Male Infertility Procedures

Subsequent to the diagnosis of male infertility, the andrologist may decide on some procedures to alleviate the condition of the patient.

Some of the possible male infertility procedures done at GarbhaGudi are

  1. Varicocelectomoy : A varicocele is a situation where there is some abnormality in the scrotum, wherin there is elongated and / or dilated veins that remove blood fomr the testicles. It is found quite often in male infertility patients. On an average it is seen in 15% of all males. Most varicoceles are seen on the left side and quite a few on both sides. They start during puberty.It is assumed that it is due to poorly functioning valves and increased resistance to blood flow and so increase in venous pressure. These are not carcinogeneic and are not life threatening.Some varicoceles do not cause any issue – no pain, no side effect, no impact on fertility etc. However, some can be uncomfortable and cause moderate scrotal pain and occurs with long periods of sitting / standing and reduces when lying down. It has no relationship with urination or erectile dysfunction; however, it can be associated with male infertility.It is not completely clear on how varicocele has an impact on male infertility. It is known that the temperature of the scrotum is normally several degrees cooler than body temperature and this is important for normal sperm production and testis function. This temperature difference is carefully maintained by the anatomy of the scrotum. The dilated veins in a varicocele may affect this temperature management process and heat-up the testis and reduce its ability to function. Increase in temperature potentially increases oxidative stress and so reduces the fertility of varicocele patients.Semen analysis in varicocele patients can show impaired sperm numbers, movement or both. Varicocele is diagnosed by physical examination, through palpation of the scrotum by a trained andrologist.To treat varicocele, we have to stop the backward flow of blood from the body to the scrotum, and so allow the testicles to cool. So, the veins of the testis are tied or obstructed as completely as possible. A single vein that does not exhibit varicocele is left open. This allows blood to leave the testicle after surgery. This can be done through – Incisional surgery or through Laparoscopic surgery. Both approaches give similar results
  2. Orchidopexy : Orchidopexy is a surgical procedure that brings a non-descended testicle/s, down into the scrotum. An orchidopexy can be done on one or both sides. When both testicles are brought down this is called a bilateral orchidopexy. The reason for surgery is that if a non- descended testicle is not brought down into the scrotum, it usually will fail to develop its ability to produce sperm. Also, if it remains undescended, there is an increased risk of developing testicular cancerAn orchidopexy surgery involves making a small incision above the groin on the effected side/s. The testicle is then located and the spermatic cord isolated. Often there is a hernia associated with these undescended testicles and if this is the case the hernia is also repaired. The testicle is then put down into the scrotum in one of two ways. If the cord is quite short a special pouch is made in the scrotum to hold the testicle down there. If the cord is long enough the testicle can be popped into the scrotum and the neck of the scrotum is narrowed by stitching it partly closed so the testicle won’t pop back up. If a pouch has to be made there will be a small external cut in the scrotum and this will be closed with dissolving stitches also. A dressing would then be placed over the wound/s to protect the incision and aid healing.The operation is a day stay procedure, which means no overnight stay is required. We need permission from the patient for the operation to go ahead. Before the consent is signed it is important that the risks and effects of the operation and anaesthetic are understood. These will be discussed prior to surgery. Usually nothing is allowed to be eaten or drunk for six hours before surgery. Exact instructions are given about ‘nil by mouth’ requirements prior to surgery. The operation usually takes about 30 minutes for a single orchidopexy and up to double this time for a bilateral orchidopexy.When the operation is completed the patient will go to the recovery room and will stay in the recovery room only for a short while where he will be cared for until ready to be dischargedOnce recovered from the anaesthetic the patient will be allowed to move around a bit. However he may be a bit wobbly on his feet due to anesthesia. Pain relief is given on a regular basis to ensure comfort is maintained. Once the patient has passed urine, is able to walk around, eating and drinking, he can go home. The doctor / nurse gives instructions on when to see the surgeon for follow-up. A discharge information letter is given prior to discharge that contains helpful information for returning home. The doctor may give some antibiotics after the operation. It is important to complete the whole course as instructed, even if everything looks well and it doesn’t look like any more tablets need to be taken.It is important for patients to take things quietly for one or 2 days as the anaesthetic can still have some effects on the body. Regular pain relief can be taken as required to maintain comfort. Instructions about wound and dressing care will be given by the nurse prior to discharge. The stitches placed during the operation dissolve slowly in the weeks following surgery. Your son will be allowed to shower or bath as usual but soap or powders should not be used directly on the wound until it has fully healed.Following discharge there may be some swelling in the region of the scrotum and the testicle may even rise up out of the scrotum partially although it almost always returns. However if any excessive bleeding or signs of infection appear please see the doctor as soon as possible.The patient should ont drive within 24 hours of the anaesthetic and must ensure they avoid any heavy lifting, straining or strenuous activity for about two weeks after surgery to ensure things have time to heal.
  3. Testicular Biopsies : The testicles are oval-shaped glands that hang in the scrotum beneath the base of the penis. The testicles produce sperm (necessary for reproduction) and male hormones, such as testosterone.A testicular biopsy is a test to remove a small sample of tissue from one or both testicles and examine it under a microscope to evaluate a man’s ability to father a child. A testicular biopsy may be done to help determine the cause of male infertility. Testicular biopsy may be done if both of the following are present:
    • The man’s semen does not have sperm.
    • Hormone test results are within the normal range.

