6 Surgical Management of Male Infertility Sandro C Esteves, Alaa Hamada, Ashok Agarwal (Sandro C Esteves) tertiary center for male reproduction, CHAPTER CONTENTS potentially surgical correctable conditions were identi- fied in 34.4% of the male partners. Azoospermia is iden- ♦ Surgical Treatment to Improve Sperm Production tified in about one-third of the individuals. Despite the ♦ Reconstructive Surgeries of Ductal System feasibility of reconstructive surgery in only about 30% of ♦ Ejaculatory Duct the azoospermic subgroup, most of the remaining would ♦ Sperm Retrieval Techniques be candidates for sperm retrieval techniques, if enrolled ♦ Preoperative Planning in assisted reproduction programs. These figures are ♦ Operative Procedure clearly shown in Table 1. ♦ Postoperative Care and Results Two major advances have recently occurred in the surgical management of male infertility. The first was the implementation of microsurgery which increased success rates for reconstruction of the reproductive tract. The second was the development of intracytoplasmic INTRODUCTION sperm injection (ICSI) and the demonstration that sper- matozoa retrieved from either the epididymis or the testis nfertility is a common problem in the urologic prac- were capable of fertilization and pregnancy.2,3 Thereafter, Itice. Approximately, 8% of men in reproductive age several sperm retrieval methods have been developed may ask for medical consultation for fertility problems. to collect epididymal and testicular sperm for ICSI in Of these, 1–10% carries conditions that compromise the azoospermic men. Microsurgery was incorporated to this reproductive potential.1 The essential roles of the urolo- armamentarium, either for collection of sperm from the gist in this context are to diagnose, to counsel, to provide epididymis in men with obstructive azoospermia or from medical or surgical treatment whenever possible or to the testicle in those with nonobstructive azoospermia correctly refer the male patient for assisted conception. (NOA).2,4 The urologist can also be part of the multiprofessional Surgeries for male infertility can be classified into reproductive team in the assisted reproduction unit, three major categories: being responsible for the above-cited tasks as well as 1. Surgeries to improve sperm production for surgical sperm retrieval. 2. Reconstructive surgeries to correct the sperm trans- Surgical management can be offered to more than port pathways 50% of our patient population in daily practice. In a group 3. Surgeries to retrieve spermatozoa from the gonads of 2,875 infertile couples attending one of the authors to be used in assisted conception. Chapter 6 Surgical Management of Male Infertility Distribution of diagnostic cause-effect relationship.11,12 Despite these facts, it is still categories of couples seeking unclear why most men with varicocele retain fertility Table 1 infertility evaluation in a male and why fertility status is not always improved after infertility clinic treatment.13 Category N % Preoperative Planning Varicocele 629 21.9 Infectious 72 2.5 Assessment and Patient Selection Hormonal 54 1.9 The aim of varicocelectomy in infertile men is to restore Ejaculatory dysfunction 28 1.0 or improve testicular function. Current recommendations Systemic diseases 11 0.4 suggest that treatment should be offered for couples with Idiopathic 289 10.0 documented infertility whose male partner has a clinically Normal/Female factor 492 17.1 palpable varicocele and abnormal semen analysis. The Immunologic 54 1.9 diagnosis of such condition is mainly clinical. Therefore, Obstruction 359 12.5 a detailed medical history must be taken and prognostic Cancer 11 0.4 factors identified. Physical examination, with the patient Cryptorchidism 342 11.9 standing in a warm room, is the preferred diagnostic Genetic 189 6.6 method. Varicoceles diagnosed by physical examination Testicular failure 345 11.9 are termed ‘clinical’ and may be graded according to the Total 2,875 size. Large varicoceles (grade III) are varicose veins seen through the scrotal skin. Moderate (grade II) and small- Source: ANDROFERT, Campinas, São Paulo, Brazil sized varicoceles (grade I) are dilated veins palpable without and with the aid of the Valsalva maneuver, This chapter describes the most common surgical respectively.14 In the presence of bilateral palpable varico- options in the management of male infertility. It includes cele, it is recommended to perform surgery on both sides not only the reconstructive interventions for the male at the same operative time.15 reproductive system but also the sperm retrieval tech- However, physical examination may be inconclu- niques to be used in cases of obstructive azoospermia sive or equivocal in cases of low grade varicocele