Human Fertility, December 2010; 13(4): 233–241

INVITED REVIEW

The role of urological surgery in male infertility

SAILAJA PISIPATI & RICHARD PEARCY

Department of Urology, Derriford Hospital, Plymouth, UK

Abstract
In 50% of involuntarily childless couples a male infertility associated factor is found together with abnormal semen parameters.
Surgical management of male infertility has advanced significantly over the last decade. This improvement in operative intervention
is due in part to advancements in assisted reproductive technologies and associated new sperm retrieval techniques, an increased
awareness among vasectomised men that they may still have their own biological offspring after a vasectomy reversal, and a more
scientific understanding of the effects of varicoceles on spermatogenesis as well as the introduction of innovative techniques in their
surgical repair. We describe various investigations to determine the underlying aetiology for male infertility and surgical techniques
to improve semen parameters and sperm delivery, including microsurgical procedures which are technically challenging and
demand specialised skills and andrological expertise.

Keywords: Male factor infertility, sperm, surgical technique

Introduction
Infertility is the inability of a sexually active couple to
achieve pregnancy in 1 year (WHO, 2000a). About 15%
of couples do not achieve pregnancy within 1 year and
seek medical treatment for infertility. Eventually, 5%
remain unwillingly childless. Infertility affects both men
and women. In 50% of involuntarily childless couples, a
male infertility associated factor is found together with
abnormal semen parameters. A fertile partner may
compensate for the fertility problem of the man and thus
infertility usually becomes manifest if both partners
have reduced fertility (WHO, 2000a,b).
Male fertility can be reduced as a result of (Sigman
& Jarow, 2007):
. congenital or acquired urogenital abnormal-ities
(including obstructions and testicular
dysgenesis)
. urogenital tract infections
. increased scrotal temperature (e.g. as a con-
sequence of varicocele)
. iatrogenic (surgical damage to the vas – intentional
or unintentional)
. endocrine disturbances
. genetic abnormalities
. immunological factors
Surgical management of male infertility has advanced
significantly over the last decade. This improvement in
operative intervention is due in part to advancements in
assisted reproductive technolo-gies and associated new
sperm retrieval techniques, an increased awareness
among vasectomised men that they may still have their
own biological offspring after a vasectomy reversal, and
a more scientific understanding of the effects of
varicoceles on spermatogenesis as well as the
introduction of innovative techniques in their surgical
repair.
Vasectomy is one of the most commonly per-formed
urologic procedures (Massey et al., 1984; Forste et al.,
1995). Up to 6% of vasectomised men return for a
reversal. Furthermore, 6% of men who suffer iatrogenic
injuries to the vas deferens, such as those associated
with a hernia repair, may also require a vasovasostomy
(Sheynkin et al., 1998). Thus, vasovasostomy and
vasoepididymostomy pro-cedures are being performed
more frequently. These microsurgical procedures,
however, are among the most technically challenging
operations performed by urologists and demand
specialised skills and andrological expertise.

Correspondence: R. Pearcy, Department of Urology, Derriford Hospital, Plymouth Hospitals NHS Trust, Derriford Road, Crownhill, Plymouth, Plymouth
PL6 8DH, UK. E-mail: Richard.pearcy@phnt.swest.nhs.uk
ISSN 1464-7273 print/ISSN 1742-8149 online 2010 The British Fertility Society DOI:
10.3109/14647273.2010.532579
234 S. Pisipati & R. Pearcy
Management
Surgical management of male infertility can be divided
into three main categories (Lipshultz et al., 2007):
(1) Diagnostic procedures –
(a) testicular biopsy
(b) testicular/epididymal sperm aspiration
(c) vasography
(2) Procedures to improve semen parameters –
(a) varicocele repair
(3) Procedures to improve sperm delivery –
(a) vasovasostomy and vasoepididymost-
omy
(b) surgical treatments of anatomical, con-
genital and organic causes of infertility,
such as hypospadias repair, electro-
ejaculation, and treatment of Peyro-nie’s
disease.
