Surgical Management of Male Infertility


Technique

Indication

Benefits

Drawbacks

Percutaneous epididymal sperm aspiration (PESA)

Obstructive Azoospermia

Quick, repeatable, less costly, low morbidity, no microsurgical expertise or surgical exploration required

Cryopreservation limited as less numbers of sperms retrieved, complications include fibrosis/obstruction at aspiration site, hematoma, spermatocele

Microsurgical epididymal sperm aspiration (MESA)

Obstructive Azoospermia

Good cryopreservation as more number of sperms retrieved, less risk of hematoma, feasible reconstruction if required

Time consuming, costly, micro surgical expertise and surgical exploration required, Postoperative discomfort is common

Testicular sperm aspiration (TESA, TEFNA)

Failed PESA in obstructive Azoospermia

Any Failed TESA in non- obstructive Azoospermia

Epididymal agenesis in congenital absence of vas deferens

Quick, repeatable, less costly, low morbidity, no microsurgical expertise or surgical exploration required, very few complications

Cryopreservation limited as less numbers of sperms retrieved, complications include hematoma, testicular atrophy

Testicular sperm extraction (single or multiple biopsies) (TESE)

Failed PESA or TESA in obstructive Azoospermia

Non obstructive Azoospermia

Quick, repeatable, no microsurgical expertise required

Few sperms retrieved with poor success rate in nonobstructive azoospermia, complications include testicular atrophy associated with multiple biopsies and postoperative pain

Microsurgical testicular sperm extraction (Micro-TESE)

Non obstructive Azoospermia

Good cryopreservation as more number of sperms retrieved in nonobstructive azoospermia, fewer complications

Time consuming, costly, micro surgical expertise and surgical exploration required, Postoperative discomfort is common



Various surgical methods have been developed to retrieve sperms either from epididymis or testis according to the cause of azoospermia. These include percutaneous epididymal sperm aspiration (PESA) [53] and microsurgical epididymal sperm aspiration (MESA) [6]. These can be successfully used to retrieve sperms from the epididymis in men with obstructive azoospermia.

Testicular sperm aspiration (TESA) can be used to retrieve sperm from the testes in men with OA who fail PESA and in men with NOA [54]. It also includes testicular fine needle aspiration (TFNA).

Testicular sperm extraction (TESE) using single or multiple open biopsies [53, 55] and, more recently, microsurgery (micro-TESE) are indicated for men with NOA. Surgically retrieved sperms could be used for cryopreservation and/or intracytoplasmic sperm injection (ICSI) during assisted reproduction.

The goals of SSR are to [56]:

(i)

Retrieve an adequate number of sperm for both immediate use and for cryopreservation

 

(ii)

Obtain the best quality sperm possible, and

 

(iii)

Minimise damage to the reproductive tract to avoid jeopardizing future SSR attempts or testicular function.

 

Published meta-analysis reported no significant difference in pregnancy rates when comparing epididymal and testicular sperm collected from obstructive azoospermia patients [57].



Percutaneous Epididymal Sperm Aspiration (PESA)


This technique is used to retrieve sperms for obstructive azoospermia. It was first described in 1994 by Craft et al. [54]. This SSR technique is the least invasive, easily repeatable, quickest to perform and is the first treatment option for obstructive azoospermia which cannot be surgically corrected. Different techniques can be used to perform PESA. Originally, the use of a larger butterfly needle was described [54] (Fig. 23.1) but currently, most experts use a fine needle (26 gauge) attached to a tuberculin syringe containing sperm washing medium [55, 58].

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Fig. 23.1
Percutaneous epididymal sperm aspiration (PESA) performed with butterfly needle (Illustrations used with permission from P N Schlegel, Cornell Medical Center, USA.)

The technical procedure for percutaneous epididymal sperm aspiration involves (Fig. 23.2), stabilisation of epididymis between the index finger, thumb and a forefinger,and a 26-guage needle which is attached to a 1-ml tuberculin syringe, is inserted into the epididymis by piercing the scrotal skin. After creating negative pressure by pulling the syringe plunger, the tip of the needle is gently and slowly moved in and out inside the epididymis until clear fluid is aspirated and is seen coming in the tuberculin syringe. Minimal amount of fluid is aspirated, usually 0.1 ml except in cases of congenital absence of vas deferens where up to 1.0 ml of fluid is aspirated. Aspirated fluid from the epididymis is flushed into a tube containing warm sperm culture medium. The tube containing the epididymal aspirate is taken to the laboratory for immediate microscopic examination to identify sperm under the microscope. If motile sperm are not obtained, PESA may be repeated at a different site (from the cauda to caput epididymis) until an adequate number of motile sperm is retrieved. Because PESA is a blind procedure, multiple attempts may be needed before high-quality sperm are found.

