Postgraduate Training Course in Reproductive Health/Chronic Disease

Surgical treatment of male infertility

G.A. de Boccard , M.D.
Urologist F.M.H., E.B.U.
Infertility and Gynecologic Endocrinology Clinic,
Department of Obstetrics and Gynecology,
University Hospital, 1211 Geneva 14, Switzerland

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Summary

Obstructive fertility problems can often be treated by surgery and the development of microsurgery has brought new possibilities and hope to many infertile men. We will discuss the different surgical techniques to by-pass an obstruction, cure a varicocele and retrieve epididymal or testicular spermatozoa.

Key-words

Fertility - Vaso-vasostomy - Vaso-epididymostomy - Microsurgery - varicocele – laparoscopy - Testicular biopsy – ICSI - TESA

Introduction

Approximately 15% of couples are unable to conceive after one year of unprotected intercourse but a male factor is solely responsible in about 20% of infertile couples and contributory in another 30-40%. There are many possible causes of male infertility but only a few among them may be cured. Male infertility may occasionally be the manifestation of an underlying life threatening disease such as testicular cancer or pituitary tumor. The incidence of obstruction of the seminal excretory pathway in infertile men is estimated to be 7-14%[1] and ductal obstruction is responsible for 40% of cases. The advent of microsurgery opened a new era, giving hope to patients otherwise considered as definitely sterile.

We will only discuss the surgically curable causes of infertility. Hormonal and infectious diseases will not be evocated.

Only a few parts of the seminal tract can be reached by surgical procedures: intra-scrotal, subcutaneous or endoscopically at the level of the prostatic portion of the urethra.

Congenital pathology or acquired obstruction

Parts of the seminal tract, especially the vas deferens, can be missing or obstructed, usually partially, sometimes totally. The cause can be congenital, associated with cystic fibrosis, post-infectious after genital tuberculosis, gonorrhea or chlamydia, or iatrogenic after hernia repair, or the cure of a hydrocele. Vasectomy is also a major cause. If a short segment is missing or obstructed, it is possible to by-pass it. In case of agenesis or obstruction of the rete testis and the first part of the head of the epididymis (Young’s syndrome), there is unfortunately no possible curative treatment and testicular biopsy coupled with in vitro fertilization (ICSI), donor insemination or adoption must be considered.

Varicocele

Varicocele is generally the consequence of the absence of valves in one of the longest vein of the body, the left gonadic vein that drains in the left renal vein. It occurs in about 15% of the normal male population. It is found in 40% of those consulting for primary infertility and in up to 80% in men with secondary infertility. It is more often bilateral than earlier believed. Progressive atrophy and deterioration of testicular function is clearly associated with varicocele. Many authors relate the problem to an elevated scrotal temperature due to the lack of heath exchange at the level of the pampiniform plexus, others describe the toxic effects of elevated venous catecholamines, cortisol and renine. Recent findings suggest a lack of testosterone aromatization due to an enzymatic dysfunction related with heat[2].
The presence of a varicocele is determined by physical examination but Doppler sonography must confirm the persistence of a retrograde flow during the Valsalva maneuver since only refluant varicoceles deserve surgery.
There are two major indications for the treatment of varicocele: scrotal pain and infertility. A painful varicocele is generally large in size and easily diagnosed but the importance of subclinical varicoceles should be considered even in the presence of a small retrograde flow[3] .
If a fertility problem is evocated, a refluant varicocele deserves a treatment anyway since the result of the cure is neither dependant upon the size of the veins or upon the degree of the retrograde flow. However palpable varicoceles have a better surgical outcome.
Young males with clinically palpable varicocele should also be offered varicocele repair since progressive testicular atrophy is to be expected with future fertility problem.

