AB61. Advances of surgical treatment in male infertility

Abstract: Approximately 15% of couples cannot conceive a child after 1 year of regular, unprotected intercourse. Male factor infertility is contributory in another 30% to 40%. Most causes of male infertility are treatable and the goal of many treatments is to restore the ability to conceive naturally. The dramatic recent improvements in the management of male infertility are largely contributable to improved surgical techniques and assisted reproductive technology (ART). Specifically in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) allow us to overcome even the most severe defects in spermatogenesis in which only a few are available.

Varicocele repair may be considered as the primary treatment option when a man with a varicocele has suboptimal semen quality and the female partner is normal. varicocele repair can reverse a pathologic condition and halt further damage to testicular function, and improve spermatogenesis. Preferred approaches of most experts are microsurgical inguinal and subinguinal operations. Studies have shown that varicocele repair can improve semen parameters, testicular function and pregnancy rates in couples with male-factor infertility associated with varicocele. Also varicocele repair can result in sperm in the ejaculate of azoospermia men when severe hypospermatogenesis or maturation arrest spermatid stage is present.

Obstructive azoospermia may result from epididymal, vasal or ejaculatory duct abnormalities. Microsurgical reconstruction remains the safest and most cost-effective treatment option for these patients (vasovasostomy, vasoepididymostomy). It is controversial that the technique of sperm retrieval (open or percutaneous) or the source of sperm (testicular, epididymal, vasal or seminal vesicular) affects pregnancy rate. Sperm extraction or aspiration for IVF via ICSI is needed in cure of surgically uncorrectable azoospermia or failed microsurgical reconstruction and the majority of patients with congenital bilateral absence of the vas deferens (CBAVD). Also sperm retrieval with IVF/ICSI is preferred to surgical treatment when the advanced female partner age, female infertility requiring IVF.

Nonobstructive azoospermia (NOA) is the most challenging type, but no specific treatment was available previously. With advent of ICSI in conjunction with sperm retrieval via testicular sperm extraction (TESE), many of nonobstructive azoospermic patients are able to father own babies. However, 20-50% of NOA patients are not able to have sperm retrieved for ART. Microsurgical TESE is an advanced type of TESE that applies microsurgical techniques. This microsurgical TESE is an effective sperm retrieval from men with NOA for ICSI. The advantages of this technique are minimally invasive technique, removal of minimal amount of testicular tissue and minimalizing negative impact on testicular function. Microsurgical TESE is more effective in men with NOA than conventional TESE.

Treatment strategies for male infertility have changed as dramatically over the past decade. These advances are largely contributable to microsurgical varicocele repair, microsurgical reconstructive techniques, and microsurgical techniques for surgical sperm retrieval and ART specifically ICSI.

Keywords: Male infertility; surgical treatment; congenital bilateral absence of the vas deferens (CBAVD)