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PESA
PESA (percutaneous epididymal sperm aspiration) is a surgical intervention applied to men with azoospermia and ejaculation disorders, where the epididymis are aspirated with a needle in order to obtain spermatozoa that will later be used for in vitro fertilization.
Aspiration of the epididymis can also be done under the control of an operating microscope and is then called an intervention MESA (microepididymal sperm aspiration). In this case, an incision is made on the skin, and under the control of a microscope, the contents are aspirated from the epididymis.
The epididymis is an elongated, thin, winding canal about 6-7 cm long that connects the testicle to the vas deferens, which further allow spermatozoa to exit the testicle.
In the epididymis, spermatozoa mature and accumulate before ejaculation. It takes 2-11 days for spermatozoa to pass through the epididymis.
For the success of PESA, in addition to the surgical part, the work of the embryologist on finding and possibly freezing the spermatozoa, as well as subsequent fertilization by the ICSI method, is very important of the in vitro fertilization (IVF) process.
Before PESA, it is necessary to perform the following analyses:
- hormones FSH, LH, T, thyrostimulating hormone (TSH), prolactin;
- genetic analyses: karyotype and Y chromosome deletions (AZF a, AZF b, AZF c). (An examination of the female partner is also required before making a decision on performing PESA)
- The patient fills out a detailed questionnaire about his state of health.
- PESA can be performed under local or general anesthesia. It is often done under local anesthesia.
- When the work is done under general anesthesia, anestesiologist performs clinical evaluation and blood tests are done. If there is a disease or risk factor, it is necessary to perform additional analyses and an examination by a doctor of another specialty, most often an internist.
- The patient receives an antiseptic shampoo in the clinic, which he will use to shower the night before and the morning before the intervention.
- 6-8 hours before PESA, the patient stops taking food and liquids. If the patient uses aspirin or other anti-clotting drugs, it is necessary to stop the therapy 7 days before the operation.
- Upon arrival, the patient goes to the patient room where he is prepared to enter the operating room. A needle is inserted into the vein so that the patient can receive the necessary medication.
- PESA is performed on the operating table. The patient receives an intravenous antibiotic immediately before surgery.
- The surgical field is treated with an antiseptic agent containing iodine or chlorine.
- After receiving local or general anesthesia, the epididymis is presented, that is, the part called the head of the epididymis, and a liquid is extracted with a thin needle, which is immediately given to the embryologists to continue work on the isolation of spermatozoa from the obtained samples.
- If embryologists can immediately isolate spermatozoa that are in sufficient numbers for in vitro fertilization procedures, the intervention is done only on one side.
- When no spermatozoa are found after aspiration of both epididymis, the intervention is most often continued with a testicular biopsy, that is testicular sperm aspiration (TESA) or testicular sperm extraction (TESE). PESA lasts for 15-20 minutes.
- PESA is performed as day surgery. The patient moves from the operating room to the patient room, where he stays for 60-120 minutes, depending on the anesthesia he received. First, he gets water, and then a light meal.
- Pain is treated with painkillers, most often paracetamol, ibuprofen and diclofenac. Discomfort is felt more than pain.
- The patient is not advised to drive a car on the day of the intervention.
- Showering is allowed on the same day after the intervention, but sitting in the bathtub is not allowed.
- The patient can return to normal activities 1-2 days after the operation, depending on the work he performs.
Information about the result, that is, whether spermatozoa were found, the patient gets immediately after the intervention. The obtained spermatozoa are used immediately for in vitro fertilization. There are usually not enough spermatozoa to freeze when doing PESA.
Expert advice: frequently asked questions
Answers by: Milan Milenković MD, PhD
When can't PESA be done?
There are no conditions when PESA cannot be done. Considering that PESA is a simple intervention, it can be repeated several times, even if no spermatozoa were found during the previous intervention.
What are the complications of the PESA procedure?
The risk of infection and bleeding after the procedure is low, but not completely excluded.
What is the preparation for PESA?
Before PESA, it is necessary to perform the following analyses (analyses that are always performed when testing for azoospermia):
- hormones FSH, LH, T, TSH, prolactin;
- genetic analysis: karyotype and Y chromosome deletions (AZF a, AZF b, AZF c). It is also necessary to examine the female partner before deciding on performing PESA.
How successful is PESA?