 Surgical and non-surgical techniques for the treatment of a varicocele are available:

 - The high ligation technique consists in finding the spermatic vein at the level of the lower pole of the kidney through a retroperitoneal approach. The skin is horizontally incised medial to the anterior superior iliac spine, the external oblique muscle is incised, the internal oblique muscle is retracted and the peritoneum is teased away. At this level the vein is generally unique and easy to ligate. It however happens that some collaterals take their origin from another vein, causing the failure of the procedure in about 2% of the cases. The surgical approach on the right side may also be more difficult because the right gonadic vein drains in the inferior vena cava.

 -Inguinal ligation is performed through a low inguinal incision. The aponeurosis of the external oblique is incised and the spermatic cord isolated. The spermatic fascia is incised and the dilated veins are dissected, ligated and excised. This allows a complete stop in the internal drainage. This technique is very safe, but the number of relapses is often high because of difficulties with dissection, which leaves patent veins in up to 21% of the cases, unless it is performed by a skilled surgeon under microscope or magnifying glasses[4],[5].

 -Radiologically controlled embolization is an easy day procedure: After puncture and catheterization of one of the femoral veins, the radiologist identifies the refluant spermatic vein by injecting an iodine dye during a Valsalva maneuver. Then, during a new maneuver he injects a sclerotizing solution, a wire coil or a detachable balloon. This technique is cost and time effective but has also a failure rate of 12% due to difficulties in finding the vein in case of anatomical variations. There is also a small risk of migration of the sclerotizing agent or coil and it also exposes the patient to rather useless irradiation.

 -The laparoscopic technique is now being routinely used in many centers. After punction of the umbilicus, the peritoneal cavity is insufflated with CO2 at a pressure of 12 mmHg. Then a camera is inserted through a 10 mm port. The vein is easily identified, often double, on the left side, running under the posterior peritoneum between the sigmoid and the internal inguinal ring. Two other 5 mm ports are needed to insert the forceps and scissors then the abdominal pressure is lowered to 8 mmHg. After dissection, the ligation of the refluent spermatic vein is made 1,5 cm over the internal inguinal ring using titanium clips. The spermatic artery and the lymphatics are easily identified and spared, collateral veins can also be clipped or coagulated during the same procedure. The laparoscopic method causes less morbidity (day procedure or only 24 hours hospitalization) and, being microsurgical, is very precise. It seems to avoid the recurrences through revascularization by peritoneal branches. This procedure needs a skilled laparoscopic surgeon in order to avoid the dangers of laparoscopy itself.
The surgeon’s experience and skill, together with the options available, should determine the choice of varicocele treatment.
Overall results of varicocele repair in collated studies show 50% to 90% improvement in semen quality and 30% to 50% may initiate a pregnancies after 6 to 9 months [6] . For men with azoospermia or severe oligospermia, modest improvement in semen quality after varicocele repair may have a significant impact on the couple's fertility options [7] .

 Ejaculatory duct resection

 In the prostate, after the junction with the seminal vesicle the vas ends in the ejaculatory duct at the level of the veru montanum. Even a small lesion in that region can cause an obstruction, often bilateral. Generally its etiology is inflammatory but in some cases a congenital malformation like a Mullerian duct cyst or a Wolffian malformation can be found. It is suspected in case of azoospermia or severe oligospermia, low semen volume (less than 1.0 ml), absence of fructose in the seminal plasma and normal FSH. Perineal pain and hematospermia may be associated. The rest of the vas deferens is usually normal. Cystic lesions or abscesses causing ejaculatory duct obstruction are best diagnosed by transrectal ultrasound echography showing also a dilatation of the seminals.
The treatment is performed endoscopically with a resectoscope incision along the veru montanum. Deep resection is sometimes needed and one must be very careful to avoid rectum perforation or sphincter lesion. Results are controversial, in 25% of the cases we will see the return of living sperm.

