectomy and reversal were assessed byvisual analogue scales (VAS). This essentially consisted ofan unmarked single line, 10 cm long. It was marked at oneend with worst-ever pain/completely dissatisfied, and on theother with no pain/completely satisfied. The patient wasasked to place a mark corresponding to the level of response

FERTILITY & STERILITY� 57

to the question of pain and satisfaction level. This is awell-established method for removing bias and giving anaccurate representation of pain perception (31). Patient sat-isfaction was also measured using a VAS. Scores on theVAS ranged from 0 for no pain at all to 100 for the worstpain ever felt. For satisfaction the scores again ranged from0 for totally dissatisfied to 100 for completely satisfied.

Sperm Retrieval MethodsFor patients with obstructive azoospermia with a dis-

tended or palpable epididymis, the initial planned procedurewas PESA. All patients undergoing PESA were also coun-seled before their consent was obtained as to the significantpossibility that epididymal retrieval would be unsuccessfuland that TESE would be required as part of the procedure toretrieve spermatozoa. Afterward, PESA was performed us-ing the standard method first described by Craft in 1995 (19).The epididymis was identified and secured between thethumb and index finger; the remaining fingers and palm wereused to cup and stabilize the testicle. Fluid was aspiratedblindly from the epididymis via the percutaneous puncture ofthe epididymis with a 19-gauge needle; suction was obtainedusing a 20-mL syringe. The procedure was performed undergeneral anesthesia for convenience should the patient requirea testicular extraction when epididymal retrieval failed. Theepididymal fluid aspirated was immediately examined, mag-nified at �400 bright-field microscopy, for the presence ofmotile spermatozoa. If no motile spermatozoa were seenafter two attempts on each palpable epididymis, the patientproceeded straight to TESE. Testicular extraction was alsoperformed without a prior attempt at PESA if no palpableepididymis was identified, the testes were small (�10 mL),or the patient had had a previous unsuccessful PESA.

We performed TESE as a unilateral open biopsy, in whicha small incision was made in the scrotal skin of the largesttesticle anterolaterally and the layers of tissue were openedthrough the spermatic fascia and the tunica vaginalis to thetunica albuginea. After opening the tunica albuginea, semi-niferous tubules were removed in three to four biopsies. Theincision was closed in layers using 3/0 Vicryl, with subcu-ticular sutures to close the skin. Following closure, 5 mL of1% bupivacaine was used to infiltrate the area around theincision.

All patients were prescribed a 5-day course of prophylac-tic antibiotics (flucloxacillin or erythromycin) and weregiven a prescription of cocodamol (ABPI) for 5 days ifrequired.

Statistical AnalysisStatistical analysis was performed using both independent

and paired t tests as well as analysis of variance (ANOVA)with Bonferroni transformation for continuous data, and �2

for comparison of complication rates. For comparisons ofpain perception and satisfaction between epididymal andtesticular recoveries, independent t-tests were used. For

comparisons of pain, satisfaction, and days absent from workbetween vasectomy, vasectomy reversal, and surgical spermretrieval, paired t-tests were used. Differences were consid-ered statistically significant when P�.05.

RESULTSThe response rate for return of completed questionnaires

was 85%. The causes of azoospermia, the type of procedureplanned or performed, and pregnancy rates did not differbetween the responders and nonresponders.

The mean age of the male patients differed in a statisti-cally significant way for causes of azoospermia, with pa-tients azoospermic following vasectomy being significantlyolder (43.2 years, range: 34 to 52 years) than those with othercauses of azoospermia (35.6 years, range: 23 to 44 years)(P�.0001). There was no statistically significant differencebetween the ages of males with germ cell failure (34.6 years,range: 27 to 44 years) and other obstructive causes (35.7years, range: 23 to 42 years).

Spermatozoa Recovery RatesSpermatozoa were never retrieved from the epididymis in

patients with nonobstructive azoospermia. With obstructiveazoospermia, the cause of obstruction did not significantlyeffect successful retrieval rates from the epididymis. Therates ranged from 3 out of 7 (42%) for congenital bilateralabsence of vas deferens (CBAVD), 13 out of 57 (35%) forprevious vasectomy/failed reversal, and 5 out of 20 (25%)for other obstructive causes.

