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Male Infertility-Surgical Management PowerPoint Presentation

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Description : Diagnostic procedures Procedures to improve sperm production Procedures to improve sperm delivery Procedures for sperm retrieval

Tags : male infertility,infertility,surgical management,ANAESTHESIA

Published on : May 14, 2022 | Views : 1531 | Downloads : 7

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Surgical Management
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Diagnostic procedures Procedures to improve sperm production Procedures to improve sperm delivery Procedures for sperm retrieval
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Diagnostic procedures Procedures to improve sperm production Procedures to improve sperm delivery Procedures for sperm retrieval
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 Indication Azoospermic Men with normal size testis Palpable vas Normal serum FSH Negative antisperm antibody Not required Cong. Absence of vas with Normal FSH Positive antisperm antibody Before ivf/icsi
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Obstructive  Non obstructive B/L irrespective of size Therapeutic: even if single sperm + Optimally done with laboratory capable of processing and cryopreserving any sperm found Open /percutaneous biopsy/ aspiration
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 Gold standard - provides optimal amount of tissue – diagnosis & IVF ANAESTHESIA : General/ spinal/local GOALS Obtain optimal tissue sample Avoid trauma to specimen Avoid trauma to epididymis and testicular vascularity
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B/L transverse or median raphe incision Tunica vaginalis opened Hemostasis ensured before incising albuginea 3 to 4mm incision – T.albuginea
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Testis biopsy Excise pea sized sample of seminiferous tubule Bouin’s; zenker’s; collidine buffered glutaraldehyde Touch preparation Glass slide with saline or RL or human tubal fluid with IVF MEDIUM- microscope Presence of sperms with motility Absent Wet crush specimen No sperm – closed with 5-0 vicryl New site chosen Sperm found Closed with 5-0 nylon
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 Biopsy 14 gauge gun Blind procedure Injury to epididymis/artery Therapeutic: fresh sperm retrieval foe IVF/ICSI in O.A Aspiration 23 gauge or angiocath sheath Less invasive Lesser yield Flow cytometry can show haploid/diploid 3 to 4 aspirations needed
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 Hematoma Inadvertent biopsy of epididymis: If sperm +  epididymis level of obstruction If sperm –ve  obstruction above or primary seminiferous tubule failure
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Indications The absolute indications for vasography are the following (must include all three): 1. Azoospermia 2. Complete spermatogenesis with many mature spermatids on testis biopsy 3. At least one palpable vas Relative indications for vasography are the following: 1. Severe oligospermia with normal testis biopsy 2. High level of sperm-bound antibodies, which indicates unilateral, bilateral, or partial obstruction (Lee et al., 2009) 3. Low semen volume and very poor sperm motility (partial ejaculatory duct obstruction) Vasography should answer the following questions: 1. Are there sperm in the vasal fluid? 2. Is the vas obstructed? If the testis biopsy reveals many sperm, the following are indications: 1. Absence of sperm in vasal fluid indicates obstruction on the testicular side of the vasotomy site, most likely an epididymal obstruction. Vasography is done in this case with saline or indigo carmine to confirm patency of the seminal vesicle (distal) end of the vas before vasoepididymostomy. 2. Copious vasal fluid containing many sperm indicates vasal or ejaculatory duct obstruction, and formal contrast vasography is performed as described later to document the exact location of the obstruction. 3. Copious thick, white fluid without sperm in a dilated vas indicates secondary epididymal obstruction in addition to a potential vasal or ejaculatory duct obstruction.
