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Oligospermia

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Oligospermia

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Oligospermia

  1. 1. Dr. Prateek Laddha SR, Department of Urology CMC Ludhiana
  2. 2. VARICOCELE  Definition  Etiology  Pathophysiology of testicular changes  Clinical features  Investigations  Treatment – - Expectant treatment - Indication of intervention - Treatment options - Complication of surgery  Complication of untreated varicocele
  3. 3. DEFINITION Dilated & tortuous veins of pampaniform plexus of spermatic cord found in about 15% of male adolescents with a marked left sided predominance
  4. 4. ETIOLOGY ?
  5. 5. ETIOLOGY
  6. 6. ETIOLOGY Responsible factors 8-10 cm longer left testicular Vv. increased→ hydrostatic pressure in upright position Entry of left testicular Vv into renal vein at 900 “Nutcraker phenomenon” due to passage of left testicular vein between SMA & Aorta Congenital absence of valve in left vein in 40% Intrinsic ectasia of plexus due to cremaster atrophy Loaded left colon
  7. 7. PATHOPHYSIOLOGY OF TESTICULAR CHANGES Adverse effects on spermatogenesis –  Reflux of renal and adrenal metabolites  Hyperthermia  Hypoxia  Local testicular hormonal imbalance  Intra testicular hyper perfusion injury  Increased oxidative stress
  8. 8. HISTO-PATHOLOGICAL CHANGES Both testes affected evenly by unilateral varicocele  Tubular thickening  Interstitial fibrosis  Hypo-spermatogensis  Maturation arrest  Leydig cell dysfunction
  9. 9. CLINICAL FEATURES (SYMPTOMS)  Asymptomatic - detected during medical examination or evaluation of infertile male  Constant dragging pain in Testis aggravated by standing & relieved by lying down  Impaired sperm quality  Cosmetic attention  Swelling in scrotum  Failure of affected testis to grow
  10. 10. CLINICAL FEATURES (SIGNS) Examine in warm room, standing & lying position, with or without valsulva maneuver  Painless compressible mass with feeling of “Bag of worms”  Small sized Testis on affected side
  11. 11. GRADES OF VARICOCELE Grade I – Palpable only during valsulva maneuver Grade II – Palpable without Valsulva in standing upright position Grade III – Visible through scrotal skin Subclinical – detected during USG
  12. 12. INVESTIGATION  Doppler stethoscope (5.3 MHz probe) -audible rush of blood on valsulva  Colour Doppler –detects Sub Clinical Varicocele also  Ultra sound of abdomen  Semen examination
  13. 13. USG & COLOUR DOPPLER
  14. 14. TREATMENT Expectant treatment – in adolescent males who are asymptomatic with normal size of testis
  15. 15. INDICATION OF INTERVENTION  Asymptomatic varicocele with >20% volume loss of Testis (>2ml)  Symptomatic varicocele - Impaired sperm quality - Pain - Cosmetic reasons  Medically unfit
  16. 16. TREATMENT ALTERATIVES(Obliteration of internal spermatic veins)  Scrotal approach  Inguinal approach (modified Ivanissevich)  Retroperitoneal approach (Palomo’s)  Sub inguinal approach  Laparoscopic approach  Per-cutaneous embolization – through trans femoral/ trans jugular access (Detachable balloons or steel coils are used)  Micro Surgery  Antigrade scrotal sclerotherapy (ASS)
  17. 17. INCISIONS
  18. 18. LAPAROSCOPIC APPROACH
  19. 19. PERCUTANEOUS EMBOLIZATION
  20. 20. MICROSURGERY
  21. 21. ANTEGRADE SCLEROTHERAPY
  22. 22. COMPLICATIONS OF TREATMENT  Hydrocele formation – due to ligation of lymphatics  Recurrence  Testicular infarction  Migration of coil to pulmonary artery – usually not fatal  Infection & haemorrhage
  23. 23. COMPLICATION OF UNTREATED VARICOCELE  Male infertility  Testicular atrophy
  24. 24. LET US REVISE  Definition  Etiology  Pathophysiology of testicular changes  Clinical features  Investigations  Treatment  Complication of untreated varicocele
  25. 25.  dilatation of the pampiniform venous plexus and the internal spermatic vein  well-recognized cause of decreased testicular function  very rare < 9 y.o.  ~16% of adolescents  ~15-20% of all males  40% of infertile males  scrotal varicoceles are the most common cause of poor sperm production and decreased semen quality
  26. 26. The prevalence of varicocele and associated testicular hypotrophy by age Age, years Prevalence, % of varicocele hypotrophic testis <11 0 0 11–14 6–8 7.3 15–19 11–19 9.3
  27. 27. first recognized as a clinical problem in 16th century relationship between infertility and varicocele proposed in late 19th century  thereafter, others reported association with arrest of sperm secretion and the subsequent restoration of fertility following repair enlarged scrotal veins in teenagers referenced as early as 1885
  28. 28. 1950s  report of fertility following varicocele repair in an individual known to be azoospermic  surgical correction as clinical approach to certain kinds of male infertility gained support among American surgeons Continued research documented recurrent pattern of low sperm count, poor motility, and predominance of abnormal sperm forms (stress pattern of semen)  not specific to varicocele  suggests early evidence of testicular damage
  29. 29. 80-90% involve the left testicle  anatomic factors (1) angle at which left testicular vein enters left renal vein (2) lack of effective antireflux valves at juncture of testicular vein and renal vein (3) increased renal vein pressure due to compression between the superior mesenteric artery and the aorta (ie, nutcracker effect)  35-40% of men with palpable left varicocele may actually have bilateral varicoceles  Recent study by Gat et al  ~ 80% of men with a left clinical varicocele had bilateral varicoceles revealed by noninvasive radiologic testing