Recovery of sperm from obstructive cases was 64 out of64 (100%) compared with 13 out of 21 (61%) in nonobstruc-tive cases, which is in agreement with the findings of otherstudies (32, 33).

Survey Results

Pain and Satisfaction

The overall satisfaction scores with treatment was high at90.6 with an average pain perception score of only 27.0. Thecause of azoospermia had no effect on pain perception(ANOVA P�.078). There was also no difference in painperception and satisfaction scores when comparing obstruc-tive and nonobstructive cases (pain perception scores: 27.2vs. 26.5, P�.91; and satisfaction scores: 92.0 vs. 86.4,P�.90, respectively). In patients undergoing TESE for non-obstructive causes, there was no difference in pain percep-tion, reported complications, or satisfaction if spermatozoawere recovered or not (pain perception scores: 22 retrievedvs. 34 not retrieved, P�.26; and satisfaction scores: 92retrieved vs. 77 not retrieved, P�.15).

The perceived pain is significantly greater for TESE thanfor PESA, at 31.0 vs. 16.5 (P�.014), and the rate of com-plications was significantly higher at 21 out of 63 vs. 2 outof 22, respectively (P�.029), with an increase in average

58 Wood et al. Patient satisfaction with surgical sperm retrieval Vol. 79, No. 1, January 2003

complications score (2.48 vs. 0.78, P�.001, respectively).These complications were mainly bleeding and bruising.However, despite these results, there was no statisticallysignificant difference in satisfaction scores (88.0 vs. 91.4,P�.40) between either treatment (Table 1).

For patients undergoing a planned PESA who have afailed epididymal retrieval and required an additional TESEto recover spermatozoa, there was no statistically significantdifference in pain perception (P�.35), complication rate(P�.062), or satisfaction rate (P�.43) from patients under-going a planned TESE (see Table 1).

Although a positive pregnancy test was associated with asmall but statistically significant increase in satisfaction rates(94 vs. 88, P�.007), it had no effect on pain perception (23vs. 28, P�.38) or complication rates (9 out of 23 vs. 12 outof 28, P�.65).

Complications

The only other major variable to affect the complicationrate was the size of the testis being operated upon. Compli-cation rates were statistically significantly greater if thetesticle was 20 mL or greater in volume (19 out of 58, 32%vs. 3 out of 27, 11%; P�.037). The average complicationscore was also significantly increased in larger testes (2.24vs. 1.56, P�.046) with an increase in bleeding and bruisingreported (Table 2). When only TESE was considered, thedifference in complication rate became even more markedwith rates of 17 out of 38 (44%) vs. 3 out of 24 (12%)(P�.012).

These results would seem to indicate that minor to mod-erate “complications” are common (24 out of 63 patientswith testes larger than 20 mL); however, the high satisfactionrates combined with favorable comments from patientswould indicate that these complications are most likely theexpected sequelae of surgery. Only one patient reported asevere complication (bruising extending over lower abdo-men/thighs following PESA).

Vasectomy and Vasectomy Reversal

The pain perception was significantly lower for surgicalsperm retrieval when compared with vasectomy, which initself was significantly lower than for vasectomy reversal (21vs. 42 vs. 56, P�.017). There were also significantly fewerdays absent from work with PESA/TESE patients than forvasectomy reversal patients (3 vs. 8.5, P�.005); and, aswould be expected, the former had greater satisfaction withtreatment (92.5 vs. 49.1, P�.005) (Table 3). If the patienthad not previously had a vasectomy reversal, there was nosignificant alteration in perceived pain or satisfaction withtreatment, nor was there any difference in complications ordays absent from work.

DISCUSSIONPrevious studies that have looked at complication and

satisfaction rates following surgical sperm retrieval havebeen small and have usually assessed comparisons of asingle new technique or analgesia regimen. In a nonrandom-ized study of 40 men with nonobstructive azoospermia who

T A B L E 1

Experiences of patients who underwent sperm retreival with PESA or TESE.

PESA TESE (all patients) TESE following failed PESA TESE alone P value

No. of patients 22 63 33 30Pain perception VAS 16.5a 31.0a 31.4 30.6 aP�0.14Complication rate 2/22b 21/63b 12/33 7/30 bP�.029Satisfaction VAS 88.0 91.4 91.5 91.3 N/S

Wood. Patient satisfaction with surgical sperm retrieval. Fertil Steril 2003.

