Surgical Procedures for Male Infertility: An Update

William R. Visser; L.I. Smith-Harrison; Sarah C. Krzastek

Disclosures

Curr Opin Urol. 2021;31(1):43-48. 

In This Article

Abstract and Introduction

Abstract

Purpose of Review: The aim of this review is to provide an overview of surgical treatment options for male infertility including varicocelectomy, treatment of ejaculatory duct obstruction, vasovasostomy, and sperm extraction, and to review recent advances in techniques and technologies that may improve operative outcomes.

Recent Findings: Microscopic subinguinal varicocelectomy has been shown to have the highest success rates with lowest rates of complications, and may be facilitated by the use of Doppler, indocyanine green angiography, and the 4K3D operating video microscope. The standard treatment for ejaculatory duct obstruction by transurethral resection of the ejaculatory ducts has changed little over time, but vesiculoscopy may allow for temporary dilation of an obstruction to allow for natural conception, while also offering diagnostic capabilities. Use of the robotic platform has gained popularity for vasectomy reversals but controversy remains regarding the cost-effectiveness of this option. Recently, a reinforcing suture technique has been described for vasovasostomy to minimize anastomotic breakdown and reversal failure. Finally, gray-scale and color-enhanced ultrasound may improve ability to predict successful sperm retrieval during extraction procedures.

Summary: Though the fundamentals of surgical treatment options for male infertility have changed little with time, technological advancements have contributed to improved surgical outcomes over recent years.

Introduction

Fertility issues are common, and a male factor may be present in up to 50% of cases.[1] Although certain causes of male infertility may be managed with medications and manipulation of the hypothalamic--pituitary--gonadal axis, surgery may be indicated in some cases to optimize sperm in the ejaculate, or to retrieve viable sperm for assisted reproductive technologies (ART).

The surgical treatment options for male infertility can be thought of in several broad categories – procedures to optimize sperm production, procedures to optimize sperm in the ejaculate, and procedures to extract sperm for ART. Procedures, which improve spermatogenesis are few, and are primarily limited to correction of a clinical varicocele. Alternatively, patients may experience a decrease in the amount of sperm in the ejaculate because of an obstruction along the excurrent ductal system. In cases of ejaculatory duct obstruction, procedures to relieve the obstruction may be appropriate. A reconstructive procedure may also be needed for a more proximal obstruction. If a patient is unable to undergo a reconstructive procedure or is unable to generate sperm in the ejaculate, sperm may be retrieved directly from the epididymis or testis.

Though the basic surgical approaches to the above procedures have remained largely unchanged since their advent, certain technological advances over the years have allowed for improved outcomes and shorter operative times with fewer complications. The aim of this review is to briefly describe the surgical techniques available for management of male infertility, and to discuss recent advances in techniques and technologies in the field.

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