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INFERTILITY: SURGICAL MANAGEMENT

Surgical anatomy

• See Epididymis Anatomy
• Anatomy of the Excurrent Ducts
• Sperm and testicular fluid exit the testes through efferent ducts. These ducts become convoluted when they exit the testes and form the caput of the epididymis. At that level, they freely anastomose with one another. They all coalesce at the distal caput to form a single epididymal tubule from the caput-corpus junction all the way to the vas deferens.
• Clinical implication: puncture of a single tubule for sperm aspiration can be safely performed at the most proximal region of the head of the epididymis because there are multiple lobules at this level
  • Any injury to the epididymis distal to the caput will result in complete obstruction of the entire system on that side
• Hydrocelectomy and orchiopexy for torsion can result in iatrogenic injury to the epididymis
• Ejaculatory Ducts
• Obstruction of ejaculatory ducts can lead to azoospermia.
  • Transurethral resection (TUR) of the ejaculatory ducts (TURED) can relieve the obstruction.

Testis Biopsy

• Fresh, unfixed tissue is examined for the presence of sperm with tails and possible motility; if sperm are not found initially, examination of multiple samples is recommended.
  • Optimal care requires the availability, at the time of biopsy, of an andrology laboratory capable of processing and cryopreserving any sperm found at the time of biopsy.
• Open Testis Biopsy: Microsurgical Technique
• Open biopsy remains the gold standard
• Open testis biopsy may be performed using either general, spinal, or local anesthetic.
• Percutaneous Testis Biopsy
• A blind procedure that could result in unintentional injury to either the epididymis or the testicular artery
• The midsection of the testis has relatively fewer vessels compared with superior or inferior areas
• Should not be used when previous surgery has resulted in scarring and obliteration of normal anatomy
• Percutaneous Testicular Aspiration
• Testicular aspiration performed with a 23-gauge needle or angiocath sheath is probably less invasive and less painful than percutaneous biopsy but usually yields few tubules with poorly preserved architecture
• Complications of Testis Biopsy
• The most serious complication associated with testis biopsy is inadvertent biopsy of the epididymis
• If histologic evaluation of the biopsy material reveals epididymis with sperm within the epididymal tubule, obstruction of the epididymis at the site of the biopsy is certain.
  • If there are no sperm within the epididymal tubules, the patient is either obstructed above the level of the epididymal biopsy site or has primary seminiferous tubular failure and no harm has been done.
• The most common complication of testis biopsy is hematoma

Vasography

• Absolute indications (must have all 3):
  1. Azoospermia
  2. Complete spermatogenesis with many mature spermatids on testis biopsy
  3. At least one palpable vas
• Relative indications:
  1. Severe oligospermia with normal testis biopsy
  2. High level of sperm-bound antibodies, which indicates unilateral, bilateral, or partial obstruction
  3. Low semen volume and very poor sperm motility (partial ejaculatory duct obstruction)
• The following diagnoses can be made with radiographic vasography
  • Inguinal vasal obstruction
  • Ejaculatory duct obstruction
  • Seminal vesicle agenesis
  • Partial agenesis of vasa deferentia
• If testis biopsy reveals normal spermatogenesis and the vasa are palpable, vasography, if necessary, should be performed only at the time of definitive repair of obstruction
  • There is no need to perform vasography at the time of testis biopsy for azoospermia unless immediate reconstruction is planned and the touch or wet prep biopsy reveals mature sperm with tails.
• Technique of Vasography and Interpretation of Findings
• Any fluid exuding from the lumen is placed on a slide, mixed with a drop of saline, and sealed with a coverslip for microscopic examination.
• If motile sperm are found in the vas, the testicular end should be gently barbotaged with 0.2 mL of human tubal fluid medium, and the fluid processed by the andrology laboratory for sperm cryopreservation for potential future use for IVF and ICSI.
  • Never inject fluid in direction of epididymis under pressure as it may rupture the epididymal tubules
  • Always sample vasal fluid first to allow cryopreservation of motile sperm if found; this should be done before injection with indigo carmine or x-ray contrast material  
    • Use indigo carmine instead of methylene blue to confirm patency; methylene blue kills sperm
    • Vasography with radiographic contrast media with intraoperative radiography is rarely indicated; formal vasography with x-ray contrast is needed only to locate obstructions proximal to the internal inguinal ring
    • Vasography may reveal the vas deferens ending blindly, far from the ejaculatory ducts. This finding indicates congenital partial absence of the vas deferens and warrants testing for cystic fibrosis mutations
• If a large amount of fluid is found in the vasal lumen and microscopic examination reveals the presence of sperm, the obstruction is toward the seminal vesical end of the vas
• If the vasal fluid is devoid of sperm with repeated sampling after milking the epididymis and convoluted vas, epididymal obstruction is present.
• Complications
  • Stricture
  • Injury to the vasal blood supply
  • Hematoma
  • Sperm granuloma