T A B L E 2

Complication rates depending on testicular size in patients who underwent sperm retrieval with PESA or TESE.

No. ofpatients Bleeding Bruising Scarring

Total patientsreporting

complications

Complicationrate

TESE only

Testicle 20 mL or larger 58 4 9 12 19/58 17/38Testicle 19 mL or less 27 0 1 2 3/27a 3/24b

a P�.037.b P�.012.



were undergoing testis biopsy, Ezeh et al. (33) compared thecomplication rates and pain scores of a combination i.v.sedation with local anesthetic technique against general an-esthesia. The results indicated better postoperative pain reliefin the sedation patients. This study found no statisticallysignificant differences in complication rates between the twosedative techniques, and found complication rates of 25%without looking at the relation to testicular size.

From the results of this study, it is clear that using asimple blind epididymal sperm aspiration technique mayprovide spermatozoa for treatment in an ICSI cycle. How-ever, a significant proportion of patients will not have sper-matozoa retrieved from the epididymis and will requirecollection of testicular spermatozoa either by an aspirationtechnique (34–36) or by a more formal extraction technique.Many investigators have suggested that, in nonobstructiveazoospermia, needle biopsy is a far less effective procedure(37, 38). The debate with regard to the number of biopsies tobe taken and whether bilateral biopsies are required is moreuncertain, with reported recovery rates of 62% with a singleincision (39) against 50% to 76% with up to 20 multipleincisions (40, 41). This suggests that the total quantity oftissue removed may be as important as the site and thatspermatozoa are distributed evenly rather than focally (42).

Our study demonstrates that testicular sperm retrieval byopen technique is associated with significantly greater painperception and complication rates than PESA, but that over-all patient satisfaction is not decreased with TESE. Further-more, these data indicate that, given adequate counseling andexplanation before treatment, even if a patient has to undergoTESE following failed PESA the overall satisfaction rate isnot decreased.

A criticism of this study is that, although the data withregard to surgical sperm retrieval were collected within 3weeks of the patients’ operations, the data on their previousvasectomy and/or reversal were necessarily collected a longtime after their operations. The patients’ true recollection ofpain (the recognized chronic pain syndrome) and satisfactionmay have been affected by the time interval. However, ourdata for all the vasectomy and reversal patients appeared

remarkably consistent, regardless of the intervening interval(18 months to 26 years for vasectomy and 1 year to 15 yearsfor reversal). Further bias may have been introduced withwho had unsuccessful vasectomy reversals; their perceptionof their operation may be affected by its failure. A modifiedquestionnaire for patients within 3 weeks of a vasectomyreversal to examine patients’ pain perception, complicationrate, and satisfaction rate as well as time absent from workcould be performed to remove the bias with regard to successor failure of vasectomy reversal. The number of patientsinvolved would require multicenter investigations and beopen to considerable bias, as many different techniqueswould be employed by urologists and general surgeons.

The low pain scores reported by patients in the presentstudy reflect the ease and simplicity of the procedures. Thehigh satisfaction rating is probably a reflection of treatmentnow being offered to patients who previously were consid-ered to have intractable infertility, for whom the only pre-vious realistic treatment option was donor sperm. This ap-pears to be reflected in the high satisfaction levels forpatients with nonobstructive azoospermia, but even patientswith failed retrieval of sperm show very high levels ofsatisfaction.

The increased complication rates particularly with regardto bleeding and bruising that are seen for patients with largertestes may well reflect the increased vasculature and bloodflow to the testis. This is especially true as most epididymalrecoveries were performed in patients with larger testicles. Ifonly TESE is compared, then the complication rate is evenmore significantly increased in patients with larger testicles.Indeed, when analyzing data in patients with testes below 17mL in volume, we found only 1 patient out of 17 (5%)reported any complications, regardless of the procedure per-formed.

The significantly lower pain perception for surgical spermretrieval compared to vasectomy reversal (as well as its100% success rate in retrieving sperm) is rarely if ever putforward as a reason for performing sperm retrieval instead ofvasectomy reversal. Many studies have looked at the eco-nomic costs and benefits for vasectomy reversal vs. surgicalsperm retrieval (43, 44), and all have been strongly in favorof vasectomy reversal in terms of operating costs, IVF costs,and multiple pregnancy costs. Even in patients who haveolder partners (45) and have had previous failed reversal(46), studies have found the cost benefit ratio in favor ofvasectomy reversal. However, none of these studies haveexamined the morbidity rates or time absent from work forthese men.

