Therapy options

This application helps to propose an appropriate fertility therapy method and to find the most suitable clinic worldwide based on the price, duration and legislative options of the treatment in various countries.

Search Results

Nothing found. Please try searching for a different keyword.

Anejaculation treatments

Self therapy does not exist.

Cognitive behavioural therapy

It works to solve current problems and change unhelpful thinking and behavior. The name refers to behavior therapy, cognitive therapy, and therapy based upon a combination of basic behavioral and cognitive principles. Most therapists working with patients dealing with anxiety and depression use a blend of cognitive and behavioral therapy. This technique acknowledges that there may be behaviors that cannot be controlled through rational thought, but rather emerge based on prior conditioning from the environment and other external and/or internal stimuli. CBT is "problem focused" (undertaken for specific problems) and "action oriented" (therapist tries to assist the client in selecting specific strategies to help address those problems), or directive in its therapeutic approach. It is different from the more traditional, psychoanalytical approach, where therapists look for the unconscious meaning behind the behaviors and then diagnose the patient. Instead, behaviorists believe that disorders, such as depression, have to do with the relationship between a feared stimulus and an avoidance response, resulting in a conditioned fear, much like Ivan Pavlov. Cognitive therapists believed that conscious thoughts could influence a person’s behavior all on its own. Ultimately, the two theories were combined to create what is now known as cognitive behavioral therapy.


Electroejaculation is a procedure used to obtain semen samples from sexually mature men through electrical stimulation (Pic. 1). The procedure is used in the treatment of:

  • an ejaculatory dysfunction,
  • retrograde ejaculation (ejaculate instead of moving antegrade goes back into the bladder), 
  • anejaculation (absence of ejaculation), 
  • delayed ejaculation or premature ejaculation) in men.

Electroejaculation is one of the several techniques now available to harvest viable sperm for the purposes of artificial insemination or in vitro fertilization (IVF). 

Electroejaculation is most often treatment of option in patients after spinal cord injury (SCI). In those patients, Functional Electrical Stimulation (FES) is a treatment that applies small electrical charges to a muscle that has become paralysed or weakened, due to damage in brain or spinal cord. The initial goal of FES technology is to provide greater mobility to the patients after spinal cord injury.

The procedure

In humans, electroejaculation is usually carried out under a general anesthetic. An electric probe is is lubricated and inserted into the rectum adjacent to the prostate gland. The probe is activated for 1–2 seconds, referred to as a stimulus cycle. Ejaculation usually occurs after 2–3 stimulus cycles. The stimulus voltage stimulates nearby nerves, resulting in contraction of the pelvic muscles and ejaculation. 

The ejaculate is collected from the urethra and prepared for use in artificial insemination. Electroejaculation has also been used for cryoconservation (restoration using freeze). 

Penile vibratory stimulation

Penile vibratory stimulation (PVS) is a first-line method for sperm retrieval in men with spinal cord injury (SCI) and inability to ejaculate. The penile vibratory stimulator (Pic. 1) is a plier-like device that is placed around glans penis to stimulate it by vibration. PVS is thought to cause ejaculation via stimulation of the dorsal penile nerve (Pic. 2). In order to achieve ejaculation, the penile vibrator must appropriately stimulate this nerve.

A wide variety of devices can be used to perform PVS, but the most effective are devices delivering at least 2.5 mm of amplitude. 

Since it is a non-invasive method, the process can be used at home by the patient himself, with no need for medical assistance. Due to the low local tactile sensitivity, patients should be instructed towards intermittent and non-prolonged use to avoid penile damage. 

Briefly, a vibrator is applied for 2-3 minutes or until antegrade ejaculation (i. e. forward) occurs. If no ejaculation occurs, stimulation is stopped for 1-2 minutes, and then resumed. These steps are repeated for up to 10 minutes of stimulation. 

Penile vibratory stimulation should be integrated into current cognitive-behavioral sex therapy techniques to achieve maximal effectiveness and satisfaction in men who had a complete inability to achieve an orgasm during sexual relations.

Pharmacotherapy of erectile dysfunction

Pharmacotherapy of erectile dysfunction represents various medications used to treat erectile dysfunction (ED). Erectile dysfunctions represents he inability (that lasts more than 6 months) to develop or maintain an erection of the penis during sexual activity. Some men suffering from ED may return to active sex life just by treating their underlying disease, such as hypertension (high blood pressure), or with the help of certain lifestyle modifications (quitting smoking, exercising regularly etc.) and counselling. Others may need medications to successfully treat the condition. The most widely used medications for treatment of ED include: 

  • PDE5 inhibitors
  • Alprostadil injection
  • Topical alprostadil
  • Trimix
  • Testosterone replacement

PDE-5 inhibitors

Phosphodiesterase 5 inhibitors (PDE5 inhibitors, PDE5i) are the firts-line medication in the treatment of ED. They work by enhancing the effect of nitric oxide (NO) on blood vessels, causing them to dilate and subsequently increasing blood flow. This allows for the cavernous bodies in the penis to fill with blood and produce an erection. These medications only enhance the blood flow, so sexual stimulation is still needed to produce an erection. These medications include Sildenafil (sold under the brand name Viagra, Pic. 1), Tadalafil (Cialis), Vardenafil (Levitra, Staxyn) and Avanafil (Stendra). They vary in dosage and how long their effet lasts, but their mechanism of action is the same.