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Vasography Testis biopsy sperms + Sperm –ve Epididymal obstruction Distal vasography Patent + VASOEPIDIDYMOSTOMY Copious thick fluid without sperms Epididymal obstruction + vas/ Ej duct obstruction Sperm retreival methods Copious fluid with sperms Vasal/ ejaculatory duct obstruction vasography
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Vasography Obstruction at EJ duct TURED Dye enters both vas Midline ejaculatory duct cyst End far from EJ duct CFTR mutations Vasal epididymal sperm retrieval Inguinal region Vasovasostomy /crossed vasovasostomy Retrograde ejaculation Normal vasogram aperistalsis
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Diagnostic procedures Procedures to improve sperm production Procedures to improve sperm delivery Procedures for sperm retrieval
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Varicocoele Cryptorchidism Hydrocoele Temperature regulation Long, hot, sauna baths impair spermatogenesis
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15% general population 35 % in 10 infertility 75 % 20 infertility Progressive and duration dependant decline in testicular function Repair halts further damage,improves spermatogenesis,improves live birth rates,better IVF/ICSI results, enhances leydig cell function
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Scrotal Retroperitoneal Laparoscopic Microscopic inguinal and subinguinal Radiographic occlusion
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Earliest method Clamping skin with enlarged veins 1900- open scrotal procedure Disadvantage- pampiniform plexus intimately entwined with coiled testicular artery Hence avoided as risk of atrophy - high
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Incision at level of deep ring Ligating the vein at site of entry to renal vein One or two large veins: fewest Artery not in proximity Children 15%- adult 15-45% children recurrence Periarterial,parallel inguinal or retroperitoneal collaterals, cremasteric or scrotal collaterals 7-33% hydrocoele
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Most popular Conventional / Microsurgical Advantages : visualisation of testicular artery , lymphatics and small veins External spermatic and gubernacular veins Access to testis , epididymis and hydrocoele
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Preferred Easier Less veins Artery easier to identify Children Solitary testis  Failed subinguinal No fascial layer opened Less pain  Testical artery smaller and branched Obese men Low lying testis  Prior history of inguinal surgery
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1 2 3 4
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 Blanching- pulsating blush method Adherent on the undersurface of the largest vein 2 veins in close proximity With H or X pattern if interconnections 1% papaverine  Microdoppler 0.5 to 1.5 mm 10-25 X magnification
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Testicular , cremasteric artery , lymphatics & vas and its vessels preserved Testis delivered 10 % recurence due to scrotal and gubernacular veins Veins ligated – cord reexamined “Impulse test”  Address hydrocoele if present
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In approximately 50% of cases the testicular artery is adherent to the undersurface of a large vein (Beck et al., 1992). All veins within the cord, with the exception of the vasal veins, are doubly ligated with either hemoclips (Fig. 67.50A) or by passing two 4-0 silk ligatures, one black and one white, beneath the vein (Fig. 67.50B). These are then tied and the vein divided. Medium hemoclips are used for veins 5 mm or larger, small auto-hemoclips for veins 1 to 5 mm, and 4-0 silk for veins smaller than 2 mm. The bipolar cautery can be used for veins smaller than 0.5 mm. The vasal veins are preserved, providing venous return. If the vas deferens is accompanied by a dilated vein greater than 2.5 mm in diameter, they are dissected free of the vasal artery and ligated. The vas deferens is always accompanied by two sets of vessels. As long as at least one set of deferential veins remains intact, venous return will be adequate.