 Vaso-vasostomy

 The most frequent cause of obstruction of the vas deferens is vasectomy. In Europe, 10-15% of the men rely on this form of contraception and among 100 men undergoing vasectomy, 2 to 6 will ask for a vasectomy-reversal. Short segmental agenesis, accidental section during hernia repair and orchidopexy, or post-infectious localized obstruction is less common. The influence of the delay after vasectomy on the fertility rate is controversial[8] because fertility rate decreases in any case naturally with time in normal men[9].
Technically, vaso-vasostomy can be performed anywhere along the scrotal and inguinal part of the vas. It is also theoretically possible intraperitoneally by laparoscopy but generally, as a consequence of vasectomy, it is done in the mid or the upper part of the scrotum.
We prefer the two-layer technique with the help of a microscope (stereoscopic f:250  lens). A 3 cm incision is made over the palpated upper end of the sectioned vas. The two ends are dissected from the surrounding tissues and exposed with the « Goldstein Microspike Approximator » if available, the scarred area are resected. The distal end is flushed with saline to check for its permeability and dilate the lumen, fluid from the testicular end is checked for sperm by an extemporaneous microscopic examination. However absence of sperm cells is not conclusive for obstruction. A large yellow Penrose drain is placed underneath in order to have a better vision of the sutures. Then six to eight 10-0 absorbable polyglycolic monofilament stitches are placed to suture the mucosa, then the same number of 9-0 absorbable polyglycolic monofilament stitches are placed on the sero-muscular layer. Non absorbable (i.e. Nylon) or braided sutures should be avoided since they may induce a macrophagic reaction.
Easy to perform is the modified two-layers technique which allows almost similar results: Four 9-0 monofilament absorbable polyglycolic stitches are placed at 6, 9, 3 and 12 o'clock through the serosa and the mucosa in order to approximate the two portions of the vas. Then four additional 9-0 stitches are placed on the serosa between the first four to ensure tightness of the vas. The use of a microscope is absolutely necessary in all cases.
In some cases, during vasectomy large part of the vas has been resected, making tensionfree direct anastomosis impossible. In order to gain some length the epididymis can be dissected free from the testis, being attached only by the head and brought up to the distal end of the vas, thus making anastomosis possible without traction.
Our own results show an 86% patency rate, comparable with the different published series. The pregnancy rate is over 60%. As stated before, the fertility rate decreases with time elapsed after vasectomy but the patency rate is still about 70% after more than 15 years of obstruction with a pregnancy rate of 49%.
Recently, researchers isolated an epididymal protein responsible for sperm penetration in the ovule and that decreases with time after vasectomy [10] .
 It should be noted that the mean time between vasectomy reversal and conception is more than twelve months and, more important, that the fertility rate of the reversal group is the same as in the normal control group8. The age of the wife is essential: between 40 and 45 years, there are only 20% of pregnancies, over 45, there is no possibility.
Attempts to repair partially obstructed ducts should be avoided. The result of microsurgery is only 60% of improvement but definitive obstruction may also happen. The indication shall be very carefully discussed, for example if the couple does not want to consider IVF with ICSI.

Vasoepididymostomy

If the obstruction is located at the level of the epididymis in the presence of a normal vas, the first choice therapy is vaso-epididymostomy. Also after an unsuccessful first vasectomy reversal attempt, and absence of sperm cells in the fluid, vaso-epididymostomy can be indicated. Anastomosis can be performed up to the efferent tubules on the testis.
After incision of the scrotum, the testis and the epididymis are exposed. The microscope is installed (stereoscopic f:250). The vas is dissected and his patency controlled by saline injection. The epididymis is freed from the testis, being only attached at the level of the head. It is then transected at an apparently healthy level, leaving a bundle of open tubules apparent. After an initial general oozing of fluid, one of the tubule will permanently emit spermatic white fluid that shall be microscopically checked for spermatozoa. If none can be found at this level, a more proximal section will be performed. With the help of a specially designed vaso-epididymal Goldstein’s microspike approximator the transected distal vas will be brought to the opened tubule. If no sperm is found at this stage a testicular biopsy with cryoconservation is done in order to provide further fertilization possibilities. We then perform an end to end anastomosis We first place four 10-0 absorbable monofilament polyglycolic stitches through the individual epididymal tubule and the mucosa of the vas to ensure a first approximation; then the seromuscular layer of the vas is tightly secured to the tunica of the epididymis by eight to ten 9-0 polyglycolic monofilament absorbable stitches. Two 7-0 PDS stitches are finally externally placed to secure the external tunica of the vas to the epididymis, preventing any harmful traction.
An older technique consists in opening laterally the epididymis proximally to the obstructed level and isolating a single tubule which is incised and not transected, and anastomosed side to end with the vas using the same described technique.
The results of this procedure show has a patency rate of 65 to 85% with a pregnancy rate of only 30 to 44%(12). Vasoepididymostomy gives however a higher pregnancy rate than IVF with ICSI and should be preferred in any case of obstructive sterility at the epididymal level. It also allows a further second pregnancy without going through IVF procedure again.

