What are the different modalities of sperm aspiration /extraction? Which method is cheap & lest painful??

Part B) based on collection / retrieval of sperm there several technologies and most popular and safe is PESA.  What is then PESA?? . the method of collection of spermatozoa. Varies as per suitability of the case i.e.  depending on the method of collection of spermatozoa

It implies almost mature eggs are aspirated and kept in suitable media. Sperms are extracted from a) epididymis-PESA-(percutaneous epididymal sperm aspiration and not sperm extraction) --> fast, low cost only for obstructive azoospermia   2) ) MESA:-à Microsurgical Epididymal  sperm aspiration(not extraction)  only for obstructive azoospermia 3)  TESA/  TEFNA à (testicular sperm extraction)à–mostly done in case PESA or MESA fails to retrieve sperms, technically challenging , TEFNA is a technically variant of TESA.4) TESE(. Testicular sperm extraction) ,   single biopsy or multiple biopsiesà only when failed TESA or PESA but indicated  in both NOA or OA as well. 5) Micro TESE )( Micro surgical Testicular sperm extraction.) Sperm retrieval for ICSI procedure is per­formed in four different ways: (i) PESA—per- epididymal sperm aspiration, (ii) TESE or TESA—testicular sperm extraction or testicular sperm aspiration, (iii) micro dissection TESE— similar to TESE but using an operative micro­scope to identify the seminiferous tubules and avoiding vascular damage and (iv) testicular biopsy—seldom performed nowadays.

Procedures 1 and 2 can be performed under local Xylocaine infiltration of the scrotal skin. But microsurgical dissection and testicular biopsy requires general anesthesia. For PESA, the distended epididymis is identified

Part C) The indications of ICSI principle ?? When thinks modality is implanted or advised?? There are about 12 indications. Methodology of ICSI implies almost like traditional ART .indications may be classified A) all Obst azoospermia

B) unexplained infertility)  repeated fertilisation failure, D) azoospermic husband in testicular cause  E) Oligospermia (< 5,00,000) with normal motility and morphology) F)  Asthenozoospermia (even in Kartageners syndrome—100% immotile spermatozoa) provided HOST ( caution àhypo- osmotic swelling test is satisfactory G) Teratozoospermia (when at least 4% sperms have normal morphology— Kruger's 'strict criteria'),,H) Repeated fertilisation failure in con­ventional IVF I) High level of ASA in seminal plasma J) Ejaculatory disorders, e.g. retrograde ejaculation (sperm recovered from post masturbated or postcoital urine sample is poor for IUI  K) Globozoospermia—but even with testicular sperms  pregnancy has been reported, but the chances of fertilisation are less. Germ cell aplasia (Sertoli-cell-only syndrome)—even in these individuals sperm may be available after multiple biopsy.3% cancellation rate is associated with absence of cumulus-corona-oocyte. Chromosomal abnormalities are more frequent in individuals with oligo- or oligoasthenozoospermia. So trans­mission of chromosomal abnormalities in the offspring is much higher following ICSI. ROSNI or round spermatid nuclei injection is preferable than aged or dysfunctional sperm, but miscarriage rate is more following ROSNI. The first step is denudation.

 Except for immature oocyte, denudation can be performed between 0 and 4 hours. It does not make any difference in fertilisation rate. The denudation should be performed by combination of enzymatic and mechanical procedures. Enzyme used is hyaluronidase. The concentration and duration of exposure of the oocyte to the enzyme are crucial for success of fertilisation. Unless this limitation is followed, it may lead to parthenogenetic activation of the oocyte. Advancing technology for identification of abnormal sperms has been introduced using higher magnification.

 What is IMSI?? Ans; In cases of compromise seminal paramours many sperms may exhibit poor morphology. If such sperm is accidentally injected in oolemma than there will be either fertilization failure/ failure of embryo  to grower properly,(pot embryonic competency),Sperm with big vacuole (> 0.8 p) or more than one small vacuole in the nucleus which is usually associated with abnormal DNA should not be selected during injection—this procedure is possible under high magnification (6,000-8,000) and the procedure is known as intra­cytoplasmic morphologically selected sperm injection (IMSI).  After denudation has been completed the oocyte should be examined under microscope for the following parameters: (i) Zona integrity, (ii) oocyte cytoplasm granularity, (iii) germinal vesicles (nucleus) and (iv) presence of first polar body in the perivitelline space. Absence of germinal vesicles and the presence of first polar body, with 'sun-burst' appearance of cumulus cell around zona indicate the classical characteristics of mature oocyte.

Following retrieval, 95% of cumulus- corona complex contains an intact oocyte For TESE, testicular sperm extraction needles are used which are larger than injection pipette (outer diameter 8-10 pm instead of 6-7 pm). Sometimes with a wide bore needle (as used in FNAC) the entire seminiferous tubule can be aspirated (Figs 15.6a and b). If the above two methods fail, surgical biopsy (multiple biopsy) may be necessary. This is seldom essential nowa­days. On the other hand, currently micro dissection TESE is being advocated. This allows exact identification of the location of the seminiferous tubule and at the same time prevents unnecessary vascular damage and risk of future fibrosis. This is necessary because in case the first attempt fails, future attempt to recover spermatozoa by TESE may be difficult.

and using a butterfly needle (Fig. 15.5) (used for pediatric IV infusion) the epididymal fluid is aspirated and immediately examined under microscope to examine the presence of spermatozoa. Testicular tissues thus obtained are minced in small volume of media into small pieces with two needles or sterile microscopic slides on the heated stage of a microscope. Mincing is to be continued till no single seminiferous tubule (Fig. 15.7) remains intact. Homogenized solution is to be checked under the inverted microscope to confirm the presence of spermatozoa. This determines if further attempt of aspiration is necessary or not.