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Fig. 23.2
Percutaneous epididymal sperm aspiration (PESA) performed with syringe

The disadvantage of this technique is that sometimes an inadequate number of sperm are collected and the surgeon may have to proceed to another approach [29]. If PESA fails to retrieve motile sperm, testicular SSR can be attempted at the same operative time.


Micro-surgical Epididymal Sperm Aspiration (MESA)


This technique is used to retrieve sperms for obstructive azoospermia and was first described by Temple-Smith et al. [59]. It is an alternative to PESA in obstructive azoospermia and involves a 2–3 cm transverse incision through the scrotum into the epididymis so that an operating microscope can be used to extract sperm [55]. As this technique involves exposing the inside of the epididymis, it allows the surgeon to aspirate a much larger amount of sperm compared to PESA [29]. The epididymal tunica is incised, and an enlarged tubule is selected. Then, the epididymal tubule is dissected and opened with sharp microsurgical scissors. The fluid that flows out of the tubule is aspirated with the aid of a silicone tube or a needle attached to a tuberculin syringe (Fig. 23.3). The aspirate is flushed into a tube containing warm sperm culture medium and is transferred to the laboratory for examination. MESA can be repeated at a different site on the same epididymis (from the cauda to caput regions) and/or the contralateral epididymis until an adequate number of motile sperm is retrieved [4].

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Fig. 23.3
Microsurgical sperm aspiration (MESA) (Illustrations used with permission from P N Schlegel, Cornell Medical Center, USA.)

If MESA fails to retrieve motile sperm, TESA or TESE can be performed as part of the same procedure. However, MESA often provides enough sperm for cryopreservation. A single MESA procedure usually enables the retrieval of a large number of high-quality sperm that can be used for ICSI or intentionally cryopreserved for subsequent ICSI attempts [60, 61].


Testicular Sperm Aspiration (TESA)


This technique is used to retrieve sperm for non-obstructive azoospermia or in cases of failed PESA in men with obstructive azoospermia.

In TESA, a needle is inserted through the scrotal skin into the testis (Fig. 23.4). The needle is usually inserted into the antero-medial or antero-lateral portion of the superior testicular pole at an oblique angle toward the medium and lower poles. These areas are the least likely to contain major branches of the testicular artery running superficially underneath the tunica albuginea. These aspirations are usually carried out using either fine (testicular fine-needle aspiration; TEFNA) or large-diameter needles attached to a syringe. The testicular parenchyma is aspirated by creating negative pressure and the specimen is sent to the laboratory for microscopic examination. TESA can be carried out in the contralateral testis if an insufficient number of or no sperm are obtained during the first attempt. Alternatively, testicular parenchyma can be obtained percutaneously using a tissue-cutting biopsy needle (e.g., a Tru-cutTM needle or Biopty TM gun). For this procedure, the needle is placed against the testis and, upon release of the springer; the needle enters the parenchyma, cuts a piece of tissue and withdraws it into a sheath [62].

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Fig. 23.4
Testicular Sperm Aspiration (TESA) (Illustrations used with permission from P N Schlegel, Cornell Medical Center, USA.)

The technique of testicular fine-needle aspiration (TFNA) of the testis was initially described as a diagnostic procedure in azoospermic men [63]. Subsequently, testicular fine needle aspiration or biopsy for the recovery of spermatozoa has been described [64].

Percutaneous puncture and aspiration of the testis can be performed using a 21–23-gauge needle connected to a 20-cc syringe in a Menghini syringe holder. Percutaneous testicular needle biopsy can be performed with an automatic biopsy gun (Fig. 23.5). The limited published experience to date with TFNA makes critical evaluation of this technique difficult, although it has been shown that SSR is routinely possible with TFNA for men with obstructive azoospermia. SSR rates are much higher in obstructive patients with almost 100 % of procedures being successful compared to around 27 % in non-obstructive azoospermia [29]. However, recently a study has shown that up to four repeat TESA attempts in non-obstructive patients can have a success rate of 67 % [65].

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Fig. 23.5
Testicular sperm aspiration (TESA) with gun. (Illustrations used with permission from P N Schlegel, Cornell Medical Center, USA.)

Occasional haematoceles and hematomas are possible with this technique. The advantages of percutaneous aspiration techniques are that they can be performed with local anaesthesia, without open scrotal exploration and its attendant postoperative discomfort, and without microsurgical expertise.


