OBJECTIVE: To report the successful and feasible use of transperineal fine needle aspiration of seminal vesicles (FNASV) for sperm retrieval in obstructive azoospermia.

DESIGN: Case report.

SETTING: Outpatient care in institutional clinic.

PATIENT(S): A 31-year-old man with obstructive azoospermia due to a middle prostatic m\ufcllerian cyst.

INTERVENTION(S): Transperineal FNASV using a coaxial 17-gauge TruGuide needle.

MAIN OUTCOME MEASURE(S): Feasibility of sperm retrieval suitable for future in vitro fertilization.

RESULT(S): Transperineal FNASV made it possible to aspirate 11 mL of fluid with a sperm count of 100 million/mL and 15% motility. This sample was cryopreserved for in vitro fertilization using intracytoplasmic sperm injection.

CONCLUSION(S): Transperineal FNASV using a coaxial needle may be a further method for sperm retrieval to add to the repertoire of assisted reproduction technologies

M. CERRUTO

NOVELLA G

ZATTONI F

ZECCHINI ANTONIOLLI S

OBJECTIVE: To report the successful and feasible use of transperineal fine needle aspiration of seminal vesicles (FNASV) for sperm retrieval in obstructive azoospermia.

DESIGN: Case report.

SETTING: Outpatient care in institutional clinic.

PATIENT(S): A 31-year-old man with obstructive azoospermia due to a middle prostatic müllerian cyst.

INTERVENTION(S): Transperineal FNASV using a coaxial 17-gauge TruGuide needle.

MAIN OUTCOME MEASURE(S): Feasibility of sperm retrieval suitable for future in vitro fertilization.

RESULT(S): Transperineal FNASV made it possible to aspirate 11 mL of fluid with a sperm count of 100 million/mL and 15% motility. This sample was cryopreserved for in vitro fertilization using intracytoplasmic sperm injection.

CONCLUSION(S): Transperineal FNASV using a coaxial needle may be a further method for sperm retrieval to add to the repertoire of assisted reproduction technologies

