Ultrasound-Guided Testicular SpermAspiration in Azoospermic Patients: A NewSperm Retrieval Method for IntracytoplasmicSperm Injection

Alexander Belenky, MD, PhD,1 Ory M. Avrech, MD,2 Gil Nissim Bachar, MD,1 Zvi Zuckerman, MD,2

Zion Ben Rafael, MD,2 Benjamin Fisch, MD, PhD,2 Maya Cohen, MD1

1 Department of Radiology, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49100, Israel, and SacklerFaculty of Medicine, Tel Aviv University, Tel Aviv, Israel2 Infertility and IVF Unit, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49100, Israel, and SacklerFaculty of Medicine, Tel Aviv University, Tel Aviv, Israel

Received 30 August 2000; accepted 8 March 2001

ABSTRACT: Purpose. We investigated the techniqueof ultrasound-guided testicular sperm aspiration(USTSA) and compared it with “blind” testicularsperm aspiration (TSA) in patients with nonobstruc-tive azoospermia.

Methods. Thirty-nine consecutive azoospermicmen underwent TSA, 16 under sonographic guidance(USTSA group) and 23 with no imaging guidance(TSA group). Clinical and hormonal evaluation and so-nography of the scrotum and testes were performed1–2 days before the procedure. The aspiration wasdone using short-term general anesthesia. Follow-upconsisted of sonographic reexamination of the scro-tum and testes immediately and 1 month after theprocedure.

Results. Intraoperative sonography with powerDoppler imaging enabled good visualization of thetesticular parenchyma, easy sampling, and avoidanceof prominent vessels. Sufficient material was re-trieved in 15 USTSA patients (94%) and 19 TSA pa-tients (83%). No patients needed more than 4 hours’ambulatory hospitalization after the procedure. In theremaining 5 patients, aspiration failed to yield sperm,so open biopsy was performed. In those patients,postaspiration surgical exploration revealed subtuni-cal bleeding in 3 patients after TSA but none afterUSTSA. Late minor complications occurred in 2 pa-

tients (13%) in the USTSA group and 7 (30%) in theTSA group. No difference was found between the 2groups in pregnancy rate in the patients’ female part-ners.

Conclusions. USTSA is a safe and accurate methodfor sperm retrieval in azoospermic patients. © 2001John Wiley & Sons, Inc. J Clin Ultrasound 29:339–343,2001.

Keywords: testis; interventional radiology; ultrasono-graphic guidance; intraoperative ultrasonography;power Doppler ultrasonography

Testicular sperm retrieval for intracytoplasmicsperm injection (ICSI) can be achieved via

open testicular biopsy or percutaneous needle as-piration.1 Both methods are used in cases of ob-structive and nonobstructive azoospermia.2–6

However, “blind” needle aspiration is associatedwith limited sampling accuracy and safety, whichplaces patients at risk for testicular bleeding andlaceration and may result in low sperm yield.

Real-time sonography is an ideal guidancetechnique for percutaneous needle biopsy andshould enhance both the accuracy and the safetyof testicular needle aspiration biopsy for spermretrieval, especially with the use of color (power)Doppler imaging, which should permit the avoid-ance of major vessels during sampling.7,8 The aimof this study was to determine the feasibility ofultrasound-guided testicular sperm aspiration

Correspondence to: A. BelenkyPresented at the Radiological Society of North America 84thScientific Assembly, Chicago, Illinois, 29 November–4 Decem-ber 1998

© 2001 John Wiley & Sons, Inc.

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(USTSA) and to compare it with blind testicularsperm aspiration (TSA).

PATIENTS AND METHODS

Between September 1997 and June 1999, 39 con-secutive men with azoospermia, 27–41 years old(mean, 33 years), underwent percutaneous tes-ticular sperm aspiration, 16 with ultrasoundguidance (USTSA) and 23 without ultrasoundguidance (TSA). The patients were randomly al-located to these 2 groups according to the finaldigit in their patient identification numbers. Thestudy protocol was approved by our institution’sreview board, and all patients provided writteninformed consent before the procedure was under-taken.