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Local anaesthesia Femoral route Use of coil or balloon Antegrade scrotal sclerotherapy Failure to cannulate 10 -25% Long duration 1 -3 hrs Migration, loss of kidney, pulm embolism Recurrence 4 to 11% Late recurrence
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Testicular artery ligation Testicular atrophy
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60-80% iprovement in semen parameters 44% to 10% Surgery vs Non surgery Microsurgical – azoospermia with large varicocoele- sperm + in 50% Larger varicocoele; Younger patients Improvement of S.Testosterone levels
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Cryptorchidism associated with high incidence of infertility Orchipexy Preserve testicular hormonal function Obviates the need for hormone replacement Can induce spermatogenesis and allow pregnancy Retractile testis Dartos pouch preferred technique
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Diagnostic procedures Procedures to improve sperm production Procedures to improve sperm delivery Procedures for sperm retrieval
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Reversal of vasectomy Obstructive azoospermia Iatrogenic Physical examination Testis Epididymis Sperm granuloma Vasal gap Scars from prev. surgery Laboratory : Semen analysis Antisperm antibody test Serum FSH PSA if AGE >40
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 Anaes : General / spinal Microsurgical so movement Large gaps , inguinal extensions,vasoepididy mostomy – longer time Scrotal Vasectomy reversal Length of vas on abdominal side may be a problem Inguinal extension Inguinal Prev surgery Testis can be delivered
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Separate cord structures from vas Free till the internal inguinal ring 4-6cm Dissecting the convuluted vas free of tunica Cut inguinal canal floor and reroute under the floor 10cm Dissecting the epididymis off of the testis- vasoepididymal jn to caput
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Check patency by passing a prolene thread <5cm- revise If >5cm – use combination of lengthening technique >10cm- single crossed vasovasostomy Preserve sperm for IVF 2 separate anastomosis- devascularised
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(1) Accurate mucosa-to-mucosa anastomosis (2)Leak proof anastomosis (3) Tension-free anastomosis (4) Adequate blood supply to the ends of the vas (5) Healthy mucosa and muscularis (6) Atraumatic technique.
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Lumina of varying diameters Planning  placement  3,9,11,1,5,7 Double arm inside out  10-0 mucosal – (6) 9-0 muscularis (6+4) 8-0 vasal sheath (6-8)
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A perfect transverse cut yielding a round ring of mucosa and a lumen directed straight down is essential oblique lumen not acceptable The convoluted vas should not be unraveled. This disturbs the blood supply at the anastomotic line The sheath of the convoluted vas may be carefully dissected free of its attachments to the epididymal tunica to prevent inadvertent perforation of adjacent convolutions Reinforce the anastomosis by approximating the vasal sheath
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Transposition of testis
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No intercourse for 3 weeks Semen analysis at 1,3,6 months 52% pregnancy If azoospermia at 6 months  Redo Hematoma Sperm granuloma Decreasing counts Encourage cryopreservation as soon as sperms appear
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Caput  corpus cauda Thinner thicker ,single lumen Distal – more chances of motile sperms 200micron  microsurgical procedure Testicular and deferential blood vessels
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 Indication: Complete spermatogenesis in atleast 1 testis prior biopsy / antisperm antibody+ Absent sperm in vas No distal vasal obstruction End to end End to side Intussuseption
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 Adv : Fluid examined Easy identification of level of obstruction Allows upward mobilisation of vas to bridge large gap Disadv : Hemostatis Tubule identification and closure Vasal blood supply from inferior epididymal A lost
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 Adv : Bloodless Fluid examined before anastomosis Disadv : Difficult suturing in collapsed tubule
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The vas deferens is drawn thru an opening in the tunica vaginalis and secured in proximity to the anastomotic site with two to four interrupted sutures of 6-0 polypropylene placed through the vasal adventitia and the tunica vaginalis. The vasal lumen should reach the opening in the epididymal tunica easily, with length to spare. The posterior edge of the epididymal tunica is then approximated to the posterior edge of the vas muscularis and adventitia with two to three interrupted sutures of double-armed 9-0 nylon (Fig. 67.30). This is done in such a way as to bring the vasal lumen in close approximation to the epididymal tubule selected for anastomosis