  30. 30. Scrotal mass/swelling, symptoms of acute or chronic scrotal discomfort, differing testicular sizes without a palpable variocele, and incidental finding on scrotal US Grading:  Grade 0 - Subclinical varicocele, Dx by US or venography  Grade 1 – palpable with Valsalva maneuver  Grade 2 - Easily detected without Valsalva maneuver  Grade 3 - Detected visually at a distance
  31. 31.  Most asymptomatic  usually unilateral and almost always left-sided  unilateral right-sided varicocele should prompt investigation for retroperitoneal process  mass that causes obstruction of the right internal spermatic vein  Thrombosis/occlusion of the inferior vena cava must be ruled out in  Situs inversus another etiology of right-sided varicocele  Initial presentation usually occurs during puberty, with incidence in 13-year-old adolescent boys equal to that of adult men
  32. 32.  Multiple investigators have directly correlated the degree of testicular atrophy with varicocele grade  Steeno et al  testis volume reduced by 81% with grade 3 and by 34% with grade 2  No patients with grade 1 had testicular atrophy
  33. 33.  Unknown how impairment of sperm structure, function, and production occurs  interference with thermoregulation  other theories include the possible effects of pressure, oxygen deprivation, heat injury, and toxins  Despite considerable research, no one theory proved unquestionably  Regardless, indisputably a significant factor in decreasing testicular function and in reducing semen quality in large percentage of men seeking infertility treatment
  34. 34.  Histologic studies  seminiferous tubule sclerosis, small vessel degenerative changes, and abnormalities of Leydig, Sertoli, and germ cells  changes have been documented in patients as young as 12 years
  35. 35.  Presence of a varicocele does not necessitate surgical correction  Indications for surgical correction  Relief of significant testicular discomfort or pain not responsive to routine symptomatic treatment  testicular atrophy (volume difference >20% or > 2cc)  possible contribution to unexplained male infertility  varicocele may cause progressive damage to testes, resulting in further atrophy and impairment of seminal parameters
  36. 36.  The AUA Male Infertility Best Practice Policy Committee recommends treatment be offered to the male partner when all the following are present:  varicocele is palpable  couple has documented infertility  female has normal fertility  one or more abnormal semen parameters or sperm function test results  men who have a palpable varicocele and abnormal semen analyses findings but are not currently attempting to conceive should also be offered varicocele repair
  37. 37.  No strict criteria necessitate surgical intervention in adolescents  Each case handled individually  discussion among patient, parents, and physician regarding risks of intervention and potential impact on future fertility  general guidelines used by some pediatric urologist include the presence of one or more of the following:  Varicocele associated with decreased ipsilateral testicular size (20% volume deficit in the involved testis)  Bilateral varicoceles  Symptomatic painful varicocele  Abnormal findings on semen analysis
  38. 38. Lipshultz and Corriere (1997)  suggested that varicoceles were associated with testicular atrophy that was progressive with age  observed that testicular biopsy specimens taken from prepubertal boys with varicoceles already revealed histologic abnormalities Kass and Belman (1987)  first to demonstrate significant increase in testicular volume after varicocele repair in adolescents  did not study semen parameters
  39. 39.  ideal technique is to ligate all of the internal and external spermatic veins with preservation of spermatic arteries and lymphatics  internal spermatic artery may be divided with transperitoneal or retroperitoneal approach  does not usually cause testicular atrophy due to generous collateral circulation to testicle  3 most common surgical approaches  inguinal  Retroperitoneal  subinguinal
  40. 40.  Surgical Treatment can be divided into 3 main categories  Diagnostic procedures  Testis biopsy  Seminal vesicle aspiration  vasography  Procedures to improve sperm production  Varicocelectomy  Procedures to improve sperm delivery  Vasovasostomy  Vasoepididymostomy
  41. 41.  Varicoceles are now recognized as the most surgically correctable cause of male infertility.  They are present in 15% of the normal male population.  Up to 40% of patients with male infertility.  Approximately 70% of patients with secondary infertility have been found to have a varicocele as an underlying cause.  Varicocele repair remains the most cost-effective procedure in helping a subfertile man establish a pregnancy.  improve spermatogenesis  increase serum testosterone  Vasectomies  ½ million performed per year. 75% by urologist  12% of men aged 20 to 39 years in the United States have had a vasectomy  6% will eventually desire a reversal
  42. 42.  Testicular Biopsy  Azoospermia with normal FSH and normal sized testicles.  Can be due to obstruction, defect in spermatogenesis, or incomplete defect  Obstruction vs. spermatogenic failure?  Can also be therapeutic - consider sperm retrieval for IVF/ICSI.  Should be perform on both testes for nonobstructive azoospermia.  In obstructive azoospermia, should biopsy the larger testis first.
