Sperm extracted from men with obstructive azospermia via minimally-invasive epididymal sperm aspiration (MIESA) results in non-inferior IVF outcomes compared with normal ejaculated semen in couples with unexplained infertility

Surgically extracted sperm is generally expected to have inferior IVF outcomes compared to ejaculated sperm. We sought to evaluate sperm quality and IVF outcomes of cryopreserved epididymal sperm samples obtained from patients with obstructive azoospermia (OA) via office-based MIESA. We report sample characteristics and compare fertility outcomes of MIESA patients who underwent IVF with intracytoplasmic sperm injection (ICSI) to a control group of couples who underwent ICSI for unexplained infertility with fresh, normal ejaculated sperm samples. Retrospective cohort study. The MIESA is performed in the office with oral or intravenous sedation using only loupe magnification. Samples are cryopreserved for later IVF/ICSI. Epididymal sperm is extracted in the same manner as an obliterative microsurgical epididymal aspiration (MESA), except without the need for general anesthesia, an operating microscope, or complete epididymal exposure. We analyzed MIESA samples for sperm quality/quantity and compared IVF cycle outcomes to a computer-generated control group of age-matched females who underwent IVF/ICSI for unexplained infertility. All couples with identified female factor infertility were excluded. Chi Square and student t test analysis were used to determine statistical significance. 43 MIESA procedures were performed between December 2013 and July 2018. Causes of OA included vasectomy (35%), failed vasectomy reversal (55%), congenital bilateral absence of the vas deferens (16%), and other (6%). High quality MIESA samples were obtained with a mean retrieved total motile sperm count of 13.7 million which were cryopreserved in a mean of 4.8 vials. Mean semen parameters of the controls were all within normal limits. The mean female partner ages were 34.0 and 33.3 years (p=0.45) for the MIESA group and controls, respectively. With the primary embryo transfer, 53.5% of MIESA couples achieved a live birth compared to 48.8% of controls (p=0.67). There was no significant difference in the fertilization rate (70.7% vs 78.1%, p=0.06) or the blastulation rate (58.9% vs 62.0%, p=0.59) between the MIESA and control groups, respectively. The cumulative live birth rate, defined as the combined fresh and subsequent frozen embryo transfers from the same IVF cycle was 79% in the MIESA group compared to 61% in the control group (p=0.13) with an average of 1.72 and 1.54 transfers per live birth, respectively. MIESA provides high-quality cryopreserved sperm samples for men with OA. IVF/ICSI outcomes, including fertilization rate, blastulation rate, and live birth rate, were non-inferior to a comparison group of couples with female age-matched controls with unexplained infertility that underwent IVF/ICSI using fresh, normal ejaculated sperm.