Surgical Procedures for Male Infertility: An Update

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


Curr Opin Urol. 2021;31(1):43-48. 

In This Article

Procedures to Optimize Spermatogenesis


Varicocele is an extremely common urologic entity caused by the abnormal dilation of the pampiniform plexus in the scrotum, which alters the scrotal environment and can have multiple negative effects on testicular function, which may contribute to subfertility, scrotal discomfort, and hypogonadism.[2,3] Varicoceles are found in approximately 15% of men, with rates increasing to 35% of men with primary infertility, and up to 80% of men with secondary infertility. It is the most common disorder seen in sub-fertile men.[4,5] Currently, all interventions are focused on management of this venous dysfunction and improving the micro-environment of the testis. Common indications for treatment of varicoceles includes decreased sperm count, motility and morphology associated with infertility. Treatment is also reasonable for varicocele-related discomfort and pain.[6] More controversial applications of varicocelectomy include treatment for azoospermia, hypogonadism, and increased sperm DNA fragmentation.[7]

Surgical treatment of varicoceles was first described in the 19th century, and since that time, the medical field has made significant advances in the treatment and management of varicoceles. Although radiographic vascular treatment options do exist, this manuscript will focus on surgical interventions and recent advances. In general, the available operative approaches include high retroperitoneal, laparoscopic, inguinal, and sub-inguinal.[8,9] Although each approach has its advantages and complications, the microscopic subinguinal approach has been shown to have the lowest rates of recurrence and hydrocele development.[10] Although the application and indications for varicocelectomies have been expanded, the surgical approach is still fundamentally the same, with the goal of minimizing venous pooling around the testis. However, there have been some recent advances and modifications to the surgical technique.

One of the feared complications of a varicocelectomy is damage to the arterial supply of the testis. Aside from meticulous dissection, the use of Doppler ultrasound has become a standard tool to identify and preserve the testicular arteries. The use of intra-operative indocyanine green angiography (ICGA) may also play a role in avoiding this dreaded complication. Koike et al. showed that use of ICGA increased the number of preserved arteries. This approach has been shown to work with both laparoscopic and microscopic approaches.[11–13] There have also been advances in the technology used to perform the varicocelectomy. Recent development of a 4K3D-operating video microscope offers surgeons an updated platform with which to perform varicocelectomies. Ramasamy et al. have shown decreased operative times and surgeon fatigue with this new technology. There was also a cost advantage when compared with the DaVinci robotic platform.[14]

Varicocelectomy is a common procedure with multiple indications. Although the central goals and general technique of the procedure remain the same, Urologists continue to adopt new technologies to improve both the surgery and patient outcomes.