  43. 43.  Testicular Biopsy  Open  Percutaneous
  44. 44. 1. Cord block with 1% lidocaine and 0.25% bupivicaine with 30-ga needle 2.The scrotal skin and tunica vaginalis are then infiltrated with 2 mL of 1% lidocaine with a 30-ga needle. 3. A 1- to 2-cm transverse incision is made to the parietal tunica vaginalis through the anesthetized region. 4.The tunica vaginalis is then opened with scissors, and the edges are grasped and held apart with two small hemostats or a small self-retaining eyelid retractor. Lidocaine (2 to 3 mL) is dripped onto the exposed tunica albuginea to anesthetize the testicular surface where the biopsy specimen will be taken.
  45. 45. 5.The tunica albuginea is carefully inspected for the least vascular area for the incision. A 5- 0 Prolene suture is passed at one end of the proposed site of incision in the testis. 6. A 4- to 5-mm incision is made in the tunica albuginea by use of a No. 11 scalpel or a microknife, allowing extrusion of the seminiferous tubules. 7.With the "no-touch" technique, fine, sharp iris scissors are used to carefully excise the extruded tubules. 8.The specimen is then placed in Zenker's, Bouin's, or buffered glutaraldehyde solution. The testicular specimen should not be placed in formalin. 9. “Touch imprint” or wet prep done.Touch imprint more predictive in the evaluation of spermatogenesis.
  46. 46. 10. If sperm are found and cryopreservation of testicular tissue is to be done, additional testicular tissue can be taken from the same site and placed in appropriate medium in individual Eppendorf tubes for processing by the andrology laboratory. 11.The incision is then closed with the previously placed 5-0 Prolene suture. It is important to close the tunica vaginalis over the testis with absorbable suture, such as 4-0 chromic or Vicryl.
  47. 47. 1. Percutaneous testicular biopsy can be performed with local anesthesia in an office-based setting, and it is generally associated with less pain and morbidity than an open testicular biopsy. 2. A 95% correlation was described between percutaneous needle and open biopsy techniques as long as sufficient materials are present for diagnosis. 3. Before the biopsy is performed, the skin is punctured with a scalpel to prevent inclusion of scrotal skin with the specimen. 4. To avoid injury to the epididymis and the surgeon's hand, the point of the needle insertion should be from the lower pole toward the upper pole.
  48. 48.  Hematoma  Testicular atrophy – rare  Inadvertent epididymal biopsy
  49. 49.  15% of the normal male population and in up to 40% of patients with male infertility  World Health Organization reported that varicoceles were found in 25.4% of men with abnormal semen parameters compared with 11.7% of men with normal semen.  Varicoceles have been associated with impaired semen quality and decreased Leydig cell function.  However, varicocele repairs have been shown to improve not only spermatogenesis but also Leydig cell function  most commonly performed surgical procedure in treatment of male infertility.  Grading of Varicocele  I - Palpable only with the Valsalva maneuver  II - Palpable without the Valsalva maneuver  III - Visible through the scrotal skin  Repair of larger varicoceles results in significantly greater improvement in semen quality than does repair of smaller varicoceles.  On scrotal US – dilated veins > 3.5 mm  Subclinical varicoceles  Diagnosed only on US  Studies have demonstrated that subclinical varicoceles have no impact on fertility and that repair of subclinical varicoceles does not improve fertility rates.
  50. 50.  Four indications for treatment in adult men  The couple has known infertility  The female partner has normal fertility or a potentially treatable cause of infertility  The varicocele is palpable on physical examination, or if it is suspected, the varicocele is corroborated by ultrasound examination  The male partner has an abnormal semen analysis  In adolescent men  Reduction in ipsilateral testicular size, otherwise observation and /or semen analysis.
  51. 51.  Surgical Approaches  Scrotal  No longer used. High failure rate and testicular artery injury risk.  Retroperitoneal  Palomo  High retroperitoneal ligation of the internal spermatic vein above the internal inguinal ring.  A common complication of the retroperitoneal approach is varicocele recurrence or persistence, estimated to be between 11% and 15%.  The recurrence can be significantly reduced by intentional ligation of the testicular artery. This is thought to ensure ligation of the periarterial/cremasteric veins and thus to prevent recurrence.  Laparoscopic  Excessively invasive for what should be a minor outpatient procedure  laparoscopic varicocele repairs have been associated with a recurrence rate of less than 2% and formation of hydroceles in 5% to 8% of patients
  52. 52.  Inguinal and subinguinal approach  Preferred approaches  Less morbidity associated with the subinguinal (infrainguinal) approach than with the laparoscopic and inguinal approach because of the preservation of the muscle layers and the inguinal canal  However, a greater number of internal spermatic veins and arteries lie below the external ring, making this procedure technically more challenging
  53. 53. 1. Essentially the same as the Palomo technique. 2. Establish pneumoperitoneum using Veress or Hassan technique. 3. Parietal peritoneum is incised just lateral to the spermatic cord.The testicular artery and veins are dissected and isolated. Pulling on the testis can help identify the vessels. 4. Once the veins are isolated, they are clipped both proximally and distally with titanium endoclips, and these vessels are then transected.