In about 80%-90% of patients with obstructive azoospermia and erectile disorders, spermatozoa are isolated during the PESA intervention. For the success of micro PESA, in addition to the surgical part, the work of the embryologist on finding and possibly freezing the spermatozoa, as well as later fertilization with the ICSI method during the in vitro fertilization (IVF) process, is very important.
Is PESA a painful intervention?
When PESA is performed under local anesthesia, the patient may have an unpleasant feeling, feeling that something is being done, but not feeling pain. The patient also receives an intravenous pain reliever.
If PESA is performed under general anesthesia, the patient does not feel pain and discomfort during the intervention.
After PESA, mild pain may occur, which stops a few hours after the intervention. Pain after PESA responds well to paracetamol, ibuprofen and diclofenac.
Can PESA be repeated?
PESA can be performed multiple times regardless of whether spermatozoa were found during the previous intervention.
When can in vitro fertilization (IVF) be done after PESA?
"Live" spermatozoa are used (which is the most common case), egg cells aspiration is done on the same day as PESA.
Given that the percentage of success of the PESA method is 80-90 %, the intervention is often planned on the day of aspiration of egg cells, so that it is done with "fresh" spermatozoa.
The intervention is planned on the same day because there are rarely enough spermatozoa to freeze after PESA. If the spermatozoa isolated during PESA are frozen, stimulation of the female partner for IVF can be started after the first menstrual cycle or later in agreement with the couple.
What is the cost of the PESA operation?
For all the prices of examinations and interventions in the Milenković Clinic, see our price list which is updated regularly.
Is it better to do in vitro fertilization (IVF) with frozen or "fresh" spermatozoa?
The percentage of pregnancies after IVF is similar when using frozen and "fresh" spermatozoa. The advantage of IVF with frozen spermatozoa is that there is no hormonal stimulation of the female partner unless the spermatozoa are isolated. If the woman already has frozen egg cells, IVF is done with "fresh" spermatozoa, and spermatozoa that are not used are frozen.
Given that the percentage of success of the PESA method is very high, intervention is often planned on the day of egg aspiration so that it is done with "fresh" spermatozoa.
When can I shower after PESA?
You can shower the same day after PESA. Since PESA is performed with a thin needle and there is no incision, bathing and swimming do not increase the risk of infection.
When can I train after PESA?
You can start training when you feel that you can train. It is most common 1-2 days after PESA.
When can I have sex after PESA?
You can have sexual intercourses when you feel you can. It is most often 1-2 days after the intervention.
When is the first control after PESA?
Post-PESA control is not required. If the patient has discomforts, the control is scheduled as necessary. The patient is advised to contact the office first for everything related to the intervention at 069 50 22222 or info@drmilenkovic.com
In which acute situations should the Clinic be contacted?
In case of pain, high fever, swelling that increases and has a blue color, you should call 069 50 22222, send a or send a message to info@drmilenkovic.com
What medicines should be taken in case of pain after PESA?
After PESA, the discomfort most often occurs in the area of the testicles. The pain is usually felt up to a few hours after the intervention. Pain after PESA is treated with analgesics and non-steroidal anti-inflammatory drugs in doses and combinations that we will recommend to you after the procedure, depending on the intensity of the pain and your individual sensitivity.
Do hormone therapy and supplements increase the success of the PESA method?
There is no therapy before PESA that can increase the success of the intervention. Since PESA is performed in patients with blockage in extracting canals there are no drugs or supplements that can improve its success. Ejaculation disorder is primarily treated by a urologist, but if there are no spermatozoa in the ejaculate even after treatment, aspiration of the epididymis is performed, that is, PESA.
When can PESA be repeated?
PESA can be done as needed. There is no waiting period between two PESA interventions.
How long does PESA last?
PESA lasts for 15-20 minutes.
What is the difference between PESA and MESA?
The main difference between PESA (percutaneous epididymal sperm aspiration) and MESA (microepididymal sperm aspiration) methods lies in the technical approach and precision of the procedure.
PESA is a less invasive method where spermatozoa are aspirated directly from the epididymis using a thin needle, without the need for a surgical incision. This procedure is usually performed on an outpatient basis, under local anesthesia.
MESA, on the other hand, is a more detailed and invasive procedure that requires an operating microscope. During the MESA intervention, a small incision is made on the skin in order to enable direct visual access to the epididymis, thus enabling more precise aspiration of sperm, especially in cases when it is necessary to select especially mature spermatozoa. MESA is often used when PESA is not available or effective and is usually performed under general anesthesia.
