I’m not sure what’s out on the fertility chat rooms, Facebook groups, Reddit posts, etc. but it seems people with unsuccessful IVF are talking more and more about sperm.  Lately people are starting to ask whether they should use testicular sperm instead of ejaculated sperm to improve embryo quality.

Let me review a couple of sperm concepts.  Roughly, if the sperm count is > 15 million and most of them are swimming couples (without any female factors) can conceive with sex.  If the sperm count is between 8-15 million then IUI often works, and below 8 million IVF with ICSI is needed.

This is simplistic. This is a gross generalization but it’s a place to start the discussion.

Now, if a couple needs IVF/ICSI then we extract eggs from the ovaries and the partner EJACULATES sperm.  We take that sperm and fertilize and eggs and watch as embryos develop.

If embryos develop poorly or are abnormal we explore whether the egg, sperm or both were the cause.  If we suspect sperm, what can we do?

Have the male take supplements, improve his lifestyle, treat a varicocele (if present)

Use donor sperm

Try with sperm we aspirate straight from the testicles/epididymus - TESA/PESA procedure

It’s been my experience over the years that the evidence has waffled back and forth about the value of ejaculated sperm when there is a reasonable number of sperm in the ejaculated sample, but has favoured testicular sperm when embryo development is poor.

Reviewing this topic on this rainy November day, it seems the controversy continues.  The latest study of about 160 couples undergoing ICSI and comparing ejaculated versus testicular sperm found NO benefit (Reference: Kendall Rauchfuss LM, Kim T, Bleess JL, Ziegelmann MJ, Shenoy CC. Testicular sperm extraction vs. ejaculated sperm use for nonazoospermic male factor infertility. Fertil Steril. 2021 Oct;116(4):963-970.). The authors concluded that testicular sperm was not better, but if you dig into the methodology of the study, explore the bias in selection of patients and look at the outcomes (higher live birth with testicular sperm, though not statistically different), I don’t think this study should necessarily be that influential.  Reading it did prompt me to go back over the other studies on the topic.

My synthesis is that there may be value to getting sperm from the testicles if the sperm parameters in the ejaculated sample are poor (low count, motility, high DNA fragmentation), particularly if there has been poor embryo development in s previous IVF cycle.  It is also a good reminder that poor quality sperm should be addressed: supplements, optimizing diet and lifestyle and addressing any correctable insults to the sperm (e.g. varicocele, if present).  Then if the ejaculated sample is low and the embryo development is poor consider testicular sperm before another IVF attempt.

Testicular aspiration of sperm isn’t taken lightly.  I would not start sending men for this procedure with low sperm counts - it is expensive (> $3000) and hurts. This a case where the doctor really needs to spend time with the sperm report, perhaps talk to the andrologists/urologists and really personalize the approach to maximize embryo health.

I suspect this is buzzing in chat-rooms these days is that some frequent or passionate poster had success when their doctor switched from ejaculated sperm to testicular sperm.  I’m glad this is being discussed.  We need to do everything to create the healthiest embryos and babies.

Dr. Beth Taylor MD, FRCSC

Reproductive Endocrinology & Infertility