Congenital bilateral absence of vas deferens (CBAVD)is diagnosed in 1.3 % of the men referred
for infertility evaluation. Moreover, CBAVD accounts for 27% of the men with primary obstructive
azzospermia. An almost equal number of men with other causes of surgically unreconstrucatable
obstructuctive azoospermia are referred for evaluation.
In the past decade, the techniques of epididymal sperm retrieval and micromanipulation to assist
fertilization have been two of the most exciting developments in the field of male infertility
treatment. Men with congenital bilateral absence of the vas defences (CBAVD), or acquired
reproductive tract obstruction are now able to achieve pregnancies with use of these advanced
techniques. We have found that microsurgical epididymal sperm aspiration (MESA) using a glass
micropipet technique simultaneous to intracytoplasmic sperm injection (ICSI) appears to
maximize opportunities of pregnancy for these infertile couples with unreconstructable male
reproductive tract obstruction. MESA from individual epididymal tubules with a micropuncture
technique allows retrieval of high numbers of sperm with optimal quality for immediate use during
ICSI as well as for cryopreservation. A unique micropuncture pipet holding apparatus, MESA-
Holder has been developed at Cornell. Its unique 180É angle adjustable pipet holding system
simplifies the procedure of micropuncture epididymal sperm retrieval. The micropuncture
technique is an atraumatic technique that limits damage to the epididymal tubules and avoids
potential blood cell contamination of the epididymal fluid, while yielding high quantities of motile
spermatozoa.
Experience with the last 59 couples with obstructive azoospermia who selected to undergo
MESA-ICSI at Cornell from April, 1995 to June, 1996 is presented. Sperm was retrieved from the
epididymis in 59/59 (100%) attempts, despite multiple aliquots of previous unsuccessful sperm
retrieval attempts at other institutions. In all 59 cases motile sperm were cryopreserved as well.
Clinical pregnancies were achieved in 80%( 47/59) cycles for these couples. Ongoing
pregnancies or deliveries have occurred for in 68% (40/59) cycles of simultaneous MESA-ICSI. .
Simultaneous MESA-ICSI appears to provide optimal pregnancy and delivery rates for couples
where the man has unreconstructable reproductive tract obstruction.