We have shown a statistically significant increase in mor-bidity and days absent from work associated with vasectomyreversal over surgical sperm retrieval. Although it is unlikelyto effect the overall cost benefit analysis in a statisticallysignificant way, it may be an important factor for individualcouples. Many of these studies also claim very high preg-

T A B L E 3

Pain and satisfaction scores with surgical spermretrieval, vasectomy, and reversal.

Surgicalsperm retrieval Vasectomy

Vasectomyreversal P value

No. of patients 37 37 30Pain perception VAS 21.4 42.7 57.6 �.005Days absent from work 3.0 Not measured 8.5 �.005Satisfaction VAS 92.5 Not measured 49.2 �.005



nancy rates following reversal, yet other studies have calcu-lated that the absolute maximum pregnancy rate followingvasectomy reversal could only be 67% (lower than somereported pregnancy rates) due to partner infertility, epididy-mal dysfunction, and sperm antibodies (47). Whereas suc-cess rates of surgical sperm retrieval and subsequent preg-nancy can be predicted accurately, and indeed are audited bystatutory regulatory bodies, there is a degree of uncertaintywith regard to the success of vasectomy reversal and subse-quent pregnancy rates. These rates are subjected to minimalreview and audit.

With increasing incidence of female pelvic inflammatorydiseases reported in the Western hemisphere as well asincreasing female partner age before embarking upon preg-nancy, it is likely that surgical sperm retrieval with IVF/ICSIwill become a popular option for many couples. An alliedconcern is recent recommendations as to restricting the num-ber of embryos replaced in each treatment cycle, with anultimate target of single embryo transfers. The risk of mul-tiple pregnancies should be reduced to below that of spon-taneous conceptions, with an elimination of high-order mul-tiple pregnancies.

References1. Temple-Smith PD, Southwick GJ, Yates CA, Trounson AO, de Kretser

DM. Human pregnancy by in vitro fertilisation (IVF) using spermaspirated from the epididymis. J In Vitro Fert Embryo Transf 1985;2:119–22.

2. Silber SJ, Ord T, Balmaceda J, Patrizio P, Asch RH. Congenitalabsence of vas deferens. The fertilising capacity of human epididymalsperm. N Engl J Med 1990;323:1788–9.

3. Bladou F, Grillo J, Rossi D, Noizet A, Gamerre M, Erny R, et al.Epididymal sperm aspiration in conjunction with in vitro fertilizationand embryo transfer in cases with obstructive azoospermia. Hum Re-prod 1991;6:1284–7.

4. Hirsh A, Montgomery J, Mohan P, Mills C, Bekir J, Tan SL. Fertili-zation by testicular sperm with standard IVF techniques. Lancet 1993;342:1237–8.

5. Van Steirteghem AC, Nagy Z, Joris H, Liu J, Staessen C, Smitz J, et al.High fertilization and implantation rates after intracytoplasmic sperminjection. Hum Reprod 1993;8:1061–6.

6. Schoysman R, Vanderzwalmen P, Nijs M, Segal L, Segal-Bertin G,Geerts L, et al. Pregnancy after fertilization with human testicularsperm. Lancet 1993;342:1237.

7. Craft I, Benett V, Nicholson N. Fertilizing ability of testicular sperma-tozoa. Lancet 1993;342:864.

8. Silber SJ, Nagy ZP, Liu J, Godoy H, Devroey P, Van Steirteghem AC.Conventional in vitro fertilization versus intracytoplasmic sperm injec-tion for patients requiring microsurgical sperm aspiration. Hum Reprod1994;9:1705–9.

9. Silber SJ, Van Steirteghem AC, Liu J, Nagy Z, Tournaye H, DevroeyP. High fertilization and pregnancy rate after intracytoplasmic sperminjection with spermatozoa obtained from testicular biopsy. Hum Re-prod 1995;10:148–52.

10. Cha K, Oum K, Kim H. Approaches for obtaining sperm in patientswith male factor infertility. Fertil Steril 1997;67:985–95.