CERRUTO, Maria Angela

ZATTONI, Filiberto

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AtcaStdlsdtaosiwsilsaaRR0dUse of transperineal fine needle aspiration of seminalvesicles to retrieve sperm in a man withobstructive azoospermiaMaria Angela Cerruto, M.D., Giovanni Novella, M.D., Stefano Zecchini Antoniolli, M.D., andFiliberto Zattoni, M.D.Urology Clinic, Policlinico G. B. Rossi, University of Verona, Verona, ItalyObjective: To report the successful and feasible use of transperineal fine needle aspiration of seminal vesicles(FNASV) for sperm retrieval in obstructive azoospermia.Design: Case report.Setting: Outpatient care in institutional clinic.Patient(s): A 31-year-old man with obstructive azoospermia due to a middle prostatic müllerian cyst.Intervention(s): Transperineal FNASV using a coaxial 17-gauge TruGuide needle.Main Outcome Measure(s): Feasibility of sperm retrieval suitable for future in vitro fertilization.Result(s): Transperineal FNASV made it possible to aspirate 11 mL of fluid with a sperm count of 100million/mL and 15% motility. This sample was cryopreserved for in vitro fertilization using intracytoplasmicsperm injection.Conclusion(s): Transperineal FNASV using a coaxial needle may be a further method for sperm retrieval to addto the repertoire of assisted reproduction technologies. (Fertil Steril 2006;86:1764.e7–9. ©2006 by AmericanSociety for Reproductive Medicine.)Key Words: Transperineal FNASV, obstructive azoospermia, müllerian cystCAswttlflpie1tbfontSwTcrrTazoospermia is the most severe form of male factor infer-ility and occurs in about 5% of all investigated infertileouples (1). One treatment for infertility due to obstructivezoospermia is intracytoplasmic sperm injection (ICSI).ince 1993, when ICSI was introduced (2), several alterna-ive microsurgical and suction techniques using hollow nee-les have been developed to recover spermatozoa. Nonethe-ess, there is still insufficient evidence to recommend anypecific sperm retrieval technique for azoospermic men un-ergoing ICSI (3).To minimize the invasiveness of surgery for sperm re-rieval in terms of both costs and anesthesia requirements,transrectal approach to perform a fine needle aspirationf the seminal vesicles (FNASV) has been recently de-cribed in an anorgasmic infertile man (4). This minimallynvasive approach made it possible to obtain seminal fluidith a sperm count of 40 million/mL and 2% motility,uitable for subsequent in vitro fertilization and resultingn a successful pregnancy (4). Those encouraging resultsed us to perform an FNASV in a young man with ob-tructive azoospermia, using our original transperinealpproach with a coaxial needle (5), with the aim ofssessing its feasibility as a sperm retrieval technique.eceived December 19, 2005; revised and accepted March 20, 2006.eprint requests: Maria Angela Cerruto, M.D., Urology Clinic, Universityof Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy (FAX: 39 045i8074080; E-mail: mcerruto@univr.it).015-0282/06/$32.00oi:10.1016/j.fertnstert.2006.03.069 Copyright ©2006 American SocietASE REPORT31-year-old otherwise healthy man was examined foruspected obstructive azoospermia. His clinical examinationas negative. His routine laboratory and hormonal parame-ers were within the normal ranges. Semen analysis showedhe following values: 1.8 mL volume, pH 7, absence ofeucocytes, rare round cells, normal fluid thickness, completeuidification after 18 minutes, normal viscosity, and com-lete absence of spermatozoa. Prostate magnetic resonancemaging with a rectal coil showed a bilateral seminal vesiclenlargement and the presence of an 8-mm-thick liquid mass,5.3 mm long and 5 mm wide, that widened the proximalract of the ejaculatory ducts (Fig. 1A).The patient was informed about the potential risks andenefits of transperineal FNAVS and provided written in-ormed consent. Antibiotic coverage with a quinolone wasrally administered. Neither bowel preparation with enemaor general anesthesia was necessary.The patient was placed in the lithotomy position. A real-ime transrectal ultrasound (TRUS) was carried out using theiemens Sonoline Omnia Diagnostic Ultrasound System,ith a 7.75-MHz linear probe inserted into the rectum. TheRUS confirmed a 13  5 mm midline anechoic prostaticyst structure, marking the ejaculatory ducts (Fig. 1B), withemarkably dilated seminal vesicles (Fig. 1C). Ultrasonog-aphy revealed no abnormalities of the prostate and urethra.wo milliliters of 1% mepivacaine was administered to thepex of the prostate, using a single 22-gauge spinal needlenserted transperineally 1.5 cm above the rectum on the1764.e7Fertility and Sterility Vol. 86, No. 6, December 2006y for Reproductive Medicine, Published by Elsevier Inc.mmTcnaffarsvpBfmtDTiwmylptttoneaFjeFtbjftsagfl(vdptcnatcpcbBcedian line. The needle was progressively retracted and 2L of anesthetic was administered along the needle path.hen, a coaxial 17-gauge TruGuide needle was placed, ac-ording to the previously described technique (5). All ma-euvers were made under continuous ultrasound control.Through the coaxial needle, a total of 11 mL of fluid wasspirated from both vesicles (4 mL from the right and 7 mLrom the left). One milliliter of latescent liquid was aspiratedrom the median cyst. Analysis of the aspirated fluid showedsperm count of 100 million/mL and 15% motility (5% withapid motility and 10% with progressive motility). Thisample was frozen and appropriately conserved for future initro fertilization using ICSI.Microscopic analysis of the aspirated sample from therostatic lesion made a diagnosis of müllerian duct cyst.acteriologic tests showed no growth. Semen analysis per-ormed 3 months after the procedure showed an improve-ent of the ejaculate volume (2 mL) with a sperm concen-ration of 3 million/mL.ISCUSSIONransperineal FNAVS may be a feasible and effective min-mally invasive technique for semen retrieval from patientsith obstructive midline prostatic duct cysts.Both artificial insemination and ICSI