I-1: Surgical Treatment of Male Infertility

Male factor is the sole reason or a component for infertility in 20 and 30% of cases respectively. The management of the disease may be via medical or surgical treatment. The surgical approach is classified as techniques which improves sperm production and delivery in order to achieve spontaneous pregnancy or sperm retrieval techniques prior to assisted reproductive techniques (ART). Varicocelectomy is the most common surgery performed for the sperm production improvement. After the surgery the prominent improvements are observed in motility and morphology with a higher chance of success in men with >10 million sperm/ml. Testosterone increase, approximately 100 ng/dl, is also reported for patients with a baseline testosterone below 400 ng/dl. The spontaneous pregnancy odds ratio after varicoselectomy was reported as 2.63 in patients with palpable varicocele and abnormal semen parameters. Surgery to allow sperm delivery are applied to patients with proximal and distal seminal duct pathologies. The obstructed passageway may be caused by a congenital or acquired anomaly or iatrogenic but the existence of sperm in ejaculate to allow spontaneous pregnancy is the main objective of this surgery. Microscopic vasavasostomy and epididymovasostomy are the elementary surgeries of this subject but technological developments such as robotics may be applied as developed. Microscopic vasovasostomy was reported to have patency and pregnancy rates of 92 and 53% with an interval of 3 years. For vasoepididymostomy patency and pregnancy rates of 48-63% and 21-45% had been reported with a mean interval of 16 months. Usage of robotic assisted VE has been suggested for increased precision and decreased operation times. TUR-ED is the endoscopic technique which is performed in distal duct pathologies. Sperm parameter improvement had been reported up to 94% in men with distal duct obstructions. Sperm retrieval techniques are treatment modalities used to gather sperm from the testis and epididymis of azospermic infertile males prior to ART. These techniques are applied to obstructive azoospermic (OA) and non-obstructive azoospermic (NOA) males. General sperm retrieval techniques are listed as: Percutanoues epididymal sperm aspiration (PESA) Microscopic epididymal sperm aspiration (MESA) Testicular sperm aspiration (TESA) Conventional testicular sperm extraction (TESE) Micro-surgical testiküler sperm ekstraksiyonu (m-TESE) PESA: Despite its minimal invasive, easy and prompt nature, inadequate material aspirates and greater risk of hematoma complication had made this technique obsolete. MESA: This technique is used for obstructive azospermia not suited for reconstructive surgery. Number of gathered sperm is which is sufficient for both ART and cryopreservation. The SRR and pregnancy rates are 90% and 14-66% respectively. The ART success rates of epididymal sperms are similar to testicular ones. TESA: It become reserved for obstructive azoospermia subsequent to the introduction of TESE. The general SRR for OA and NOA patients are 100 and 27% respectively. Although adequate number of sperms are gathered for ART, cryopreservation may not be possible all the time. This technique is not preferred anymore because of possible vascular injury and insufficient sperm numbers. TESE: The SRR of this technique is 36% via multiple biopsies and drops to 23% for single biopsy. Conventional TESE is replaced by mTESE in routine practice because of low SR rates. mTESE: Requirement of micro surgical skills, greater learning curve and longer operation time is balanced by much higher SRR for this technique. In addition preservation of testicular tissue and vascular structure are further advantages. The SRR is correlated with seminefer tubule diameters with a threshold value of 110 microns. This rate was demonstrated to be 84 and 36% for >300 micron and <300 micron diameters of seminifer tubule respectively. Up to 60% sperm retrieval rate was reported for mTESE which is superior to its conventional counterpart. The predictive factors for SRR are accepted as experience of the surgeon, duration of the operation and histopathology of testis