The role of surgery in male infertility

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The role of surgery in male infertility

  1. 1. The Role of Surgery in Male Infertility<br />By Dr. Farouk Hammoud<br />
  2. 2. Basic Concepts in Male Infertility<br /> In 15%of couples<br /> After 1 year ..<br />Over 50% <br />Prevalence:<br /> Definition:<br />Incidence:<br />
  3. 3. Basic Concepts in Male Infertility<br />History<br />Sexual History<br />Past History<br />Surgical/Medical History<br />Drug History<br />Family History<br />Physical Examination<br />General <br />Testis<br />Spermatic Cord<br />
  4. 4. Semen analysis is the cornerstone of the lab evaluation in the infertile man. <br />*As defined by WHO reference values 1999<br />
  5. 5. Hormonal status may be used as a function of clinical diagnosis when sperm density falls below 10 × 106 or indicated by history/physical examination…<br />
  6. 6.
  7. 7. Based on the initial history, physical exam, and laboratory studies, a differential diagnosis may be developed…<br />
  8. 8. The Role of Surgery <br />There are many possible causes of male infertility but only a few among them may be cured..<br />
  9. 9. Surgical treatments of male infertility can be divided into:<br />Diagnostic procedures<br />Procedures to improve sperm production<br />Procedures to improve sperm delivery<br />Sperm retrieval techniques<br />Other<br />
  10. 10. Diagnostic Procedures<br />Testis biopsy is no longer performed for diagnostic purposes alone.<br />In select patients, testicular biopsy is also therapeutic. <br /> Sperm retrieval IVF + ICSI.<br />Diagnostic testicular biopsy should be avoided.<br />
  11. 11. Diagnostic Procedures<br />“The rising incidence of testis cancer and carcinoma in situ(CIS), especially in infertile populations, requires that everyeffort be made for its early detection.”<br />“Testis biopsy is importantin the evaluation of men at risk of CIS or testicular cancer such as those with idiopathicinfertility, priorcryptorchidism, a history of testicularneoplasia or suggestive features onultrasound, such as an identified lesion or microlithiasis.”<br /> *R.I. McLachlan et. Al, Histological evaluation of the human testis: Mini Review. Hum. Reprod. Journal 2007<br />
  12. 12. Indications: <br />Azoospermia, normal testicular size, bilateral palpable vasadeferentia and normal FSH.<br />Diagnostic Procedures<br />Findings:<br />Motile sperm on wet preparation indicates normal spermatogenesis, therefore azoospermia is due to obstruction. <br />
  13. 13. Diagnostic Procedures<br />Taking bilateral biopsies from multiple sites should be reserved for patients with NOA when preparing for IVF + ICSI or cryopreservation.<br />Studies show that spermatogenesis often occurs focally even within the testes of patients with severe spermatogenicdisorders.<br />
  14. 14. A. Open testicular biopsy may be surgical or microsurgical (less complications).<br />Extruded tubules are excised with iris scissors and prepared by 2 methods.<br /> 1. Cytologic smear “touch imprint”<br /> 2. Wet preparation<br />Researchers found touch imprint cytology to be more quick as well as accurate.<br />Diagnostic Procedures<br />
  15. 15. Diagnostic Procedures<br />B. Percutaneous testicular biopsy uses a prostate biopsy gun.<br />This method can be done in an office setting and has fewer complications (pain + bleeding).<br />However the needle biopsy offers fewer seminiferous tubules for examination. <br />
  16. 16. C. FNA is the least invasive and least painful technique.<br />A simple, low-cost and low-risk procedure.<br />However, like percutaneous testis biopsy, pregnancy rates are much lower (25%).<br />Diagnostic Procedures<br />
  17. 17. Procedures to Improve Sperm Production<br />
  18. 18. Improving Sperm Production<br />Varicocele:<br />15% of the population<br />40% of infertile males<br />70% of secondary infertility<br />Therefore, varicocele is the most surgically correctablecause of male infertility.<br />
  19. 19. Improving Sperm Production<br />Indications for treatment in an infertile patient:<br />If the couple has known infertility<br />The female has normal or correctable cause of infertility<br />Palpable varicocele on physical examination or is corroborated with ultrasound examination<br />Has abnormal semen analysis<br />
  20. 20. Improving Sperm Production<br />Varicocelectomy involves ligation of all internal spermatic veins to prevent the retrograde flow of blood.<br />Surgical approaches:<br />Scrotal approach – now obsolete due to increased risk of testicular artery injury & high failure rate.<br />
  21. 21. Improving Sperm Production<br />Retroperitoneal (open or laparoscopic) – high ligation of int. spermatic vein above int. ing. ring. & preserving the int. spermatic art.<br />Disadvantage= Recurrence 15%; ligation of test. art. <br />Inguinal (Ivanessivich) – ing. incision above ext. ring with ligation of dilated veins<br />Disadvantage = test. art. to vein adherence in 50%; hydrocele formation<br />
  22. 22. Improving Sperm Production<br />The subinguinalapproach -Preservation of muscles & inguinal canal<br />Disadvantage = greater number of veins & art. lie below ext. ring; <br />The optimal approach is microscopic inguinal/subinguinal.<br />Microsurgical techniques = less complications<br />
  23. 23. Improving Sperm Production<br />Comparison of Recurrence Rates of Varicocelectomy Procedures<br />
  24. 24. Improving Sperm Production<br />Outcomes show statistically significant improvement in semen parameters following varicocele repair.<br />Rates of improvement following <br />varicocelectomy:<br /><ul><li>Motility = 41%
