Infertility management- surgical

Infertility management- surgical

1. SURGICAL MANAGEMENT OF
MALE INFERTILITY
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

1

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. Three main categories:

1.Diagnostic procedures:
a. Testicular biopsy
b. Testicular sperm aspiration

2.Procedures to improve sperm production:
Varicocele repair

3.Procedures to improve sperm delivery:
Vasectomy reversal

3 Dept of Urology, GRH and KMC, Chennai.

4. Sperm retrieval procedures:
a. vasal aspiration of sperm
b. Epididymal aspiration of sperm
C. Open testis biopsy
d. Testis sperm aspiration & needle biopsy

Surgical management of ejaculatory duct
obstruction:
a. Transurethral resection of ejaculatory duct
b. Transurethral balloon dilatation of
ejaculatory duct
c. Laser drilling of ejaculatory duct
d. Transurethral incision of ejaculatory duct 4 Dept of Urology, GRH and KMC, Chennai.

5. TESTICULAR BIOPSY
useful to confirm Azoospermia due to
obstruction or spermatogenic failure
Indications:
1.Diagnostic purposes
2.Therapeutic purposes
for IVF- ICSI
Diagnostic:
Indications:
a. pt should be Azoospermic
b. Normal FSH
c. Testis: Normal size and consistency

5 Dept of Urology, GRH and KMC, Chennai.

6. OPEN TESTICULAR BIOPSY:
-Local or General or Spinal anaesthesia
-Vasal block is better
-Isolate Vas medial to the cord, grasp the cord
-Inject 1 ml of 1% lidocaine + 0.25% bupivicaine
over the skin with 30 G needle
-another 1-2ml beneath the skin to the area of VAS
-Scrotal skin & tunica vaginalis is infiltrated with
2ml of 1% lidocaine
-1-2mm transverse incision
-tunica opened with scissors
-lidocaine 2-3ml is dripped on to exposed tunica
albuginea
6 Dept of Urology, GRH and KMC, Chennai.

7. -stay sutures taken with 5-0 prolene
-4-5mm incision made in tunica albuginea
-no 11 scalpel used
-gentle pressure applied , extruded seminiferous
tubule excised with iris scissor
-the specimen is placed in ZENKERS , BOUINS , or
BUFFERED GLUTARALDEHYDE solution
COMPLICATIONS:
1.Bleeding
2.Hematoma formation
7 Dept of Urology, GRH and KMC, Chennai.

8. 8 Dept of Urology, GRH and KMC, Chennai.

9. 9 Dept of Urology, GRH and KMC, Chennai.

10. 10 Dept of Urology, GRH and KMC, Chennai.

11. 11 Dept of Urology, GRH and KMC, Chennai.

12. 12 Dept of Urology, GRH and KMC, Chennai.

13. 13 Dept of Urology, GRH and KMC, Chennai.

14. VARICOCELE REPAIR:
Indications:
1.known infertility
2.female partner has normal fertility
3.palpable by physical examination ,
corraborated by USG
4.abnormal semen analysis
14 Dept of Urology, GRH and KMC, Chennai.

15. SURGICAL APPROACHES:
1.Scrotal approach:
-Hartmann 1907
- obsolete now (Testiculae artery injury,high
rate of failure
15 Dept of Urology, GRH and KMC, Chennai.

16. -peritoneum pushed medially
-internal spermatic vein identified ligated &divided
COMPLICATIONS:
1.Recurrence:-11%-15%
because of not ligating cremastric veins
2.Retroperitoneal approach:
-PALOMO –(1948)
-ligation of internal spermatic vein above the
internal ring
-Transverse abdominal incision at the level of
internal ring approximately 2 finger breath medial
to anterior superior iliac spine
-muscles cut & split

16 Dept of Urology, GRH and KMC, Chennai.

17. 3.LAPROSCOPIC APPROACH:
-Veres needle or 10mm trocar placed just below
the umbilicus
-10mm port is placed on contra lateral side just
lateral to rectus muscle and below the umbilicus
-5mm port is placed to the left of the umbilicus
-parietal peritoneum incised lateral to spermatic
cord
-testicular artery & veins are dissected and
isolated
-the veins are clipped both proximally& distally
with Titanium endoclips & transected
17 Dept of Urology, GRH and KMC, Chennai.

18. COMPLICATIONS:
1.Recurrence rates <2%
2.Hydrocele formation 54.8%
3.Numbness of anterior thigh 4.8%
18 Dept of Urology, GRH and KMC, Chennai.

19. 4.INGUINAL APPROACH
-modified Ivanissevich-3-4 cm oblique inguinal
incision , 2 fingerbreadth above the symphysis
pubis , above the external ring
-Inguinal canal opened
-spermatic cord mobilised , microscope used
-veins dissected, isolated, and doubly ligated with
2-0 silk
19 Dept of Urology, GRH and KMC, Chennai.

20. 20 Dept of Urology, GRH and KMC, Chennai.

21. 5.SUB INGUINAL APPROACH:
-2-3cm transverse incision made at the level of
external ring
-incision carried up to external oblique fascia
-spermatic cord is identified at its exit the external
ring
-cord is mobilised at the external ring & brought
out of the wound
-Penrose drain placed beneath it
-Identify & ligate post.crimasteric veins
-veins identified isolated , doubly ligated & divided
-microscope also used
21 Dept of Urology, GRH and KMC, Chennai.

22. Advantages of microscopical approach:
1.Recurrence rate less 1-2% vs. non
microscopic
2.Hydrocele formation –nil vs. 3-39%
3.Less testicular artery injury
22 Dept of Urology, GRH and KMC, Chennai.

23. 23 Dept of Urology, GRH and KMC, Chennai.