11. Devroey P, Liu J, Nagy Z, Goosens A, Tournaye H, Camus M, et al.Pregnancies after testicular sperm extraction (TESE) and intracytoplas-mic sperm injection (ICSI) in non obstructive azoospermia. Hum Re-prod 1995;10:1457–60.

12. Mansour RT, Kamal A, Fahmy I, Tawab N, Serour GI, Aboulghar MA.Intracytoplasmic sperm injection in obstructive and non-obstructiveazoospermia. Hum Reprod 1997;12:1974–9.

13. Salzbrunn A, Benson D, Holstein A. A new concept for the extractionof testicular spermatozoa as a tool for assisted fertilisation (ICSI). HumReprod 1996;11:752–55.

14. Rosenlund B, Kvist U, Ploen L, Rozell BL, Sjoblom P, Hillensjo T. Acomparison between open and percutaneous needle biopsies in menwith azoospermia. Hum Reprod 1998;13:1266–71.

15. Hauser R, Botchan A, Amit A, Ben Yosef D, Gamzu R, Paz G, et al.Multiple testicular sampling in non-obstructive azoospermia—is it nec-essary? Hum Reprod 1998;13:3081–5.

16. Amer M, Haggar S, Moustafa T, Abd El-Naser T, Zohdy W. Testicularsperm extraction: impact of testicular histology on outcome, number ofbiopsies to be performed and optimal time for repetition. Hum Reprod1999;14:3030–4.

17. Schlegel PN, Palermo GD, Goldstein M, Menendez S, Zaninovic N,Veeck LL, et al. Testicular sperm extraction with intracytoplasmicsperm injection for non obstructive azoospermia. Urology 1997;49:435–44.

18. Shrivastav P, Nadkarni P, Wensvoort S, Craft I. Percutaneous epidid-ymal sperm aspiration for obstructive azoospermia. Hum Reprod 1994;9:2058–61.

19. Craft I, Tsirigotis M, Benett V, Taranissi M, Khalifa Y, Hogewind G,et al. Percutaneous epididymal sperm aspiration and intracytoplasmicsperm injection in the management of infertility due to obstructiveazoospermia. Fertil Steril 1995;63:1038–42.

20. Gorgy A, Meniru GI, Naumann N, Beski S, Bates S, Craft IL. Theefficacy of local anaesthesia for percutaneous epididymal sperm aspi-ration and testicular sperm aspiration. Hum Reprod 1998;13:646–50.

21. Madgar I, Seidman DS, Levran D, Yonish M, Augarten A, Yemini Z,et al. Micromanipulation improves in-vitro fertilisation results afterepididymal and testicular sperm aspiration in patients with congenitalabsence of the vas deferens. Hum Reprod 1999;10:2956–9.

22. Silber S. Micoepididymal sperm aspiration or percutaneous epididymalsperm aspiration? The dilemma. Hum Reprod 1996;11:681.

23. Nudell DM, Conaghan J, Pedersen RA, Givens CR, Schriock ED,Turek PJ. The mini-micro-epididymal sperm aspiration for sperm re-trieval: a study of urological outcomes. Hum Reprod 1998;13(5):1260–5.

24. Belker A, Sherins R, Dennison-Lagos L, Thorsell LP, Schulman J.Percutaneous testicular sperm aspiration: a convenient and effectiveoffice procedure to retrieve sperm for in vitro fertilisation with intra-cytoplasmic sperm injection. J Urol 1998;160:2058–62.

25. Levine L, Lisek E. Successful sperm retrieval by percutaneous epidid-ymal and testicular sperm aspiration. J Urol 1998;159:437–40.

26. Schlegel P, Su L. Physiological consequences of testicular sperm ex-traction. Hum Reprod 1997;12:1688–92.

27. Ron-El R, Strauss S, Friedler S, Strassburger D, Komarovsky D, RazielA. Serial sonography and colour flow Doppler imaging followingtesticular and epididymal sperm extraction. Hum Reprod 1988;12:3390–3.

28. Manning M, Junemann K, Alken P. Decrease in testosterone bloodconcentrations after testicular sperm extraction for intracytoplasmicsperm injection in azoospermic men. Lancet 1998;352:37.