    Testicular biopsy may also be done to retrieve sperm for in vitro fertilization for intracytoplasmic sperm injection (IVF-ICSI). Read TESA / PESA for this.

    If a testicular biopsy is done under local anesthesia, no other special preparation is needed. If the biopsy is done under general anesthesia, your doctor will tell you how soon before surgery to stop eating and drinking. Follow the instructions exactly about when to stop eating and drinking, or your surgery may be canceled. If your doctor has instructed you to take your medicines on the day of surgery, please do so using only a sip of water. During preparation for the biopsy, an intravenous line (IV) is inserted in your arm, and a sedative medicine is given about an hour before the biopsy.

    The biopsy is done by a surgeon or a doctor who treats reproductive health problems in men (urologist). The skin over the testicle is cleaned with an antiseptic solution, and the area around it is covered with sterile cloth. It is very important that you do not touch this sterile area. The patient will feel a brief sting when the IV line is inserted or when the local anesthetic is injected. Other than that, the procedure should be painless.

    A local anesthetic will be injected into the skin of the scrotum to numb (anesthetize) the area. Then a small incision is made through the skin, and a tiny piece of testicular tissue is removed with small scissors. A single stitch is used to close the incision in the testicle, and another stitch is used to close the incision in the skin. The procedure is usually repeated on the other testicle. The scrotal area is then bandaged. If general anesthesia is used, you will be asleep during the procedure but the same method will be used.

    The biopsy usually takes 15 to 20 minutes. The patient will be advised to refrain from sexual activity for 1 to 2 weeks after the biopsy. You should avoid washing the area for several days. The scrotum and testicles may be somewhat sore for 3 to 4 days after the biopsy and some bruising may be present. The patient may also notice a small amount of bleeding through the bandage, which is normal.

    There is a slight risk of prolonged bleeding or infection from this procedure. There is no risk of erection problems or infertility as a result of this biopsy. If general anesthesia is used, there is a small risk of complications from anesthesia.

    Call your doctor immediately if you have:

    • Severe pain in your scrotum. Some mild discomfort is normal.
    • Severe swelling of your scrotum. Some mild swelling is normal.
    • A fever higher than 100&degF (38&degC).
    • Excessive bleeding through the bandage.

    A testicular biopsy is a test in which a small sample of tissue is taken from one or both testicles and examined under a microscope to evaluate a man’s ability to father a child. Results are usually available in 2 to 4 days. A pathologist examines the biopsy sample through a microscope for any abnormalities in sperm production or maturation. If sperm development appears normal yet a semen analysis test shows reduced or absent sperm, a blockage of the tube from the testes to the urethra is suspected. A blocked tube can sometimes be repaired by surgery.

  4. TESA / PESA / MESA : Azoospermic patients (no presence of spermatozoa in the ejaculate) have the option to undergo semen surgical collection procedure, a technique for collecting spermatozoa directly from the vas deferens, epididymis or testis. Sperm retrieval may be performed under local or general anesthetic.The samples can then be prepared for use on the same day after egg collection, cryopreserved for future use, or do both. Once the spermatozoa have been collected and isolated, fertilization can be achieved through ICSI procedurePESA (Percutaneous Epididymal Sperm Aspiration): This procedure involves the insertion of a fine needle into the epididymis. Fluid is gently removed from the epididymis by aspirating it through the needle. This liquid is then analyzed under the microscope for sperm content and motility.MESA (Microsurgical Epididymal Sperm Aspiration) : This procedure involves microsurgical techniques to remove small samples of epididymal tissue followed by highly specialized laboratory handling and processing and eventual extraction of spermatozoa from the tissue.TESA (Testicular Sperm Aspiration): This procedure involves the insertion of a needle into the testis and the aspiration of spermatozoa through the needle. The liquid is then analyzed under the microscope for sperm content and motility.TESE (Testicular Sperm Extraction): TESE procedure, also called testicular biopsy, involves a small surgical incision in the testis, aiming to remove small samples of testis tissue for processing and eventual extraction of sperm.

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