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Cost effective Office Based Loupe Magnification Microscopic Epididymal Sperm Aspiration (MESA) with Local Anesthesia only: Is it Safe and
Efficacious?

Guy J. Manetti, M.D.1, Stanton C. Honig, M.D.2.
1Yale New Haven Hospital, New Haven, CT, USA, 2The Urology Center, New Haven, CT, USA.

Background: Microscopic Epididymal Sperm Aspiration with Intracytoplasmic sperm injection (ICSI) has been utilized since 1984 in the treatment of obstructive azoospermia (OA). Since that time, less invasive options such as percutaneous sperm aspiration (PESA), testis sperm aspiration and extraction (TESA, TESE) have been described. Historically, MESA has been performed with some systemic anesthesia in an operating room setting. This procedure involves an added cost of a surgical facility and anesthesia team. The objective of the study was to report on the safety and efficacy of an office based MESA program performed under local anesthesia for treatment of OA.
Methods: A chart review was performed at one male infertility center from a single surgeon from 2003 to mid-2009. 94 in office MESA procedures were performed on 88 pts. Pts with high anxiety or anatomical abnormalities where local anesthesia could not be performed safely in office were excluded (<5% of pts). The mean pt and partner age was 42 and 35 respectively. MESA was performed on the right side in 53% and left in 47%. Etiology of OA was post vasectomy in 59.1% patients, congenital absence of the vas in 20.5%, primary epididymal obstruction 5.7%, and other in 14.7%. MESA procedures were performed prior to procedure with intentional cryopreservation in 79, and timed with the cycle in 15. All pts underwent either unilateral (n=91) or bilateral procedures (n=3).
Results: 100% of procedures were completed successfully without need for conversion to a procedure done in the operating room. Motile epididymal sperm were obtained in 80 pts and was cryopreserved for multiple ICSI cycles. 14 procedures were converted to TESE due to either non motile or borderline motility with epididymal sperm. One case needed to be repeated and timed with ICSI cycle due to non motile epididymal sperm and poor testis sperm quality. The complication rate was 6.3%, including hematocele (2), hematoma (1), hydrocele (2), cellulitis (1). 2% of pts required a subsequent procedure for resolution. Overall, the procedure was well tolerated.
Discussion: Office based, local anesthesia only, loupe magnification MESA may be performed safely with a high success rate. With the high costs of assisted reproductive technologies, this procedure allows the surgeon familiar with this technique to allow couples to have a safe, lower cost procedure with equal efficacy to a procedure requiring a surgical center and anesthesia team.


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