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Review
. 2011;66(8):1463-78.
doi: 10.1590/s1807-59322011000800026.

Surgical treatment of male infertility in the era of intracytoplasmic sperm injection - new insights

Sandro C Esteves  1 , Ricardo Miyaoka, Ashok Agarwal
Affiliations
Review

Surgical treatment of male infertility in the era of intracytoplasmic sperm injection - new insights

Sandro C Esteves et al. Clinics (Sao Paulo). 2011.

Abstract

Assisted reproductive technology is an evolving area, and several adjuvant procedures have been created to increase a couple's chance of conceiving. For male infertility, the current challenges are to properly accommodate old and new techniques that are both cost-effective and evidence-based. In this context, urologists are expected to diagnose, counsel, provide medical or surgical treatment whenever possible and/or correctly refer male patients for assisted conception. Urologists are sometimes part of a multiprofessional team in an assisted reproduction unit and are responsible for the above-cited tasks as well as the surgical retrieval of sperm from either the epididymides or testicles. We present a comprehensive review of the surgical treatment options for infertile males, including the perioperative planning and prognostic aspects, with an emphasis on the role of microsurgery in the optimization of treatment results. This review also discusses current techniques for sperm retrieval that are used in association with assisted reproductive technology and includes sperm retrieval success rates according to the technique and the type of azoospermia. New insights are provided with regard to each surgical treatment option in view of the availability of assisted conception to overcome male infertility.

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Figures

Figure 1
Figure 1
Microsurgical Subinguinal Varicocele Repair. A) A transverse incision is made just below the level of the external inguinal ring. B-D) Intraoperative photographs of the spermatic cord. B) Dilated cremasteric veins are identified by elevating the spermatic cord with a Babcock clamp. C) Testicular artery (blue vessel loop), lymphatics (blue cotton suture), and dilated varicose veins (red vessel loops) are demonstrated. D) Final surgical aspects of the varicose veins are transected and ligated with nonabsorbable sutures.
Figure 2
Figure 2
Microsurgical Vasoepididymostomy Techniques. A) Illustration of the end-to-end, B) end-to-side, and C) triangulation end-to-side anastomoses.
Figure 3
Figure 3
Microsurgical Sperm Retrieval Techniques. Operating microscope and microsurgical techniques are used throughout the procedures. The top image shows microsurgical epididymal sperm aspiration (MESA). After exposure of the testis and epididymis, a dilated epididymal tubule is dissected and opened. Fluid is aspirated, diluted with sperm medium and sent to the laboratory for examination. The bottom images show microsurgical testicular sperm extraction (micro-TESE). A) After the testicle is exteriorized, a single and large incision is made in an avascular area of the albuginea to expose the seminiferous tubules. B) Dilated tubules are identified and removed with microforceps (intraoperative photograph at 40X magnification). C) Illustration of the histopathology cross-section of a dilated seminiferous tubule with active spermatogenesis. D) Illustration of the histopathology cross-section of a thin tubule with Sertoli-cell-only syndrome.
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