Vasovasostomy/Vasoepididymostomy

• Preoperative Evaluation
• Before attempted surgical reconstruction of the reproductive tract, adequate spermatogenesis should be documented. A prior history of natural fertility pre-vasectomy is usually adequate
• Contraindications:
  • Non-obstructive azoospermia
• Physical Examination
  • Testis: small or soft testes suggest impaired spermatogenesis and predict a poor outcome
  • Epididymis: an indurated irregular epididymis often predicts secondary epididymal obstruction, necessitating vasoepididymostomy
  • Sperm granuloma: suggests that sperm have been leaking at the vasectomy site.
    • Sperm are highly antigenic, and an intense inflammatory reaction occurs when sperm escape outside the reproductive epithelium.
    • The granuloma vents the high pressures away from the epididymis and is associated with a better prognosis for restored fertility
    • Rarely symptomatic
  • Hydrocele: the presence of a hydrocele in the presence of excurrent ductal system obstruction is often associated with secondary epididymal obstruction
  • Vasal gap: when a very destructive vasectomy has been performed, most of the scrotal straight vas may be absent or fibrotic and the patient should be advised that inguinal extension of the scrotal incision will be necessary to mobilize adequate length of vas to enable a tension-free anastomosis.
  • Scars from previous surgery: operative scars in the inguinal or scrotal region should alert surgeon to the possibility of iatrogenic inguinal obstruction (hernia repair) or vasal or epididymal obstruction (hydrocelectomy, orchiopexy)
• Laboratory Tests
  • Semen analysis with centrifugation and examination of the pellet for sperm should be performed preoperatively.
    • Complete sperm with tails are found in 10% of preoperative pellets a mean of 10 years after vasectomy. Under these circumstances sperm are certain to be found in the vas on at least one side, indicating a favorable prognosis for restored fertility.
  • Serum anti-sperm antibody studies: the presence of serum anti-sperm antibodies corroborates the diagnosis of obstruction and the presence of active spermatogenesis
  • Serum FSH: men with small soft testes should have serum FSH measured; an elevated FSH predicts impaired spermatogenesis and a poorer prognosis
• Surgical Approaches
• Scrotal Incision
• Bilateral high vertical scrotal incisions provide the most direct access to the obstructed site in cases of vasectomy reversal
• If the vasal gap is large or the vasectomy site is high, this incision can easily be extended toward the external ring
• The testis should be delivered with the tunica vaginalis left intact
• Inguinal Incision
• An inguinal incision is the preferred approach in men when obstruction of the inguinal vas deferens from prior herniorrhaphy or orchiopexy is strongly suspected
• Maneuvers to gain vasal length what a large vasal gap is present (sequential):
  1. Separate the cord structures from the vas with blunt dissection using a gauze-wrapped index finger
  2. Dissect the entire convoluted vas free of its attachments (additional 4-6 cm of length) to the epididymal tunica, allowing the testis to drop upside down.
     • The convoluted vas should not be unraveled. This disturbs the blood supply at the anastomotic line
  3. Reroute vas under the floor of the inguinal canal by extending the incision to the internal inguinal ring and cutting the floor of the inguinal canal cut, as in a difficult orchiopexy
  4. Dissect the epididymis off the testis from the vasoepididymal (VE) junction to the caput epididymis (additional 4-6 cm of length)
• See Epididymis Anatomy Notes
• The epididymis can be intentionally dissected off the testis and mobilized to the caput, with the inferior and medial epididymal arteries intentionally ligated without adverse consequence. As long as the superior epididymal artery remains intact, the blood supply to the epididymis will be adequate
• With this combination of maneuvers, up to 10-cm gaps can be bridged

