Editing Infertility: Management (section)

===Surgical Sperm Extraction===
*Fresh, unfixed tissue is examined for the presence of sperm with tails and possible motility; if sperm are not found initially, examination of multiple samples is recommended.
** Optimal care requires the availability, at the time of extraction, of an andrology laboratory capable of processing and cryopreserving any sperm found at the time of biopsy
====Indications ====
*'''Azoospermia (obstructive or non-obstructive)'''
*'''Ejaculatory dysfunction'''
==== Options====
=====Epididymal sperm retrieval=====
*'''<span style="color:#ff0000">Techniques (2):'''
*#'''<span style="color:#ff0000">Microsurgical Epididymal Sperm Aspiration (MESA)'''
*#'''<span style="color:#ff0000">Percutaneous Epididymal Sperm Aspiration (PESA)'''
=====Testicular sperm retrieval=====
*'''<span style="color:#ff0000">Techniques (3):'''
*#'''<span style="color:#ff0000">Open Testicular Sperm Extraction (TESE)'''
*#*Allows retrieval of the largest number of sperm with potential for cryopreservation
*#*'''Remains the gold standard'''
*#*Involves wide opening of the tunica albuginea to allow examination of multiple regions of testicular tissue, each of which are oriented in a centrifugal pattern in parallel to the intratesticular blood supply, allowing extensive search of nearly all areas of the testis with limited risk of devascularization of tissue.[https://pubmed.ncbi.nlm.nih.gov/33295257/]
*#**'''<span style="color:#ff0000">Preferably done with an operating microscope (micro-TESE)'''
*#***Conventional TESE has been associated with decreased postoperative testosterone levels, and males men with non-obstructive azoospermia have baseline testosterone deficiency levels.
*#***Less effect on testosterone levels is seen after micro-TESE than with conventional TESE, but testosterone deficiency requiring testosterone replacement remains a risk, even after micro-TESE.
*#*Contraindications
*#**Sertoli-only cell syndrome
*#**Spermatogenic arrest
*#*Adverse events
*#** Decreased postoperative testosterone levels
*#'''<span style="color:#ff0000">Percutaneous core biopsy'''
*#*Uses the same 14-gauge biopsy gun used for prostate biopsy
*#*'''A blind procedure that could result in unintentional injury to either the epididymis or the testicular artery'''
*#*'''The midsection of the testis has relatively fewer vessels compared with superior or inferior areas'''
*#*'''Should not be used when previous surgery has resulted in scarring and obliteration of normal anatomy'''
*#'''<span style="color:#ff0000">Percutaneous aspiration (testicular sperm aspiration [TESA])'''
*#*Done with a high-suction glass syringe and a 23-gauge needle or angiocath sheath
*#*'''Least invasive and least painful procedure but usually yields few tubules with poorly preserved architecture and often requires 10 to 20 passes to obtain an adequate yield'''
* '''Adverse Events'''
**'''Most common complication is hematoma'''
====Approach====
*'''<span style="color:#ff0000">If azoospermia'''
**'''<span style="color:#ff0000">Due to obstruction, sperm may be extracted from either the testis or the epididymis.[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
*** Fertilization, pregnancy, and live birth rates similar for epididymal and testicular derived sperm in men with azoospermia due to obstruction
**'''<span style="color:#ff0000">Without obstruction (non-obstructive azoospermia), microdissection testicular sperm extraction (TESE) should be performed.</span>[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
**#Micro-TESE was observed to result in successful extraction 1.5 times more often than non-microsurgical testis sperm extraction