1.The Role of Surgery in Male Infertility
By Dr. Farouk Hammoud

2. Basic Concepts in Male Infertility
In 15%of couples
After 1 year ..
Over 50%
Prevalence:
Definition:
Incidence:
3. Basic Concepts in Male Infertility
History
Sexual History
Past History
Surgical/Medical History
Drug History
Family History
Physical Examination
General
Testis
Spermatic Cord
4. Semen analysis is the cornerstone of the lab evaluation in the infertile man.
*As defined by WHO reference values 1999
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
6. 7. Based on the initial history, physical exam, and laboratory studies, a differential diagnosis may be developed
8. The Role of Surgery
There are many possible causes of male infertility but only a few among them may be cured..
9. Surgical treatments of male infertility can be divided into:
Diagnostic procedures
Procedures to improve sperm production
Procedures to improve sperm delivery
Sperm retrieval techniques
Other
10. Diagnostic Procedures
Testis biopsy is no longer performed for diagnostic purposes alone.
In select patients, testicular biopsy is also therapeutic.
Sperm retrieval IVF + ICSI.
Diagnostic testicular biopsy should be avoided.
11. Diagnostic Procedures
The rising incidence of testis cancer and carcinoma in situ(CIS), especially in infertile populations, requires that everyeffort be made for its early detection.
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.
*R.I. McLachlan et. Al, Histological evaluation of the human testis: Mini Review. Hum. Reprod. Journal 2007
12. Indications:
Azoospermia, normal testicular size, bilateral palpable vasadeferentia and normal FSH.
Diagnostic Procedures
Findings:
Motile sperm on wet preparation indicates normal spermatogenesis, therefore azoospermia is due to obstruction.
13. Diagnostic Procedures
Taking bilateral biopsies from multiple sites should be reserved for patients with NOA when preparing for IVF + ICSI or cryopreservation.
Studies show that spermatogenesis often occurs focally even within the testes of patients with severe spermatogenicdisorders.
14. A. Open testicular biopsy maybe surgical or microsurgical (less complications).
Extruded tubules are excised with iris scissors and prepared by 2 methods.
1. Cytologic smear touch imprint
2. Wet preparation
Researchers found touch imprint cytology to be more quick as well as accurate.
Diagnostic Procedures
15. Diagnostic Procedures
B. Percutaneous testicular biopsy uses a prostate biopsy gun.
This method can be done in an office setting and has fewer complications (pain + bleeding).
However the needle biopsy offers fewer seminiferous tubules for examination.
16. C. FNA is the least invasive and least painful technique.
A simple, low-cost and low-risk procedure.
However, like percutaneous testis biopsy, pregnancy rates are much lower (25%).
Diagnostic Procedures
17. Procedures to Improve Sperm Production
18. Improving Sperm Production
Varicocele:
15% of the population
40% of infertile males
70% of secondary infertility
Therefore, varicocele is the most surgically correctablecause of male infertility.
19. Improving Sperm Production
Indications for treatment in an infertile patient:
If the couple has known infertility
The female has normal or correctable cause of infertility
Palpable varicocele on physical examination or is corroborated with ultrasound examination
Has abnormal semen analysis
20. Improving Sperm Production
Varicocelectomy involves ligation of all internal spermatic veins to prevent the retrograde flow of blood.
Surgical approaches:
Scrotal approach now obsolete due to increased risk of testicular artery injury & high failure rate.
21. Improving Sperm Production
Retroperitoneal (open or laparoscopic) high ligation of int. spermatic vein above int. ing. ring. & preserving the int. spermatic art.
Disadvantage= Recurrence 15%; ligation of test. art.
Inguinal (Ivanessivich) ing. incision above ext. ring with ligation of dilated veins
Disadvantage = test. art. to vein adherence in 50%; hydrocele formation
22. Improving Sperm Production
The subinguinalapproach -Preservation of muscles & inguinal canal
Disadvantage = greater number of veins & art. lie below ext. ring;
The optimal approach is microscopic inguinal/subinguinal.
Microsurgical techniques = less complications
23. Improving Sperm Production
Comparison of Recurrence Rates of Varicocelectomy Procedures
24. Improving Sperm Production
Outcomes show statistically significant improvement in semen parameters following varicocele repair.
Rates of improvement following
varicocelectomy:

Motility = 41%

25. Forward progression = 21% 26. Pregnancy rate = 25-53% by 1 yr 27. Serum free testosterone = increase 28. FSH levels = decrease