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 Adv: Four points of fixation Bloodless anastomosis Disadv : Cannot assess tubular fluid before setup
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 50-85% have sperms Patency rate - Intussusception 80% End to side 70% end to end 43% Sperm banking Failure : Intraop sperm  IVF MESA
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Ej.Duct obstruction – cong. Anamoly Excurrentductal system anomaly When aplastic segment is the terminal portion that enters the urethra Can occur due to chronic prostatitis Prostate or seminal vesicle cysts
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Azoospermic/severly oligospermic with atleast one palpable vas Low semen volume,acid semen ph Negative equivocal or low fructose levels Normal FSH and biopsy has spermatogenesis DRE : midline cystic structure TRUS: midline cystic lesion / dilated ej.duct and seminal vesicle
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Trus – aspirate cystic /dilated EJD/SV Microscopic examination Sperm “+ve” Cryopreserve sperm 2-3ml indigocarmine + water soluble contrast injected Radiograph- obstruction TURED Sperm “-ve” Vasography Sperm “-ve” + EJ duct obstruction Abandon MESA= cryopreservation Sperm “+ve” Place 3fr ureteral stent in vas for dye instillation TURED
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Resectoscope with 24 fr cutting loop Finger in rectum ant displaces the post.lobe of prostate Resection of veru reveals EJ duct orifice Efflux of indigo carmine Care – bladder neck, striated sphincter, rectum
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 Reflux of urine VCUG/ semen creatinine Impairs semen quality Epididymitis Antibiotic prophylaxis till pregnancy Vasectomy/ epididymectomy Retrograde ejaculation Medical management Sperm retrieval from alkalinised urine  IVF +ICSI
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Pseudoephedrine 60 mg orally 90 minutes before ejaculation or Ornade spansules (chlorpheniramine and phenylpropanolamine) twice a day for a week may prevent this. If this is not successful, sperm can be retrieved from alkalinized urine and used for either intrauterine insemination or IVF with ICSI.
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 Indications Neurological impairment in sympathetic outflow Spinal cord injury, demyelinating disorderr, diabetes, RPLND {?}mimicking a neurophysiological response directly activating local pelvic musculature. High spinal cord above T6- AUTONOMIC DYSREFLEXIA Sperms recovered in 90% of men – IUI / IVF +ICSI
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General anaes If complete spinal cord injury- no anaes req Lateral decubitus- bladder emptied 10ml buffer (HEPES-BSA) instilled DRE and Anoscopy done and probe inserted Electrodes facing anteriorly against prostate and seminal vesicle
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Record temp Electrostimulation started at 3 to 5 volts and increased by 1 volt Stop if temp >400c Ejaculate colleccted in container Bladder catheterised to collect retrograde ejaculate Second sequence Anoscopy to rule out rectal injury
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Diagnostic procedures Procedures to improve sperm production Procedures to improve sperm delivery Procedures for sperm retrieval
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Congenital absence of vas Failed / surgical uncorrectable obstruction Intraop retrieval during reconstruction Use for IVF or cryopreserve for later use Poor motility and decreased fertilizing capacity
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Microsurgical epididymal sperm aspiration (MESA) Percutaneous epididymal sperm aspiration(PESA) Testicular sperm aspiration(TESA) Testicular sperm extraction(TESE)
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Open tubule technique During intraop reconstructive, isolated Median raphe Tunica opened Epididymis 16-25X Incised over a dilated tubule Tubule isolated – 150 knife
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Open Tubule Technique The technique described here can be employed for either intraoperative sperm retrieval at the time of vasoepididymostomy or as an isolated procedure in men with congenital absence of the vas or unreconstructable obstructions (Matthews and Goldstein, 1996; Nudell et al., 1998). A median raphe approach through two small transverse scrotal incisions within the scrotal skinfolds are made. After delivery of the testis, the tunica vaginalis is opened and the epididymis inspected under 16× to 25× magnification using the operating microscope. The epididymal tunica is incised over a dilated tubule as described previously for vasoepididymostomy. Meticulous hemostasis is obtained using the bipolar cautery. A dilated tubule is isolated and incised with a 15-degree microknife. The fluid is touched to a slide, a drop of human tubal fluid media is added, a cover slip is placed, and the fluid is examined. If no sperm are obtained, the epididymal tubule and tunica are closed with 10-0 and 9-0 monofilament nylon sutures, respectively, and an incision is made more proximally in the epididymis or even at the level of the efferent ductules until motile sperm are obtained.
