Surgical treatment of male infertility
G.A. de Boccard
Department of Obstetrics and Gynecology, Geneva University Hospital
Obstructive fertility problems can often be treated by surgery and the developpement of microsurgery has brought new posibilities to many infertile men. We will discuss the different surgical techniques to by-pass an obstruction, cure a varicocele and retrieve epididymal or testicular spermatozoa
Fertility - Vaso-vasostomy - Vaso-epididymostomy - Microsurgery - varicocele – laparoscopy - Testicular biopsy
The causes of male infertility are multiple and only a few among them may be cured. The incidence of obstruction of the seminal excretory pathway in infertile men is estimated to be 7-14%(4). The advent of microsurgery opened a new era, giving hope to patients otherwise considered as definitely sterile.
In the following paragraphs the author will expose only the surgically curable causes of infertility. Hormonal and infectious diseases are evocated in another chapter.
Only a few parts of the seminal tractus can be reached by surgical procedures: those that are apparent either intra-scrotally, subcutaneously or endoscopically at the level of the prostatic portion of the urethra.
CONGENITAL PATHOLOGY OR AQUIRED OBSTRUCTION
Parts of the seminal tractus, especially the vas deferens, can be missing or obstructed, usually partially, sometimes totally. The cause can be congenital, associated with cystic fibrosis, post-infectious after genital tuberculosis, gonorrhea or chlamydia, or iatrogenic after hernia repair, cure of an hydrocele. If a short segment is missing or obstructed,it is possible to by-pass it.
Varicocele is commonly due to the absence of valves in one of the longest vein of the body, the left gonadic vein that drains in the left renal vein. It occurs in about 15% of the normal male population. It is found in 40% of those consulting for primary infertility and in up to 80% in men with secondary infertility. It is more often bilateral than earlier believed. Progressive deterioration of testicular function is clearly associated with varicocele. Many authors relate the problem to an elevated scrotal temperature due to the lack of heath exchange at the level of the pampiniform plexus, others describe the toxic effects of elevated venous catecholamines, cortisol and renin(2). The presence of a varicocele is determined by physical examination but Doppler sonography must confirm the persistance of a retrogade flow during the Valsalva maneuver since only refluant varicoceles deserve surgery.
There are two major indications for the treatment of varicocele: scrotal pain and infertility. A painful varicocele is generally large in size and easily diagnosed but the importance of subclinical varicoceles should be considered even in the presence of a small retrograde flow(5).
If a fertility problem is evocated, a refluant varicocele deserves a treatment anyway since the result of the cure is neither dependant upon the size of the veins nor upon the degree of the retrograde flow.
Surgical and non surgical techniques for the treatment of a varicocele are available:
The high ligation technique consists in finding the spermatic vein at the level of the lower pole of the kidney through a retroperitoneal approach. The skin is horizontaly incised medial to the anterior superior iliac spine, the external oblique muscle is incised, the internal oblique muscle is retracted and the peritoneum is teased away. At this level the vein is generaly unique and easy to ligate. It however happens that some collaterals take their origin from another vein, causing the failure of the procedure in about 2% of the cases. The surgical approach on the right side may also be more difficult because the right gonadic vein drains in the inferior vena cava.
Inguinal ligation is performed through a low inguinal incision. The aponeurosis of the external oblique is incised and the spermatic cord isolated. The spermatic fascia is incised and the dilated veins are dissected, ligated and excised. This allows a complete stop in the internal drainage. This technique is very safe, but the number of relapses is often high because of difficulties with dissection wich leaves patent veins in up to 21% of the cases, unless it is performed by a skilled surgeon under microscope or magnifiying glasses(3, 17).
Radiologicaly controlled embolization is an easy day procedure: After puncture and catheterization of one of the femoral veins, the radiologist identifies the refluant spermatic vein by injecting a iodine dye during a Valsalva maneuver. Then, during a new maneuver he injects a sclerotizing solution, a wire coil or a detachable ballon. This technique is cost and time effective but has also a failure rate of 12% due to difficulties in finding the vein in case of anatomical variations. There is also a small risk of migration of the sclerotizing agent or coil and it also exposes the patient to rather useless irradiation.