Diagnostic procedures
Testicular biopsy
Testicular biopsy should be performed only when the
information obtained will help direct future therapy or
enable sperm retrieval. Since the introduction of
intracytoplasmic sperm injection (ICSI), a testicular
biopsy is performed for therapeutic as well as for
diagnostic purposes. Diagnostic testicular biopsy is
indicated when an azoospermic male has normal
follicle-stimulating hormone (FSH) levels and testes of
normal size and consistency. A biopsy in this instance
can determine whether a patient’s azoos-permia is due
to obstruction or not. An azoospermic patient with an
elevated FSH level, especially if it is combined with
3
bilateral small (515 cm ) testes, usually has
nonobstructive azoospermia. Such pa-tients who may
desire attempted sperm retrieval and assisted conception
should undergo a testicular biopsy for both diagnostic
and therapeutic purposes (testicular exploration and
sperm extraction, TESE) (Lipshultz et al., 2007).
Results of a single biopsy of one testis may not be
indicative of the spermatogenic process in the remainder
of that testis or the contralateral testis (Skakkebaek et
al., 1973; Kahraman et al., 1996; Yoshida et al., 1997).
A study by Kahraman et al. (1996) found that successful
sperm recovery would be missed in 25% of cases if only
a single testis had been sampled. Other investigators
have shown that the percutaneous testis biopsy with one
pass through the testis failed to provide adequate tissue
for a correct diagnosis in approximately 8% of patients
(Kessaris et al., 1995). Thus, multiple biopsies or
microscopic sperm extraction from both testes should be
performed in patients with nonobstructive azoospermia.
Testicular biopsy can be performed either through the
open technique which is safe (Figure
1) or via the percutaneous approach which carries
several potential disadvantages, including an in-creased
risk of injury to the testicular artery or epididymis and
offers fewer seminiferous tubules for examination.
Open testicular biopsy can be performed under local,
spinal, or general anaesthesia. Whilst using local
anaesthesia, one must be cautious not to inadvertently
injure the testicular artery or cause a cord haematoma.
Parietal tunica vaginalis is opened via a 1- to 2-cm
transverse incision. The tunica albuginea is carefully
inspected for the least vascular area for the incision. A
4- to 5-mm incision is made in the tunica albuginea
using a no. 11 scalpel or a microknife, allowing
extrusion of the seminiferous tubules. Further extrusion
of the seminiferous tubules is achieved by applying
gentle pressure to the testis. Multiple similar biopsies
are advocated for best results. With the ‘no-touch’
technique, fine, sharp, iris scissors are used to carefully
excise the extruded tubules. The specimen is then
placed in Zenker’s, Bouin’s, or buffered glutaraldehyde
solu-tion. The testicular specimen should not be placed
in formalin; this solution will distort the histologic
features, making fine detail more difficult to read
(Lipshultz et al., 2007). The incision in tunica albuginea
is closed using 5-0 prolene.
Kessaris et al. (1995) demonstrated a high correlation
between percutaneous and open surgical biopsy
specimens. A 95% correlation was reported between
percutaneous needle and open biopsy techniques in 24
testes when both techniques were applied.
Figure 1. Open testicular biopsy.

Testicular/epididymal sperm aspiration
Though the least invasive and least painful technique
possible for sperm retrieval, fine-needle aspiration of
the testis/epididymis (percutaneous epididymal sperm
aspiration – PESA) provides only cytological, not
histological, information about the testis. It involves
insertion of a 21- to 23- gauge needle into the testis and
aspiration with a 10- to 20-ml syringe. It is
recommended that at least three separate sites be
aspirated because of the heterogeneity of the testis and
the small amount of material that is obtained. A study in
13 patients demonstrated that fine-needle aspirates taken
from three different sites had a wide deviation in
cytological results from each of the different sites
(Gottschalk-Sabag et al., 1995).