Testicular Sperm Extraction (TESE)


This technique is used to retrieve sperms for non-obstructive azoospermia, failed PESA or TESA in men with obstructive azoospermia. Testicular sperm extraction (TESE) is the most commonly employed SSR technique in men with non-obstructive azoospermia and has much higher success rates in this group of patients compared to TESA. Systematic review reported the 49.5 % success of TESE in this group of patients [66]. The difference between TESE and TESA is that this technique involves an incision into the testes to remove a testicular tissue.

TESE can be used to assess the degree of sperm production in the setting of azoospermia as well as to obtain sufficient tissue for sperm extraction, either for immediate use or to be preserved as a frozen specimen for IVF with ICSI. The procedure can be performed with unifocal biopsies from both testicles and open scrotal exploration for obtaining multifocal testicular biopsies.


Unifocal TESE


Through a scrotal incision the testis is exposed after opening the tunica vaginalis layer. The tunica albuginea is incised, and a piece of protruding testicular tissue is excised. The tunica albuginea and vaginalis is sutured in separate layers and the skin incision is closed (Fig. 23.6a–c). It is an easy method and yields a good amount of tissue. But the drawback is that it is an open surgical procedure and there is risk of damage to the testicular vessels whilst excising the testicular tissue and during incision and closure of the tunica albuginea. Testicular arteries are end-arteries, and hence multiple, conventional biopsies in men with testicular failure can demonstrably impair testicular function [67, 68].

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Fig. 23.6
(ac) Unifocal testicular sperm extraction (TESE)


Multifocal TESE


Multifocal TESE can be performed under spinal/ general anaesthesia. A small either vertical incision in the median scrotal raphe or a transverse 2–3 cm incision is given after the scrotal skin is stretched over the anterior surface of the testis. The skin, dartos muscle and tunica vaginalis is opened to expose the tunica albuginea. Testes are exteriorised. The tunica albuginea is incised for up to 4 mm at multifocal sites representing all areas of the testicle. Gentle pressure is applied to the testis to extrude a sufficient tissue volume, which is excised with sharp scissors. The same procedure is subsequently repeated on the contralateral testis. The tunica albuginea is closed with 3-0 Vicryl, and then the scrotal skin is closed separately using a continuous subcuticular 4-0 vicryl suture (Fig. 23.7a–k). Scrotal dressing and scrotal supporter are placed. Pain relief is given in the form of local infiltration with bilateral nerve block to the genital region.

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Fig. 23.7
(ak) Multifocal testicular sperm extraction (TESE)

This technique is used in order to increase the success of SSR as often only a few areas within the testes are producing sperm in non-obstructive azoospermic males [29]. As a significant amount of the seminiferous tubules are removed in the procedure, studies have shown there to be an adverse effect on spermatogenesis temporarily and potentially in the long term too. As a result, repeat sampling is much more difficult [69]. Therefore surgeons are recommended to wait around 3–6 months for any repeat procedure in order to give the testes time to resume spermatogenesis [4].


Microsurgical Testicular Sperm Extraction (Micro-TESE)


Micro TESE involves testicular sperm extraction, involving micro-dissection with the help of operating microscope. This technique was first described by Schlegel in 1999 and is used to retrieve sperms for non-obstructive azoospermia [61, 70, 71].

Micro-TESE is performed under general or regional anaesthesia. The scrotal skin is stretched over the anterior surface of the testis after which a 2–3-cm transverse incision is made [4]. Alternatively, a single midline scrotal incision can be used [70]. The incision extends through the dartos muscle and the tunica vaginalis. The tunica is opened, and identifiable bleeders are cauterized. The testis is delivered externally, and the tunica albuginea is examined. Then, a single, large, mid-portion incision is made in an avascular area of the tunica albuginea under 6–86 magnification, and the testicular parenchyma is widely exposed in its equatorial plane. The testicular parenchyma is dissected at 16–256 magnification to enable the search and isolation of seminiferous tubules that exhibit larger diameters (which are more likely to contain germ cells and eventually normal sperm production) in comparison to non-enlarged or collapsed counterparts. If needed, the superficial and deep testicular regions can be examined, and microsurgical-guided testicular biopsies are performed by carefully removing enlarged tubules using microsurgical forceps. If enlarged tubules are not observed, any tubule that differs from the remaining tubules in size is excised [4]. The excised testicular tissue specimens are placed into the inner well of a Petri dish containing sperm media, and are sent to the laboratory for processing and sperm search [4]. The tunicas albuginea and vaginalis are then closed in a running fashion using non-absorbable and absorbable sutures; dartos muscle is closed with interrupted absorbable sutures, respectively. Immediately prior to complete closure, 3 cc of 1 % xylocaine solution may be injected into the subcuticular layers. The skin is closed using a continuous subcuticular 4-0 vicryl suture. Scrotal dressing and scrotal supporter are placed.

