0022-5347/97/1584-1524$03.0010 THE JorRYAL OF UROIDCY Copyright 0 1997 by A w E R l r m U R O m x A L ASSOCIATION, INC

Vol. 158, 1524, October 1997 Printed i n (I.S.A.

PERCUTANEOUS SPERM ASPIRATION OF A SPERMATOCELE FOR INTRACYTOPLASMIC SPERM INJECTION

PHILIP WERTHMAN, MINDA HAMILTON, LISA YES, DAVID MELDRUM AND JACOB RAJFER From the Departments of Urology and Obstetrics and Gynecology, UCLA Schwl of Medicine, Harbor-UCLA Medical Center. Torrance,

Ca 1 i forn ia

KEY WORDS: spermatocele; infertility, male

Recent advances in assisted reproduction have led to successful pregnancies and deliveries despite obstructed azoospermia using sperm from the testis andor epididymis. Microscopic epididymal sperm aspiration (MESA) is a tech- nique that has been widely used to retrieve sperm from the epididymis, but it requires open surgery on the epididymis.' Percutaneous aspiration of sperm from the testis or epididy- mis is another technique that is used in combination with intracytoplasmic sperm injection (ICSI) to obtain the few gametes necessary for fertilization.2.3

A naturally occurring spermatocele would be another po- tential source of sperm that could be used for single or re- peated aspirations in assisted reproduction procedures. We describe a case of an azoospermic man with a spermatocele who underwent such an aspiration in combination with ICSI.

CASE REPORT

J. J., a 50-year-old man, presented 3 years ago with the complaint of infertility. At that time, he was found to be severely oligospermic. Bilateral testicular biopsies demon- strated spermatogenesis present in the left testis but atrophy (without spermatogenesis) of the right testis. Medical history was unremarkable, and physical examination was normal except for the atrophic right testis and an approximate 5 cc spermatocele in the left hemiscrotum. The left testis was of normal size and consistency. The spermatocele was aspirated percutaneously and found to contain many weakly motile sperm. A semen analysis was fructose-positive and revealed a volume of 2.1 ml. with a sperm density of 1.3 X 106/ml., 34% normal forms and 1% motility. A transrectal ultrasound ex- amination showed no ejaculatory duct obstruction. At explo- ration, a left vasogram revealed a patent vas deferens. No sperm were found in the left vasal fluid. A large left sper- matocele was noted and was left untouched. An epididymal tubule on the caput but inferior to the spermatocele was incised, and the fluid revealed whole, nonmotile sperm. A microsurgical end-to-side vasoepididymostomy was per- formed. During the first year postoperatively, the semen parameters revealed azoospermia. The option of epididymal sperm aspiration and ICSI was pursued by the couple, and sperm from the spermatocele was used for the ICSI procedure. On the day of oocyte retrieval, about 5 ml. of fluid were aspirated percutaneously from the spermatocele in the left hemiscrotum. Eight million sperm with 12% motility were obtained and prepared by Percoll density centrifuga- tion.

The 36-year-old wife, gravida 0, was stimulated with 3 ampules per day of urofollitropin following a mid-luteal sup- pression with leuprolide acetate. All 21 oocytes were meta- phase 11. Following ICSI, 13 oocytes were fertilized, l of

Accepted for publication February 28, 1997.

which had 3 pronuclei. Four embryos were transferred, and 5 were frozen at the 5 to 8-cell stage. A single 16-week preg- nancy is progressing.

DISCUSSION

ICSI offers hope to the patient with obstructive azoosper- mia who has failed microsurgical reconstruction. The combi- nation of ICSI and the use of epididymal sperm maximizes the chance for pregnancy with ongoing pregnancies and de- liveries reported in up to 48%, per oocyte r e t r i e ~ a l . ~ MESA has been the standard technique for sperm retrieval, but with the decreased sperm requirement of ICSI, percutaneous epididymal sperm aspiration can give satisfactory yields. Percutaneous aspiration is advantageous because it is quick, easy to perform, can be done in the clinic under local anes- thesia, is inexpensive and does not require an incision. The only potential risks are hematoma formation and a n iatro- genic injury of the epididymal tubules from a needle injury. MESA or percutaneous aspiration of testicular sperm can be reserved for failure of adequate epididymal sperm retrieval by percutaneous means.

A naturally occurring spermatocele, although rare in the male factor patient, is an ideal target for placement of the as- piration needle. Its presence in such a patient provides the urologist with an easily accessible reservoir of sperm for any assisted reproduction technique. There has been a single case report of aspiration of a spermatocele and sperm injection into the perivitalline space resulting in pregnancy and deliv- ery.: To our knowledge, this is the first report of use of sperm aspirated from a naturally occurring spermatocele in con- junction with ICSI to achieve pregnancy.

REFERENCES

1. Silber, S. J., Balmaceda, J., Borrero, C., Ord, T. and Asch, R.: Pregnancy with sperm aspiration from the proximal head of the epididymis: a new treatment for congenital absence of the vas deferens. Fertil. Steril. 5 0 525, 1988.

2. Shrivastav, P., Nadkarni, P., Wensvoort, S. and Craft, I.: Percu- taneous epididymal sperm aspiration for obstructive azoosper- mia. Hum. Reprod., 9 2058, 1994.

3. Bourne, H., Watkins, W., Speirs, A. and Baker, H. W.: Pregnan- cies after intracytoplasmic injection of sperm collected by fine needle biopsy of the testis. Fertil. Steril. 64. 433, 1995.

4. Schlegel, P. N., Palmero, G. D., Alikani, M., Adler, A,, Reing, A. M., Cohen, J. and Rosenwaks, 2.: Micropuncture retrieval of epididymal sperm with in vitro fertilization: importance of in vitro micromanipulation techniques. Urology 46: 238, 1995.

5. Wittemer, C., Arbogast, E., Moreau, L., Ohl, J., Fegen, B., Plumere, C . and Dellenbach, P.: Pregnancy by micromanipu- lation in a case of excretory azoospermia associated with a natural spermatocele. J. Gynec. Obst. Biol. Reprod., 2 2 467, 1994.

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