Alprostadil injection

Alprostadil is another name of Prostaglandin E1, a naturally-occurring bioactive molecule in the body that is also used as a medication. This drug causes blood vessels to dilate, increasing the flow of blood. Alprostadil is used in the form of self-injection (Pic. 2), which is injected into either side of the penis by the patient to produce an erection. The injectable form of alprostadil causes an erection firm enough for sexual intercourse in roughly 80% men.

Topical alprostadil

Alprostadil can be also administered in the form of urethral suppository, which is inserted into the opening of the urethra. It should produce an erection in about 10 – 30 minut after the application of the suppository. However, the urethral form is not as effective as the self-injection, causing an erection in only about 30 – 40%. Quite recently, a cream containing alprostadil has been approved for the treatment of ED in some countries. Sold under the name Vitaros, it is applied to the urethra by a preloaded delivery device. Trials have shown promising results of this cream in patients with ED.


Alprostadil can be combined with other drugs that also cause vasodilation (dilation of blood vessels), most notably phentolamine and papaverine. Depending on the specific combination, the mixture is known as Bimix (two-drug medication) or Trimix (three-drug medication). This medication is coumpounded by a pharmacy and administered via self-injection into the cavernous bodies of the penis.

Testosterone replacement

In some men, ED may be attributed to low levels of testosterone (the male sex hormone). These men may benefit from the administration of testosterone.

Pharmacotherapy of retrograde ejaculation

Pharmacotherapy of retrograde ejaculation represents various medications used to treat retrograde ejaculation. Retrograde ejaculation (RE) is defined as a substantial redirection of seminal fluid from the posterior urethra into the bladder (Pic. 1) and mainly caused by bladder neck dysfunction (Pic. 2). Men suffering from RE present with total, or sometimes partial, absence of semen, despite the sensation of an orgasm, after intercourse or masturbation. Current treatment methods are based on two different strategies. The first is pharmacologic intervention or surgical management in order to restore antegrade ejaculation by increasing bladder neck tone. The second is urinary sperm retrieval or electroejaculation; this aims to facilitate fertility by obtaining spermatozoa with invasive methods and then applying artificial reproductive technologies. 

The treatment depends on the cause. Medications may work for retrograde ejaculation but only in a few cases. Nevertheless, pharmacotherapy can be tried as a first-line treatment because it is simple, time-saving, cost-effective and non-invasive.

Currently, these medications are most commonly used:

  • tricyclic antidepressants (such as imipramine or amoxapine)
  • antihistamines (such as promethazine or diphenhydramine)
  • decongestants (such as pseudoephedrine)

These medications tighten the bladder neck muscles and prevent semen from going backwards, into the bladder. However, the medications do have many side effects and they have to be taken at least 1–2 hours prior to sexual intercourse.

Clinically, imipramine, a tricyclic antidepressant agent (TCA), is commonly used to treat RE due to a variety of causes. However, the overall success rate does not exceed 50%, and adverse effects are reported frequently.

Amoxapine, a tetracyclic antidepressant that is chemically distinct from TCAs, has been reported to result in far fewer adverse events than imipramine in patients treated for depression. Amoxapine also selectively blocks neuronal reuptake of norepinephrine and, to a lesser extent, serotonin, and thus upregulates peripheral sympathetic activity to contract the bladder neck; therefore, it also exerts actions that are potentially beneficial in the treatment of RE.

Around 40% of sufferers from retrograde ejaculation have found that use of pseudoephedrine (brands names include Sudafed) noticeably improves the quantity of ejaculate. People with erectile dysfunction and retrograde ejaculation (not uncommon in those with diabetes) are strongly advised to seek medical advice about the best 'dual' treatment methods available to them, i.e. combining pseudoephedrine or an alternative with an erectile dysfunction treatments such as sildenafil.

Psychotherapy of erectile dysfunction

It is important for men to discuss their anxiety regarding their ED with their partners. It will help them to reduce their fears while their partner will be able to help them to cope. When is necessary to assess their erectile function by qualified professionals - talk therapy may be the first treatment for men with erectile dysfunction, licensed therapist can ease sexual anxiety.
Cognitive Behavioural Therapy (CBT) or sex therapy could be helpful in treatment of psychological problems which could be contributing to erectile dysfunction. For sex the mind and body cooperation is very crucial and sometimes persistent feelings of stress and anxiety may actually lead to problems with erection. Anxiety, stress or even relationship troubles could be addressed during counselling. Also sex therapy which is focused on improving overall relationship between partners could be useful for some people. Sex therapy is aimed to overcome sex difficulties and is led by trained mental professionals or psychologists.

