Microsurgical Management of Male Infertility by Jonathan Schiff, M.D.
Microsurgical Management of Male Infertility
by Jonathan Schiff, M.D.
The surgical management of male infertility is one of the most exciting topics in all of medicine. Over the last 25 years, the application of advanced microsurgical techniques has made the treatment of the infertile male one of the great success stories in medicine. We can now offer successful treatment options to thousands of couples affected by male factor infertility whose only options in the past were donor sperm or adoption.
The most common correctable conditions that are associated with male infertility are varicoceles, vasal obstruction or severe testicular sperm production defects. Microsurgical ligation of a varicocele or surgical reconstruction of the vas deferens can correct these two states. With severe sperm production problems, microsurgical testicular sperm extraction is the most successful means of retrieving sperm for IVF.
Varicoceles are found in 35-40% of men with primary infertility (never had a pregnancy). The presence of a varicocele is even more likely among couples who have had a child in the past and now can not (secondary infertility) and is found in 75-80% of these men. Ligation of a varicocele may prevent infertility and low testosterone levels after repair.
The microsurgical, subinguinal approach is the preferred technique to fix varicoceles. This approach with optical magnification produces the best results in terms of removing all of the veins that may contribute to the formation of a varicocele. Furthermore, the microsurgical approach minimizes the complications associated with fixing varicoceles. We can precisely identify the testicular artery and prevent damage to this important structure. We also preserve any cremasteric arteries and lymphatic channels to prevent the formation of hydroceles.
Obstruction to the vas and epididymis represents the most treatable causes of male infertility. In these states, the testis functions normally and the problem is strictly a transport problem. In the United States, the most common cause of obstruction of the vas deferens is vasectomy. Up to 500,000 vasectomies are done annually and up to 5% ultimately are reversed. Injury to the vas is another common cause of obstruction, most often the result of childhood hernia repair or testis surgery. Several conditions including congenital bilateral absence of the vas deferens also result in variable lengths of vasal or epididymal obstruction. Microsurgical techniques have vastly improved the success rate of surgery to repair vasal or epididymal obstruction. Vasovasostomy is successful in up to 99% of cases, while vasoepididymostomy has a success rate of up to 90%.
Vasectomy Reversal – Vasovasostomy:
Overall patency rates of 86% and pregnancy rate of 51.6% were reported with the results for men with obstruction less than 3 years of 97% patency with a 76% pregnancy rate. Others have reported similarly good results with a microsurgical approach to vasectomy reversal. Several recent innovations have improved vasovasostomy outcomes. The use of the microdot technique represented an important technical point in terms of planning for optimal suture placement. Using this technique allows the surgeon to precisely target where to place sutures to achieve a water-tight anaastomosis and can result in up to a 99.5% rate of return of sperm to the ejaculate.
Vasectomy Reversal – Vasoepididymostomy:
Vasovasostomy is not always a feasible option to restore vasal patency. If epididymal obstruction is present, whether primary or secondary to chronic vasal obstruction, a vasoepididymostomy is required proximal to the obstruction in order to restore continuity for sperm transport. In the situation of epididymal obstruction, the decision to perform a vasovasotomy or vasoepididymostomy is made intraoperatively and is based on the microscopic examination of the vas fluid and the time of obstruction. To provide optimal outcomes, surgeons should be skilled at performing a microsurgical vasoepidymostomy if they perform vasectomy reversals.
Results comparing the four main techniques of vasoepididymostomy were recently published. The newer intussusception techniques which provide a more water-tight anastomosis have comparable patency rates with lower late failure rates than the older techniques. This very important finding suggests that men undergoing the intussusception techniques have a much lower failure rate after reconstruction, and will remain potentially fertile longer.
Sperm Retrieval Techniques
Not infrequently, men will have severe impairments in sperm production, with or without female factors. In these cases, sperm retrieval for assisted reproductive techniques may be the most appropriate option. Most couples prefer natural conception, and we make every effort to enable couples to conceive on their own. However, we evaluate each couple’s best reproductive options on a case by case basis, and when needed, microsurgical sperm retrieval is the surest path to success.
Several genetic and acquired problems cause men with obstructive azoospermia to be unreconstructable. Some patients with congenital bilateral absence of the vas deferens have defects in the sperm transport system. Many of these men are not candidates for reconstruction. Non-obstructive azoospermia occurs when men without obstruction have no sperm in their ejaculation. This is caused by either genetic or environmental problems -such as chemotherapy- that results in severe depression in spermatogenesis to the point that no sperm are present in the ejaculate. However, sperm retrieval is still possible in the majority of cases. Sperm production within the testicle is very variable. We believe that a technique that exposes the entire testis is critical to find sperm in these difficult cases.
Men with Klinefelter’s syndrome have a very severe form of genetic infertility associated with an abnormal karyotype of 47 XXY. Prior to modern assisted reproductive techniques, men with this problem were sterile. Today, a technique of sperm retrieval with intra-cytoplasmic sperm injection (ICSI), is the preferred treatment modality in those desiring paternity. Even in this severely impacted group of men, sperm can be retrieved in over 70% of cases and pregnancies are now routinely reported.
The technique of microsurgical epididymal sperm aspiration is used to obtain sperm in men with an intact epididymis. In men with non-obstructive azoospermia, the micro-dissection testicular sperm extraction technique provides the highest yield in terms of sperm retrieval while preserving as much testicular parenchyma as possible. Even in men with severe genetic causes of infertility such as Klinefelter’s syndrome, successful retrieval of sperm is possible in up to 70% of men. After chemotherapy, sperm can be found in nearly half of retrieval attempts in men with azoospermia.
Microsurgical testicular sperm extraction is the most successful technique to retrieve sperm in men with non-obstructive azoospermia and it results in the least damage to the testis. Post-operative scarring is substantially lower with this technique compared to open biopsy. The disadvantages of any microsurgical technique are the need for experience and the acquisition of microsurgical skills.
Most men with infertility are treatable using either medical therapy or via surgical techniques. The advances of microsurgery in the past 20 years have enabled thousands of men who would otherwise have been unable to father their own genetic children to help create life. Some obstacles remain, but each day brings new advances that allow us to help couples conceive.
Jonathan Schiff, M.D.
Assistant Clinical Professor, Urology, Mount Sinai School of Medicine, New York, NY
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