require sperm whichay be retrieved from the following sources: testis, epidid-mis, vas deferens, seminal vesicles, and deferential ampul-ae. The approach may be by open surgery, percutaneousuncture, and other rare procedures (6). Although currentlyesticular sperm extraction followed by ICSI is the standardechnique, it has some drawbacks, including localized tes-icular fibrosis, bleeding, infections, and the need for localFIGURE 1(A) Rectal coil magnetic resonance imaging scan shopresence of an 8-mm-thick liquid mass, 15.3 mm lonthe ejaculatory ducts. (B) Transrectal ultrasound scanstructure, with (C) remarkably dilated seminal vesicleCerruto. Transperineal FNASV for sperm retrieval. Fertil Steril 2006.r, more commonly, general anesthesia. s1764.e8 Cerruto et al. Transperineal FNASV for sperm retrievaBoehlen and Schmid developed a transrectal FNASV as aovel method for sperm retrieval to minimize these sideffects (4). We modified this method, using a transperinealpproach. Indications for either transrectal or transperinealNASV might include obstructive azoospermia distal to theunction of the vas deferens and ejaculatory duct and anyjaculatory disorder (4). A potential drawback of transrectalNASV could be rectal environment contamination. In con-rast, the transperineal approach makes it possible to performilateral multiple punctures and aspiration with neither ma-or complications nor the risk of rectal contamination. There-ore, the transperineal approach could be better than theransrectal route when multiple punctures and a bilateraleminal vesicles aspiration is required and in subjects withnatomically intact rectum (7). Moreover the use of a 17-auge needle makes it possible to aspirate a larger amount ofuid than a transrectal 21-gauge needle (11 mL vs. 3 mL)4), to obtain a notably higher sperm count (100 million/mLs. 40 million/mL) (4).The conventional transperineal approach could have theisadvantages of necessitating good local anesthesia at theerineal site of needle penetration and being more irritatinghan transrectal puncture and aspiration (7). Concerning lo-al anesthesia, both transrectal and transperineal FNASVeed anesthesia at the apex of the prostate. The transperinealpproach may simplify the anesthetic injection at the pros-ate apex (5). Because the use of a coaxial needle signifi-antly reduced the pain experienced during prostate sam-ling and improved patient compliance compared with theonventional transperineal biopsy technique (5), it is possi-le to obtain similar results using this approach for FNASV.ecause no data are currently available that make a directomparison between the transperineal coaxial needle and theg bilateral seminal vesicle enlargement and thed 5 mm wide, which widened the proximal tract ofwing a 13  5 mm midline anechoic prostatic cyst prostate; sv  seminal vesicle; cy  cyst.wing anshos. ptandard TRUS-guided biopsy, it is not possible to distin-l Vol. 86, No. 6, December 2006gtvpusTavtocaiCTfamptAsR123456789Fuish which is better in terms of less pain and discomfort. Inhe present case, fluid was aspirated from both the seminalesicles and the middle prostate duct cyst, with no particularatient discomfort.A müllerian duct cyst may cause obstruction of the ejac-latory ducts with congestion of the seminal vescicles, re-ulting in low ejaculate volume and infertility (8). TheRUS-guided aspiration and emptying of the cyst could ben important diagnostic tool in the work-up of low ejaculateolume and male infertility, allowing a differentiation be-ween müllerian duct cyst and ejaculatory duct cyst (9). Inur case, the transperineal aspiration and emptying of theyst allowed us to confirm the müllerian origin of the cystnd to reduce ejaculatory duct obstruction, thereby improv-ng the semen analysis 3 months after the procedure.ONCLUSIONransperineal FNASV using a coaxial needle may be aurther method for sperm retrieval to add to the repertoire ofssisted reproduction technologies. Moreover, this techniqueay help both to perform a reliable diagnosis of middlerostatic müllerian cyst, and to treat the consequent obstruc-ive azoospermia.ertility and Sterilitycknowledgments: We would like to thank Dr. Gabriella Torregrossa for theperm analysis and Ms. Christine Harris for revising the manuscript.EFERENCES. Irvine DS. Epidemiology and aetiology of male infertility. HumReprod 1998;13 Suppl 1:33–44.. Schoysman R, Vanderzwalmen P, Nijs M, et al. Pregnancy after fertil-ization with human testicular spermatozoa. Lancet 1993;342:1237– 8.. Van Peperstraten AM, Proctor ML, Phillipson G, Johnson NP. Tech-niques for surgical retrieval of sperm prior to ICSI for azoospermia(review). Cochrane Database Syst Rev 2006;3:CD002807.. Boehlem D, Schmid HP. Novel use of fine needle aspiration of seminalvesicles for sperm retrieval in infertile men. Urology 2005;66:880.. Novella G, Ficarra V, Galfano A, Ballario R, Novara G, Cavalleri S,Artibani W. Pain assessment after original transperineal prostate biopsyusing a coaxial needle. Urology 2003;62:689–92.. Tournaye H. Surgical sperm recovery for intracytoplasmic sperm injec-tion: which method is to be preferred? Hum Reprod 1999;14 Suppl1:71–81.. Sag˘lam M, Ug˘urel S¸, Kilciler M, Tas¸ar M, Somuncu I˙, Üçöz T. Trans-rectal ultrasound–guided transperineal and transrectal management ofseminal vesicle abscesses. Eur J Radiol 2004;52:329–34.. Mayersak JS. Urogenital sinus–ejaculatory duct cyst: a case report withproposed classification and review of the literature. J Urol 1989;142:1330–2.. Moukaddam HA, Haddad C, El-Sayyed K, Wazzan W. Diagnosis andtreatment of midline prostatic cysts. Clin Imag 2003:44–6.1764.e9

Use of transperineal fine needle aspiration of seminal vesicles to retrieve sperm in a man with obstructive azoospermia

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Use of transperineal fine needle aspiration of seminal vesicles to retrieve sperm in a man with obstructive azoospermia

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