  54. 54. 1. 3- to 4-cm oblique incision, two fingerbreadths above the symphysis pubis and just above the external ring, is carried laterally along Langer's lines 2. Incision is carried down to the external oblique aponeurosis, which is incised in the direction of its fibers. Care is taken to identify and to preserve the ilioinguinal nerve . 3. The spermatic cord is mobilized near the pubic tubercle, and a Penrose drain is passed beneath the cord.The Penrose drain is used to elevate the cord and bring it through the incision. 4. (+/-) microscope/loupes 5. Varicoceles generally appear with a typical vascular pattern in which the artery is next to or adherent to several veins, and there is a separate isolated vein nearby.
  55. 55. 6. Once the dilated veins are isolated, they are doubly ligated with either 2-0 silk sutures or small titanium surgical clips. 7.With the microsurgical technique, the lymphatic channels can be clearly visualized, and these should be preserved to prevent postoperative hydrocele formation. 8.The floor of the inguinal canal, near the external ring, should also be inspected to identify and ligate any external cremasteric veins. 9.The cord is placed back into the canal, and the external oblique fascia is closed with a 3-0 Vicryl suture.The subcutaneous layer is reapproximated with a 3-0 plain catgut suture, and the subcuticular layer is closed with a 4-0 Monocryl suture.The incision is infiltrated with 1% lidocaine mixed with an equal amount of 0.5% bupivacaine.
  56. 56.  Percutaneous Embolization  Cut-down to femoral or internal jugular vein  embolization of the spermatic veins can be accomplished with coils, balloons, or sclerotherapy  Overall success rate – 68%  Percutaneous varicocele embolization is especially useful in a recurrent or persistent varicocele, when the anatomy causing the varicocele needs to be radiographically clarified.
  57. 57.  Outcomes  studies have shown that repair of varicoceles can retard further damage to testicular function  overall rate of improvement in semen parameters after varicocelectomy ranged from 51% to 78%  improve not only semen motility, density, and morphologic features but also serum FSH and testosterone levels  No difference noted between laparoscopic and open approach, but higher complications in the lap. Group  Predictors of successful repair  Sperm concentration > 5million/ml or density > 50 million per ejaculate  lack of testicular atrophy  sperm motility of 60% or more  serum FSH values less than 300 ng/mL (normal, 50 to 300 ng/mL)
  58. 58.  Probability of a live birth after a varicocelectomy was 29.7% versus 25.4% after IVF-ICSI.  The cost per delivered baby was $26,268 after varicocelectomy compared with $89,091 with IVF-ICSI.
  59. 59.  6% of men who have undergone vasectomy will subsequently request a vasectomy reversal  Chances for success (patency or pregnancy) based on the personal experience of the surgeon, the patient's health history, and the results of examination of the man and the age and reproductive potential of his partner are discussed.  Epididymal obstruction appears, in most instances, to be a time-related phenomenon  62% of patients who underwent reversal 15 years or more after their vasectomy required either a unilateral or a bilateral vasoepididymostomy  VE depends on quality of fluid from proximal vas  when the material coming from the proximal vas lumen is thick, pasty, and devoid of sperm; if the fluid is creamy, containing only debris.  microsurgical vasectomy reversal are superior to results of nonmicrosurgical techniques  No significant difference if a multilayer anastomosis is performed as opposed to a modified single-layer technique but the success is physician-dependent.
  60. 60. A. Nonlocking needle holder. B.Suture scissors. C.Dissecting scissors. D,E. Very fine pointed and round-tipped scissors. F.Round-handled platform forceps. G.Curved dilating forceps. H.Round-handled small knife blade holder. I.Microtip bipolar cautery
  61. 61. Anesthetic Considerations 1.General vs. local? 2.Preparing the vas for anastomosis 1. Vas grasped through skin above the vasectomy site. 2. Once the vas is exposed, injection of a mixture of 0.5% bupivacaine and 1% lidocaine into the distal perivasal sheath will provide sufficient anesthetic coverage for the vasal anastomosis to be performed. 3. Placement of 6-0 Prolene sutures just into the muscularis holds the vas above the incision and make it easily accessible for anastomosis.