Nevertheless, fine-needle aspiration is slowly gaining
acceptance because of its accuracy in assessing different
histological patterns in the testis. A study of 87 men who
underwent both diagnostic fine-needle aspiration
mapping and open testicular biopsy demonstrated a 94%
correlation between biopsy specimen results (Meng et
al., 2001). Others have used fine-needle aspiration testis
mapping as an adjunct to open testicular biopsy to help
locate sperm (Turek et al., 1997, 2000; Meng et al,
2000).
Microsurgical testicular sperm extraction
Identification of wider calibre seminiferous tubules that
may contain sperm in a patient with nonob-structive
azoospermia using an operating microscope may have
the following advantages over the process of random
biopsy of the testis:
(i) It allows more meticulous opening of the
tunica albuginea, possibly avoiding cutting
across blood vessels that may be critical to
survival of the testis.
(ii) Less tissue needs to be extracted and therefore
more of the testis is preserved.
(iii) There appears to be a higher rate of sperm
retrieval for use with ICSI (Schlegel, 1999).
The seminiferous tubules of men with Sertoli cell-
only syndrome, sclerosis associated with Klinefelter’s
syndrome, testicular atrophy, cryptorchidism, or prior
orchitis are generally smaller than tubules with active
spermatogenesis. The operating microscope enables us
to identify the tubules that are relatively large and full
and thus, facilitates extraction.
This method was initially described by Schlegel in
1999. A horizontal incision is made at mid-testis
approximately two-thirds of the circumference of the
testis. Arteries and large veins are carefully pre-served.
Once the bleeding from the incision is controlled, the
testis is gently spread open, exposing
Role of urological surgery 235
the lobules of seminiferous tubules. High magnifica-tion
is used in a systematic search for prominent tubules that
may contain mature sperm. Most of the testis can be
explored through this single incision. Larger, full
tubules thought to contain sperm are teased away from
the thinner tubules and placed in a collecting well
containing sperm nutrient medium. This is immediately
examined by an embryologist or technician to determine
the presence or absence of sperm. If sperms are found or
if adequate sampling has not resulted in identification of
sperm, the procedure is terminated and the incision in
the tunic is closed with 5-0 prolene suture (Lipshultz et
al., 2007).
Schlegel (1999) reported an increase in the number of
men who produced sperm from 45% (10 of 22 men) to
63% (17 of 27 men), including six men who had
undergone biopsy without findings of sperm.
Furthermore, the amount of tissue removed with
microdissection averaged 9.4 mg as opposed to 750 mg
in the non-microsurgical group. Subsequent reports
have continued to demonstrate high yields for sperm
retrieval in patients with various causes of their
nonobstructive azoospermia (Chan et al., 2001; Raman
& Schlegel, 2003). However, a comparative study of
microtesticular sperm extraction and stan-dard multiple
biopsies reported by Tsujimura et al. (2002) found that
the differences were marginal and did not reach
statistical significance.
Vasography
Vasography is performed to determine if the vas
deferens is obstructed, and sometimes to indicate the
presence or absence of sperm in the vasal fluid. It is
indicated in azoospermic men where obstruction is a
possibility on clinical examination and investigations.
Copious amounts of vasal fluid containing many sperm
indicate vasal obstruction or ejaculatory duct
obstruction, and formal contrast vasography is
performed to document the exact anatomical site of the
obstruction. Copious, thick, white fluid without sperm
in a dilated vas deferens indicates secondary epididymal
obstruction in addition to a potential vasal obstruction
or ejaculatory duct obstruction.
Procedures to improve sperm production
Varicocele repair
Varicocele is an abnormal tortuosity and dilatation of
the pampiniform plexus of veins in the spermatic cord.
The venous drainage of the testis and epididymis is
provided by three sets of venous channels (testicular
vein, vein to vas deferens, and cremasteric vein) that run
parallel and freely com-municate.