Direct vision with the operating microscope in microdissection TESE is of great advantage, since larger, more opaque, whitish tubules, presumably containing more intra-tubular germ cells with active spermatogenesis, can be identified. Generally, the testis is small in patients with NOA involving severely impaired spermatogenesis, such as in Sertoli cell only syndrome (SCOS) and Klinefelter syndrome. Minute foci of normal spermatogenesis in the small testis can be detected under the operating microscope; only tiny portions need to be removed, minimizing operative damage.

The use of microsurgical techniques in sperm extraction represent a newer approach to retrieval and appear to have a higher success rate and a lower risk of reducing spermatogenesis following the procedure as less tissue is removed. These may form the future of SSR [29].

Percutaneous SSR is an effective method to retrieve sperm in men with obstructive azoospermia irrespective of the cause of obstruction but chance of achieving a live birth and the after sperm injection is not related to the cause of obstruction [61]. Cochrane review [61] showed that no specific SSR technique for azoospermic men is preferable to achieve better outcome undergoing ICSI. In the absence of robust evidence it is recommended to use the least invasive and simplest technique available.

The number of spermatozoa collected with testicular sperm extraction is linked to the number of clinical pregnancies, independent of the number of ICSI cycles and the number of oocytes collected/injected. FSH level and testicular volume are also linked to ICSI success [72].


Post Operative Complications


Carefully performed testicular biopsy is associated with few complications. Postoperative complications of SSR techniques include persistent pain, swelling, infection, hydrocele and hematoma formation [71, 73]. The complication rates vary depending on the SSR technique. Percutaneous retrievals have an increased risk of hematoma compared with open techniques [45, 74]. Nevertheless, except for minor pain and local swelling, there have been no reports of clinically significant intra- or postoperative complications with PESA [56].

The incidence of complications after SSR, including persistent pain, swelling, infection, hydrocele, and hematoma, ranges from 0 to 70 % [71, 73]. Patients who undergo TESE, with single or multiple biopsies have increased risk of intra-testicular hematoma formation and therefore scrotal support is given at least 24 h after surgery. Large-volume conventional TESE has been associated with a higher risk of a transient or even permanent decrease in serum testosterone levels due to testicular devascularisation and excessive tissue removal [75, 76]. On the other hand, the incidence of complications is lower following micro-TESE compared to conventional TESE [66, 70, 77].

In micro-TESE, the testicular vessels under the tunica albuginea are identified prior to the placement of an incision in the testis. In addition, the use of optical magnification and microsurgical techniques allows the preservation of the intra-testicular blood supply [56]. But the risk of serum testosterone insufficiency has been documented following micro-TESE in patients with Klinefelter syndrome who already have diminished androgen production due to small atrophic testicular volume [73]. Nonetheless, it has been observed that serum testosterone levels returns to pre-surgical values in most individuals within 12 months following surgery [76]. Any procedure that requires a general anaesthetic also carries an increased risk of complications.

Given the potential serious postoperative complications of SSR, it is recommended that these procedures be performed by surgeons who have specific training in the above-mentioned techniques [76].


Post Operative Care After SSR


SSR is a relatively low risk procedure and is performed as a day case procedure, with patients being discharged 4–5 h after surgery. The patient should not be allowed to leave for home without an accompanying person. The recovery time depends on what technique was used and can range from a few days to a couple of weeks. Most patients can return to light office work in 24–48 h after percutaneous retrievals. Bed rest is recommended for the first 48 h, especially following open retrievals. The patients are instructed to keep the pressure dressing and scrotal support on for at least 24 h to reduce the risk of testicular haematoma formation and bruising that can happen in the immediate postoperative period (Fig. 23.8). They are encouraged to take warm showers and wash the incision area with soap and water after 24 h and keep the area dry, but to avoid hot baths to prevent infection. Most men will be instructed to avoid strenuous activity and use a scrotal or athletic supporter, for approximately 1 week after the procedure or until they are fully recovered. This reduces the risk of chronic testicular pain in the long run. Oral analgesia is generally prescribed for 3–5 days. Postoperative antibiotics are not routinely prescribed but just given as a single dose of antibiotic peri-operatively. Patients are instructed to resume a normal diet and increase their daily activities to a normal level over a 3–4-day period. The patient should abstain from sports activities, heavy lifting and sexual intercourse for approximately 10 days [56]. Moreover, patients should be informed of the likelihood of scrotal swelling and ecchymosis at the wound site, as well as mild discomfort that should subside in approximately 1 week [4].