• When to Perform Vasoepididymostomy

• A vasovasostomy is performed when:
  1. Copious, crystal clear, water-like fluid squirts out from the vas and no sperm are found in this fluid
  2. If microscopic examination of the vasal fluid reveals the presence of sperm with tails
• If no fluid is found, a 24-gauge angiocatheter sheath is inserted into the lumen of the testicular end of the vas and barbotaged with 0.1 mL of saline while the convoluted vas is vigorously milked. The barbotage fluid is expressed onto a slide and examined
• Men with large sperm granulomas often have virtually no dilation of the testicular end of the vas and little or no fluid initially; however, with barbotage and vigorous milking, invariably sperm can be found in this scant fluid and vasovasostomy is performed
• If there is no sperm granuloma, and the vas is absolutely dry and spermless after multiple samples have been examined, vasoepididymostomy is indicated
• If the fluid expressed from the vas is found to be thick, white, water insoluble, and toothpaste-like in quality, microscope examination rarely reveals sperm. Under these circumstances, the tunica vaginalis is opened and the epididymis inspected. If clear evidence of obstruction is found—that is, an epididymal sperm granuloma with dilated tubules above and collapsed tubules below—vasoepididymostomy is performed. When in doubt, or if not very experienced with vasoepididymostomy, vasovasostomy should be performed.
  • Vasoepididymostomy should only be performed on an epididymal tubule containing sperm
• See Table 67-2 CW12th edition for relationship between gross apperance of vasal fluid and microscopic findings
  • UrologySchool.com Summary
    • Clear/thin, water vasal fluid: vasovasostomy
    • Thick/dry vasal fluid: vasoepididymostomy

• Multiple Vasal Obstructions
• See section on arterial supply in Vas Deferens Anatomy Chapter Notes
• Simultaneous vasovasostomies at two separate sites will usually lead to devascularization of the intervening segment with fibrosis and necrosis
• Varicocelectomy and Vasovasostomy
• See Varicocelectomy Chapter Notes
• When varicocelectomy is properly performed, all spermatic veins are ligated and the only remaining routes for testicular venous return are the (deferential) vasal veins
• Varicocelectomy in men with a history of vasectomy with or without reversal requires careful preservation of the testicular artery as the primary remaining testicular blood supply as well as preservation of some avenue for venous return since the vasal arteries and veins are likely to be compromised from either the original vasectomy or the reversal itself
• Anastomotic Techniques: Keys to Success
  1. Mucosa-to-mucosa approximation
  2. Leakproof anastomosis
  3. Tension-free anastomosis
  4. Good blood supply
  5. Healthy mucosa and muscularis
  6. Good atraumatic anastomotic technique
• Microsurgical Multilayer Microdot Method
• The microdot technique ensures precise suture placement by exact mapping of each planned suture.
• Exactly 6 mucosal sutures are used for every anastomosis
• Crossed Vasovasostomy
• Used to connect a healthy testicle to the contralateral unobstructed vas
• Indications (2):
• Unilateral obstruction of the inguinal vas deferens or ejaculatory duct associated with contralateral:
  1. Atrophic testis
  2. Epididymal obstruction
• It is preferable to perform one anastomosis with a high probability of success (vasovasostomy) than two operations with a much lower chance of success (e.g., unilateral vasovasoepididymostomy and contralateral TURED
• Postoperative Management
• Scrotal support at all times (except in the shower), even when sleeping, for 6 weeks postoperatively. Thereafter, scrotal support is worn during athletic activity until pregnancy is achieved.
• Desk work is resumed in 3 days. No heavy work or sports are allowed for 3 weeks.
• No intercourse or ejaculation is allowed for 3 weeks postoperatively.
• Semen analyses are obtained at 1, 3, and 6 months postoperatively and every 6 months thereafter. If azoospermia persists at 6 months, a redo vasovasostomy or vasoepididymostomy will be necessary
• Postoperative Complications
• The most common complication is hematoma
• Progressive loss of motility followed by decreasing counts indicates stricture
• Because of the risk of late stricture and obstruction, cryopreservation of semen specimens as soon as motile sperm appear in the ejaculate is strongly recommended