236 S. Pisipati & R. Pearcy
A varicocele is the most common surgically
correctable abnormality found in infertile men and
may be responsible for sperm motility defects as well
as defects in sperm count and shape. Varicocele is a
physical abnormality present in 11% of adult males
(Hargreave, 1994; Pfeiffer et al., 2006) and in 25% of
those with abnormal semen analysis (Nieschlag et al.,
1995). Bennett first described semen quality changes
in varicocele in 1889. The prevalence of varicoceles in
men presenting with infertility is 20–40% (Dubin
& Amelar, 1977; Cockett et al., 1979; Aafjes & van
der Vijver, 1985; Marks et al., 1986). Approximately
90% of varicoceles are left sided. The incidence of
pain and discomfort associated with varicocele is 2–
10% (Peterson et al., 1998).
Classification
The following classification of varicocele (Hudson et
al., 1986; WHO, 2000b) is useful in clinical practice.
. Subclinical: not palpable or visible at rest or
during Valsalva manoeuvre, but demonstrable
by special tests (reflux found upon Doppler
examination) (Dhabuwala et al., 1992).
. Grade 1: palpable during Valsalva manoeuvre
but not otherwise.
. Grade 2: palpable at rest, but not visible.
. Grade 3: visible and palpable at rest.
A Cochrane review of controlled trials (1966– 2003)
(Evers & Collins, 2004) stated that ‘the evidence for
the treatment of varicocele in men with subfertility
improving the chance of partner preg-nancy was
insufficient’. However, there is definite evidence that
varicocele can impair semen quality and this can be
improved by treatment.
The mechanism by which varicoceles affect testi-
cular function remains unclear (Howards, 1995).
Intratesticular temperatures decrease by 0.58C in men
without varicoceles when they rise from a supine to a
standing position as opposed to an increase of 0.788C
in men with varicoceles (Yamaguchi et al., 1989). In
addition, oligospermic patients with varico-celes have
been found to have intrascrotal tempera-tures of 0.68C
higher than oligospermic patients without varicoceles
(Zorgniotti & MacLeod, 1973). Other studies have
found that elevated intratesticular temperatures are
common in oligospermic patients regardless of the
cause of the spermatogenic defect (Mieusset et al.,
1989). Not all investigators have found an association
between higher intratesticular temperatures and
varicoceles (Tessler & Krahn, 1966; Stephenson &
O’Shaughnessy, 1968). Other sug-gested causes for
the detrimental effect of varicoceles have included
reflux of renal and adrenal metabolites
from the renal vein (Comhaire & Vermeulen, 1974),
decreased blood flow (Saypol et al., 1981) and
hypoxia (Chakraborty et al., 1985).
The exact association between reduced male
fertility and varicocele is not known, but WHO data
(WHO, 1992) clearly indicates that varicocele is
related to semen abnormalities, decreased testicular
volume and decline in Leydig cell function. Two
prospective randomised studies showed increased ipsi-
and contra-lateral testis growth in adolescents who had
received varicocele treatment compared with those
who did not (Laven et al., 1992; Paduch &
Niedzielski, 1997). A cohort follow-up study, which
took serial measurements of testicular size in children,
showed that varicocele halted testicular development.
However, following treatment for varicocele, catch-up
growth occurred and reached the expected growth
percentile (Butler & Ratcliffe, 1984). A series of
studies suggested that altered endocrine profiles in
men with varicocele might predict who would benefit
from treatment (Hudson, 1996; Kass, 1996). However,
five prospective ran-domised studies of varicocele
treatment in adults gave conflicting results (Nilsson et
al., 1979; Breznik et al., 1993; Madgar et al., 1995;
Nieschlag et al., 1998; Hargreave, 1997). The largest
study indicated that treatment was beneficial (Madgar
et al., 1995; Hargreave, 1997). However, a meta-
analysis of the five trials indicated no benefit
(common odds ratio 0.85%; 95% confidence interval:
0.49–1.45) (Evers & Collins, 2003).