Surgical therapy of ejaculatory duct obstruction

Surgical therapy of ejaculatory duct obstruction comprises procedures which correct ejaculatory duct obstruction and lead to restoration of fertility.The most preferred therapy of this type of obstruction is transurethral resection of ejaculatory ducts.

Ejaculatory duct obstruction (EDO) is a congenital or acquired pathological condition which is characterized by the obstruction of one or both ejaculatory ducts. Thus, the efflux of (most constituents of) semen is not possible. It is a cause of male infertility and / or pelvic pain.

A method to treat ejaculatory duct obstruction is transurethral resection of the ejaculatory ducts (TURED). This operative procedure is relatively invasive, has some severe complications, and has led to natural pregnancies of their partners in approximately 20% of affected men.

Another, experimental approach is the recanalization of the ejaculatory ducts by transrectal or transurethral inserted balloon catheter. Though muchless invasive and preserving the anatomy of the ejaculatory ducts, this procedure is probably not completely free of complications either and success rates are unknown. There is a clinical study currently ongoing to examine the success rate of recanalization of the ejaculatory ducts by means of balloon

In case of ejaculatory duct obstruction being caused by midline prostatic (Prostatic cyst is a rare disease with uncertain origin) cyst (MPC) there are several alternatives of surgical treatment. Invasive procedures include transperineal or transrectal puncture and endoscopic section of the utricle meatu. However, puncture therapy has a high recurrence rate while endoscopic incision faces persistent post-operative severe oligozoospermia (semen with a low concentration of sperm)or azoospermia (semen contains no sperm). It is possible that MPC may cause seminal vesiculitis (inflammation of the seminal vesicles) and further promote the abnormal semen quality through oppressing ejaculatory duct and causing semen stasis. Therefore, the dilation of ejaculatory duct can be performed after transurethral unroofing of the cyst. One particular study showed pregnancy rate of 41.7% and an obviously improved semen quality of 75%.

Surgical therapy of erectile disfunction

In patients with ED, inflatable penile prosthesis (IPP) surgery is regarded as the gold standard treatment in medically refractory cases or where its conservative treatment options are contraindicated. 
There are two primary types of penile prosthesis: noninflatable, semirigid devices and inflatable devices. Noninflatable, semirigid devices consist of rodsim planted into the erection chambers of the penis and can be bent into position as needed for sexual penetration. With this type of implant the penis is always semi-rigid and therefore may be difficult to conceal.
Hydraulic, inflatable prosthesis also exist and were first described in 1973 by BrantleyScott et al. These saline-filled devices consist of inflatable cylinders placedin the erection chambers of the penis, a pump placed in the scrotum for patient-activated inflation/deflation, and a reservoir placed in the abdomen which stores the fluid. The device is inflated by squeezing the pump several times to transfer fluid from the reservoir to the chambers in the penis. After successful sexual relations, the pump can be deactivated to return the penis to a flaccid condition. Almost all implanted penile prosthesis devices perform satisfactorily for a decade or more before needing replacement.

Surgical therapy of retrograde ejaculation

Surgical therapy of retrograde ejaculation represents surgical techniques used in the treatment of retrograde ejaculation. Retrograde ejaculation (RE) is defined as a substantial redirection of seminal fluid from the posterior urethra into the bladder (Pic. 1) and mainly caused by bladder neck dysfunction. Men suffering from RE present with total or sometimes partial absence of semen, despite the sensation of an orgasm, after intercourse or masturbation.

Current treatment methods are based on two different strategies. 

  1. The first is pharmacologic intervention or surgical management in order to restore antegrade ejaculation (ejaculation in the “healthy” direction) by increasing bladder neck tone. 
  2. The second is urinary sperm retrieval or electroejaculation; this aims to facilitate fertility by obtaining spermatozoa with invasive methods and then applying artificial reproductive technologies. 

The treatment of retrograde ejaculation is based on underlying aetiology. Anatomical causes, for instance, after prostate surgery, are rarely curable, and sperm harvesting from the urine should be considered if pregnancy is desired. Surgery rarely is the first option for retrograde ejaculation and the results have proven to be inconsistent. 

Sometimes, surgical treatment has been reported to be beneficial when medical treatment has failed. It usually involves surgical reconstruction of the neck of the urinary bladder and the adjoining part of the urethra. The goal is to restore the ability of the bladder neck to tighten during ejaculation and prevent the retrograde flow of semen.


During ICSI just one sperm is injected directly into the egg cytoplasm using a micromanipulative apparatus that transforms imperfect hand movements into fine and precise movements of micromanipulation tools.