The recent laparoscopic technique has now been extensively used in many centers. After punction of the ombilicus, the peritoneal cavity is insuflated with CO2 at a pressure of 14 mmHg. Then a camera is inserted through a 10 mm trocart. The vein is easily identified, often double, on the left side, running under the posterior peritoneum between the sigmoid and the internal inguinal ring. Two other ports are needed to insert the forceps and scissors then the abdominal pressure is lowered to 8 mmHg. After dissection, the ligation of the refluent spermatic vein is made 1,5 cm over the internal inguinal ring using titanium clips. The spermatic artery and the lymphatics are easily identified and spared, collateral veins can also be clipped or coagulated during the same procedure. The laparoscopic method causes less morbidity (only 24 hours hospitalization) and, being microsurgical, is very precise. it seems to avoid the recurrences through revascularization by peritoneal branches. This procedure needs a skilled laparoscopic surgeon in order to avoid the dangers of laparoscopy itself.
Overall results of varicocele repair in collated studies show 50% to 90% improvement in semen quality and 30% to 50% may initiate a pregnancies after 6 to 9 months(7).For men with azoospermia or severe oligospermia, modest improvement in semen quality after varicocele repair may have a significant impact on a couples’ fertility options(18)
EJACULATORY DUCT RESECTION
In the prostate, after the junction with the seminal vesicle the vas ends in the ejaculatory duct at the level of the veru montanum. Even a small lesion in that region can cause an obstruction, often bilateral. Generally its etiology is inflammatory but in some cases a congenital malformation like a Mullerian duct cyst or a Wolffian malformation can be found. It is suspected in case of low semen volume (less than 1.0 ml) and absence of fructose in the seminal plasma. Perineal pain and hematospermia may be associated. The rest of the vas deferens is usually normal. Ejaculatory duct obstruction is best diagnosed by transrectal ultrasound echography.
The treatment is performed endoscopically with a resectoscope incision along the veru montanum. Deep resection is sometimes needed and one must be very careful to avoid rectum perforation or sphincter lesion(5).
The most frequent cause of obstruction of the vas deferens is vasectomy. Among 100 men undergoing vasectomy, 1 or 2 will ask for a reversal. Short segmental agenesis, accidental section during hernia repair or post-infectious localized obstruction are more uncommon. The influence of the delay after vasectomy on the fertility rate is controversial because fertility rate decreases in any case naturally with time in normal men (15).
Surgically, vaso-vasostomy can be performed anywhere along the scrotal and inguinal part of the vas. It is also theoretically possible intraperitonealy by laparoscopy but generally, as a consequence of vasectomy, it is done in the mid or upper part of the scrotum.
We prefer the two-layers technique with the help of a microscope (stereoscopic f:300 lens). A 3 cm incision is made over the palpable vas, its lower end being at the level of the distal part of the resected vas. The two ends are dissected from the surrounding tissues and exposed with the « Goldstein Microspike Approximator » if available, the scarred area are resected. The distal end is flushed with saline to check its permeability and dilate the lumen, the testicular end is checked for sperm by an extemporaneous microscopic examination. The microspike approximator is installed and a yellow plastic drape is placed underneath in order to have a better view of the sutures. Then six 10-0 adsorbable monofilament sutures are placed to approximate the mucosa, then the same number of 9-0 adsorbable sutures are placed on the sero-muscular layer. Non adsorbable sutures (i.e. Nylon) should be avoided since they may induce a macrophagic reaction within two years resulting in fibrosis of the anastomosis.
If a microscope is not avalaible and for beginners we recommand the modified two-layers technique wich allows very good results and is much easier to perform: Four 9-0 monofilament adsorbable sutures are placed at 6, 9, 3 and 12 O'clock through the serosa and the mucosa in order to approximate the two portions of the vas. Then four additional 9-0 sutures are placed on the serosa between the first four to ensure tightness of the vas.
In some vasectomy cases a large part of the vas has been resected, making tensionfree direct anastomose impossible. The epididymis can be dissected free from the testis, beeing attached only by the head and and brought up to the distal end of the vas, thus making anastomosis posible without traction.
