|
|
There are two basic ways to deal with male factor infertility. The first is surgical and the other is pharmacologic.
Male Surgical Procedures:
Vasectomy reversal: Much of the success of a vasectomy reversal depends on two factors:
The skill of the surgeon: The individual who operates more frequently will increase his technical expertise. Although microscopic vasovasostomy is not always necessary to produce an effective outcome, it certainly aids the microsurgeon in performing a successful reconnection (anastomosis) of the previous vasectomy. I perform approximately one to two of these procedures a week and prefer to have my patients operated on as an outpatient. This saves a considerable expense and makes the overall experience much more pleasant.
Findings at the time of surgery: When the vas is opened, fluid will flow from the testicular side of the vasectomy site. If sperm are present, then we expect 90% or more of patients to demonstrate the return of sperm with an associated 60-65% pregnancy rate. If no sperm are present and vasectomy fluid looks abundant and appropriate for ultimate sperm production, then a direct vasovasostomy is performed with an outcome of approximately 40-50% success. If fluid is not found or the fluid that is present is not prognostically acceptable, then connection of the vas to the epididymis will be performed as the primary procedure. This is called an epididymovasostomy. It is associated with a successful outcome of approximately 40-50%.
The operating time for a vasovasostomy or epididymovasostomy is approximately 2 to 3 hours. A general anesthetic is used in order to keep the patient as still as possible for the lengthy period of time. Out of town patients are encouraged to remain in Atlanta on day following surgery. Postoperative care should include a semen analysis at six weeks as well as an inspection of the wound. Monthly semen analyses are obtained for approximately 4 to 6 months or until the semen analysis stabilizes.
Varicocele ligation: The mere presence of a varicocele does not mean that surgical correction is necessary. Usually the varicocele is asymptomatic and the patient is seen primarily for evaluation of a possible male factor in an infertile relationship. Reasons for surgical correction include:
- The presence of significant testicular pain
- Impairment of testicular function as evidenced by decreased semen quality
- Loss of testicular size (atrophy)
- There are two commonly used surgical approaches for the correction of a scrotal varicocele:
Subinguinal microscopic (groin) approach, under routine conditions this is the procedure of choice.
Retroperitoneal (abdominal) approach is used in patients who have already had an attempted varicocele or hernia repair where considerable scarring may be encountered.
The side effects following varicocele repair are remarkably low.
Electoejaculation (EEJ) involves controlled electrical stimulation to induce ejaculation in a man with damage to the nerves that control ejaculation. The procedure can usually be accomplished in 10 to 15 minutes. In general, there are two indications for this procedure:
Spinal cord injured (SSI) males: Most SSI patients do not require anesthesia since there is no sensation in the rectal vault, the point at which the electrical simulation is placed. However, some SSI patients do have rectal sensation and require anesthesia (commonly a combination of narcotics and nitrous oxide) administered in an outpatient surgical center.
Retroperitoneal lymph node dissections (RLND) for testicular tumors: Having survived their disease, patients who are desirous of establishing a pregnancy have been quite successful in obtaining good semen quality with the assistance of EEJ. General anesthesia is required in an outpatient surgical center.
- Surgical sperm retrieval ("Options for Sperm Retrieval")
- Microepididymal sperm retrieval (MESA)
- Testicular sperm aspiration (TESA)
- Percutaneous sperm aspiration (PESA)
- Testicular sperm extraction (TESE)
Pharmacological treatment:
Certain hormones that inform the pituitary to make more testosterone can help to produce sperm. Unfortunately, for most male infertility cases these hormonal treatments aren’t appropriate because they don’t increase the amount of sperm or make it any more productive. Two hormone supplements that have proven effective are FSH and LH. Hormone preparations that are commonly used when indicated include:
- Clomiphene citrate
- Mesterolone
- Tamoxifen
- Gonadotropin injections
- Steroids
Advanced Reproductive Technology
In many cases, neither medicines nor surgical procedures are of help. In such cases, an attempt is made in the reproductive laboratory to improve semen quality and facilitate the penetration of the sperm into the ovum. This includes:
- Sperm washing/capacitation in conjunction with intrauterine insemination
- Gamete intra-fallopian transfer (GIFT)
- In vitro fertilization, with or without intracytoplasmic sperm injection (ICSI)
|