Surgery of the Epididymis

• The superior and middle epididymal branches of the testicular artery are medial to and separate from the main testicular artery and veins
  • Clinical implication: surgical procedures may be performed on the epididymis without compromise to testicular blood supply
• Vasoepididymostomy
• Indications:
  • Testis biopsy reveals complete spermatogenesis and scrotal exploration reveals the absence of sperm in the vasal lumen with no vasal or ejaculatory duct obstruction
    • If microscopic examination of the vasal fluid sampled reveals the absence of sperm, the diagnosis of epididymal obstruction is confirmed and a vasoepididymostomy is performed.
• Banking sperm both intraoperatively and as soon as they appear in the ejaculate postoperatively after vasoepididymostomy is recommended.

Ejaculatory Duct Obstruction

• Causes
  • Congenital (most common cause)
    • Aplastic segment at the terminal end of the vas
  • Acquired
    • Occasionally results from chronic prostatitis or extrinsic compression of the ejaculatory ducts by prostate or seminal vesical duct cysts
• Diagnosis and Evaluation
• Findings associated with ejaculatory duct obstruction:
  1. Azoospermic or severely oligospermic and/or asthenospermic men with at least one palpable vas deferens
  2. Low semen volume
  3. Acidic semen pH
  4. Negative, equivocal, or low semen fructose levels
  5. Normal serum levels of FSH
  6. Testis biopsy reveals normal spermatogenesis
• Transrectal US
• A (müllerian duct) midline cystic lesion or dilated ejaculatory ducts and seminal vesicles can be visualized  
  • Suggestive if AP diameter of seminal vesicle >1.5cm
• Microscopic examination of TRUS-guided aspiration of the cystic or dilated ejaculatory ducts or seminal vesicles can be performed.
  • If motile sperm are found, they are cryopreserved and 2 to 3 mL of indigo carmine diluted with water-soluble radiographic contrast is instilled. If a radiograph confirms a potentially resectable lesion, TURED is performed without the need for prior vasography
    • Transrectal sonography with aspiration should be performed immediately before anticipated [TURED] surgery and uses the same bowel preparation and antibiotic prophylaxis as for transrectal prostate biopsy.
  • If no sperm are found in the aspirate, vasography is necessary.
    • If no sperm are found in either vas when the vasotomy is made and vasography reveals ejaculatory duct obstruction, it is best to abandon attempts at reconstruction and simply perform microsurgical epididymal sperm aspiration and cryopreservation for future IVF and ICSI.
    • Performance of simultaneous vasoepididymostomy and TURED is unlikely to be successful.
• Management
  • Transurethral resection of ejaculatory ducts (TURED)
    • Should be performed only in azoospermic men or in severely oligoasthenospermic men and only after the male and female partners have stated they are unwilling to undergo IVF
    • Technique
      • Resection of the verumontanum will often reveal the dilated ejaculatory duct orifice or cyst cavity. Resection should be carried out in this region with great care to preserve the bladder neck proximally, the striated sphincter distally, and the rectal mucosa posteriorly.
    • Complications (4):
      1. Reflux into the ejaculatory ducts, vas, and seminal vesicles resulting in acute and chronic chemical and/or bacterial epididymitis
         • This can be assessed by voiding cystourethrography or measurement of semen creatinine levels
         • Recurrent epididymitis often results in epididymal obstruction
         • Chronic low-dose antibacterial suppression, such as that used for vesicoureteral reflux, may be necessary until pregnancy is achieved
      2. Retrograde Ejaculation
         • Common after TUR, even when care has been taken to spare the bladder neck
      3. Urethral stricture

