World J Mens Health.  2012 Aug;30(2):108-113.

Advances in Surgical Treatment of Male Infertility

• Lee HS
• Seo JT

Abstract

A male factor is the only cause of infertility in 30% to 40% of couples. Most causes of male infertility are treatable, and the goal of many treatments is to restore the ability to conceive naturally. Varicoceles are present in 15% of the normal male population and in approximately 40% of men with infertility. Varicocele is the most common cause of male infertility that can be corrected surgically. In males with azoospermia, the most common cause is post-vasectomy status. Approximately 6% of males who undergo vasectomy eventually seek reversal surgery. Success of vasectomy reversal decreases with the number of years between vasectomy and vasovasostomy. Other causes of obstructive azoospermia include epididymal, vasal or ejaculatory duct abnormalities. Epididymal obstruction is the most common cause of obstructive azoospermia. Patients with epididymal obstruction without other anatomical abnormalities can be considered as candidates for vasoepididymostomy. With microsurgical techniques, success of patency restoration can reach 70~90%. In case of surgically uncorrectable obstructive azoospermia, sperm extraction or aspiration for in vitro fertilization is needed. Nonobstructive azoospermia is the most challenging type of male infertility. However, microsurgical testicular sperm extraction may be an effective method for nonobstructive azoospermia patients.

Keyword

Infertility; Diagnosis

MeSH Terms

Azoospermia
Ejaculatory Ducts
Family Characteristics
Fertilization in Vitro
Fibrinogen
Humans
Infertility
Infertility, Male
Male
Spermatozoa
Varicocele
Vasectomy
Vasovasostomy
Fibrinogen

Reference

1. Thonneau P, Marchand S, Tallec A, Ferial ML, Ducot B, Lansac J, et al. Incidence and main causes of infertility in a resident population (1,850,000) of three French regions (1988-1989). Hum Reprod. 1991. 6:811–816.

2. Goldstein M, Tanrikut C. Microsurgical management of male infertility. Nat Clin Pract Urol. 2006. 3:381–391.

3. Meng MV, Greene KL, Turek PJ. Surgery or assisted reproduction? A decision analysis of treatment costs in male infertility. J Urol. 2005. 174:1926–1923.

4. Lee JS, Park HJ, Seo JT. What is the indication of varicocelectomy in men with nonobstructive azoospermia? Urology. 2007. 69:352–355.

5. Male Infertility Best Practice Policy Committee of the American Urological Association. Practice Committee of the American Society for Reproductive Medicine. Report on varicocele and infertility. Fertil Steril. 2004. 82:Suppl 1. S142–S145.

6. Agarwal A, Deepinder F, Cocuzza M, Agarwal R, Short RA, Sabanegh E, et al. Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach. Urology. 2007. 70:532–538.

7. Sharlip ID, Jarow JP, Belker AM, Lipshultz LI, Sigman M, Thomas AJ, et al. Best practice policies for male infertility. Fertil Steril. 2002. 77:873–882.

8. Evers JL, Collins JA. Assessment of efficacy of varicocele repair for male subfertility: a systematic review. Lancet. 2003. 361:1849–1852.

9. Goldstein M, Gilbert BR, Dicker AP, Dwosh J, Gnecco C. Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol. 1992. 148:1808–1811.

10. Kim ED, Barqawi AZ, Seo JT, Meacham RB. Apoptosis: its importance in spermatogenic dysfunction. Urol Clin North Am. 2002. 29:755–765.

11. Su LM, Goldstein M, Schlegel PN. The effect of varicocelectomy on serum testosterone levels in infertile men with varicoceles. J Urol. 1995. 154:1752–1755.

12. Al-Kandari AM, Shabaan H, Ibrahim HM, Elshebiny YH, Shokeir AA. Comparison of outcomes of different varicocelectomy techniques: open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: a randomized clinical trial. Urology. 2007. 69:417–420.

13. Thomason AM, Fariss BL. The prevalence of varicoceles in a group of healthy young men. Mil Med. 1979. 144:181–182.

14. Fariss BL, Fenner DK, Plymate SR, Brannen GE, Jacob WH, Thomason AM. Seminal characteristics in the presence of a varicocele as compared with those of expectant fathers and prevasectomy men. Fertil Steril. 1981. 35:325–327.

15. Jarow JP. Effects of varicocele on male fertility. Hum Reprod Update. 2001. 7:59–64.

16. Dhabuwala CB, Hamid S, Moghissi KS. Clinical versus subclinical varicocele: improvement in fertility after varicocelectomy. Fertil Steril. 1992. 57:854–857.

17. Seo JT, Kim KT, Moon MH, Kim WT. The significance of microsurgical varicocelectomy in the treatment of subclinical varicocele. Fertil Steril. 2010. 93:1907–1910.

18. Czaplicki M, Bablok L, Janczewski Z. Varicocelectomy in patients with azoospermia. Arch Androl. 1979. 3:51–55.

19. Kim ED, Leibman BB, Grinblat DM, Lipshultz LI. Varicocele repair improves semen parameters in azoospermic men with spermatogenic failure. J Urol. 1999. 162:737–740.

20. Weedin JW, Khera M, Lipshultz LI. Varicocele repair in patients with nonobstructive azoospermia: a meta-analysis. J Urol. 2010. 183:2309–2315.

