Surgical Management of Male
Infertility: Part I
By
Peter Tran D.O.
Garden City Hospital
12/17/2008
Overview
• 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
Epidemiology
•
Varicoceles are now recognized as the most surgically correctable cause of male
infertility.
–
–
–
•
Varicocele repair remains the most cost-effective procedure in helping a subfertile
man establish a pregnancy.
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–
•
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.
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
Diagnostic Procedures
• 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.
Diagnostic Procedures
• Testicular Biopsy
– Open
– Percutaneous
Open Testicular Biopsy
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.
Open Testicular Biopsy
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.
Open Testicular Biopsy
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.
Percutaneous Testicular
Biopsy
1.
2.
3.
4.
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.
A 95% correlation was described
between percutaneous needle
and open biopsy techniques as
long as sufficient materials are
present for diagnosis.
Before the biopsy is performed,
the skin is punctured with a
scalpel to prevent inclusion of
scrotal skin with the specimen.
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.
Testicular Biopsy Complications
• Hematoma
• Testicular atrophy – rare
• Inadvertent epididymal biopsy
Varicoceles
•
•
•
•
•
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.
Varicoceles
•
•
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.
Varicoceles
•
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
Varicoceles
•
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
Lap Varicolectomy
1.
2.
3.
4.
Essentially the same as the
Palomo technique.
Establish pneumoperitoneum
using Veress or Hassan technique.
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.
Once the veins are isolated, they
are clipped both proximally and
distally with titanium endoclips,
and these vessels are then
transected.
Inguinal Approach
1.
2.
3.
4.
5.
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
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 .
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.
(+/-) microscope/loupes
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.
Inguinal Approach
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 30 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.
Varicocelectomy
Microsugical vs. Non-microsurgical Approach
• Significant reduction in postoperative complications, such as testicular
artery injury, hydrocele formation, and varicocele recurrence.
• Complication rates for hydrocele formation with the non-microsurgical
technique range from 3% to 39%, whereas hydrocele formation is
rarely reported in association with a microsurgical technique
• The recurrence rate for microscopic inguinal varicocelectomy has been
reported between 1% and 2%, compared with 9% and 16% for nonmicroscopic inguinal varicocele repair
• The recurrence rate for non-microscopic subinguinal varicocele repair is
reported to be 5% to 20%
Varicocelectomy
•
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.
Varicocelectomy
•
•
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)
Varicolectomy Complications
Technique
Artery Preserved
Hydrocele (%)
Recurrence (%)
Retroperitoneal
No
7
11-15
Conventional
inguinal
No
3-39
9-16
Laparoscopic
Yes
5-8
<2
Radiographic
Yes
0
4-11
Microscopic
inguinal or
subinguinal
Yes
0
<2
Cost Effectiveness
•
•
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.
Vasectomy Reversal
•
•
•
•
•
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.
Vasovasostomy Instruments
A. Nonlocking needle holder.
B. Suture scissors.
C. Dissecting scissors.
D,E. Very fine pointed and roundtipped scissors.
F. Round-handled platform forceps.
G. Curved dilating forceps.
H. Round-handled small knife blade
holder.
I. Microtip bipolar cautery
Vasovasostomy
Anesthetic Considerations
1.
2.
General vs. local?
Preparing the vas for anastomosis
1.
2.
3.
Vas grasped through skin above
the vasectomy site.
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.
Placement of 6-0 Prolene
sutures just into the muscularis
holds the vas above the incision
and make it easily accessible for
anastomosis.
Vasovasostomy
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.
Vasovasostomy Multilayer Anastomosis
1.
2.
3.
4.
The anastomosis is begun by
passing a 9-0 suture through the
muscularis and the adventitia at
the 5- and 7-o'clock positions .
A double-armed 10-0 suture is
passed through the lumen at the
posterior 6-o'clock position and
tied.
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.
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.
Vasovasostomy Multilayer Anastomosis
5.
6.
Once the anastomosis of the
lumen has been completed, the 90 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 .
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.
Vasovasostomy – Single
Layer Anastomosis
1.
2.
3.
4.
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.
Two more sutures are placed, full
thickness, at the 4- and 8-o'clock
positions and tied.
Three more full-thickness sutures
are passed at the 10-, 12-, and 2o'clock positions and then tied.
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.
Vasovasostomy
•
•
•
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
Vasovasostomy
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)
Vasoepididymostomy
•
•
•
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
Vasoepididymostomy
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.
Vasoepididymostomy :
End to End
1.
2.
3.
The epididymal tail can be dissected
free from the inferior aspect of the
testis and the epididymis transected at
its distal end.
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.
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 doublearmed 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.
Vasoepididymostomy :
End to End
4. The muscularis and adventitia of the
vas deferens are secured to the tunic
of the epididymis with interrupted 9-0
sutures .
Vasoepididymostomy :
End to Side
1.
2.
3.
4.
The rationale is that there is far
less dissection required, less
troublesome bleeding from the
transected epididymis, and
therefore a clearer field.
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.
The anterior surface of this loop is
incised along its longitudinal axis
with a microknife, making an
opening of approximately 0.5
mm.
Fluid is examined for normalappearing sperm.
Vasoepididymostomy :
End to Side
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.
Vasoepididymostomy :
End to Side
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.
Vasoepididymostomy :
End to Side
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.
Vasoepididymostomy : 3
Suture Intussusception
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.
Vasoepididymostomy : 2
Suture Intussusception
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.
Vasoepididymostomy
•
•
Post-op Care
– Similar to VasoVas
Complications
– Infection
– Hematoma
– DVT
– Injury to testicular artery
• Results
– Very wide variation even with microsurgical techniques.