The studies mentioned above were summarised in a
recent review (Ficarra et al., 2006), criticising the
Cochrane meta-analysis of randomised controlled
trials on varicocele treatment and pregnancies (Evers
& Collins, 2004). The authors concluded that the
Cochrane meta-analysis conclusions should not
support guideline recommendations against varico-
cele treatment in subfertile patients.
Varicocele treatment is recommended for adoles-
cents who have progressive failure of testicular
development documented by serial clinical examina-
tion. Varicocele treatment for infertility should not be
undertaken, unless there has been full discussion with
the infertile couple regarding the uncertainties of
treatment benefit and outcomes (Table I). An infertile
adult man with a varicocele should be considered a
candidate for a varicocele repair if all of the following
four conditions are met: the couple has known
infertility; the female partner has normal fertility or a
potentially treatable cause of infertility; the varicocele
is palpable on physical examination, or if it is
suspected, the varicocele is corroborated by ultrasound
examination; and the male partner has an abnormal
semen analysis (Report on Varicocele and Infertility,
2004). Furthermore, there must be sufficient time to
allow for recovery of semen

Table I. Recurrence rates of different treatment methods for
varicocele.
Recurrence/
Technique of repair persistence rates (%)
Antegrade sclerotherapy 9
Retrograde sclerotherapy 9.8 (Sigmund et al., 1987)
Retrograde embolisation 3.8–10% (Lenk et al., 1994;
Feneley et al., 1997)
Scrotal approach – midline mass or dilated seminal vesicles. Jarow et al.
Inguinal approach 13.3% (Bassi et al., 1996)
High ligation 29% (Bassi et al., 1996)
Microsurgical 0.8–4% (Goldstein, 1995;
Goldstein et al., 1996)
Laparoscopy 3–7% (McDougall, 1995;
Miersch et al., 1995;
Tan et al., 1995)
parameters, which may take up to 18 months. If the
female partner is already in her mid-thirties, the couple
may be better served by assisted contraceptive
techniques.
Procedures to improve sperm delivery
Vasectomy reversal
Approximately 6% of men who have undergone
vasectomy will subsequently request a vasectomy
reversal (Potts et al., 1999). Vasovasostomy results have
shown patency rates up to 90%. The longer the interval
from vasectomy to reversal, the lower the pregnancy
rate. In a study of 1469 men who had undergone
microsurgical vasectomy reversal, pa-tency and
pregnancy rates, were 97% and 76%, respectively, for
an interval up to 3 years after vasectomy, 88% and 53%
for 3–8 years, 79% and 44% for 9–14 years and 71%
and 30% for 15 years (Belker et al., 1991). The chance
of secondary epididymal obstruction after vasectomy
increases with time. If secondary epididymal obstruction
occurs, vasoepididymostomy is needed to reverse the
vasectomy. Results of vasoepididymostomy are
considerably poorer as are the results of vasovasost-omy
for non-vasectomy obstructive causes.
Ejaculatory duct obstruction
Ejaculatory duct obstruction is diagnosed in 1–5% of
infertile men (Pryor & Hendry, 1991). These
obstructions can be classified as cystic or post-
inflammatory. Ejaculatory duct obstruction can be either
congenital or acquired, partial or complete. Congenital
causes include utricular, Mu¨ llerian and Wolffian duct
cysts as well as congenital atresia or stenosis of the
ejaculatory ducts. Acquired causes include infection,
calculus formation (Hellerstein
Role of urological surgery 237
et al., 1992), trauma and cyst formation associated with
prior instrumentation (Mayersak, 1989).
Complete ejaculatory duct obstruction should be
suspected in patients with azoospermia and de-creased
ejaculatory volume (51.0 ml) in the pre-sence of acidic
semen lacking fructose. Serum testosterone and
gonadotropin levels are usually within normal limits.