Our own results show a 86% patency rate, comparable with the different published series. The pregnancy rate is between 50 and 60%. As stated before, the fertility rate decreases with time elapsed after vasectomy but the patency rate is still about 70% after more than 15 years of obstruction.
It should be noted that the mean time between vasectomy reversal and conception is more than twelve months and, more important, that the fertility rate of the reversal group is the same as in the normal control group(1).
If obstruction is located at the level of the epididymis in the presence of a normal vas, the first choice therapy is vaso-epididymostomy.
After incision of the scrotum, the testis and the epididymis are exposed. The microscope is installed (stereoscopic f:300). The vas is dissected and his patency controlled by saline injection . The epididymis is freed from the testis, being only attached at the level of the head. It is then transsected at an apparently healthy level, leaving a bundle of open tubules apparent. After an initial general oozing of fluid, one of the tubule will permanently emit spermatic white fluid that shall be microscopically checked for spermatozoa. If none can be found at this level, a more proximal section will be performed. With the help of a microspike approximator the transsected distal vas will be brought to the opened tubule. If no sperm is found at this stage a testicular biopsy with cryoconservation is done in order to provide further fertilization possibilities(11).We then perform an end to end anastomosis We first place four 10-0 adsorbable sutures through the individual epididymal tubule and the mucosa of the vas; then the seromuscular layer of the vas is tightly secured to the tunica of the epididymis by eight to ten 9-0 adsorbable sutures. Two 7-0 Nylon suture are finally externally placed to secure the external tunica of the vas to the epididymis, preventing any harmful traction.
An older technique consists in opening laterally the epididymis proximally to the obstructed level and isolating a single tubule wich is incised and not transsected, and anastomosed side to end with the same described technique.
The results of this procedure show has a patency rate of 85% with a pregnancy rate of only 44%(12). Vasoepididymostomy has however a higher pregnancy rate than IVF with ICSI and should be preffered in any case of obstructive sterility at the epididymal level.
EPIDIDYAL SPERM ASPIRATION
Until recent years, there was no available treatment in cases of bilateral absence or total obstruction of the vas. The first description by Temple-Smith(11) of sperm micro-aspiration from the epididymis and in vitro fertilization resulting in a pregnancy followed by Silber(9) who repeated the procedure with success opened a new field. Silber had even a better pregnancy rate in cases of agenesis than in those with acquired obstruction. The actual fecondation rate is 70% with 30% to 50% pregnancy rate(13).
For the urologist, the technique is quite simple. The preparation of the epididymis is made as decribed for the second vaso-epididymostomy technique but instead of anastomosing the vas, the sperm coming out of the tubule is aspirated in a 2 ml insulin seringue( gamma sterilization only) prefilled with Percoll. It is generally possible to collect 10 to 20 million spermatozoa within 30 to 60 minutes. The spermatozoa are exemporaneously examined, then frozen. The epididymal duct and the tunica of the epididymis should be closed as precisely as possible with 10-0 and 9-0 resorbable sutures, as well as the outer layers of the scrotum, to be able to repeat the procedure easily if required. The stimulation and the sampling of the oocytes from the partner will be indicated only in the presence of living spermatozoa, avoiding unnecessary procedures.
I.C.S.I WITH TESTICULAR BIOPSY
The most recent developpment of the intra cytoplasmic sperm injection (I.C.S.I.) has opened a new field in treating sterile men. In fact, living spermatozoa can be retrieved in almost all cases of obstructive azoospermia. In other cases, even after a former negative biopsy and elevated FSH, it is still possible to retrieve living spermatozoa in about 50% of cases.