Ejaculatory Stimulation

• Neurologic conditions associated with abnormal or absent seminal emission due to impaired sympathetic outflow:
  1. Spinal cord injury
  2. Demyelinating neuropathies (multiple sclerosis)
  3. Diabetes
  4. Iatrogenic (retroperitoneal lymph node dissection, pelvic surgery)
• With stimulation, motile sperm can be obtained for assisted reproduction techniques (IUI, IVF with ICSI).
  • Semen collected from men with SCI is often initially senescent and of poor quality with a low sperm count and reduced sperm motility but may improve with subsequent ejaculations
• Stimulation can be done with penile vibratory devices or electroejaculation
  • Approach depends on level of spinal cord lesion§
    • If lesion above T10, ejaculatory reflex arc will be intact so can stimulate with penile vibratory devices
    • If lesion T10 or below, consider electroejaculation
    • If these fail, sperm retreival is performed

 

• Ejaculatory stimulation for men with spinal cord injuries may result in autonomic dysreflexia
  • Autonomic dysreflexia
    • See 2019 CUA NLUTD Guideline Notes
    • An uninhibited sympathetic reflex accompanied by headache, diaphoresis, hypertension, bradycardia, and diaphoresis
    • More common with spinal cord injury at a level of T6 or above
    • Can be life-threatening.
    • Pretreatment, 15 minutes before the procedure, with 20 mg of sublingual nifedipine is used
    • Should have intravenous access and their blood pressure and pulse should be monitored every 2 minutes before, during, and for 20 minutes after ejaculatory stimulation.
    • In the event of a sympathetic outflow (autonomic dysreflexia), termination of the procedure should be sufficient to break the response; however, intravenous access allows for delivery of sympatholytic agents should they become necessary

Sperm Retrieval Techniques

• Epididymal sperm retrieval techniques (2):
• Microsurgical Epididymal Sperm Aspiration (MESA)
• Percutaneous Epididymal Sperm Aspiration (PESA)
• Testicular sperm retrieval techniques (3):
• Open microsurgical Testicular Sperm Extraction (TESE)
• Preferably done with an operating microscope (micro-TESE)
• Indications:
  1. Failure to find sperm in the epididymis in the presence of the spermatogenesis or complete absence of the epididymis.
  2. Non-obstructive azoospermia
• Contraindications
  • Sertoli-only cell syndrome
  • Spermatogenic arrest
• Allows retrieval of the largest number of sperm with potential for cryopreservation
• Best technique in men with non-obstructive azoospermia
• Percutaneous core biopsy
• Uses the same 14-gauge biopsy gun used for prostate biopsy
• Percutaneous aspiration (testicular sperm aspiration [TESA])
• Done with a high-suction glass syringe and a 23-gauge needle.
• Least invasive procedure but often requires 10 to 20 passes to obtain an adequate yield

Assisted reproduction

• Indications
  • Surgically unreconstructable obstruction such as congenital absence of the vas deferens
  • Few viable sperm in the ejaculate
  • Azoospermia with varicoceles (half of these men will respond to varicocelectomy with return of enough sperm to ejaculate to achieve pregnancy using IVF with ICSI)
  • Non-obstructive azoospermia
• Intrauterince insemination (IUI)
  • Pregnancy rates with IUI are increased in couples with abnormal semen parameters if the woman undergoes ovulation induction.
    • In men with male factor infertility due to abnormal semen parameters, natural cycle intracervical or intrauterine insemination (IUI) is no better than timed vaginal intercourse.
      • Natural cycle refers to allowing the woman to ovulate on her own without pharmaceutical induced stimulation of the development of multiple follicles through ovulation induction.
      • Natural cycle IUI is useful in infertility caused by mechanical problems such as hypospadias, retrograde ejaculation, impotence, or pure cervical factor infertility.

Orchiopexy in Adults

• When scrotal orchiopexy is performed for retractile or ectopic testis in adults, a dartos pouch operation should be performed.
• Simple suture orchiopexy of the tunica albuginea of the testis to the dartos, as is performed sometimes to prevent torsion, will not prevent retraction of these testes into the groin. Creation of a dartos pouch will keep the testis well down in the scrotum and permanently prevent retraction. This is also the most reliable and safest technique for the prevention of testicular torsion

References

• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 25