 Epididymal sperm aspiration

 Until recent years, no treatment was available in case of bilateral absence or bilateral total obstruction of the vas. The first description by Temple-Smith[11] of sperm micro-aspiration from the epididymis and in vitro fertilization resulting in a pregnancy followed by Silber[12] who repeated the procedure with success opened a new field. Silber had even a better pregnancy rate in cases of agenesis than in those with acquired obstruction. The actual fecundation rate is 70% with 30% pregnancy rate[13].
 For the urologist, the technique is quite simple. The preparation of the epididymis is made according to the second vaso-epididymostomy technique but instead of anastomosing the vas, the sperm coming out of the tubule is aspirated in a 2 ml insulin seringue (gamma sterilization only, no gas) prefilled with Percoll. It is generally possible to collect 10 to 20 million spermatozoa within 30 to 60 minutes. The epididymal duct and the tunica of the epididymis should be closed as precisely as possible with 10-0 or 9-0 absorbable polyglycolic stitches in order to allow repeating the procedure easily if required. The spermatozoa are extemporaneously examined, then frozen. The stimulation and the sampling of the oocytes from the partner being indicated only in the presence of living spermatozoa, thus avoiding unnecessary procedures.

 I.C.S.I.  with testicular biopsy

 The development of the intra cytoplasmic sperm injection (I.C.S.I.) has brought us further in treating sterile men. In fact, living spermatozoa can be retrieved in almost all cases of obstructive azoospermia. In other cases, even after a former negative biopsy and elevated FSH, it is still possible to retrieve living spermatozoa in about 50% of cases.
Biopsy is best performed by the exteriorization of both testes. Incision is done longitudinally on the whole length of the testis in order to obtain a long and thin ribbonlike sample, which shall be extemporaneously examined in order to find a producing zone in the testis7. Percutaneous biopsy, although described, does not give as good results. The biopsy, if containing a complete spermatogenetic process, even in patients with tubular atrophy, will allow the biologist to pick up one single spermatozoa and inject it in the oocyte. This procedure has a comparable or even higher fertilization and pregnancy rate than IVF alone11, [14] , [15] . In that case again cryopreservation of the sperm cells allows delaying female stimulation, avoiding unnecessary expensive treatments.
Since  genetic disorders are present in 17% of severe oligozoospermia and 34% of azoospermia, especially CF and microdeletion of Y, genetic testing and counselling is formally indicated [16] .
Diagnostic testicular biopsy should be avoided since it doesn’t bring any therapeutical advice and can unfortunately cause inflammatory or immunological impairment of the testicular function. It is however of great interest to get a histological examination of the samples collected for sperm retrieval.

 Microsurgical repair versus sperm retrieval

 Vasovasostomy and vasoepididymostomy have been proven more cost-effective than sperm retrieval with FIV or ICSI. Also, successful reconstruction allows couples to have a second child without additional medical procedure. Therefore, microsurgical reconstruction is best indicated as an initial treatment for obstructive azoospermia.

REFERENCES

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Edited by Aldo Campana,