In all patients, azoospermia was documentedby analysis after high-speed centrifugation of atleast 3 semen samples obtained at 2-month inter-vals. The preaspiration evaluation, performed 2days before the procedure, consisted of a hormoneprofile (serum levels of follicle-stimulating hor-mone, luteinizing hormone, prolactin, and testos-terone); a genetic study (analysis of karyotypeand Y chromosome microdeletion status); trans-rectal sonography to exclude any distal obstruc-tion such as prostate enlargement and to verifythe status of seminal vesicles; and real-time scro-tal sonography. Ultrasound studies were per-formed with an ATL 3000 ultrasound scanner(Advanced Technology Laboratories, Bothell, WA)and a 5–10-MHz broadband linear-array trans-ducer. The scanner’s settings were adjusted foroptimal visualization of blood flow.

All aspiration procedures were performed 1 or2 days before the patients’ female partners under-went oocyte retrieval for ICSI. The aspirationtechnique was performed using short-term gen-eral anesthesia in both the USTSA and TSAgroups. We preferred this method because if nosperm were retrieved via aspiration, an open bi-

opsy with excision of a small wedge of the testiscould be performed immediately. The sperm re-trieval protocol9–11 in the TSA group included 3passes, 1 each in the upper, middle, and lowerthirds of each testis, with a 21-g butterfly needleand tubing connected to a 20-ml syringe placed ina syringe holder designed to facilitate manual as-piration (B. Braun, Melsungen, Germany) (Figure1). The needle was inserted into the testis and,after negative pressure was created, was movedslowly back and forth 4 or 5 times in differentdirections within the sampled volume. Before theneedle was completely withdrawn, the negativepressure was slowly released.

In the USTSA group, the 21-g butterfly needlewas directed into the testicular regions to besampled under real-time gray-scale and powerDoppler sonographic guidance, avoiding the echo-genic mediastinum testis and the vascular plexusof the tunica albuginea as well as the prominenttesticular parenchymal vessels (Figure 2). Thesperm samples were aspirated by connecting theneedle to the same syringe apparatus and follow-ing the same technique used in the TSA group.

Before each procedure was terminated, a labo-ratory technologist examined the aspirate micro-scopically to ensure that at least 10 motile spermcould be identified. If no motile sperm could befound, aspiration was performed in the contralat-eral testis. If insufficient motile sperm were foundin the aspirate from the contralateral testis, thepatient underwent open biopsy. Immediately af-ter aspiration, all patients underwent scrotal so-nography to evaluate early complications.

One month after the aspiration procedure, thepatients underwent gray-scale scrotal sonogra-phy and power Doppler imaging for detection oflate complications, such as a hematoma, definedas hyperechoic fluid around the testis or in theparenchyma in the area where the needle had

FIGURE 1. Apparatus used for testicular sperm aspiration. Aspiration is performed with a 21-g butterfly needleconnected by a short piece of tubing to a 20-ml syringe that is activated by a manual pistol-grip device.

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been inserted, or a laceration, defined as a hy-poechoic avascular stripe in the parenchyma ofthe testis.

Because our groups were too small to permitmeaningful statistical analysis, we calculated onlythe percentages of complications and the preg-nancy rate.

RESULTS

The intraoperative sonographic examination en-abled good visualization of the testicular paren-chyma and mapping of its vascularization, allow-ing avoidance of prominent vessels. Sufficientmaterial was retrieved in 15 patients (94%) in theUSTSA group and 19 (83%) in the TSA group. In5 patients, 1 (6%) from the USTSA group and 4(17%) from the TSA group, aspiration failed toyield any sperm, so open biopsy was performed.Postaspiration open biopsy revealed no cases ofsubtunical bleeding as a result of the needleaspiration in the USTSA group and minimalbleeding in 3 patients from the TSA group. Thefindings of the scrotal sonography performed im-mediately after aspiration were in accord withthose of the surgical exploration in the 5 patientswho had open biopsy. None of the patients in ei-ther group needed more than 4 hours’ ambulatoryhospitalization after the sperm retrieval proce-dure. Scrotal pain was minimal.