  62. 62. 4.The vas above and below the vasectomy site should be transected with use of the operating microscope Once the point of the vas that is to be cut is chosen, the vasal vessels are secured with 7-0 Prolene sutures just proximal to the point of transection. Some experienced microsurgeons prefer to cut the vas deferens through the groove of a nerve-holding forceps to ensure a straight cut. 5. A few drops of fluid from the testicular end of the vas lumen are placed on a sterile glass slide and examined by light microscopy. 6. If there are sperm or sperm parts (sperm heads, sperm with partial tails) in large numbers or the fluid is clear and copious with no visible sperm, vasovasostomy is generally indicated. If the fluid is thick, pasty, and devoid of sperm or contains only a few sperm heads, vasoepididymostomy should be considered.
  63. 63. 1. The anastomosis is begun by passing a 9-0 suture through the muscularis and the adventitia at the 5- and 7- o'clock positions . 2. A double-armed 10-0 suture is passed through the lumen at the posterior 6-o'clock position and tied. 3. The next sutures are placed in the wall of the lumen on either side of the first.These sutures are tied after both are in place. 4. Three to five more sutures are placed equidistant from one another to close the remainder of the lumen but are left untied until all the sutures have been placed.
  64. 64. 5. Once the anastomosis of the lumen has been completed, the 9-0 suture is again used to bring the muscularis together. A suture is placed at the 12- o'clock position first, then sequentially around the cut end of the vas until the first two sutures are reached . 6. The adventitia is brought together over the muscularis suture line with interrupted 9-0 sutures to further enhance the blood supply at the level of the anastomosis.
  65. 65. 1. A double-armed 10-0 suture is passed full thickness through the edge of the proximal and distal lumen at the 6-o'clock position. 2. Two more sutures are placed, full thickness, at the 4- and 8-o'clock positions and tied. 3. Three more full-thickness sutures are passed at the 10-, 12-, and 2-o'clock positions and then tied. 4. The anastomosis is completed by closing the muscularis and adventitia to the opposite side, placing two 9-0 sutures between each of the 10-0 full- thickness sutures.
  66. 66.  Consider sperm retrieval/cryo during vasovas  8-14% of pts. Use their cryopreserved sperm  Can always do testis biopsy and sperm extraction at a later date.  Post-op Care  Moderate activity for the first week after surgery and to refrain from heavy exercise and sexual activity for 3 weeks. Examination of the semen occurs at 1 month and every 3 months in the year after surgery. Most patients will have sperm in their semen within 4 weeks after vasovasostomy.  If sperm are not present by 6 months, the operation is considered a failure.  Repeated surgery or sperm retrieval and IVF-ICSI may be offered.  Complications  Secondary obstruction and consequent azoospermia after initially successful vasovasostomy have been reported to occur in 3% to 12% of men.  marked decrease in motility and the appearance of sperm heads along with some normal sperm
  67. 67. Years of Obstruction Patency (%), Sperm Present Pregnancy (%) <3 86/89 (97) 56/74 (76) 3-8 525/600 (88) 253/478 (53) 9-14 205/261 (79) 92/209 (44) ≥15 32/45 (71) 11/37 (30)
  68. 68.  Epididymal Obstruction  Can be idipathic, inflammatory, iatrogenic, congenital.  Time-dependent with vasectomy.  Decision to perform a vasoepididymostomy is based primarily on the quality of fluid found at the proximal (testicular) vas.  3 microsurgical techniques  Direct end-to-end  End-to-side  End-to-side intussusception  Pre-op Consideration  General/epidural anesthetic  Cryopreserve sperm?  Patient positioning/comfort/safety
  69. 69. 1. Testis biopsy to confirm spematogenesis. 2. Incision is enlarged and the testis delivered out of the scrotum and examined. In most instances, the epididymis will be visibly dilated, even without optical magnification . 3. Mobilize the distal vas. 4. Confirm vasal patency with vasography.
  70. 70. 1. The epididymal tail can be dissected free from the inferior aspect of the testis and the epididymis transected at its distal end. 2. When the epididymis is cut proximal to the obstructed area, there will be a continuous flow of sperm-laden fluid from one opened epididymal tubule. 3. The lumen of the vas deferens is anastomosed to the cut, open tubule exuding sperm.The first step is to secure the cut end of the abdominal vas to the epididymal tunic with two 9-0 nylon sutures passed through the edge of the epididymal tunic and into the adventitia and muscularis of the vas deferens at the 5- and 7-o'clock positions. Four equally spaced double- armed 10-0 sutures are placed into the edge of the epididymal tubule, inside out, and then carried through the vas lumen, beginning at the 6-o'clock position.The first suture is tied, but the sutures at the 3-, 9-, and 12-o'clock positions are not tied until all are placed.
  71. 71. 4.The muscularis and adventitia of the vas deferens are secured to the tunic of the epididymis with interrupted 9-0 sutures .
  72. 72. 1. The rationale is that there is far less dissection required, less troublesome bleeding from the transected epididymis, and therefore a clearer field. 2. Beginning at the level of the cauda, a 0.5-cm incision is made in the tunic of the epididymis, pushing the tubule toward the tunic surface. 3. The anterior surface of this loop is incised along its longitudinal axis with a microknife, making an opening of approximately 0.5 mm. 4. Fluid is examined for normal-appearing sperm.