Biopsy is best performed by exteriorizating both testis and obtaining 3 to 4 small fragments wich should be extemporaneously examined in order to find a producing zone in the testis(18). Percutaneous biopsy, although described, doesn’t give as good results. More recently it has been suggested to press a slide to the opened testis and look for spermatozoa, under microscope(19). This technique avoids useless damaging of sometimes allready smal testis. The biopsy, if containing a complete spermatogenetic process, even in patients with tubular atrophy, will allow the biologist to pick up one single spermatozoa and inject it in the oocyte. This procedure has a comparable fertilization and pregnancy rate (13,14,16)
1. Belker A.M., Thomas A.J.JR., Fuchs E.F., Konnak J.W. and Sharlip I.D.,(1991): Results of 1,469 microsurgical vasectomy reversals by the vasovasostomy study group. J Urol 145:505-511
2. Biase, J.N. and Nagler M.N.(1992): The varicocele: current concepts and controversies. Current Op Urol 2:463-466
3. Chehval M.J., Purcell M.H. (1992): Varicocelectomy: Incidence of external spermatic veins involvment in the clinical varicocele. Urology 39:573-575
4. Denil J. and Jonas U.(1993): The management of disturbance of sperm transport. Eur Urol Update series 2:82-87
5. Hadziselimovic F., Herzog B., Leibundgut B., Jenny P.,and Buser M. (1989): Testicular and vascular changes in children and adults with varicocele. J Urol 142:583-585
6. Hellstrom W.J.G.,(1992): New techniques in the diagnosis and treatment of male infertility and vasectomy reversal. Current Op Urol 2:457-462
7. Lipschultz L.I., KesslerD.L.,(1986): Evaluation and treatment of male infertility. Monogr Urol 7 (april/may)
8. Shekarriz M., Pomer S.(1991):Microsurgical vasoepididymostomy: a comparison between the end to side anastomosis and the invagination technique. Urol Res 19:285-287
9. Silber S.J., Balamaceda J., Borrero C., Ord T., Asch R., (1988): Pregnancy with sperm aspiration from the proximal head of the epididymis: a new treatment for congenital absence of the vas deferens . Fertil Steril 50:525-528
10. Stefanovic K., Clark S., Buncke H., (1991): Microsurgical epididymovasostomy by loop intussuception. A new technique in the rat model. Br J Urol 68:518-523
11. Temple-Smith P.D., Southwick G.J.,Yates C.A., Trounson A.O. and de Krester D.M.(1985):Human pregnancy by in-vitro fertilization (IVF) using sperm aspirated from the epididymis. J in Vitro Fert and Emb Trans 2:119-122
12. Kolettis PN, Thomas AJ Jr : Vasoepididymostomy for vasectomy reversal a critical assessement in the era of intracytoplasmic sperm injection. J Urol 158(2) : 467-70, 1997
13. Tournaye H., Devroey P., Liu J., Nagy Z., Lissens W. & Van Steirteghem A.: Microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection: a new effective approach to infertility as a result of congenital bilateral absence of the vas deferens. Fert and Ster 61:1045, 1994
14. Yemini M., Vanderzwalmen P., Mukaida T., Schoengold s. & Birkenfeld A.: Intracytoplasmic sperm injection, fertilization, and embryo transfer after retrieval of spermatozoa by testicular biopsy from an azoospermic male with testicular tubular atrophy. Fertil Steril 63:1118-20, 1995
15. Meacham R. & Murray M.: Reproductive function in the aging male. Urol Clin North Am 21:549-56, 1994
16. Craft I., Tsirigotis M., Bennett V., Taranissi., KhalifaY., Hogewind G. & Nicholson N.: Percutaneous epididymal sperm aspiration and intracytoplasmic sperm injection in the management of infertility due to obstructive azoospermia. Fertil Steril 63:1038-42, 1995
17. Goldstein M, Gilbert BR, Dicker AP, Dwosh j, Gnecco C. : Microsurgical inguinal varicocelectomy with delivery of the testis : an artery and lymphatic sparing technique. J.Urol 148 :1808-11, 1992
18. Matthews G., Matthews E,. Goldstein M. : Induction of spermatogenesis and achievement of pregnancy after microsurgical varicocelectomy in men with azoospermia and severe oligoasthenospermia. Fert & Ster 70 :71-75, 1998
19. Wisard M., Senn A., Germond M., Guillou L. :Azoospermie sécrétoire et procréation médicalement assistée : faut-il faire des biopsies multifocales et bilatérales ? Communication SSU, 1999
20. Fehr J.-L., Eberli D., Pestalozzi D., Fehr P. : Testikuläre Spermienentnahme (TESE) zur Kryokonservierung: die Bedeutung des direkten Abklatsch-Präparates. Communication SSU, 1999