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Fig. 23.8
Post-operative scrotal dressing after surgical sperm procedure

A follow up appointment in the clinic is arranged in 2 weeks to assess the postoperative recovery and to discuss the results. If sperms are successfully cryosperserved then discussion of IVF with ICSI treatment is taken place. Failing that, option of donor sperm and adoption is discussed. A scrotal ultrasound may be indicated in cases with any complications after surgery or where repeat surgery is required; In that case determination of hormone levels, including total and free testosterone, FSH and LH level, is also recommended in 6 months. The author suggests that patient selection should be done appropriately and the right procedure is selected in order to avoid repeat procedure and reduce morbidity associated with repeat testicular biopsies.



Surgery to Improve Sperm Production



Varicocele Repair (Varicocelectomy)


Varicoceles are thought to be present in approximately 15 % of the normal male population but are found in around 35 % of infertile men [4]. They are an abnormal enlargement of the scrotal veins which can reduce venous drainage and can result in elevated scrotal temperature, disrupting spermatogenesis. Varicoceles are considered to cause progressive damage to the testes with spermatogenesis decreasing over time. Larger varicoceles appear to cause more damage than small varicoceles and, conversely, repair of large varicoceles results in greater improvement of semen quality. The prevalence of varicocele in men with secondary infertility is higher compared to those evaluated for primary infertility [78, 79].


Improvement in Sperm Parameters


Varicocelectomy can halt the progressive duration-dependent decline in semen quality found in men with varicoceles. The earlier the age at which varicocele is repaired, the more likely is recovery of spermatogenic function. A number of studies suggest varicocele repair results in improved semen quality, especially sperm morphology and motility. Multiple reports have documented improvement in sperm counts after varicocelectomy with more benefit observed in men with sperm concentrations of >10 million/ml [80]. Men with decreased testicular size persistently show less improvement in sperm count [81, 82] while higher grade and larger size of the preoperative varicocele is associated with greater improvement in semen quality [83, 84]. However, as roughly 80 % of the male population with varicoceles are fertile, the risks of surgery should be weighed up with the likelihood of improved fertility following the procedure [29].


Effects on Conception After Varicocele Repair


There remains a debate on whether the procedure results in increased pregnancy rates or not [29]. A recent Cochrane review analysed 8 randomised controlled trials of couples who were having difficulty conceiving where the male was diagnosed with either a subclinical or clinical varicocele with normal or abnormal semen analysis. It indicated that there was no benefit of treating a varicocele as there was little change in pregnancy rates following the procedure [85]. However, a meta-analysis published in 2007, evaluated 5 studies looking at males with palpable varicoceles with abnormalities in their sperm. It was found that there was a substantial improvement in pregnancy rates following varicocele treatment [86]. Therefore, these reports suggest treatment of varicoceles should be restricted to patients who have a clinical varicocele and at least two abnormalities in their semen analysis.


Surgical Techniques for Varicocele


They are the commonest treatable cause of male infertility [3]. Surgical procedure used to treat varicocele is called varicocelectomy [23]. The main aim of varicocele repair is to remove or thrombose the veins which are contributing to the varicocle as well as others that have a potential to form variccocle in the future while preserving adequate venous drainage and preventing damage to the arteries, vas and lymphatics.

Surgical repair remains the most popular form of treatment for varicocele and it can be achieved by conventional open varicocelectomy (retroperitoneal high ligation, inguinal and sub-inguinal ligation), laparoscopic/robotic varicocelectomy and microsurgical varicocelectomy [87]. In recent years, however, a safe and effective nonsurgical alternative called varicocele embolization is becoming the treatment of choice for many patients and their doctors.


Reconstructive Surgery of the Vas Deferens and Epididymis


The number of men undergoing vasectomy has not changed over years. Up to 6 % of men (approximately 30,000 men each year), change their minds after vasectomy and wish to father children again. Although intended for permanent sterilization, vasectomy can be reversed in most men seeking to restore their fertility due to a change in marital status or reproductive goals. Furthermore, obstructive azoospermia can be the result of iatrogenic injuries to the vas deferens, usually from hernia repair [88] in 6 % of azoospermic men [89].

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May 29, 2017 | Posted by in GYNECOLOGY | Comments Off on Surgical Management of Male Infertility

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