Surgical Sperm Retrieval Techniques - Coursework Example

SURGICAL SPERM RETRIEVAL By and Table of Contents Table of Contents 2 1.0 Introduction 3 2.0 SOPs Correlation with Established Literature 3 3.0 Process Observed Correlation with Relevant SOPs 5 4.0 Verification of Staff Training, Equipment, Consumables, and Materials. 7 1.0 Introduction Surgical sperm retrieval techniques are standard procedures that have been developed for the extraction of the spermatozoa from the testicles and the epididymis. Some men are infertile not because they do not produce healthy sperms but the sperms are prevented from getting into the semen by a blockage in the testicles. In vitro fertilization is the only processes that can help the men in this category conceive with their own sperm. Intracytoplasmic sperm injection (ICSI) is the sperm retrieval method that facilitates this process. The sperm extraction techniques are used on men with what is referred to as obstructive azoospermia. Men in this category can undergo percutaneous epididymal sperm aspiration (PESA) among other testicular sperm extraction techniques. Depending on the type of azoospermia, testicular biopsy can also be used in sperm extraction for ICSI. In the non-obstructive type, Testicular Sperm Aspiration (TESA) is the preferred option. The procedure is performed in men suffering from azoospermia seeking reproductive treatment (Bernie, Ramasamy, & Schlegel, 2013, p.37). Intracytoplasmic injection of the sperm is done after the acquisition of the non-ejaculated sperms instead of using the standard fertilization in vitro (Bansal, & Bansal, 2011, p.12). The standard operating procedure also details how the sperm can be preserved for future use in sperm injection. The procedure is popular among azoospermic males seeking biological offspring. 2.0 SOPs Correlation with Established Literature The SOP for sperm retrieval is dependent on the type of azoospermia being treated, which can either be obstructive or non-obstructive. The procedure is also dependent on the preference of the attending surgeon and his or her experience. The obstructive azoospermia is attributed to the failure of detection of spermatozoa, especially in the ejaculate and post-ejaculate fluid (Esteves, Miyaoka, Orosz, & Agarwal, 2013, P.100). Sperm for ICSI can be retrieved in a number of ways based on the type of azoospermia. Sperm extraction in non-obstructive azoospermia is obtained directly from the testis. The techniques used in this case include but are not limited to the testicular biopsy and testicular sperm aspiration (teas). The procedures may require multiple biopsies in one or both testes. In many obstructive azoospermia cases, sperm can be extracted from the testis or the epididymis through percutaneous epididymal sperm aspiration (PESA) among other testicular sperm extraction methods. PESA is the preferred technique because it requires no microsurgical equipment or skills and is less invasive (Carrell, D& Peterson, 2010, P.4). In most of the obstructive azoospermia cases, spermatozoa can be extracted from the testicles and the epididymides regardless of the sperm collection technique used and the primary cause of the obstruction. Researchers have reported non-obstructive azoospermia to be a result of spermatogenic failure. The non-obstructive type has acquired and congenital etiologies over and above the hypothalamic-pituitary disease and the usual obstruction of the genital tract (Esteves, Miyaoka, & Agarwal, 2011, p.572). Unlike the obstructive azoospermia, patients with non-obstructive azoospermia do not have treatment options apart from the testicular sperm retrieval techniques. This implies that spermatozoa can be focal in non-obstructive azoospermia. Literature has reported that spermatozoa can be used for Intra plasmic sperm injection in an estimated 50 percent of azoospermic men (Parekattil, & Agarwal, 2012, p.8). in TESA, a needle is carefully inserted into a syringe and percutaneous inserted into one side of the testis. The tip of the needle is moved sideways as negative pressure is created to facilitate disruption of the seminiferous tubules and ensure that different areas are sampled. The SOP requires compliance with research studies on azoospermia because of the high level of precision associated with the treatment. Patients suffering from obstructive azoospermia have normal hormone profiles and testes sizes. In most cases, the seminal vesicles and the epididymides may be enlarged leading to a palpable cyst on the rectal examination. There may also be a low volume or acidic azoospermic ejaculate with little or no fructose (Goldstein & Schlegel, 2013, p.16). More than two-thirds of the men with obstructive azoospermia have biological mutations of cystic fibrosis transmembranous conductor regulator gene. The high precision requirement in the SOP is due to the failure of the identification of azoospermic abnormality. However, this does not automatically rule out the presence of a biological mutation. 