Intracytoplasmic Sperm Injection (ICSI) is an assisted reproductive technique (ART) initially developed by Dr. Gianpiero D. Palermo in 1993 to treat male infertility. It is most commonly used in conjunction with in vitro fertilization (IVF). Following IVF procedure, the physician places the fertilized egg into the female’s uterus for implantation. Sperm are obtained by the same methods as with IVF: either through masturbation, by using a collection condom, or by surgically removing sperm from a testicle through a small incision (MESA, TESE). The females are treated with fertility medications for approximately two weeks prior to oocyte retrieval to stimulate superovulation, where the ovaries produce multiple oocytes rather than the normal one oocyte. The oocytes are retrieved by either laparoscopy, or more commonly, transvaginal oocyte retrieval. In the latter procedure, the physician inserts a thin needle through the cervix, guided by a sonogram and pierces the vaginal wall and then the ovaries to extract several mature ova. Before the embryologist can inject the sperm into the oocyte, the sperm must be prepared by washing and exposing it to various chemicals to slow the sperm movement and prevent it from sticking to the injection plate. Also, the oocytes are treated with hyaluronidase to single out the oocyte ready for fertilization by the presence of the first polar body. Then, one prepared sperm is injected into an oocyte with a thin needle. Often, embryologists try to fertilize several eggs so they can implant more than one into the uterus and increase the chance of at least one successful pregnancy. This also allows them to save extra embryos, using cryopreservation, in case later IVF rounds are needed.

After the embryologist manually fertilizes the oocytes, they are incubated for sixteen to eighteen hours and develop into a pronucleate eggs (successfully fertilized eggs about to divide into an embryo). The egg then grows for one to five days in the laboratory before the physician places it in the female’s uterus for implantation.

The chance of fertilization increases dramatically with ICSI compared to simply mixing the oocytes and sperm in a Petri dish and waiting for fertilization to occur unaided (classical IVF procedure). Studies have shown that successful fertilizations occur 50% to 80% of the time. Since the introduction of ICSI, intrauterine insemination (IUI) has decreased in popularity by 80%.

See full description of ICSI

Laser-assisted immotile sperm selection

Method, which uses a laser to identify viable sperm cell for subsequent ICSI, recommended in MESA/TESE IVF cycles (surgical sperm retrieval) and any other cases of immotile spermatozoa (severe asthenospermia or necrospermia).
Sperm viability is a prerequisite for a successful ICSI treatment, because the injection of a nonviable spermatozoon into an oocyte generally results in fertilization failure. Normally, the spermatozoa are selected according to motility, which is a clear indication for viability. However, in cases with complete asthenozoospermia, it is impossible to select viable sperm by morphological means.
To identify viable sperm in patients presenting with complete sperm immotility is a challenging but very important step. Using LAISS a single laser shot is applied close to the tip of the sperm tail using a non-contact 1.48 µm diode laser system. In a few seconds, two possible reactions can be observed:
1.    either the tail of the spermatozoa starts curling after the laser shot, or
2.    the spermatozoa show no reaction at all.
Spermatozoa showing a curling reaction are considered to be viable and can be used for ICSI treatment immediately. In contrast to another methods e.g. hypo-osmotic swelling test, the laser selection can be performed directly in IVF medium with no additional micromanipulation.

See full description of Laser-assisted immotile sperm selection


MACS  technique eliminates apoptotic sperms and may be indicated prior to ICSI, in order to guarantee that the injected spermatozoa are not damaged at a molecular level. Alternatively it could be combined with PICSI.

The externalization of the phospholipid phosphatidylserine (PS) to the sperm plasma membrane is a characteristic feature of the apoptotic phenomenon that occurs early during the process of sperm cell death. This basic knowledge has prompted investigators to develop a magnetic-based selection system for sperm cells that can separate early apoptotic from non-apoptotic germ cells (MACS).

Human sperm quality is defined by the classical parameters, concentration, motility and morphology, according to standard WHO diagnostic semen analysis. Nevertheless, hidden anomalies affecting spermatozoa membranes and causing apoptosis are present. Such features are not routinely detected in ejaculated spermatozoa but they have been proven to have a negative impact on ART outcome. Indeed, successful assisted reproduction is mainly dependent on the quality of the sperm plasma membrane, requiring normal integrity and function to provide motility, acrosome reaction, and fertilization. Spermatozoa with impaired membrane integrity occur more frequently in infertile men, partly explaining suboptimal results in assisted medical procreation. However, striking modifications of sperm plasma membrane occur physiologically in ejaculated sperm. During capacitation, there is a lipid remodelling of the sperm plasma membrane due to phospholipids translocation that lead to externalization of phosphatidylserine (EPS) and phosphatidylethanolamine, and to an albumin mediated efflux of cholesterol resulting in an increase in membrane fluidity.

Externalization of phosphatidylserine (EPS) on ejaculated mature spermatozoa is either the result of a plasma membrane modification because of capacitation and/or acrosome reaction or the sign of an early apoptotic phenotype. Apoptosis in ejaculated sperm is the result of a spermatogenetic failure, thus an abortive apoptotic process that started before ejaculation. 

