Some causes of male infertility are treatable by surgery. Options for surgical treatment may include:
- Microsurgical Reconstruction
- Testicular Biopsy
- Transurethral Resection of the Ejaculatory Duct
- Sperm Retrieval (Epididymis or Testis)
- Vasectomy Reversal
A varicocele is an enlarged vein (varicose vein) in the scrotum, and is the most common, surgically-correctable cause of male infertility and is present in about 40% of infertile males. Usually, the varicocele is asymptomatic, and the patient is seen primarily for evaluation of a possible male factor in an infertile couple. However, he may sometimes complain of pain or heaviness in the scrotum. Careful physical examination remains the primary method of varicocele detection.
It is important to examine the patient in the standing position, having him perform the Valsalva maneuver (i.e., take a deep breath and bear down) to magnify a small varicocele. When small varices are difficult to diagnose, more objective means can be used such as high-resolution color-flow Doppler ultrasonography.
The reasons for surgical correction include testicular discomfort or pain unrelieved by routine symptomatic treatment, testicular atrophy (loss of testicular size), or the possible contribution to unexplained male infertility. However, the mere presence of a varicocele does not mean that surgical correction is necessary.
Successful surgery will often increase the incidence of eventual pregnancy in the infertile couple. The surgical correction of a varicocele is called a varicocelectomy. The outpatient procedure has three common approaches: through the groin (transinguinal), through the abdomen (retroperitoneal), or below the groin (infrainguinal/subinguinal). Under routine conditions, we prefer the transinguinal approach, utilizing optical magnification (with an operating microscope) to ensure precise identification of all contributory veins and the testicular arteries. All abnormal veins are permanently tied off to prevent continued abnormal blood flow.
Some men have a blockage within the epididymis for a variety of reasons. Causes of epididymal blockage can be due to a trauma, injury, infection, or being a carrier of the cystic fibrosis gene. If present, this blockage can be bypassed with microsurgical reconstruction by the epididymovasostomy procedure.
Testicular biopsy is used less frequently than in the past. The procedure is performed particularly to differentiate obstructive from non-obstructive azoospermia, and can be used to see if a varicocele repair has any chance of success in the azoospermic patient.
Men with neurologic impairments such as traumatic spinal cord injury (SCI), multiple sclerosis, diabetes, or retroperitoneal surgical damage may result in difficulties or the inability to have a visible ejaculate. Spinal cord injured (SCI) patients represent the largest physical medicine and rehabilitation population seen with this type of fertility-related disorder. Eighty percent of these patients are male and have an average age of 30 years at the time of injury. Although a small percentage (3%-20%) of patients with spinal cord injuries maintain the capacity to ejaculate, this capacity tends to be unpredictable and is rarely effective in the initiation of a pregnancy. Between 85 to 97% of these men experience permanent loss of ejaculatory function.
Electroejaculation (EEJ) has been proven to be a safe and effective means to obtain motile sperm suitable for assisted reproductive techniques, such as in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI), or intrauterine insemination (IUI).
Electroejaculation is normally performed under general anesthesia, though for men with a complete spinal cord injury (SCI), anesthesia may not be necessary. After a careful patient history and physical examination, the patient is catheterized and the bladder emptied entirely. A digital rectal examination and anoscopy should be performed before and after the procedure to identify any rectal injuries. After proper inspection, a lubricated rectal probe is introduced gently into the rectum. All patients are given an initial trial of vibratory stimulation to initiate an ejaculation. If vibratory stimulation is not effective, electrostimulation via the rectal probe may then begin. Specimens are immediately moved to a warming tray.
Most often, semen specimens are washed and subsequently used for intrauterine insemination (IUI) or in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). Occasionally, if sperm motility is adequate, a sperm swim-up procedure can be employed, and sperm of excellent quality can be recovered for IUI. Occasionally, we have cryopreserved sperm from electroejaculation, but poor sperm motility often limits the success of this procedure.
The results of electroejaculation in terms of sperm harvesting have been excellent, with recent data suggesting that an ejaculate of sufficient quality to use in intrauterine insemination or in vitro fertilization can be obtained in approximately 80% of individuals. Most patients tend to have good sperm concentrations, with averages of 180-300 million sperm recovered per ejaculate. The major problem has been that sperm motility has averaged only 11-22% with poor functional characteristics, as well.
Transurethral Resection of the Ejaculatory Duct
The ejaculatory duct is a tubular structure that joins the prostatic portion of the urethra and is responsible for transporting sperm and seminal vesicle fluid into the prostatic urethra, the final destination of sperm prior to ejaculation. A number of factors can cause obstruction of the ejaculatory duct and thus block the flow of sperm. These include problems such as congenital narrowing or scarring due to infection and compression due to a prostatic cyst or tumor.
Obstructed ejaculatory ducts are usually diagnosed by transrectal ultrasound imaging or by special radiographic tests called vasograms. Obstructed ducts are treated by a simple transurethral procedure whereby the obstructed part of the duct is removed, leaving a normal, unobstructed duct behind.