3.0 Process Observed Correlation with Relevant SOPs Surgical sperm retrieval (SSR) can be performed as a diagnostic process to confirm if sperms are present or for sperm recovery. In the event that no eggs are to be recovered, the SSR is cancelled. Before the day of the surgery, the medical practitioners should refer to SOP on supply and use of Pharmacy Consumables to be informed about the media used in the surgery and the drugs to be avoided as a result. The SOP on Advance Preparation for Clinical Activities should also be consulted. The notes should be evaluated and relevant history entered in the diagnostic SSR record. The patient should be consented by the clinical staff prior to the operation. The clinician should consent for TESA, PESA, and biopsy enabling him to proceed from one procedure to the next in a sperm recovery attempt. The procedure plan should be discussed with the patient before it is conducted. As the initial SSR procedure, it is routine to start with the Percutaneous Epididymal Sperm Aspiration (PESA) before proceeding to Testicular Sperm Aspiration (TESA). Open biopsy should then be conducted if no sperm is seen using the other two procedures. If the volume recovered through TESA is poor, the clinician is notified by the embryologist of the findings. The most popular surgical processes are the open surgery method and the percutaneous acquisition method. Open surgery is performed for the retrieval of spermatozoa from the testicles or the epididymis without necessarily conducting a microsurgery. On the other hand, the percutaneous retrieval requires a percutaneous insertion of the needle into the source of the sperms, either in the testicles or the epididymis (Lipshultz, Howards, & Niederberger, 2009, p.2). Regardless of the method used, the objective is to have a correlation with the standard procedures for the extraction of the epididymal fluid and the seminiferous tubules. The SOP requires that the procedure, the results, and possible implications be discussed and reviewed with the patient by an experienced medic. Before any surgery is conducted, the patient is also required to sign a consent form. Moreover, nonsteroidal anti-inflammatory components and aspirin should also be avoided for the duration of one week prior to the surgery. The SOP also requires that patients on anti-coagulating agents discontinue their intake before and during the preoperative period (Kalsi, n.d, p.4). Open retrieval also requires shaving of the scrotal hair and emptying the bladder before the operation. The operating room SOP requires all the materials and instruments used in the retrieval procedure assessed for operational conditions. A grounding pad should be made available in the open procedures. The operating microscope should also be appropriately positioned and adjusted for the microsurgical techniques. Povidone-iodine should be used to clean the skin where the operation is to be carried out (Rao, Carp, & Fischer, 2014, p.20). Only the scrotum should be exposed. Sperm retrieval also requires a simple application of anesthesia. Both the local and the locoregional anesthesia may be used as per the standard procedure. Open surgical procedures are used in both the testicular and epididymal sperm collection. An incision in the scrotum is conducted in both cases to facilitate the approach to the testis or the epididymis. The optional method is the testicular delivery to aid the exposure of the testis or the epididymis (Proctor, Johnson, Peperstraten, & Phillipson, 2008, p.10). The goal of the SOP procedures is to penetrate the epididymal tubule to facilitate the aspiration of the epididymal fluid by use of a needle. The open testicular sperm extraction procedure requires a single or multiple biopsies performed to reach the seminiferous tubules. The spermatozoa retrieved in both cases can be applied in fresh sperm injection or can be cryopreserved for subsequent attempts. The open epididymal sperm aspiration procedures are only done in obstructive azoospermia cases while the open extractions are applicable in both the obstructive and the non-obstructive azoospermia cases. Among the important SOPs include embryo transfer, intra-uterine insemination, sperm collection, sperm surgical removal, sperm preparation, and preservation. 