Annexin V binding to spermatozoa characterizes modified sperm plasma membrane. MACS Technology uses annexin V-conjugated superparamagnetic microbeads (50 nm) to separate nonapoptotic spermatozoa from those with deteriorated plasma membranes with EPS. The spermatozoa/microbeads suspension is loaded on a separation MS column (specialized columns for MACS techniques) containing iron balls, which is fitted in a miniMACS separator (magnet), attached to a multistand. The fraction with intact membranes that passed through the column is labeled as MACS -negative fraction, depleted in phosphatidylserine (PS), whereas the fraction composed of apoptotic or deteriorated PS-positive membranes spermatozoa is retained in the separation column and labeled as MACS -positive fraction. After the column is removed from the magnetic field, the retained fraction is eluted using annexin V-binding buffer.

The positive fraction (called like this due to the fact that the spermatozoa stay retained in the magnetic columns because of their damaged DNA) will allow us to recover a negative fraction (made up of spermatozoa with unharmed DNA), with optimal sperm characteristics to be able to proceed. In other words, the spermatozoa passing through the magnetic columns without being retained will prove to have an unharmed DNA and, therefore, they will be eligible to be used.

See full description of MACS


MESA was first described in 1985. This surgical technique requires testis delivery through a 2-3-cm transverse scrotal incision. The epididymal tunica is incised, and an enlarged tubule is selected. Then, the epididymal tubule is dissected and opened with sharp microsurgical scissors. The fluid that flows out of the tubule is aspirated with the aid of a silicone tube or a needle attached to a tuberculin syringe (Pic.1) The aspirate is flushed into a tube containing warm sperm medium and is transferred to the laboratory for examination. MESA can be repeated at a different site on the same epididymis (from the cauda to caput regions) and/or the contralateral epididymis until an adequate number of motile sperm is retrieved. 

An embryologist examines the sample for the presence of motile sperm. If no motile spermatozoa are found at the first site, the maneuver is repeated. Typically, only a few microliters of epididymal fluid are retrieved because sperm are highly concentrated in the epididymal fluid (approximately 1x106 sperm/ml). A MESA approach should provide more than adequate numbers of sperm for immediate use, as well as for cryopreservation. 

If MESA fails to retrieve motile sperm, TESA or TESE can be performed as part of the same procedure. However, MESA often provides enough sperm for cryopreservation. A single MESA procedure usually enables the retrieval of a large number of high-quality sperm that can be used for ICSI or intentionally cryopreserved for subsequent ICSI attempts. As reported by Dr. Shlegel and colleagues, who used MESA and ICSI in a group of men with obstructive azoospermia, clinical pregnancies were detected by a fetal heartbeat in 75% (57/ 76) of attempts, and healthy deliveries occurred in 64% (49/ 76) of attempts.

ANESTHESIA FOR SPERM RETRIEVAL PROCEDURES Sperm retrievals are relatively simple surgeries that can be safely performed with general anesthesia or spinal blocks. However, because sperm retrievals are typically outpatient procedures, the latest trend is to employ local or locoregional anesthesia with or without intravenous sedation. In another study of 26 patients undergoing MESA, only 38% of the patients tolerated the procedure solely under spermatic cord block through the infiltration of 5-8 mL of 1% lidocaine; the remaining 62% required intravenous sedation. The percentage of patients who underwent a bilateral procedure and required intravenous sedation was as high as 75%.

General anesthesia may offer comfort and the efficient management of anxiety. However, when performed with inhalational agents such as N2O and halogenated agents, this approach is associated with a high incidence of postoperative nausea and vomiting. These two complaints are among the most frequent causes of hospitaliza-tion and the inability to discharge patients scheduled for ambulatory procedures. Additionally, these symptoms are among the most feared by patients undergoing minor surgery, surpassing even postoperative pain.

See full description of MESA

Micro TESE

The concept of micro-TESE is to identify areas of sperm production within the testes with the aid of optical magnification (15-25x) and based on the size and appearance of the seminiferous tubules. Micro-TESE is recommended for the most severe cases of non-obstructive azoospermia (NOA).

MicroTESE yields the highest sperm retrieval rate and causes the least amount of damage to the testis.

Miniinvasive alternative to TESE using microdissection microscope. In microsurgical testicular sperm extraction (microdissection TESE; micro-TESE), the testicular parenchyma is dissected under magnification to search for enlarged seminiferous tubules, which are more likely to contain germ cells and foci of sperm production compared to non-enlarged or collapsed tubules. Such seminiferous tubules are removed rather than proceeding with the large single or multiple biopsies performed in conventional TESE.