and, in (OA) and NOA. men with a history of previous scrotal surgery, concom- itant hydrocele or obesity. Therefore, imaging studies may be recommended when assessing infertile men for SURGICAL TREATMENT TO IMPROVE varicocele when physical examination is inconclusive. SPERM PRODUCTION When a varicocele is not palpable but a retrograde blood flow is detected by other diagnostic methods, such as Varicocele Repair venography, Doppler examination, ultrasonography, Varicocele is believed to be the cause or a contributing scintigraphy or thermography, the varicocele is termed factor of male infertility/subfertility in up to 35% of the subclinical.16,17 The role of subclinical varicocele as a cases.1 Several hypotheses try to explain the mecha- cause of male infertility remains debatable, and current nisms underlying the negative impact of varicocele on evidence does not recommend surgical intervention for male fertility. Proposed mechanisms include hypoxia treating infertile men with subclinical varicocele.18,19 It is and stasis, testicular venous hypertension, elevated our routine, however, to examine the contralateral cord testicular temperature, increase in spermatic vein with a pencil-probe Doppler (9 MHz) stethoscope to catecholamine leading to testicular underperfusion determine if a subclinical varicocele exists when a clini- and increased oxidative stress. Nevertheless, none of cally palpable varicocele is only identified at one side. them fully elucidates the unpredictable effect of vari- In such cases, the subclinical varicocele is treated at the cocele on human spermatogenesis and male fertility.5-8 same time as the coexistent clinical varicocele. This is The association between varicocele and infertility is still based on the observation that altered blood flow after a matter of debate. However, there is an unquestionable varicocelectomy may unmask an underlying venous increased incidence of this condition among infer- anomaly and results in clinical varicocele formation.20,21 tile men.9 Moreover, an association of varicocele with Preoperative workup should include hormone reduced semen parameters and testicular size exists,10 profile testing particularly, follicle-stimulating hormone and improvement in semen quality and pregnancy rates (FSH) and testosterone level. Testicular volume should after varicocelectomy constitute strong evidence for a be assessed using a measurement instrument such as the 91 Section 2 Male Factor Infertility Prader orchidometer or a pachymeter. At least two semen with the surgeon and patient’s preferences. The authors analyses must be obtained and evaluated according to routinely perform microsurgical subinguinal varicocele the World Health Organization guidelines.22. repair using short-acting propofol intravenous anes- Infertile men either with higher preoperative semen thesia associated with the blockage of the spermatic parameters or undergoing varicocele repair for large cord using 10 ml of a 2% lidocaine hydrochloride in an varicoceles are more likely to show postoperative outpatient basis.30 semen parameters improvement.23 On the other hand, reduced preoperative testicular volume, elevated serum Techniques FSH levels, diminished testosterone concentrations and Varicoceles are surgically treated either by open (with subclinical varicocele are negative predictors for fertility or without magnification) or laparoscopic approaches. improvement after surgery.18,24-29 The principle of the surgery is the occlusion of the Men with clinical varicoceles presenting with dilated veins of the pampiniform plexus. The high retro- azoospermia may be candidates for surgical repair. peritoneal and laparoscopic approaches are performed In such cases, genetic evaluation including Giemsa for internal spermatic vein ligation, while the inguinal karyotyping and polymerase chain Yq microdeletion and subinguinal approaches allow the ligation of the screening for AZFa, AZFb and AZFc regions are recom- internal and external spermatic and cremasteric veins mended. A testis biopsy (open or percutaneous) may be that may contribute to the varicocele. obtained to assess testicular histology, which has been shown to be the only valid prognostic factor for restora- Retroperitoneal techniques: High open retroperitoneal vari- tion of spermatogenesis.30,31 The benefit of varicocelec- cocele ligation involves incision medial to the anterior tomy in azoospermic men with genetic abnormalities superior iliac spine at the level of the internal inguinal is doubtful and should be carefully balanced. The same ring (Figure 1). The external oblique muscle is split, the caution is valid for patients with atrophic testes and/ internal oblique muscle is retracted and the peritoneum or history of cryptorchidism, testicular