  25. 25. Forward progression = 21%
  26. 26. Pregnancy rate = 25-53% by 1 yr
  27. 27. Serum free testosterone = increase
  28. 28. FSH levels = decrease</li></li></ul><li>Procedures to Improve Sperm Delivery<br />
  29. 29. Sperm Delivery<br />Vasectomy reversal is a microsurgical procedure that takes place in 6% of males who have vasectomy; the most common reason being a desire to have children with a new spouse after divorce..<br />.. But only 50– 70% of couples actually achieve a pregnancy after vasovasostomy. <br />
  30. 30. Sperm Delivery<br />Timing is everything..<br />Secondary obstruction of the epididymis becomes increasingly more common when >10 yr have passed after vasectomy. Vasoepididymostomy may be required for these pts. <br />In female partners under age 30 yr at the time of vasectomy reversal, 94.2% established a pregnancy, whereas only 61.1% of female partners aged 40 yr became pregnant.<br />
  31. 31. Sperm Delivery<br />Vasoepididymostomy should be considered when:<br />The material coming from the proximal vas lumen is thick, pasty and devoid of sperm<br />The fluid is creamy and contains only debris<br />There is no fluid even when the vas is milked <br />There is no wash out of sperm when the proximal vas is irrigated<br />
  32. 32. Sperm Delivery - Vasovasostomy<br />Multilayer vasovasostomy<br />Modified single layer vasovasostomy<br />Optimal results with vasovasostomyare achieved when:<br />(1) accurate mucosa-to-mucosa anastomosis to allow a leakproofanastomosis, <br />(2) tension-free anastomosis, <br />(3) adequate blood supply to the ends of the vas with healthy mucosa and muscularis, and <br />(4) atraumatictechnique. <br />These fundamental principles are far more important than the number of layers performed or the exact suture material used.<br />
  33. 33. Sperm Delivery<br />Complications include <br /><ul><li>Granuloma formation
  34. 34. Scrotal hematoma
  35. 35. 2ndry obstruction and </li></ul>consequent azoospermia<br />in 3-12%<br />
  36. 36. Sperm Delivery<br />At present there are 3 types of microsurgical technique for anastomosis of lumen of the vas and tube of epididymis. <br />End-to-end<br />
  37. 37. Sperm Delivery<br />End-to-side<br />2<br />1<br />3<br />
  38. 38. Sperm Delivery<br />End-to-side intussusception<br />2<br />1<br />
  39. 39. Sperm Delivery<br />Complications include <br /><ul><li>Infection
  40. 40. Scrotal hematoma
  41. 41. Potential for injury to the art. blood supply to the testis</li></li></ul><li>EJDO (ejaculatory duct obstrution) is diagnosed in 1%-5% of infertile men. <br />The cause may be:<br />Congenital – utricular, mullerian, wolffianductcysts or atresia or stenosis of the EJD<br />Acquired – infection, trauma<br />Partial/Complete obstruction<br />Sperm Delivery - EJDO<br />
  42. 42. Diagnosis of EJDO:<br />Complete obstruction - low volume azoospermia, acidic semen lacking fructose, gonadotropins & testosterone levels are normal<br />Partial obstruction may present as low semen volume, severe oligoasthenospermia out of proportion to what might be expected from the testis size, and consistency combined with hormonal data.<br />Sperm Delivery - EJDO<br />
  43. 43. Patients with those findings should be evaluated by TRUS, along with vasography and seminal vesiculography. TRUS alone has a poor specificity for EJDO. <br /> TRUS shows dilated seminal vesicles (over 1.5cm)<br /> Once visualised, seminal vesicle aspiration is important to document sperm production if present, and initiate surgery.<br /> No sperm = obstruction = vasography to confirm obstruction<br />Sperm Delivery - EJDO<br />
  44. 44. Surgical management of EJDO is TURED – transuretheral resection of the ejaculatory ducts<br />Assoc. with risk of bladder neck and ext sphincter injury ie retrograde ejac, urine reflux into ducts leading to acute/chronic epididymitisand rectourethral fistula<br />Alternative methods are TUBED – transurethral balloon dilation of th ejaculatory duct.s<br />Sperm Delivery - EJDO<br />
  45. 45. EJDO treatment results in a 55% improvement in semen parameters and 27% pregnancy rate.<br />Sperm Delivery - EJDO<br />
  46. 46. Procedures to Improve Sperm Retrieval <br />
  47. 47. Epididymal retrieval techniques can be used in patients with OA (ex. CBAVD, prior vasectomy) since sperm is highly concentrated in the epididymal fluid (approx. 100 000 000/μL)<br />Unlike normospermic men, the best quality sperm is located in the proximal epididymis near the testis. <br />MESA (microsurgical epididymal sperm aspiration) vs. PESA (percutaneous) <br />Sperm Retrieval<br />
  48. 48. Sperm Retrieval<br />The most successful combination reported to date is MESA + ICSI.<br />In one small scale study (81 male patients) at Cornell University from 1995-1998, Clinical pregnancies were achieved in 76% of couples.<br />The only drawback is cost effectiveness.<br />
  49. 49. Other methods include:<br />Testis biopsy<br />Percutaneous testis biopsy<br />FNA<br />Percutaneous TESA may be sufficient for immediate IVF +ICSI, but inadequate for cryopreservation<br />Sperm Retrieval<br />
  50. 50. Other Procedures to Improve Outcome of Fertiliy<br />
  51. 51. Other<br />Hypospadias repair<br />Plication for Peyronie’s disease<br />Electroejaculation/Penile Vibratory stimulation for anejaculation (caused by SC injury or retroperitoneal lymph node dissection)<br />Testicular tumor removal/orchiectomy ex Leydig cell tumor causing azoospermia<br />

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