For micro-TESE, the scrotal skin is stretched over the anterior surface of the testis, after which a 2 3 cm transverse incision is made. Alternatively, a single midline scrotal incision can be used. The incision extends through the dartos muscle and the tunica vaginalis. The tunica is opened, and identifiable bleeders are cauterized. The testis is delivered extravaginally, and the tunica albuginea is examined. Then, a single, large, mid-portion incision is made in an avascular area of the tunica albuginea under 6-8× magnification, and the testicular parenchyma is widely exposed in its equatorial plane (Pic. 1). The testicular parenchyma is dissected at 16-25× magnification to enable the search and isolation of seminiferous tubules that exhibit larger diameters (which are more likely to contain germ cells and eventually normal sperm production) in comparison to non-enlarged or collapsed counterparts (Pic. 2). If needed, the superficial and deep testicular regions can be examined, and microsurgical-guided testicular biopsies are performed by carefully removing enlarged tubules using microsurgical forceps. If enlarged tubules are not observed, any tubule that differs from the remaining tubules in size is excised. The excised testicular tissue specimens are placed into the inner well of a Petri dish containing sperm media, and are sent to the laboratory for processing and sperm search (Pic. 3). The tunicas albuginea and vaginalis are then closed in a running fashion using non-absorbable and absorbable sutures. The dartos muscle is closed with interrupted absorbable sutures, respectively. Immediately prior to complete closure, 3 cc of 1% xylocaine solution may be injected into the subcuticular layers. The skin is closed using a continuous subcuticular 4-0 vicryl suture. A fluffy-type scrotal dressing and scrotal supporter are placed.

See full description of Micro TESE


The technical procedure for PESA involves the insertion of a needle attached to a syringe through the scrotal skin into the epididymis (Pic 1). Originally, the use of a larger butterfly needle was described. Currently, most experts use a fine needle (26 gauge) attached to a tuberculin syringe containing sperm washing medium. After creating negative pressure by pulling the syringe plunger, the tip of the needle is gently and slowly moved in and out inside the epididymis until fluid is aspirated. If motile sperm are not obtained, PESA may be repeated at a different site (from the cauda to caput epididymis) until an adequate number of motile sperm is retrieved. These aspirations are usually performed in the corpus epididymis and then in the caput epididymis if needed, as aspirates from the cauda are often rich in poor-quality senescent spermatozoa, debris and macrophages. Because PESA is a blind procedure, multiple attempts may be needed before high-quality sperm are found. If PESA fails to enable the retrieval of motile sperm, testicular sperm retrieval can be attempted during the same operation.
Craft and Shrivastav, in 1994, first described the use of the percutaneous approach to retrieve sperm from the epididymis. Percutaneous retrievals are usually undertaken under local anesthesia only or in association with intravenous sedation. Percutaneous sperm retrieval can be either diagnostic or therapeutic. In the former, it is used to confirm the presence of viable spermatozoa prior to ICSI. In the latter, it is carried out at the same day of oocyte retrieval or at the day before.

See full description of PESA

Sperm donation

Sperm donation is the donation by a male (known as a sperm donor) of his sperm (known as donor sperm), principally for the purpose of inseminating a female who is not his sexual partner. Sperm donation is a form of third party reproduction including sperm donation, oocyte donation, embryo donation, surrogacy, or adoption. Number of births per donor sample will depend on the actual ART method used, the age and medical condition of the female bearing the child, and the quality of the embryos produced by fertilization. Donor sperm is more commonly used for artificial insemination (IUI or ICI) than for IVF treatments. This is because IVF treatments are usually required only when there is a problem with the female conceiving, or where there is a “male factor problem” involving the female's partner. Donor sperm is also used for IVF in surrogacy arrangements where an embryo may be created in an IVF procedure using donor sperm and this is then implanted in a surrogate. In a case where IVF treatments are employed using donor sperm, surplus embryos may be donated to other women or couples and used in embryo transfer procedures. 

On the other hand, insemination may also be achieved by a donor having sexual intercourse with a female for the sole purpose of initiating conception. This method is known as natural insemination.

The donation
Donor sperm and fertility treatments using donor sperm may be obtained at a sperm bank or fertility clinic. Here, the recipient may select donor sperm on the basis of the donor's characteristics, e.g. looks, personality, academic ability, race, and many other factors. Sperm banks or clinics may be subject to state or professional regulations, including restrictions on donor anonymity and the number of offspring that may be produced, and there may be other legal protections of the rights and responsibilities of both recipient and donor. Some sperm banks, either by choice or regulation, limit the amount of information available to potential recipients; a desire to obtain more information on donors is one reason why recipients may choose to use a known donor and/or private donation.

A sperm donor will usually donate sperm to a sperm bank under a contract, which typically specifies the period during which the donor will be required to produce sperm, which generally ranges from 6–24 months depending on the number of pregnancies which the sperm bank intends to produce from the donor. Donors may or may not be paid for their samples, according to local laws and agreed arrangements. Even in unpaid arrangements, expenses are often reimbursed. Depending on local law and on private arrangements, men may donate anonymously or agree to provide identifying information to their offspring in the future. Private donations facilitated by an agency often use a "directed" donor, when a male directs that his sperm is to be used by a specific person. Non-anonymous donors are also called known donors, open donors or identity disclosure donors.