21. Jarow JP, Espeland MA, Lipshultz LI. Evaluation of the azoospermic patient. J Urol. 1989. 142:62–65.

22. Berardinucci D, Zini A, Jarvi K. Outcome of microsurgical reconstruction in men with suspected epididymal obstruction. J Urol. 1998. 159:831–834.

23. Hendry WF, Parslow JM, Stedronska J. Exploratory scrototomy in 168 azoospermic males. Br J Urol. 1983. 55:785–791.

24. Jequier AM. Obstructive azoospermia: a study of 102 patients. Clin Reprod Fertil. 1985. 3:21–36.

25. Pierik FH, Vreeburg JT, Stijnen T, De Jong FH, Weber RF. Serum inhibin B as a marker of spermatogenesis. J Clin Endocrinol Metab. 1998. 83:3110–3114.

26. Jarow JP, Sigman M, Buch JP, Oates RD. Delayed appearance of sperm after end-to-side vasoepididymostomy. J Urol. 1995. 153:1156–1158.

27. Eguchi J, Nomata K, Hirose T, Nishimura N, Igawa T, Kanetake H, et al. Clinical experiences of microsurgical side-to-end epididymovasostomy for epididymal obstruction. Int J Urol. 1999. 6:271–274.

28. Kolettis PN, Thomas AJ Jr. Vasoepididymostomy for vasectomy reversal: a critical assessment in the era of intracytoplasmic sperm injection. J Urol. 1997. 158:467–470.

29. Pavlovich CP, Schlegel PN. Fertility options after vasectomy: a cost-effectiveness analysis. Fertil Steril. 1997. 67:133–141.

30. Donovan JF Jr, DiBaise M, Sparks AE, Kessler J, Sandlow JI. Comparison of microscopic epididymal sperm aspiration and intracytoplasmic sperm injection/in-vitro fertilization with repeat microscopic reconstruction following vasectomy: is second attempt vas reversal worth the effort? Hum Reprod. 1998. 13:387–393.

31. Potts JM, Pasqualotto FF, Nelson D, Thomas AJ Jr, Agarwal A. Patient characteristics associated with vasectomy reversal. J Urol. 1999. 161:1835–1839.

32. Singh I, Kaza RC. A case in favour of one sided microscopic vasovasostomy--the New Delhi experience. Int Urol Nephrol. 1996. 28:27–31.

33. Belker AM, Thomas AJ Jr, Fuchs EF, Konnak JW, Sharlip ID. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol. 1991. 145:505–511.

34. Silber SJ. Microscopic vasectomy reversal. Fertil Steril. 1977. 28:1191–1202.

35. Bhasin S. Approach to the infertile man. J Clin Endocrinol Metab. 2007. 92:1995–2004.

36. Kumar R, Mukherjee S, Gupta NP. Intussusception vasoepididymostomy with longitudinal suture placement for idiopathic obstructive azoospermia. J Urol. 2010. 183:1489–1492.

37. Kumar R, Gautam G, Gupta NP. Early patency rates after the two-suture invagination technique of vaso-epididymal anastomosis for idiopathic obstruction. BJU Int. 2006. 97:575–577.

38. Peng J, Yuan Y, Zhang Z, Gao B, Song W, Xin Z, et al. Patency rates of microsurgical vasoepididymostomy for patients with idiopathic obstructive azoospermia: a prospective analysis of factors associated with patency--single-center experience. Urology. 2012. 79:119–122.

39. Lee JS, Seo JT. The need for sperm cryopreservation at the time of vasovasostomy or vasoepididymostomy. Korean J Urol. 2003. 44:801–804.

40. Park YS, Lee SH, Song SJ, Jun JH, Koong MK, Seo JT. Influence of motility on the outcome of in vitro fertilization/intracytoplasmic sperm injection with fresh vs. frozen testicular sperm from men with obstructive azoospermia. Fertil Steril. 2003. 80:526–523.

41. Seo JT. Diagnosis and treatment of surgically uncorrectable azoospermia. Korean J Androl. 2004. 22:1–10.

42. Silber SJ, Ord T, Balmaceda J, Patrizio P, Asch RH. Congenital absence of the vas deferens. The fertilizing capacity of human epididymal sperm. N Engl J Med. 1990. 323:1788–1789.

43. Schlegel PN, Berkeley AS, Goldstein M, Cohen J, Alikani M, Adler A, et al. Epididymal micropuncture with in vitro fertilization and oocyte micromanipulation for the treatment of unreconstructable obstructive azoospermia. Fertil Steril. 1994. 61:895–901.

44. Devroey P, Liu J, Nagy Z, Goossens A, Tournaye H, Camus M, et al. Pregnancies after testicular sperm extraction and intracytoplasmic sperm injection in non-obstructive azoospermia. Hum Reprod. 1995. 10:1457–1460.

45. Seo JT, Park YS, Lee JS. Successful testicular sperm extraction in Korean Klinefelter syndrome. Urology. 2004. 64:1208–1211.

46. Seo JT, Ko WJ. Predictive factors of successful testicular sperm recovery in non-obstructive azoospermia patients. Int J Androl. 2001. 24:306–310.

47. Schlegel PN, Li PS. Microdissection TESE: sperm retrieval in non-obstructive azoospermia. Hum Reprod Update. 1998. 4:439.

48. Ramasamy R, Yagan N, Schlegel PN. Structural and functional changes to the testis after conventional versus microdissection testicular sperm extraction. Urology. 2005. 65:1190–1194.