Male Surgical Procedures
Surgical Procedures as Birth Control and to Assist with Infertility
Approximately 10 percent of couples suffer from infertility, which is defined as the inability to conceive through unprotected intercourse for 12 months. Evaluation of the infertile male includes semen analysis, a detailed medical history, and a thorough physical examination. There are several surgical procedures that can assist with male infertility, including vasectomy reversal, varicocele repair, ejaculatory duct resection, and epididymovasostomy. Diagnostic surgical procedures include testicular biopsy, microsurgical sperm aspiration (MESA), testicular sperm extraction (TESE), and percutaneous sperm aspiration (PESA). Sperm retrieval techniques have given hope to many men with obstructive and nonobstructive azoospermia (low or no sperm count). Obstructive azoospermia is caused by ejaculatory duct obstruction, a previous vasectomy, or a congenital absence of both vas deferens. Men with nonobstructive azoospermia have impairment of normal sperm production and maturation. Their fertilization rates are lower than men with the obstructive form of the condition.
A vasectomy is a method of birth control and surgical procedure where the vas deferens from each testicle is cut, clamped, or otherwise sealed. These measures all prevent sperm from mixing into the semen that will be ejaculated from the penis. With no sperm, the egg cannot be fertilized. The procedure takes around 20 to 30 minutes, and under local anesthesia. The doctor makes one or two small openings in the scrotum, cuts or clamps the vas deferens, and stitches or ties the ends. The skin is closed with stitches that dissolve.
Vasectomy reversal results in return of the sperm back into the ejaculate to allow for natural biologic pregnancy. Successful vasectomy reversal depends on the number of years since the initial vasectomy. The chance of conception following a reversal is greater if the man had the vasectomy less than three years prior, as compared to 15 or 20 years. The surgeon will perform the procedure using local or epidural anesthesia. Two methods of vasectomy reversal include vasovasostomy and vasoepididymostomy. The surgeon decides which procedure to do after evaluating the reproductive structures. A small cut is made on the underside of the scrotum and the surgeon repairs the vas deferens by:
- Vasovasostomy: A procedure where the surgeon sews back together the severed ends of the vas deferens tubes.
- Vasopepididymostomy: A procedure where the surgeon attaches the vas deferens directly to the epididymis, the small organ near the back of the testicle.
A varicocele is a scrotal abnormality where dilated, elongated, and tortuous veins accumulate. These veins are supposed to drain the testicle, and when this condition occurs, they engorge with blood making a hostile environment for sperm. Varicocele repair is done on an outpatient basis using local or general anesthesia. A small incision is made in the abdomen over the area where the testicles lie. Once the surgeon identifies the varicocele, it is cut and surgically repaired to eliminate the blood flow to the area.
Ejaculatory Duct Resection
Ejaculatory duct obstruction causes low ejaculate volume of semen, low (or no) sperm count, and low sperm motility. This condition can cause male infertility in as many as five percent of cases. An ejaculatory duct resection is performed through the penile urethra near the prostate. This procedure is done to reconstruct (resect) the ejaculatory duct and remove the obstruction so sperm can pass normally.
An epididymovasostomy is a nonsurgical procedure that is performed to correct blockage found in the epididymis. Epididymal obstruction occurs due to previous injury or infection, from vasectomies, and due to cystic fibrosis. Some men experience leakage of sperm and testicular fluids into the surrounding tissues, causing an obstruction or adhesion of the epididymal tubule. When this occurs, reproductive specialists can use this technique to stitch the inner and outer layers of the vas directly to the epididymis and its inner tubule above the area of obstruction.
Several forms of diagnostic surgery are done to assess the cause of male infertility. In the past, the absence or low number of sperm permitted men from fathering a child. With the development of intracytoplasmic sperm injection, men with these conditions now can father a child following a single injection of sperm into the cytoplasm of a single egg. The only reliable predictor of sperm formation (spermatogenesis) is the cytological identification of mature sperm within the testicular tissue. Common diagnostic surgeries include:
- Testicular biopsy. A tissue sample that contains seminiferous tubules is useful for determining the cause of male infertility. If the testis is normal, this indicates another source of the infertility. This procedure can be done using local anesthesia on an outpatient basis.
- Microsurgical sperm aspiration. Often called MESA, the microsurgical sperm aspiration is a procedure to obtain sperm to be used during in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). This is done when a man has a vasectomy, there is severe epididymal scarring, or there is a congenital absence of the vas deferens. This technique is performed under local anesthesia, and the surgeon uses a microscope to isolate the structure and retrieve the seminal fluid. The fluid is processed in a laboratory to assess for sperm presence, and the tubules are closed microsurgically.
- Testicular sperm extraction. Testicular sperm extraction (TESE) is performed under local anesthesia in the outpatient setting. The surgeon removes a small piece of testicular tissue through a tiny incision. The tissue is processed in a laboratory to extract sperm. This approach is reserved for severe cases of low sperm production.
- Percutaneous epididymal sperm aspiration. Often called the PESA, percutaneous epididymal sperm aspiration is done to extract sperm using a butterfly needle placed into the epididymis. Adequate numbers of sperm are retrieved during the procedure and preserved for ICSI.
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