  73. 73. 5. Once the patent loop is identified and opened, three 10-0 double-armed sutures are placed (inside-out) in a triangular fashion equidistant from one another 6.The vas deferens is brought through the uppermost portion of the tunica vaginalis . 7.Two 9-0 nylon sutures are used to hold the muscularis and adventitia of the vas deferens to the opened epididymal tunic.
  74. 74. 8.The apical suture that was passed into the epididymal lumen is now passed into the lumen of the vas deferens and secured. 9. Three other sutures are then placed in between the previous one and tied posteriorly to anteriorly.
  75. 75. 10.The muscularis and adventitia of the vas deferens are approximated to the epididymal tunic, in a circumferential fashion, with eight to ten 9-0 sutures.
  76. 76. 1. This technique differs from the end-to-side technique in that the lumen is opened after the sutures are positioned in the epididymal loop.
  77. 77. 1. In the two-suture modification, once the dilated epididymal loop is identified and the end of the vas brought in close to the epididymal loop, it is secured to the tunic with a single 9-0 suture, and two parallel sutures are passed into the tubule and left in position.
  78. 78.  Post-op Care  Similar to VasoVas  Complications  Infection  Hematoma  DVT  Injury to testicular artery  Results  Very wide variation even with microsurgical techniques.
  79. 79.  Incision made over external ring at or near the pubic tubercle  obviates the opening of the external oblique aponeurosis  Dilated cremasteric veins ligated  Spermatic cord opened  spermatic veins in pampiniform plexus separated and ligated  any dilated veins that accompany the vas deferens also ligated Microscopic subinguinal approach  Operating microscope used to dissect out and preserve the testicular arteries and lymphatic vessels  Some advocate delivering testicle into wound and ligating external spermatic and gubernacular veins  recurrence rate 0-2%, complication rate 1-5%
  80. 80.  Incision made over course of inguinal canal  Ligation of cremasteric, deferential, and spermatic veins performed with arterial preservation  Microscope may be used as well
  81. 81.  Low abdominal incision above internal ring  High ligation performed of entire spermatic pedicle (Palomo procedure)  testicular artery–sparing procedure performed by opening the spermatic fascia to identify and preserve the artery Laparoscopic-assisted retroperitoneal approach  Artery may be spared  lengthens the procedure  higher recurrence rate (6-15%)  due to inguinal and retroperitoneal collateral veins, failure to ligate fine periarterial veins when testicular artery preserved  20% incidence of hydroceles at 6 months if lymphatics not preserved
  82. 82. Percutaneous Embolization  Least invasive means of varicocele repair  Internal spermatic vein accessed via cannulation of femoral vein  balloon and/or coil occlusion of varicocele  failure rate of up to 15% Antegrade sclerotherapy  success rate is > 90%  hydroceles are not a complication
  83. 83. Most methods of varicocelectomy result in similar short-term results Open microsurgical inguinal or subinguinal techniques in adults shown to cause fewer recurrences and complications Given that efficacy all techniques is nearly equivalent, attention must be paid to the morbidity of the individual procedure and expertise of the operating surgeon
  84. 84.  Check patient's semen 3-4 months after surgery if done for infertility  spermatogenesis requires approximately 72 days  any effects from varicocele repair on semen parameters are delayed
  85. 85.  Vasectomy after mass ligation varicocelectomy likely to result in testicular atrophy  Further supports artery-sparing technique
  86. 86. Hasan Farsi K.A.University Hospital King Faisal Specialist Hospital Jeddah
  87. 87.  26y male with 1ry infertility of 3y.  Examination: Bilateral normal testes, Bilateral grade II varicocele.  Semen x2 Azooepermia, Volume 2-3cc, normal semen fructose  FSH was normal.  Bilateral inguinal varicocelectomy, testicular biopsy:  Hypospermatogenisis
  88. 88.  18 months later one child  Semen:  Volume: 1.5 cc  Conc.: 3 m/cc  Motility: 25%
  89. 89.  10-15% general population  40% 1ry infertility  80% 2ry infertility
  90. 90.  Ambroïse Paré (1500–1590): a clinical problem  Barfield, late 19th century: Relationship to infertility  Lipshultz, 1979: Relationship to testicular atrophy that is progressive with age  Kass and Belman, 1987:significant increase in testicular volume after varicocele repair in adolescents
  91. 91.  Sixty-four infertile male patients with varicocele :  Varicocelectomy 31 cases  No surgery 30 cases  The mean follow-up duration was 76.2 months  The pregnancy rate: (60%) VS (28%) Int J Urol. 2002 Aug;9(8):455-61.
  92. 92.  146 men left varicocelectomy  62 men refused surgery treated with tamoxiphene  Followed up for at least 1 year  Improvement in semen parameters:  83.2% VS 32.3%  Pregnancy within 1 year:  62(46.6%) VS 8 (12.9%) (p<0.001). Eur Urol. 2001 Mar;39(3):322-5.
