MALE INFERTILITY

Surgical Aspect

G. Wirya K. Duarsa

UROLOGY Division
Department of Surgery School of Medicine
Udayana University-Sanglah Hospital Denpasar
 Infertility

Inability to achieve conception or pregnancy

>1 year of regular,
unprotected sexual intercourse
Primer >< Sec infertility
An estimated 15% of couples are infertile
20% due to male factors alone
30% due to female and male factor

Comprehensive urology, 2002

 TESTIS
Oval :L. 3,6-5.5 cm
W. 2,1-3,2 cm
± 20 gram

250 Lobules
each Lobules :
1. Tubule Seminiferous Spermatogenesis
2. Leydig cells  Testosterone
3. Blood vessel
4. Lnn
5. Macrophage
 Hipotalamus - Hipofise - Testis
T
Hypothalamus

LHRH (+)

E2
Pituitary
T Inhibin (-)
(-) E2
(DHT)
LH (+) FSH (+)

Leydig cells T (+)

Seminiferous tubule Sperm

(sertoli and
Germinal cells)
 TRANSPORT SPERMA
 Tubulus seminiferus  rete
testicle  duktus eferen 
epididimis (maturation)  vas
deferens  ampula dukts
deferens
 Ejakulasi diawali fase emisi 
terkumpul di uretra posterior
 Proses ejakulasi  dorongan
ritmik dari kontraksi otot bulbo
kavernosus
 Testicular Microscopic

AV. Spermatika Interna

AV. Kremasterika
AV. Defferensia
SPERMATO
GENESIS
 Pretesticles (8%)
 Pituitary Disease
 Hipothalamus Disease
Kallman Syndrome
Prader Willi Syndrome
 Testicles (80%)
 Chromosom abnormalty (Klinefelter, XYY syndrome)
 Noonan syndrome (male Turner syndrome)
 Radiation, drugs, chemotherapy
 Systemic diseases (renal failure, cickle cell anemia)
 Testicles injury (torsio, orchitis, trauma)
 Criptorchismus
 Varicocele
 Post testicles (12%)
 Reproduction obstruction
 CABVD

 Ejaculatory duct obstruction

 Sperm function or motility abnormality

 Coitus problems (impotensi,hipospadia)
 Immune disease
 Epididymal Dysfunction
 Obstructive change of passage
 Infection of Accessory glands
Specific Causes vs. Idiopathic
 Varicocele 39%
 Obstructive 8%
 Mechanical 8%
 Endocrine 6%
 Developmental 5%
 Immunologic 1%
 Idiopathic 33%
Schlegel and Pavlovich, 2007
 DIAGNOSIS
 HISTORY TAKING
 PHYSICAL EXAMINATION
 TESTICLE EVALUATION
 EXTERNAL GENITAL EVALUATION
 Lab and Ro
Sperm Analysis
Hormonal Analysis (sperm < 10 mil)
Dopler Stetoscope
Ultrasonography (color flow doppler)
CT scan
Spermatic venography
Thermography scrotal
Testicles biopsy
Sperm Analysis (WHO)

(Dikutip dari EAU Guidelines, 2013)

 TERAPI
 Konseling
 Psikis, perubahan gaya hidup, konseling
waktu koitus, frekuensi, penggunaan lubrikan
 Medikamentosa
 hipogonadotropik-hipogonadisme  LH  sel
Leydig  testosterone + hCG (Pregnyl)
 antibodi antisperma  kortikosteroid
 Retrograde ej  adrenergik alfa, trisiklik
 Anti oksidan, chlomipen dll
 PEMBEDAHAN
 VARICOCELE

Most surgically
correctable cause
of Male infertility
 VARICOCELE
Dilated & tortuous veins within the pampiniformis
plexus of scrotal vein
Mostly asymptomatic
Failure of ipsilateral testicular growth
Pain & discomfort
Infertility (most common cause of poor sperm
production and decreased semen quality)
differing testicular sizes
Most surgically correctable cause of Male infertility
very rare < 9 y.o. ; 16% of adolescents
15-20% of all males
40% of primer infertile of males
80-90% of secunder infertile of males
 80-90% involve the left testicle
a. angle at which LTV enters LRV
b. lack of effective antireflux valves at
junct of testicular - ren vein
c. Increased renal vein pressure due to
compression between the superior
mesenteric artery and the aorta
(nutcracker effect)
d. Longer left spermatic vein

 Recent study by Gat et al  ~ 80% of

men with a left clinical varicocele had
bilateral varicoceles revealed by
noninvasive radiologic testing
 Initial presentation usually occurs during puberty, with
incidence in 13-year-old adolescent boys equal to that
of adult men
 Direct correlation the degree of testicular
atrophy with varicocele grade
 Steeno et al  testis volume reduced by 81% with
grade 3 and by 34% with grade 2
 Grading:
 Grade 0 - Subclinical varicocele, (US or venography)
 Grade 1 – palpable with Valsalva maneuver
 Grade 2 - Easily detected wo Valsalva maneuver
 Grade 3 - Detected visually at a distance
 History
first recognized in 16th century
relationship to infertility proposed in 19th century
in teenagers referenced as early as 1885
1950s  fertility following varicocele repair
pattern of low sperm count, poor motility, and
predominance of abnormal sperm forms
(stress pattern of semen)
Pathophysiology

 Unknown
 Histologic
studies 
seminiferous
tubule
sclerosis, small
vessel
degenerative
changes, and
abnormalities
of Leydig,
Sertoli, and
germ cells
DNA fragmentation index (DFI) (percentage DNA
with denatured DNA values) and the TUNEL positive-
cells were significantly greater in patient in varicocele,