Donor selection
A sperm donate must generally meet specific requirements regarding age (most often up to 40) and medical history. Potential donors are typically screened for genetic diseases, chromosomal abnormalities and sexually transmitted infections that may be transmitted through sperm. The donor's sperm must also withstand the freezing and thawing process necessary to store and quarantine the sperm. Samples are stored for at least 6 months after which the donor will be re-tested for sexually transmitted infections. This is to ensure no new infections have been acquired or have developed during the period of donation. If the result is negative, the sperm samples can be released from quarantine and used in treatments.

Screening includes:

  • Taking a medical history of the donor, his children, siblings, parents, and grandparents etc. for three to four generations back. This is often done in conjunction with the patient’s family doctor.
  • HIV risk assessment interview, asking about sexual activity and any past drug use.
  • Blood tests and urine tests for infectious diseases, such as: HIV-1/2, HTLV-1/2, Hepatitis B and C, Syphilis, Gonorrhea, Chlamydia, Cytomegalovirus (CMV), not all clinics test for this.
  • Blood and urine tests for blood typing and general health indicators: ABO/Rh typing, CBC, liver panel and urinalysis
  • Complete physical examination including careful examination of the penis, scrotum and testicles.
  • Genetic testing for carrier traits, for example: Cystic Fibrosis, Sickle-cell disease, Thalassemia, other hemoglobin-related blood disorders.
  • General health
  • Semen analysis for: sperm count, morphology, motility, acrosome activity may also be tested

Preparing the samples
A sperm donor is usually advised not to ejaculate for two to three days before providing the sample, to increase sperm count and to maximize the conception rate. A sperm donor produces and collects sperm by masturbation or during sexual intercourse with the use of a collection condom.

Sperm banks and clinics usually "wash" the sperm sample to extract sperm from the rest of the material in the semen. A cryoprotectant semen extender is added if the sperm is to be placed in frozen storage in liquid nitrogen, and the sample is then frozen in a number of vials or straws. One sample will be divided into 1-20 vials or straws depending on the quantity of the ejaculate and whether the sample is washed or unwashed. Following the necessary quarantine period, the samples are thawed and used to inseminate women through artificial insemination or other ART treatments. Unwashed samples are used for ICI treatments, and washed samples are used in IUI and IVF procedures.

Anonymous sperm donation occurs where the child and/or receiving couple will never learn the identity of the donor, and non-anonymous when they will. Non-anonymous sperm donors are, to a substantially higher degree, driven by altruistic motives for their donations.

Even with anonymous donation, some information about the donor may be released to the female/couple at the time of treatment. Limited donor information includes height, weight, eye, skin and hair color. In Sweden, this is all the information a receiver gets. In the US, on the other hand, additional information may be given, such as a comprehensive biography and sound/video samples.

Information made available by a sperm bank will usually include the race, height, weight, blood group, health, and eye color of the donor. Sometimes information about his age, family history and educational achievements will also be given.

Different factors motivate individuals to seek sperm from outside their home state. For example, some jurisdictions do not allow unmarried women to receive donor sperm. Jurisdictional regulatory choices as well as cultural factors that discourage sperm donation have also led to international fertility tourism and sperm markets.

Legal aspects
A sperm donor is generally not intended to be the legal or de jure father of a child produced from his sperm. Depending on the jurisdiction and its laws, he may or may not later be eligible to seek parental rights or be held responsible for parental obligations. Generally, a male who provides sperm as a sperm donor gives up all legal and other rights over the biological children produced from his sperm. However, in private arrangements, some degree of co-parenting may be agreed, although the enforceability of those agreements varies by jurisdiction.

Laws prohibits sperm donation in several countries: Algeria, Bahrain, Costa Rica, Egypt, Hong Kong, Jordan, Lebanon, Lithuania, Libya, Maldives, Oman, Pakistan, Philippines, Qatar, Saudi Arabia, Syria, Tajikistan, Tunisia, Turkey, UnitedArab Emirates, and Yemen. 

See full description of Sperm donation

Standard IVF

In vitro fertilization (IVF) is a process by which an egg is fertilised by sperm outside the body: in vitro . The process involves monitoring and stimulating a woman's ovulatory process, removing an ovum or ova (egg or eggs) from the woman's ovaries and letting sperm fertilise them in a liquid in a laboratory. The fertilised egg (zygote) is cultured for 2–6 days in a growth medium and is then implanted in the same or another woman's uterus, with the intention of establishing a successful pregnancy.