Follow-up sonography of the testes after 1month revealed a small hematoma in 2 patients(13%) in the USTSA group and 4 hematomas

(17%) (Figure 3) and 3 sites of laceration (13%)(Figure 4) in the TSA group. Thus, the rate of latecomplications was higher in the TSA group (30%)than in the USTSA group (13%). The hematomasand lacerations were asymptomatic and were de-tected only with sonography; no treatment wasnecessary.

No difference was found between the groups inthe pregnancy rate in the patients’ female part-ners: 4 (17%) of 23 in the TSA group and 3 (19%)of 16 in the USTSA group.

DISCUSSION

In 1993, Van Steirteghem et al12 showed thatICSI could be used to achieve fertilization andpregnancy with semen samples from men whopreviously had been considered sterile (eg, thosewith extremely low sperm counts or sperm motil-ity). Recently, the combination of ICSI and micro-surgical testicular sperm aspiration or biopsyhas been very successful in the treatment of ob-structive azoospermia, with good fertilization andpregnancy rates.13,14 However, testicular spermaspiration involves a certain amount of traumaand is associated with morbidity, including pain,hematoma formation, and infection. Further-more, the formation of postoperative adhesionsand fibrosis could complicate any additional sur-gery if necessary. In this study, we evaluated the

FIGURE 2. Color Doppler sonogram of the testis. Note the relativelyavascular area (arrows), which is suitable for sperm aspiration.

FIGURE 3. Left testicular sonogram of a patient 1 month after TSA,demonstrating an echogenic hematoma (arrows) surrounding the hy-poechoic testis.

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safety and potential advantages of USTSA in pa-tients with azoospermia.

According to the study of Levine and Lisek,3

local or spermatic cord blockage alone providessufficient anesthesia for testicular sperm aspira-tion in most patients. However, we preferredshort-term general anesthesia so that open biopsyof the testis could be performed immediately ifaspiration failed to yield any sperm.

Several reports in the literature have sug-gested that more than 1 testicular specimen isneeded for a quantitative evaluation of the sper-matogenic process.9–11 Therefore, our sperm re-trieval protocol included 3 passes, 1 each in theupper, middle, and lower thirds of each testis.

Harrington et al15 reported a 7% rate of in-tratesticular bleeding at sonographic follow-up af-ter sperm aspiration. In our study, the group whounderwent blind aspiration showed a slightlyhigher incidence of minimal subtunical bleedingimmediately after aspiration than did the USTSAgroup; however, all patients were completelyasymptomatic, and no treatment was needed.

No difference was found between the 2 groups

in pregnancy rate, which was similar to the ratespublished in the literature.11,13,14

In summary, percutaneous testicular spermaspiration is the treatment of choice in cases ofmale infertility due to azoospermia. The additionof sonographic guidance contributes to the proce-dure’s safety, resulting in a lower rate of compli-cations.

REFERENCES

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2. Schroeder-Printzen I, Haidl G, Ernst E, et al.Analysis of intra-operative aspirates taken duringmicrosurgical refertilization in obstructive azo-ospermia—preliminary results. The BMFT StudyGroup for Microsurgery, Giessen. Andrologia 1996;28(suppl 1):61.

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10. Schlegel PN, Li-Ming S. Physiological consequencesof sperm extraction. Hum Reprod 1997;12:1688.

11. Belker AM, Sherins RJ, Dennison-Lagos L, et al.Percutaneous testicular sperm aspiration: a conve-nient and effective office procedure to retrievesperm for in vitro fertilization with intracytoplas-mic sperm injection. J Urol 1998;160(6 pt 1):2058.

12. Van Steirteghem AC, Nagy Z, Joris H, et al. High

FIGURE 4. Left testicular sonogram of a patient 1 month after TSA,demonstrating the hypoechoic stripe (arrow) that is consistent with alaceration.

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fertilization and implantation rates after intracy-toplasmic sperm injection. Hum Reprod 1993;8:1061.

13. Mansour R, Aboulghar M, Serour G, et al. Intracy-toplasmic sperm injection using microsurgically re-trieved epididymal and testicular sperm. FertilSteril 1996;64:644.

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