Male Surgeries to Treat Infertility

Congenital and other structural defects, scar tissue and blockages from prior surgeries and infection can contribute to male infertility. One problem in particular, a condition called azoospermia, or lack of sperm in the semen, may be amenable to surgical therapy. There are two subtypes of azoospermia, obstructive (with normal sperm production) and non-obstructive (with decreased or absent sperm production).

Obstructive azoospermia can be caused by vasectomy, the elective sterilization procedure; absence of the vas deferens, which carries sperm to the ejaculatory duct, and by scar tissue resulting from surgery. Non-obstructive azoospermia is linked to no or poor sperm production. Many cases involving either form of azoospermia can be addressed successfully with relatively new surgeries that rely on sophisticated microscopes and delicate instruments to restore normal function to the male reproductive system.

These procedures include vasovasostomy and vasoepididymostomy to reverse vasectomies, microsurgical epididymal sperm aspiration (MESA) and testicular sperm extraction (TESE) to remove sperm from tissue and varicocelectomy to correct a condition that may hamper sperm production. Should you require surgery, you will be referred to a urologist. He or she will provide you with more information about these procedures.

Vasectomy Reversal (Vasovasostomy and Vasoepididymostomy)

Vasectomy is an elective surgical sterilization procedure that eliminates sperm from the ejaculatory fluid by cutting and tying off the ends of the vas deferens (the vas), the tube through which sperm passes from the epididymis to the ejaculatory duct. In many cases, the vas can be restored and re-attached during a microsurgical process called vasovasostomy, an outpatient procedure performed under general or local anesthesia. If damage to the epididymis has occurred, vasoepididymostomy is required to restore sperm flow. Regardless of the method used, vasectomy reversals have a very substantial success rate for reversing obstructive azoospermia.

More About Vasovasostomy

Vasovasostomy is performed through two small incisions on each side of the scrotum near the original vasectomy site. Using a microscope as a guide, your doctor locates both ends of the vas and collects a drop of semen from one of them. The fluid is examined for thickness and the presence of healthy sperm, which should continue to be produced by the testis after vasectomy. If the semen and sperm are normal, the ends of the vas are reattached, restoring the passageway.

More About Vasoepididymostomy

A secondary blockage or “blowout” of the epididymis may have occurred if there has been a long duration since vasectomy, or if the vasectomy was performed close to the epididymis. In this case, vasovasostomy would not be successful in restoring sperm to the ejaculate. Vasoepididy-mostomy involves stitching the inner and outer layers of the vas directly to the epididymis and its inner tubule at a point above the obstruction so semen can bypass the blockage and reach the ejaculatory duct.

Like vasovasostomy, vasoepididymostomy is performed through small incisions on each side of the scrotum near the original vasectomy site. The outpatient procedure requires general anesthesia or spinal anesthesia. A semen analysis is generally performed four to six weeks after surgery.

Sperm Extraction Procedures (MESA and TESE)

Some males have few or no sperm in their ejaculate (obstructive azoospermia) as a result of vasectomy, congenital absence of the vas deferens or epididymis, prior failed surgery or epididymal scarring from infection. In these cases, microsurgical epididymal sperm aspiration (MESA) or testicular sperm extraction (TESE) may be successful in obtaining enough sperm to use in conjunction with in vitro fertilization (IVF). Both procedures involve the direct collection of sperm, which is processed in the laboratory for intracytoplasmic sperm injection (ICSI). During ICSI, a single sperm is injected into the core of an egg retrieved during IVF.

More About MESA

MESA is a very effective procedure for obstructive azoospermia because it usually yields high numbers of sperm for IVF. Epididymal sperm usually freezes well; therefore, after MESA, it is possible that you will not have to undergo additional procedures for subsequent IVF cycles if enough sperm are collected.

During this outpatient procedure, and while you are under anesthesia, your physician will make a small incision in the skin of the scrotum. MESA relies on an operating microscope to isolate the epididymis and locate the tiny epididymal tubules storing the sperm. An epididymal tubule is opened and its fluid examined for sperm. If present, both the fluid and sperm are removed and processed in the laboratory. If none or very few are found, additional tubules are opened. Once they are examined, the tubules are closed and any sperm that are not needed for IVF, and meet certain criteria, are frozen and stored in the laboratory.

More About TESE

Testicular tissue dissection

TESE is an open biopsy procedure used for sperm extraction. Like MESA, it is performed in an outpatient setting. The procedure is an effective means for sperm collection and there are sometimes circumstances that make it the procedure of choice over MESA (i.e., cases of non-obstructive azoospermia where no sperm are present in the epididymis). TESA usually yields fewer sperm than MESA and testicular sperm is more difficult to process in the laboratory. Many facilities also believe that testicular sperm does not freeze as well as sperm taken from the epididymis.

While you are under anesthesia, your doctor will make a small incision in the scrotal skin. A small piece of tissue is removed, placed in a special medium and processed in the laboratory to release any sperm.

Varicocele Repair (Varicocelectomy)

A varicocele is a collection of abnormally swollen (varicose) veins around the testes. They can interfere with the ability of the testicles to cool off, possibly affecting sperm production. Varicocele repair also is an outpatient surgical procedure.

While you are under anesthesia, a small incision is made in the lower abdomen or groin area. Some doctors use a microscope to better visualize the varicocele and help avoid testicular damage. During varicocelectomy, the doctor ties off the swollen veins so blood no longer pools, allowing the testicle to better maintain proper temperature.