On occasion, rectal examina-tion will reveal a palpable
(1989) reported that 37% of infertile patients with
azoospermia have some form of ductal obstruction and
that 6% of azoos-permic men have ejaculatory duct
obstruction.
Transrectal ultrasonography, testicular biopsy and
seminal vesicle aspiration provide the diagnosis.
Transurethral resection of the ejaculatory duct or
transurethral balloon dilatation of the ejaculatory ducts
may relieve the obstruction.
Ejaculatory dysfunction
Disorders of ejaculation are uncommon, but im-portant
causes of male infertility. This group includes several
heterogeneous dysfunctions, which can be either
organic or functional (Dohle et al., 2010).
Anejaculation involves complete absence of ante-
grade or retrograde ejaculation and is caused by failure
of emission of semen from the seminal vesicles, the
prostate and the ejaculatory ducts into the urethra
(Glossaire, 1984). True anejaculation is usually
associated with a normal orgasmic sensation.
Occasionally (e.g. in incomplete spinal cord inju-ries),
this sensation is altered or decreased. True anejaculation
always is associated with central or peripheral nervous
system dysfunction, i.e. spinal cord injury, cauda
equina, retroperitoneal lympha-denectomy, aortoiliac or
horseshoe kidney surgery, colorectal surgery, multiple
sclerosis, Parkinson’s disease and autonomic
neuropathy secondary to diabetes mellitus or with
drugs, such as antihyper-tensives, antipsychotics,
antidepressants and alcohol (Wang et al., 1996).
Anorgasmia is the inability to reach orgasm and can
give rise to anejaculation. Anorgasmia is often a
primary condition and its cause is usually psycholo-
gical. Some patients report sporadic events of nocturnal
emission or of ejaculation occurring during great
emotional excitement unrelated to sexual activity
(Pryor, 1997).
In delayed ejaculation, abnormal stimulation of the
erect penis is needed to achieve orgasm with ejaculation
(Glossaire, 1984). Delayed ejaculation can be
considered a mild form of anorgasmia, and both
conditions can be found alternately in the same patient.
The causes of delayed ejaculation can be psychological
or organic for example incomplete
238 S. Pisipati & R. Pearcy
spinal cord lesion (Pryor, 1997), iatrogenic penile nerve
damage (Yachia, 1994); or pharmacological
(antidepressants, antihypertensives, antipsychotics)
(Rudkin et al., 2004)].
Retrograde ejaculation is the total, or sometimes
partial, absence of antegrade ejaculation as a result of
semen passing backwards through the bladder neck into
the bladder. Patients experience a normal or decreased
orgasmic sensation, except in paraplegia. Partial
antegrade ejaculation must not be confused with the
secretion of bulbo-urethral glands. The causes of
retrograde ejaculation can be divided into (Dohle et al.,
2010):
. neurogenic – spinal cord injury, cauda equine
lesions, multiple sclerosis, autonomic neuro-
pathy, retroperitoneal lymphadenectomy,
sympathectomy, colorectal and anal surgery.
. pharmacological – antihypertensives, a-1 an-
tagonists, antipsychotics, antidepressants.
. urethral – ectopic uricocele, urethral stricture,
urethral valves, congenital dopamine b-hydro-
xylase deficiency.
. bladder neck incompetence – bladder exstro-phy,
bladder neck resection, prostatectomy,
congenital/dysfunctional trigone.
Premature ejaculation is the inability to control
ejaculation for a sufficient length of time during vaginal
penetration. Although a universally accepted definition
of sufficient length of time does not exist, some patients
are unable to delay ejaculation beyond a few coital
thrusts, or even after vaginal penetration. Premature
ejaculation may be strictly organic (e.g. prostatitis-
related) or psychogenic, primary or ac-quired, partner-
related or non-selective, and can be associated with
erectile dysfunction (ED). Premature ejaculation does
not impair fertility, provided in-travaginal ejaculation
occurs.
