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…

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 may be 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

25. Forward progression = 21%

26. Pregnancy rate = 25-53% by 1 yr

27. Serum free testosterone = increase

29. Sperm Delivery 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.. .. But only 50– 70% of couples actually achieve a pregnancy after vasovasostomy.

30. Sperm Delivery Timing is everything.. Secondary obstruction of the epididymis becomes increasingly more common when >10 yr have passed after vasectomy. Vasoepididymostomy may be required for these pts. 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.

31. Sperm Delivery Vasoepididymostomy should be considered when: The material coming from the proximal vas lumen is thick, pasty and devoid of sperm The fluid is creamy and contains only debris There is no fluid even when the vas is milked There is no wash out of sperm when the proximal vas is irrigated

32. Sperm Delivery - Vasovasostomy Multilayer vasovasostomy Modified single layer vasovasostomy Optimal results with vasovasostomyare achieved when: (1) accurate mucosa-to-mucosa anastomosis to allow a leakproofanastomosis, (2) tension-free anastomosis, (3) adequate blood supply to the ends of the vas with healthy mucosa and muscularis, and (4) atraumatictechnique. These fundamental principles are far more important than the number of layers performed or the exact suture material used.

34. Scrotal hematoma

35. 2ndry obstruction and consequent azoospermia in 3-12%

36. Sperm Delivery At present there are 3 types of microsurgical technique for anastomosis of lumen of the vas and tube of epididymis. End-to-end

37. Sperm Delivery End-to-side 2 1 3

38. Sperm Delivery End-to-side intussusception 2 1

40. Scrotal hematoma

42. Diagnosis of EJDO: Complete obstruction - low volume azoospermia, acidic semen lacking fructose, gonadotropins & testosterone levels are normal 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. Sperm Delivery - EJDO

43. Patients with those findings should be evaluated by TRUS, along with vasography and seminal vesiculography. TRUS alone has a poor specificity for EJDO. TRUS shows dilated seminal vesicles (over 1.5cm) Once visualised, seminal vesicle aspiration is important to document sperm production if present, and initiate surgery. No sperm = obstruction = vasography to confirm obstruction Sperm Delivery - EJDO

44. Surgical management of EJDO is TURED – transuretheral resection of the ejaculatory ducts Assoc. with risk of bladder neck and ext sphincter injury ie retrograde ejac, urine reflux into ducts leading to acute/chronic epididymitisand rectourethral fistula Alternative methods are TUBED – transurethral balloon dilation of th ejaculatory duct.s Sperm Delivery - EJDO

45. EJDO treatment results in a 55% improvement in semen parameters and 27% pregnancy rate. Sperm Delivery - EJDO

46. Procedures to Improve Sperm Retrieval

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) Unlike normospermic men, the best quality sperm is located in the proximal epididymis near the testis. MESA (microsurgical epididymal sperm aspiration) vs. PESA (percutaneous) Sperm Retrieval

48. Sperm Retrieval The most successful combination reported to date is MESA + ICSI. In one small scale study (81 male patients) at Cornell University from 1995-1998, Clinical pregnancies were achieved in 76% of couples. The only drawback is cost effectiveness.

49. Other methods include: Testis biopsy Percutaneous testis biopsy FNA Percutaneous TESA may be sufficient for immediate IVF +ICSI, but inadequate for cryopreservation Sperm Retrieval

50. Other Procedures to Improve Outcome of Fertiliy

51. Other Hypospadias repair Plication for Peyronie’s disease Electroejaculation/Penile Vibratory stimulation for anejaculation (caused by SC injury or retroperitoneal lymph node dissection) Testicular tumor removal/orchiectomy ex Leydig cell tumor causing azoospermia