Surgical Treatments

The role of surgery in the treatment of male infertility is well established and cost-effective when compared to high-technology approaches. Surgery also attempts to reverse specific pathophysiologic effects and may allow for conception at home rather than in the laboratory.

Microsurgery in Urology

The rise of microsurgery as a surgical discipline followed 3 advances. The first was refinements in optical magnification; the second, the development of more precise microsuture and microneedles; and the third, the ability to manufacture smaller and more refined surgical instruments. In urology, microsurgical techniques were first applied to renal transplantation and vasectomy reversal. Microsurgical techniques evolved quickly from humble beginnings using borrowed forceps from the local jewelry store (the “jeweler’s forceps”) and human hair for fine suture material to its current highly refined state.

 

Even with these advances, microsurgery in urology is one of the most challenging disciplines in the field.

Varicocele

Although most men with varicoceles are fertile, the association of varicoceles with infertility is well established by observational, retrospective, and prospective studies. Several treatment modalities, both surgical and nonsurgical, are available for varicoceles. These include incisional ligation of the veins through the retroperitoneal, inguinal, or subinguinal approaches; percutaneous embolization; and laparoscopy. The common goal of all treatments is to eliminate the retrograde reflux of venous blood through the internal spermatic veins. Treatments can be compared in terms of expected success rates (semen improvement and pregnancy), cost, and outcomes (pain pills, return to work or other activity), and their relative merits can be analyzed. A basic comparison of 3 treatment options is outlined in

Table 42-15. Remember that if watchful waiting is chosen, a pregnancy rate of 16% can be expected. If IVF is chosen, a pregnancy rate of 35% can be expected. An overall complication rate of 1% is associated with the incisional approach, compared with a 4% complication rate for laparoscopy and 10-15% for radiologic occlusion. A significant component of the complications with the radiologic approach is technical failure, meaning the inability to access and occlude the spermatic vein.