Infertility caused by disorders of ejaculation is
seldom treated on the basis of aetiology. Treatment
usually involves retrieving spermatozoa for use in
assisted reproduction techniques (ARTs). The fol-lowing
aspects must be considered when selecting treatment:
. Age of patient and his partner.
. Psychological problems of the patient and his
partner.
. Associated pathology.
. Psychosexual counselling.
. Couple’s willingness and acceptance of differ-ent
fertility procedures.
If possible, any pharmacological treatment that is
interfering with ejaculation should be stopped.
Tamsulosin, an a-selective a blocker, can be admi-
nistered during antidepressant treatment (Perimenis et
al., 2001). Treatment should be given for urogenital
infections (i.e. in cases of painful ejacula-tion) (Abdel-
Hamid et al., 2001). Selective serotonin re-uptake
inhibitors (SSRIs) should be given for premature
ejaculation that appears to be related to serotonin levels
(Demyttenaere & Huygens, 2002). If possible, any
underlying urethral pathology or metabolic disorder
(e.g. diabetes) should be cor-rected. Psychosexual
counselling may be helpful.
Drug treatment for anejaculation caused by
lymphadenectomy and neuropathy or psychosexual
therapy in anorgasmic men is not very effective. In all
these cases, and in men who have a spinal cord injury,
vibrostimulation (i.e. the application of a vibrator to the
penis) is first-line therapy. If vibrostimulation has failed,
electro-ejaculation is the therapy of choice (Elliott &
Rainsbury, 1994). Electro-ejaculation involves electric
stimulation of the periprostatic nerves via a probe
inserted into the rectum, which seems unaffected by
reflex arc integrity. Anaesthesia is required except in
cases of complete spinal cord injury. In 90% of patients,
electro-stimulation induces ejaculation, which is
retrograde in one-third of cases. Semen quality is often
poor and most couples will need to enter an IVF
programme (Denil et al., 1996).
In the absence of spinal cord injury, anatomical
anomalies of the urethra, or pharmacological agents,
drug treatment with ephedrine sulphate, midodrin,
brompheniramine maleate, imipramine or desipra-mine
must be used to induce antegrade ejaculation in patients
with retrograde ejaculation. Alternatively, the patient
can be encouraged to ejaculate when his bladder is full
to increase bladder neck closure (Crich & Jequier,
1978).
Premature ejaculation can be treated with topical
anaesthetic agents to increase intravaginal ejaculation
latency time, off-label use of SSRIs (e.g. paroxetine,
fluoxetine), or behavioural therapy and/or psy-
chotherapy.
Erectile dysfunction
ED is defined as the persistent inability to achieve and
to maintain an erection sufficient for intercourse.
Feldman et al. (1994) have shown that in the general
population, complete impotence increases from 5%
among men 40 years of age to 15% among men 70
years and older. Thus, a significant number of men,
particularly in their later reproductive years, are infertile
because of ED. ED can be managed medically or
surgically. Lifestyle changes such as smoking cessation,
weight loss and improved overall general health may
promote remission or delay progression of ED
(Travison et al., 2007). Cessation or alteration of
medication that account for ED may

reverse ED in some patients. In some patients with
mixed psychogenic and organic ED, psychosexual
therapy may help relieve anxiety and remove
unrealistic expectations associated with medical or
surgical therapy (Lue & Broderick, 2007). Testoster-
one replacement therapy, phosphodiesterase 5 in-
hibitors, intracavernosal alprotadil, intraurethral
alprostadil (MUSE) and vacuum devices prove to be
very effective. Surgical treatments for ED include
insertion of a penile prosthesis and revascularisation
procedures and are reserved as last resort.
Conclusion
In the treatment of male infertility, an overall
assessment of the infertile couple should be made.
However, priority should be given to surgical
intervention and, in case of failure, assisted repro-
ductive technology could be considered. A Urologist
with andrological expertise can be very helpful in the
diagnosis and treatment of the underlying conditions
accounting for male infertility.
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