Surgery of male infertility: An update

Abstract

Surgery for male infertility includes three main areas: varicocele surgery, recanalization of seminal tract, sperm retrieval.Varicocele treatment in infertily is still controversial. Recent scientific evidence appears to demonstrate that in selected cases varicocele treatment is beneficial in improving semen parameters and pregnancy rate. The key for the success of treatment seems to be a correct indication. It is our opinion that varicocele should be treated in presence of abnormal semen parameters, when clinically significant, and in adolescents with atrophy of the affected testis. So far, no specific technique, either surgical, microsurgical or sclerotherapic, can be considered the gold standard. Good results in our hands have been obtained with the microsurgical lymphatic sparing high ligation of internal spermatic vein.Innovations in surgery for seminal tract obstructions include the new tubular invagination techniques for epididimovasostomy, which showed excellent results with a simplified and time-saving microsurgical approach. In distal obstructions, a new transperineal ultrasound-guided approach has been proposed for the diagnostic work-up and treatment. Advantages of this technique and of the TURED must be balanced with those of immediate sperm retrieval for ART.In sperm retrieval, microTESE represents the most important surgical evolution in non-obstructive azoospermia. We have recently proposed a new stepwise approach starting with a minimal equatorial incision for conventional testicular biopsy which is extended to perform microTESE only when no sperm is retrieved. In this way microTESE is offered only to patients who really need it. Another field of innovation is sperm retrieval for ICSI in patients with Klinefelter Syndrome.

Comparison of intracytoplasmic sperm injection outcome with fresh versus frozen-thawed testicular sperm in men with nonobstructive azoospermia: a systematic review and meta-analysis

“…Nonobstructive azoospermia (NOA) is one of the most challenging subsets, which is caused by spermatogenic dysfunction. Surgical sperm retrieval, such as testicular sperm extraction (TESE) and microdissection testicular sperm extraction (microTESE), combined with intracytoplasmic sperm injection (ICSI) was an effective treatment for men with NOA, and these men can now father their own biologic children [2].…”

Correlation of genetic results with testicular histology, hormones and sperm retrieval in nonobstructive azoospermia patients with testis biopsy

“…Two cases of reciprocal translocations t (5; 19) and t (15; 20) were detected. It is hypothesised that balanced translocations interfere with normal chromosome pairing and segregation during meiosis I, providing a potential for the formation of unbalanced gametes and abnormal offspring subsequently (Franco et al., ; Hotaling & Carrell, ; Niederberger, ). When facing with the NOA men accompanied with the abnormality of chromosome, it is advisable for such cases to perform pre‐implantationgenetic diagnosis (PGD) for the couple to conceive a child with normal karyotype.…”

Varicocele: To Treat or Not to Treat?

“…Varicocele may cause spermatogenetic damage resulting in altered seminal parameters, abnormalities in the development and growth of the affected testis, and, rarely, symptoms such as discomfort and pain [ 11 ]. Thus observational studies suggest that men with a varicocele tend to have a higher proportion of spermatozoa with fragmented DNA, lower total sperm counts, lower progressive sperm motility, lower sperm vitality, and higher abnormal forms when compared to control groups [ 12 ]. The exact pathophysiology and, especially, the cause–effect relationship between the presence of varicocele and abnormalities of the semen analysis has not been clearly established [ 13 ].…”