4.0 Verification of Staff Training, Equipment, Consumables, and Materials. Staff training is done to ensure that the medical practitioners go through the induction to comply with the code of practice guidance. At the induction period, the mentor or supervisor discusses the relevant SOPs with the staff members. The new member of staff will be eligible to sign the register of witnesses after the induction. Among the SOP staff induction include but are not limited to: the induction of new embryonic staff, the SOP for induction of new adrology staff, new nursing staff induction SOP, and new medical staff induction SOP. The induction SOP also includes manual witnessing SOP, basic instructions SOP, and the advanced preparation of medical activities as well as induction on labeling of embryo and gametes (Carrell, D& Peterson, 2010, P.18). The medical staff must be compliant with the relevant procedures and SOPs of egg and sperm collection in PESA. They must also be able to assess and diagnose the type of infertility and the required treatment option. A significant process also includes the evaluation of consumables taken by the patient before the surgical procedure and whether or not the patient has taken drugs that may interfere with the operation. Labeling and maintenance of the medical instruments and materials, especially those used for surgery, is also vital to guarantee safety. 5.0 Reasons for Non-Conformance Non-conformance during the sperm removal may occur on the side of the medical staff, tools and techniques as well as the patients. The code of practice guidelines requires that the medical staff must undergo staff training before undertaking the surgery (Lipshultz, Howards, & Niederberger, 2009, p.14). The staff who must participate in the induction include the new nursing staff, new embryonic staff as well as the adrology staff. The staffs are required to undergo induction under a responsible supervisor. The induction entails basic instructions SOP, advanced preparation of medical activities and labeling of gametes and embryo. A staff who fails to undergo the induction may not be able to identify the type of infertility in a patient or the best treatment to be given. Where the medical staff is not aware of the procedures, the instruments and materials to be used during the sperm removal may fail to perform (Carrell, D& Peterson, 2010, P.13). The medical staff should be cautious when handling the instruments not to cause injury to patients or self. Failure to follow the relevant SOPs in the preparation of surgical instruments results in the failure of instruments. Improper labeling and maintenance of instruments also poses a safety threat. The medical staff carrying out surgery may mistake some of the tools, and this may have adverse effects on the patient. The materials and instruments to be assessed for functionality are made available prior to the surgery time (Rao, Carp, & Fischer, 2014, p.41). Non-compliance may also occur on the side of the patients. The sperm surgery requires patients to confirm their willingness to undergo the surgery by signing the relevant forms just before the surgery. The consent to perform surgery should come from both the man and the woman since they are both parties to the infertility situation. Where there are disagreements between the man and the woman on the surgery, then the medical staff should not go ahead with the surgery till there is a formal agreement. The SOPs also requires the patients should discontinue the uptake of non-coagulating agents before and during the preoperative period (Esteves, Miyaoka, Orosz, & Agarwal, 2013, P.105). The patients are also supposed to avoid anti-inflammatory components as well as aspirin before the surgery. Some patients may fail to comply with these requirements out of lack of knowledge or even ignorance. Therefore, medical staff should enlighten the patients on the effects of not complying with the requirements of SOPs. The SOPs require that an experienced medical practitioner should discuss the procedure, results and implications of the sperm surgery with the patient. 6.0 Recommendations and Implementation Plan Before the patient signs the consent form, an experienced medic should discuss with the patient about the surgery. The medical staff should explain to the patient the procedures, the results and any side effects the patient is likely to experience. The procedures should be made aware of both husband and wife who are suffering from infertility. The explanations will prepare the staff mentally on what to expect. The medical staff should also perform tests on the patients’ body to determine the best procedure to use and recommended treatment options (Bansal, & Bansal, 2011, p.34). Prior to the surgery, the medics should consult the SOP on the use of pharmacy consumables to get informed about