IVF techniques can be used in different types of situations. It is a technique of assisted reproductive technology for treatment of infertility. IVF techniques are also employed in gestational surrogacy, in which case the fertilised egg is implanted into a surrogate's uterus, and the resulting child is genetically unrelated to the surrogate. In some situations, donated eggs or sperms may be used. Some countries ban or otherwise regulate the availability of IVF treatment, giving raise to fertility tourism. Restrictions on availability of IVF include to single females, to lesbians and to surrogacy arrangements. Due to the costs of the procedure, IVF is mostly attempted only after less expensive options have failed.

The first successful birth of a "test tube baby", Louise Brown, occurred in 1978. Louise Brown was born as a result of natural cycle IVF where no stimulation was made. Robert G. Edwards, the physiologist who developed the treatment, was awarded the Nobel Prize in Physiology or Medicine in 2010. With egg donation and IVF, women who are past their reproductive years or menopause can still become pregnant. Adriana Iliescu held the record as the oldest woman to give birth using IVF and donated egg, when she gave birth in 2004 at the age of 66, a record passed in 2006.

See full description of Standard IVF


Testicular sperm extraction (TESE) is the process of removing a small portion of tissue from the testicle under local anesthesia and extracting the few viable sperm cells present in that tissue for intracytoplasmic sperm injection (ICSI).

The testicular sperm extraction process is recommended to men who cannot produce sperm by ejaculation due to azoospermia, such as that caused by primary testicular failure, congenital absence of the vas deferens or non-reconstructed vasectomy.

The introduction of the technique of intracytoplasmic sperm injection to achieve fertilization, especially using surgically retrieved testicular or epididymal sperm from men with obstructive or non-obstructive azoospermia, has revolutionized the field of assisted reproduction. Testicular sperm retrieval techniques associated with intracytoplasmic sperm injection have reduced the need for donor sperm and given many azoospermic men the chance to become biological fathers.

The extraction of the testicular parenchyma for sperm search and isolation was first described in 1995. For conventional TESE, a standard open surgical biopsy technique is used to remove the testicular parenchyma without the aid of optical magnification. This procedure is usually carried out without delivering the testis. Briefly, a 2-cm transverse incision is made through the anterior scrotal skin, dartos and tunica vaginalis. A small self-retaining retractor can be used to ensure proper exposure of the tunica albuginea. A 1-cm incision is made in the albuginea, and gentle pressure is applied to the testis to aid the extrusion of the testicular parenchyma. A fragment of approximately 5x5 mm is excised with sharp scissors and placed in sperm culture media. Single or multiple specimens can be extracted from the same incision. Alternatively, individual albuginea incisions can be made in the upper, middle and lower testicular poles in an organized manner for the sampling of different areas. The testicular specimens are sent to the laboratory for processing and immediate microscopic examination. The tunica albuginea is closed with a running, non-absorbable suture.

See full description of TESE

How can Anejaculation affect fertility

Ejaculatory duct obstruction is the underlying cause for 1–5% of male infertility. If both ejaculatory ducts are completely obstructed, affected men will demonstrate male infertility due to aspermia/azoospermia. They will suffer from a very low volume of semen which lacks the gel-like fluid of the seminal vesicles or from no semen at all while they are able to have the sensation of an orgasm during which they will have involuntary contractions of the pelvic musculature. This is contrary to some other forms of anejaculation.

Men with spinal cord injury (SCI) rank the ability to father children among their highest concerns relating to sexuality. Male fertility is reduced after SCI, due to a combination of problems with erections, ejaculation, and quality of the semen. As with other types of sexual response, ejaculation can be psychogenic or reflexogenic, and the level of injury affects a man's ability to experience each type. As many as 95% of men with SCI have problems with ejaculation (anejaculation), possibly due to impaired coordination of input from different parts of the nervous system. Erection, orgasm, and ejaculation can each occur independently; however the ability to ejaculate seems linked to the quality of the erection, and the ability to orgasm is linked to the ejaculation facility. Even men with complete injuries may be able to ejaculate, because other nerves involved in ejaculation can effect the response without input from the spinal cord. In general, the higher the level of injury, the more physical stimulation the man needs to ejaculate. Conversely, premature or spontaneous ejaculation can be a problem for men with injuries at levels T12–L1 (12th thoracic nerve and 1st lumbal nerve) (Pic. 2). It can be severe enough that ejaculation is provoked by thinking a sexual thought, or for no reason at all, and is not accompanied by orgasm. 

Most men with spinal cord injury have a normal sperm count, but a high proportion of sperm are abnormal; they are less motile and do not survive as well. The reason for these abnormalities is not known, but research points to dysfunction of the seminal vesicles and prostate, which concentrate substances that are toxic to sperm. Cytokines, immune proteins which promote an inflammatory response, are present at higher concentrations in semen of men with SCI, as is platelet-activating factor acetylhydrolase; both are harmful to sperm. Another immune-related response to SCI is the presence of a higher number of white blood cells in the semen.

Pic. 1
See full description