Surgical

Treatment of
Male Infertility
By Dr Pradeep Sharma
Dr Pradeep
Sharma
UROLOGIST/ ANDROLOGIST /
GENITOURINARY SURGEN MBBS MS
Mch (GOLD MEDALIST)

Director, urology, andrology and kidney

transplant, vinayaka hospitals, Jodhpur

Former hod , urology and kidney transplant,

SNMC, jodhpur
Upgrading Fertility Status

Natural conception
IUI
IVF/ICSI
Decreasing Risk and Cost
Increased Desirability
Ejaculated sperm
Surgical sperm retrieval for IVF/ICSI
Donor sperm insemination Adoption
Positive effect of pathophysiologic specific surgical
treatment of male infertility on ART
• To obviate the need for ART ( In very few cases
only)
• To downstage the level of ART needed to bypass
• male factor infertility
• From IUI to spontaneous pregnancy
• From IVF/ICSI to IUI
• To increase pregnancy rates with ART in cases who
had improved sperm morphology after the treatment
Correctable Pathologies of Male
Infertility
• Varicocele
• Obstructive azoospermia
• Ejaculatory duct obstruction
• Hormonal abnormality
• Infection
• Ejaculatory dysfuntion
• Gonadotoxin exposure
Varicocele Approach in infertile men with
varicocele
Semen abnormalities • Treatment of Varicocele
Density • Surgery (Open, laparoscopic)
Motility • Microsurgical Varicocelectomy
Morphology • Radiologic embolization
Testicular volume • Assisted Reproductive
Leydig cell function Technologies
WHO, Fertil Steril, 1992 • IUI, IVF/ICSI
Guidelines on Treatment of Varicocele
Varicocelectomy should not be offered to improve
fertility, since pregnancy rates do not increase.

Treatment of varicocele should be offered to

infertile men with palpable varicocele and
abnormal semen analysis.

Treatment of varicocele is still controversial,

although it improves spontaneous pregnancy rates.

EAU (2004)
Best Candidates for Varicocelectomy
• Palpable, large varicocele
• Normal testicular volume
• Normal FSH/testosterone, inhibin B?
• Total Motile Sperm count 5 million
• No genetic abnormality
• Short infertility duration
Correctable Pathologies in
Azoospermic Men

• Obstructive azoospermia
• Epididymal obstruction
• Vas deferens obstruction
• Distal ejaculatory duct obstruction
• Treatment Surgery
End of Week Check-In
Candidates for IUI or
ICSI with fresh motile
Obstructive sperm from ejaaculate
azoospermia

Microsurgical Pregnancy No need for additional

surgical procedure for
reconstruction 30-60 sperm retrieval
(TESA/PESA)

Upgrade from azoospermia to normal semen

parameters
 Varicocele repair
• microsurgical repair.
• to obviate the need for ART,
• downstage the level of ART .
• A cost effective treatment of infertility.
• Upgrade from azoospermia to oligospermia (20-30)
• Allow fresh sperm for IUI or IVF/ICSI
• Even if patients remain azoospermic, it may
preserve foci of spermatogenesis for Testicular
sperm recovery (TESA/TESE)
Vasovasostomy- Epididymovasostomy
• Patency 60-99.5
• Spontaneous pregnancy 40-60
 Transurethral resection of Ejaculatory Duct (TUR-ED)

Endoscopic resection of veru-montanum

 Summary

• Achieving natural pregnancy

• Upgrade from nothing to IVF/ICSI
• Upgrade from IVF/ICSI to IUI
• Upgrade from IUI to natural pregnancy
Thank you
for being a
great
audience
Any
Questions?
Presentation by Dr Pradeep Sharma