the media and drugs that should not be taken. On the use of media, the medical practitioner will consider the advance preparation for the clinical process, verification and warming, embryo thaw, sperm preparation for clinical treatment and semen cryopreservation (Esteves, Miyaoka, & Agarwal, 2011, p.564). When starting the sperm removal procedure, the medics should start will Percutaneous Epididymal Sperm Aspiration then to Testicular Sperm Aspiration, and if the two procedures are not successful, then an open biopsy should be conducted. Before the sperm retrieval surgery occurs, a grounding pad and an operating microscope should be made available in the operating room. The scrotum should be visible and povidone-iodine used to clean the surface where the surgery will be performed. A local anesthesia should also be made available and used as required. Under anesthesia, an incision is made to facilitate the approach to both testes. An equatorial incision is then made under magnification, taking care not to tamper with vessels of each testis (Parekattil, & Agarwal, 2012, p.25). Using the operating microscope at x25 magnification, make a tubular dissection. Still using the microscope, remove the opaque and dilated tubules and place them into a sperm buffer. An embryologist then uses a highly powered microscope to dissect the tubules. If sperm is found, it is frozen, or a fresh sperm injection can be done. The important SOPs entail the embryo transfer, sperm collection, sperm removal, preparation of sperm and its preservation. Patients are allowed to leave after surgery and prophylactic antibiotics administered for seven days (Kalsi, 2014). 7.0 Reflections on the Process Validation The sperm surgical removal is important in solving cases of infertility (Carrell, D& Peterson, 2010, P.20). The process allows parents who cannot bear children to get assistance through a surgical process. Infertility in men is due to blockage in the testicles and not the inability to produce quality and healthy sperms. The surgical process helps men sire their children instead of turning to child adoption or living without children. The validation of the process will ensure conformance with all medical requirements such as proper labeling and maintenance of instruments, proper instrument preparation as well as staff training. The validation will help improve staff training so that medical practitioners involved in surgical sperm removal can exercise more professionalism in the process. The validation will also ensure that infertility patients get better medical care and professional treatment while reducing cases of negligence among medical practitioners. 8.0 Reference List Bansal, K., & Bansal, K. (2011). Manual of intrauterine insemination (IUI) in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). New Delhi, Jaypee Bros. Medical Publishers. Bernie, A. M., Ramasamy, R., & Schlegel, P. N. (2013). Predictive factors of successful microdissection testicular sperm extraction. Genetics, 36, 37. Carrell, D. T., & Peterson, C. M. (2010). Reproductive endocrinology and infertility integrating modern clinical and laboratory practice. New York, Springer.  Esteves, S. C., Miyaoka, R., & Agarwal, A. (2011). Sperm retrieval techniques for assisted reproduction. International braz j urol, 37(5), 570-583. Esteves, S. C., Miyaoka, R., Orosz, J. E., & Agarwal, A. (2013). An update on sperm retrieval techniques for azoospermic males. Clinics, 68, 99-110. Goldstein, M., & Schlegel, P. N. (2013). Surgical and medical management of male infertility. Cambridge, Cambridge University Press. Kalsi, M. J. Micro-surgical sperm retrieval. Kalsi, J., 2014. Micro-Surgical Sperm Retrieval. Consultant Urological Surgeon, pp. 1-4. Lipshultz, L. I., Howards, S. S., & Niederberger, C. S. (2009). Infertility in the male. Cambridge, UK, Cambridge University Press. Parekattil, S. J., & Agarwal, A. (2012). Male infertility: contemporary clinical approaches, andrology, ART & antioxidants. Proctor, M., Johnson, N., van Peperstraten, A. M., & Phillipson, G. (2008). Techniques for surgical retrieval of sperm prior to intra‐cytoplasmic sperm injection (ICSI) for azoospermia. The Cochrane Library. Rao, K. A., Carp, H. J. A., & Fischer, R. (2014). Principles and practice of assisted reproductive technology. Sandlow, J. I. (2013). Microsurgery for fertility specialists a practical text. New York, NY, Springer Schlegel, P. N. (1999). Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Human Reproduction, 14(1), 131-135. Seifer, D. B., & Collins, R. L. (2002). Office-based infertility practice. New York, Springer. South West Center for Reproductive Medicine. Patient Information - Surgical Sperm Retrieval Read More