24. 24 Dept of Urology, GRH and KMC, Chennai.

25. 25 Dept of Urology, GRH and KMC, Chennai.

26. 26 Dept of Urology, GRH and KMC, Chennai.

27. 27 Dept of Urology, GRH and KMC, Chennai.

28. 28 Dept of Urology, GRH and KMC, Chennai.

29. 29 Dept of Urology, GRH and KMC, Chennai.

30. Delivery of testicle method:(Goldstein et al 1992)
-2-3cm inguinal incision , testis is delivered
-All external spermatic & gubernacular veins are
ligated
-Testis is returned into scrotum
-standard Varicocele repair done
Advantage:
-To prevent recurrence
30 Dept of Urology, GRH and KMC, Chennai.

31. PERCUTANEOUS EMBOLIZATION
-Transvenous sclerotherapy through femoral or
Internal jugular veins
-A catheter is passed into the Internal spermatic
veins and balloon or coil are deployed
COMPLICATIONS:
1.Balloon deflation & migration
2.Varicocele recurrence
3.Failure of initial attempted procedure
31 Dept of Urology, GRH and KMC, Chennai.

32. EFFECTS OF VARICOCELECTOMY:
1.Improvements in semen parameter 51%-78%
semen motility , density , morphologic features
2.Improvements in sr.FSH & Testosterone levels
3.Pregnancy rates after varicocelectomy repair:
a. Goldstein & coworkers (1992)
43% pregnant at 1 year
68% pregnant at 2year
b. Pryor & Howards (1987)
24 % -53% pregnancy rate
c. Several investigators:
61% pregnancy rate if initial sperm conc.>5million/ml
8% pregnancy rate if initial sperm conc.<5million/ml

32 Dept of Urology, GRH and KMC, Chennai.

33. cost effectiveness:
The cost is less when compared with IVF- ICSI
follow up:
-Semen analysis 4 months after varicocelectomy
-semen to be monitored regularly for atleast
1year or until pregnancy is achieved
33 Dept of Urology, GRH and KMC, Chennai.

34. PROCEDURES TO IMPROVE SPERM
DELIVERY
Vasectomy reversal:
1.Vasovasostomy
2.Vasoepididymostomy
34 Dept of Urology, GRH and KMC, Chennai.

35. 35 Dept of Urology, GRH and KMC, Chennai.

36. VASOVASOSTOMY
ANASTOMOTIC TECHNIQUE:
1.Accurate mucosa to mucosa approximation
2.Leak proof anastomosis
3.Tension free
4.Good blood supply
5.Healthy mucosa & muscularis
6.Good atraumatic anastomatic technique
POST OPERATIVE CARE:
-Moderate activities -1 week
-Refrain from heavy exercises & sexual activity-3 weeks
-Examination of semen at 1 month
-Every 3 months in 1 year
-most pts have sperm in their semen within 4 weeks
36 Dept of Urology, GRH and KMC, Chennai.

37. 37 Dept of Urology, GRH and KMC, Chennai.

38. 38 Dept of Urology, GRH and KMC, Chennai.

39. 39 Dept of Urology, GRH and KMC, Chennai.

40. 40 Dept of Urology, GRH and KMC, Chennai.

41. 41 Dept of Urology, GRH and KMC, Chennai.

42. 42 Dept of Urology, GRH and KMC, Chennai.

43. 43 Dept of Urology, GRH and KMC, Chennai.

44. 44 Dept of Urology, GRH and KMC, Chennai.

45. 45 Dept of Urology, GRH and KMC, Chennai.

46. 46 Dept of Urology, GRH and KMC, Chennai.

47. VASOEPIDIDYMOSTOMY:
Indications:
when Testis biopsy reveals complete
spermatogenesis and scrotal exploration reveals
absence of sperm in the vasal lumen with no vasal
or ejaculatory duct obstruction
Types:
1.Intussusepting
2.End to side
3.End to end
47 Dept of Urology, GRH and KMC, Chennai.

48. COMPLICATIONS:
1.Scrotal ecchymoses & small hematoma
2.Infection –rare
3.Secondary obstruction & Azoospermia after
successful vasovasostomy -3-12%
PATENCY& PREGNANCY RATE:
-patency rate-75%-85%
-pregnancy rate -45%-70%
48 Dept of Urology, GRH and KMC, Chennai.

49. SPERM RETRIEVAL TECHNIQUE:
Indications:
1.Congenital absence or B/L partial aplasia of vas
2.Failed reconstructable obstructions
3.In conjunction with IVF
SURGICAL TECHNIQUE:
1.MESA
2.PESA
3.TESA
4.TESE
49 Dept of Urology, GRH and KMC, Chennai.

50. 50 Dept of Urology, GRH and KMC, Chennai.

51. 51 Dept of Urology, GRH and KMC, Chennai.

52. 52 Dept of Urology, GRH and KMC, Chennai.

53. 53 Dept of Urology, GRH and KMC, Chennai.

54. 54 Dept of Urology, GRH and KMC, Chennai.

55. TRANSURETHRAL RESECTION OF EJACULATORY
DUCT
DIAGNOSIS:
suspected in Azoospermic or
severely oligospermic with atleast one palpable
vasdeferens,
a low semen volume , acid semen PH and
–ve ,equivocal, or low semen fructose levels
-Transrectal USG

55 Dept of Urology, GRH and KMC, Chennai.

56. 56 Dept of Urology, GRH and KMC, Chennai.

57. COMPLICATIONS:
1.Reflux
2.Epididymitis
3.Retrograde ejaculation
57 Dept of Urology, GRH and KMC, Chennai.

58. 58 Dept of Urology, GRH and KMC, Chennai.