ROS level is significantly higher in both group patient

with varicocele & higher IL-6 in seminal plasma.
 Varicocele &ART

After microligation:
Spermatogenesis was achieved in 7 (of 15) patients
(-) sperm retrieval
Semen samples should be cryopreserved
ICSI is still needed
 Varicocele Repair in Patients With Nonobstructive
Azoospermia: A Meta-Analysis
John W. Weedin,*,† Mohit Khera‡ and Larry I. Lipshultz§
From the Scott Department of Urology, Baylor College of Medicine, Houston, Texas

 Result of this meta analysis is some men with NOA

can benefit from varicocele repair
 Resulting the motile of sperm, and spontaneous
pregnancy
 Histopathology as the only statistically significant
factor of predictor success
 Overall this meta analysis demonstrate that
varicocele repair can performed safely and
effectively in men with NOA
 Management
AUA Male Infertility Committee: Indications for
surgical correction
 Relief of significant testicular discomfort or
pain not responsive to routine sympt tx
 testicular atrophy (vol diff >20% or > 2cc)
 possible contribution to male infertility
 resulting in atrophy and impairment of
seminal parameters and leydig cells
 abnormal semen parameters function
 varicocele is palpable
 Management in Adolescents
 No strict criteria necessitate surgical intervention
 Each case handled individually
 general guidelines used by some pediatric urologist
include the presence of one or more:
 decreased ipsilateral testicular size (20%)
 Bilateral varicoceles
 Gr 2 or gr 3
 Symptomatic painful varicocele
 Abnormal semen analysis (if needed)
 Surgical Management
 Technique
 Open surgery
 Microscopic surgery
 Laparoscopy
 Embolization / schlerotherapy
 3 most common surgical approaches
 inguinal
 Retroperitoneal
 subinguinal
 Check patient's semen 3-4 months
Varicocelectomy
 Results
Researchers % SPERM Pregnancy
Improvment Rate (%)
Dubin and Amelar. 70 53
Lome and Ross 78 50
Mc Fadden and Mehan 62 41
Cockett et al. 81 52
Newton et al. 66 44
Aafjes & V.D. Vijver 79 46
Marks et al. 61 39
Dikutip dari : Pryor, J.L., Howards, S.S., 2008
 Pregnancy Rate
Researchers Surgery Konservative
Tulloch 55,2% 7,1%

Scott and Young 35,4% 12,2%

Hanley and Harrison 27,8% 17,1%
Charny and baum 33,6% 12,8%
Macleod 39,4% 21,0%
Dikutip dari : Pryor, J.L., Howards, S.S., 2008
 Azoospermia
 the absence of spermatozoa in the ejaculate after
assessment of centrifugated semen on at least 2
occasions
 1% of the male population
 10-15% of men who seek fertility evaluation

 Classification :
 Obstructive Azoospermia (OA)

 Non Obstructive Azoospermia (NOA)

 The key components of evaluation:

 sexual and medical history, Ext genital PE

 Hormonal measurements
 Sperm retrieval for ART
ICSI is possible for many men with OA and NOA

In obstructive azoospermia Several techniques exist to allow for

sperm retrieval rates approaching 100%

In NOA, TESE/ m-TESE is essential for subsequent ICSI.

Some couples will not have sperm retrieved with TESE.

Therefore, the use of frozen donor spermatozoa as back-up
should be discussed
Eseteves, 2013
 Obstructive Azoospermia Classification

EAU, 2015

4. Intratesticulair obstraction
Seminiferus tubulus
Rete testiis obstruction
management
 Sperm Retrieval for OA
 Percutaneous epididymal sperm aspiration (PESA), TOC
 microsurgical epididymal sperm aspiration (MESA)
 Goal Sperm retrieval
Best sperm quality
Minimize damage
Simplest method
Enough samples to cryopreservation

 Successful
rate was of 62-85 % from total cases. Faliure
rate 20%  MESA/TESE-mTESE
 PESA
ADVANTAGE
 Minimal discomfort for the patient

 Minimal fibrosis

 Lesser complication compare to open surgery.

 (-) microsurgical instruments

 Simple technique with low cost.

DISADVANTAGE
 Blind procedure

 Sometime mixed with blood

 Fibrosis?!
SIDNEY GLINA, Int. Braz J Urol, 2013
Microsurgical epididymal sperm aspiration

MESA
 TERAPI
 Pembedahan
 Vasovasostomi,
 vasoepdidimiostomi
 TURED
 Sperm retrieval
PESA
MESA
TESA
TESE/ mTESE
--- ICSI
Vasovasostomi

 Mikroskop
 Single-layer anastomosis
dan two-layer anastomosis
 vasovasostomi  watertight
 ASA
 Tension-free
 TURED
 Sistoskopi  resektoskope kecil dan loop
elektrokauter  verumontanum direseksi di
midline
 Reseksi mulai dari apeks prostat berdekatan
dengan sfingter uretra eksterna dan rektum
 Pasien pria infertil 65-70% menunjukkan
perbaikan kualitas semen secara signifikan
setelah TURED dan 20-30% pasangannya
menjadi hamil
3. ICSI
 a single wash sperm is injected directly into

an oocyte’s cytoplasm using a very fine

needle.
 low sperm count is involved

 Started in 1992 for severe OAT & Azoospermia

 Sperms retrieval from testis/epididymal
 Wife ovarian stimuli & oocyte retrieval