  93. 93.  A meta-analysis was performed to evaluate both randomized controlled trials and observational studies using a new scoring system.  Adjust and quantify for various potential sources of bias, including selection bias, follow-up bias, confounding bias, information or detection bias, and other types of bias, such as misclassification  Of 136 studies identified through the electronic and hand search of references, only 17 studies met our inclusion criteria
  94. 94.  Statistically significant improvement in:  Concentration  Motility  Morphology  CONCLUSIONS: Surgical varicocelectomy significantly improves semen parameters in infertile men with palpable varicocele and abnormal semen parameters. Agarwal A, Department of Obstetrics Gynecology, Cleveland Clinic Urology. 2007 Sep;70(3):532-8
  95. 95.  24 pts 63 intrauterine insemination cycles without varicocele treatment.  34 pts 101 intrauterine insemination cycles following varicocelectomy.  No statistically significant difference was noted in the mean post-wash total motile sperm count in the treated and untreated groups.  The pregnancy rate per cycle = 6.3 VS 11.8, p = 0.04  Live birth rate per cycle =1.6 VS 11.8, p = 0.007  Conclusion: A functional factor not measured on routine semen analysis may affect pregnancy rates in this setting Daitch JA. J Urol. 2001 May;165(5):1510-3
  96. 96.  68 infertile men  Seminal plasma levels of two ROS and six antioxidants on the day prior to varicocelectomy  Same parameters were measured again 3 and 6 months post- operatively.  concluded that varicocelectomy reduces ROS levels and increases antioxidant activity of seminal plasma from infertile men with varicocele.  Conclusion: Varicocelectomy reduces ROS levels and increases antioxidant activity of seminal plasma from infertile men with varicocele. Mostafa T, Department of Andrology, Faculty of Medicine, Cairo University Int J Androl. 2001 Oct;24(5):261-5.
  97. 97.  286 infertile men  Physical examination, contact thermography, Doppler sonography, and venography of both testes.  88.8% bilateral  Mean sperm concentration increased from 6.12 +/- 1.02 to 21.3 +/- 1.69 million/mL  mean sperm motility from 16.81 +/- 1.51 to 35.90 +/- 1.41%  mean sperm morphology from 9.75 +/- 0.85 to 16.92 +/- 1.17%.  Pregnancy rate was 43.5%  This may suggest that we should consider varicocele a bilateral disease Gat Y. Fertil Steril. 2004 Feb;81(2):424-9.
  98. 98.  The cost per delivery with ICSI was found to be $89,091  The cost per delivery after varicocelectomy was only $26,268  The average published U.S. delivery rate after one attempt of ICSI was only 28%. whereas a 30% delivery rate was obtained after varicocelectomy.  CONCLUSIONS: Specific treatment of varicocele- associated male factor infertility with surgical varicocelectomy is more cost-effective than primary treatment with assisted reproduction. Schlegel PN. Urology. 1997 Jan;49(1):83-90
  99. 99.  4.3-13.3%
  100. 100.  Interestingly, the first study on the importance of varicocelectomy to male infertility (Tulloch, 1952 ) reported spontaneous pregnancy after varicocele repair in an azoospermic man Tulloch, W.STulloch, W.S Edinb. Med. J. 1952 , 59, 29–34.
  101. 101.  10 azoospermic patients  2 pregnancies Mehan DJ. Fertil Steril. 19761976 Jan;27(1):110-4.
  102. 102.  13 azo inguinal varicocelectomy  Induction of spermatogenesis was achieved in 3 (23%) patients  Two of them had hypospermatogenesis and one had maturation arrest at spermatid stage  No pregnancies by natural intercourse Cakan M. Arch Androl. 2004 May-Jun;50(3):145-50
  103. 103.  14 Azo sclerotherapy 7/14 produced sperms Sperm con 3.1 ± 1.2 × 106/mL Mean sperm: 2.2 ± 1.9% mean sperm normal morphology: 7.8 ± 2.2%  2 pregnancies Poulakis V. Asian J Androl. 2006 Sep;8(5):613-9.
  104. 104.  32 men with azoospermia  Improved in 18/32:  sperm concentration in the ejaculate 3.81±1.69 x 106/ml  mean sperm motility: 1.20±3.62%  mean sperm morphology: 8.30±2.64  Nine pregnancies (26%)  Four (12%) unassisted  Five (15%) by ICSI Gat Y. Human Reproduction 2005 20(4):1013-1017
  105. 105.  27 azoospermia microsurgical varicocelectomy  Induction of spermatogenesis was achieved in nine men (33.3%)  Sperm conc 1.2 x 10(6)/mL to 8.9 x 10(6)/mL  Motility 24% to 75.7%,  One patient with maturation arrest established pregnancy  Five relapsed into azoospermia 6 months after the recovery of spermatogenesis Pasqualotto FF, Fertil Steril. 2006 Mar;85(3):635-9.Pasqualotto FF, Fertil Steril. 2006 Mar;85(3):635-9. Is the Effect Durable?