29. Tournaye H, Clasen K, Aytoz A, Nagy Z, Van Steirteghem AC,Devroey P. Fine needle aspiration versus open biopsy for testicularsperm recovery: a controlled study in azoospermic patients with normalspermatogenesis. Hum Reprod 1998;13:901–4.

30. Girardi S, Schlegel P. MESA; review of techniques, preoperative con-siderations and results. J Androl 1996;17:5–9.

31. Huskisson E. Measurement of pain. Lancet 1974;2:1127–31.32. Fahmy I, Mansour R, Aboulghar M, Serour G, Kamal A, Tawab NA, et

al. Intracytoplasmic sperm injection using surgically retrieved epidid-ymal and testicular sperm in cases of obstructive and non obstructiveazoospermia. Int J Androl 1997;1:37–44.

33. Ezeh U, Shepherd S, Moore H, Cooke I. Morbidity and cost effective-ness analysis of outpatient analgesia versus general anaesthesia fortesticular sperm extraction in men with azoospermia due to defects inspermatogenesis. Hum Reprod 1999;14:321–8.

34. Tournaye H. Surgical sperm recovery for intracytoplasmic sperm in-jection: which method is to be preferred? Hum Reprod 1999;14:71–81.

35. Mallidis C, Baker H. Fine needle tissue aspiration biopsy of the testes.Fertil Steril 1994;61:367–75.

36. Craft I, Tsirigotis M, Courtauld E, Farrer-Brown G. Testicular needleaspiration as an alternative to biopsy for the assessment of spermato-genesis. Hum Reprod 1997;12:1483–7.

37. Ezeh U, St John J, Barratt C. A prospective study of needle biopsyversus open testicular biopsy for testicular sperm extraction in thosewith non-obstructive azoospermia. Br J Obstet Gynaecol 1996;104:632–4.

38. Friedler S, Raziel A, Strassburger D, Soffer Y, Komarovsky D, Ron-ElR. Testicular sperm retrieval by percutaneous fine needle sperm aspi-ration compared with testicular sperm extraction by open biopsy in menwith non-obstructive azoospermia. Hum Reprod 1997;12:1488–93.

39. Schlegel P, Palermo GD, Goldstein M, Menendez S, Zaninvic N, VeeckL, et al. Testicular sperm extraction with intracytoplasmic sperm injec-tion for non obstructive azoospermia. Urology 1997;49:435–40.


40. Tournaye H, Verhayen G, Nagy P, Ubaldi F, Goosens A, Silber S, et al.Are there any predictive factors for successful testicular sperm recoveryin azoospermic patients? Hum Reprod 1997;12:80–6.

41. Tournaye H, Liu J, Nagy Z, Camus M, Goosens A, Silber S, et al.Correlation between testicular histology and outcome after intracyto-plasmic sperm injection using testicular sperm. Hum Reprod 1996;11:127–32.

42. Silber SJ, Nagy Z, Devroey P, Tournaye H, Van Steirteghem AC.Distribution of spermatogenesis in the testicles of azoospermic men: thepresence or absence of spermatids in the testes of men with germinalfailure. Hum Reprod 1997;12:2422–8.

43. Pavlovich C, Schlegel P. Fertility options after vasectomy: a costbenefit analysis. Fertil Steril 1997;67:133–41.

44. Heidenreich A, Altmann P, Engelmann U. Microsurgical vasovasos-tomy versus microsurgical epididymal sperm aspiration/testicular ex-traction of sperm combined with intracytoplasmic sperm injection: acost benefit analysis. Eur Urol 2000;37:609–14.

45. Deck A, Berger R. Should vasectomy reversal be performed in menwith older female partners? J Urol 2000;163:105–6.

46. Donovan JF, Jr, DiBaise M, Sparks AE, Kessler J, Sandlow JI. Com-parison of microscopic epididymal sperm aspiration and intracytoplas-mic sperm injection/in vitro fertilization with repeat microscopic re-construction following vasectomy. Is second attempt vas reversal worththe effort? Hum Reprod 1998;13:387–93.

47. Sharlip I. What is the best pregnancy rate that may be expected fromvasectomy reversal? J Urol 1993;149:1469–71.


postoperative pain, complications, and satisfaction rates in patients who undergo surgical sperm...

Documents