Surgical treatment of male infertility
G.A. de Boccard , M.D.
See also presentation
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.
Fertility - Vaso-vasostomy - Vaso-epididymostomy - Microsurgery - varicocele – laparoscopy - Testicular biopsy – ICSI - TESA
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% 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 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
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,.
-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.
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 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
because fertility rate decreases in any case naturally with time in normal
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.
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 of sperm
micro-aspiration from the epididymis and in vitro fertilization resulting
in a pregnancy followed by Silber
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.
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.
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.
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