  106. 106.  17 azo microsur  Spermatozoa in the ejacultae 47% (8/17)  Only 35% (6/17) of them had motile sperm  Mean time for appearance of spermatozoa in the ejaculates was 5 months (3 to 9 months). Esteves SC. Int Braz J Urol. 2005 Nov-Dec;31(6):541-8.
  107. 107.  33 men with infertility & varicocele  7 has coexisting genetic infertility:  Abnormal karyotype in 4  Y chromosome microdeletion in 3  26 No defect  Same semen parameters  All had varicocelectomy  54% VS 0% improvement  CONCLUSIONS: From this early experience, men with varicocele and genetic lesions appear to have a poorer response to varicocele repair than men without coexisting genetic lesions.
  108. 108.  What are the sonographic findings that could predict the outcome of varicocele repair in the treatment of male infertility?  107 patients with varicocele.  CONCLUSIONS: The best preoperative sonographic parameters of success of varicocele repair are:  The presence of normal-sized testes  Clinically palpable veins  Bilateral varicocele Donkol RH. J Ultrasound Med. 2007 May;26(5):593-9.
  109. 109.  grade 1--small (22 patients)  grade 2--medium (44)  grade 3--large (20)  Sperm count, per cent motility, per cent tapered forms were measured preoperatively and postoperatively.  Conclusion: infertile men with a large varicocele have poorer preoperative semen quality but repair of the large varicocele in those men results in greater improvement than repair of a small or medium sized varicocele. Goldstein M.J Urol. 1993 Apr;149(4):769-71
  110. 110.  FSH  Histology
  111. 111.  Preoperative FSH levels between men who did (14.8 ± 3.1 IU/L) and did not (19.4 ± 3.8 IU/L) show improvement in semen parameters after sclerotherapy were not significantly different Czplick M.Czplick M. Arch Androl. 1979;3(1):51-5
  112. 112.  Germinal Aplasia  Maturation arrest at spermatocyte stage  Hypospermatogenisis  Maturation arrest at spermatid stage
  113. 113.  13 Azoospermic patients  Age  Preoperative sex hormones  Unilaterl VS Bilateral  Varicocele grade  Hypospermatogenesis and late maturation arrest Arch Androl. 2004 May-Jun;50(3):145-50 No association
  114. 114. Author Year No. of pts Tech. % of pts with sperms Pregnancy(%) Czaplicki 1979 33 Micro 12(34%) 3 patients Matthews 1998 22 Micro 12(55%) 3PTS Kadioglu 2001 24 Micro 5(20.8%) ? Kim 1999 28 Micro 12(43%) 2 Schlegel 2004 31 Micro 7(22%) Nil Cakan 2004 13 Inguin 3(23%) Nil Pasqualotto 2006 27 Micro 9(33.3) 1 Lee 2007 19 Micro 7(36.4%) 1 Esteves 2005 17 Micro 8(47%) 1 Spontan 4 ICSI Gat 2005 32 Embo. 18(56.2%) 9(26%) Poulakis 2006 14 Sclero 7(50) 2 Osmonov 2006 15 sclerot 8(53) all <0.1m/cc Nil TOTAL 275 108 (39.27%)
  115. 115.  subclinical in 73 patients  Clinical in 66 patients, based on palpation in addition to ultrasonography.  Conclusion: ligation of varicoceles detected using Doppler ultrasonography, whether palpable or not, results in an increase in sperm concentration and motility. Pierik FH, Rotterdam, The Netherlands. Int J Androl. 1998 Oct;21(5):256- 60.
  116. 116.  76 underwent varicocele repair  Improvement: Clinical VS subclinical:67% VS 41%  But: Equal number were worse postoperatively and, thus, mean sperm count was unchanged for the group with subclinical varicocele  Conclusion: The results of our study suggest that subclinical varicocelectomy is of questionable benefit. Jarow JP North Carolina, USA. J Urol. 1996 Apr;155(4):1287-90
  117. 117.  350 patients:  Ejaculated sperm  Epididymal  Testicular CONCLUSION: The fertilizing ability of sperm in ICSI is highest with normal ejaculated semen and lowest with sperm extracted from a testicular biopsy in non-obstructive azoospermia. Aboulghar M. Fertil Steril. 1997 Jul;68(1):108-11Aboulghar M. Fertil Steril. 1997 Jul;68(1):108-11
  118. 118.  Varicocele may cause any variation of severity in spermogram including azoospermia.  The treatment of varicocele may significantly improve spermatogenesis and renew sperm production.  Adequate treatment may spare the need for TESE as preparation for ICSI in >30% of azoospermic patients.  Since achievement of pregnancy in IVF units is higher when spermatogenesis is better, the treatment of varicocele is an effective medical adjunct for IVF units prior to the treatment.  In men with spermatogenic failure, freshly ejaculated sperm are easier to use, and fertilization ability in ICSI is higher with normal semen than with sperm retrieved by TESE
  119. 119. Thank You Thank You
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