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As soon as motile sperm are found, a dry micropipette (5 μL; Drummond Scientific Co., Broomall, PA) is placed adjacent to the effluxing epididymal tubule (Fig. 67.34). A standard hematocrit pipette is less satisfactory but can be used if micropipettes are not available. Sperm are drawn into the micropipette by simple capillary action. Negative pressure, as is generated by action of an in-line syringe, should not be applied during sperm recovery because this may disrupt the delicate epididymal mucosa. Two micropipettes may be employed simultaneously to increase speed of sperm recovery. The highest rate of flow is observed immediately after incision of the tubule. Progressively better quality sperm are often found after the initial washout. Gentle compression of the testis and epididymis enhances flow from the incised tubule. With patience, 10 to 20 μL of epididymal fluid can be recovered.
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The micropipette is connected to a short (3–5 cm) segment of medical grade silicone tubing (American Scientific Products, McGaw Park, IL). Alternatively, the tubing attached to a 25-gauge butterfly needle may be employed. A 20-gauge needle fitted to a Luer-tip syringe is then placed in line. The fluid is flushed with IVF media (0.5–1.0 mL) into a sterile container. Once a micropipette has been used, it is discarded. Residual fluid in the pipette will disrupt capillary action. A typical procedure requires 4 to 12 micropipettes. The sperm bank should be instructed to cryopreserve the aspirate in multiple vials (aliquots) so that several IVF cycles may be attempted if required
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Fluid touched on a slide and examined No sperm Epididymal tubule closed with 10-0 nylon Incision made more proximally Till efferent ductule till motile sperms found Sperm present Dry micropipette 5uL (4-12) Mild testis and epididymal compression Tubing attached and flushed with IVF FLUID into sterile container Store in multiple vials for several cycles
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 Advantages Microsurgical Lower complication  Epididymal sperms Large number of sperms – several cycles 60 % success Disadvantages Anaesthesia Microsurgical equipment Nonobstructive azoospermia X
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 Advantages No Microsurgical Local anaesthesia  Disadvantages Hematoma pain vascular injury Variable success Epididymal sperms Small quantity of sperm Nonobstructive azoospermia X
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Failure to find sperm in epididymis In presence of spermatogenesis Or absence of epididymis Non obstructive azoospermia Heterogeneity
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 Advantages No Microsurgical Local anaesthesia  Obstructive azoospermia  Disadvantages Immature sperms Small quantity Hematoma pain vascular injury  Poor results in Nonobstructive azoospermia X
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 Similar to testicular biopsy Microsurgical Tubule cut and placed in human tubal medium, passed multiple times thro a 24 gauge angiocath sheath Incision closed / new site opened Diff. in size of tubules Tubules with spermatogenesis Larger, Plumper somewhat yellow Sertoli only tubules Thin , stringy Whiter
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Advantages Microsurgical Preferred for NON Obstructive azoospermia Pregnancy 45% LBR 40% Disadvantages Anaesthesia Microsurgical skills Spont. abortion 19%
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 Absolute (must include all three): Azoospermia Complete spermatogenesis with many mature spermatids on testis biopsy 3. At least one palpable vas Relative indications Severe oligospermiawith normal testis biopsy High level of sperm- bound antibodies, which indicates unilateral,bilateral, or partial obstruction Low semen volume and very poor sperm motility (partial ejaculatory duct obstruction)
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High vertical scrotalincision operating microscope 10× power magnification vasal sheath is longitudinally incised and the vasal vesselspreserved Under 25× power magnification a 15-degree microknife is used to hemitransect the vas until the lumen is revealed vas toward the seminal vesicles is then cannulated with a 24-gauge angiocatheter sheath
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injected with 1 mL of Ringer’s lactate solution with a 1-mL tuberculin syringe to confirm its patency If further proof of patency of the vas deferens is desired, 1 mL of 50% dilute indigo carmine may be injected and the bladder catheterized. The presence of blue/green dye in the urine confirms patency of the vas.
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Stricture Injury to the Vasal Blood Supply Hematoma in the perivasal sheath Sperm Granuloma
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Thinner layers of germ cells within seminiferous tubules Decreased no of elongated late spermatids/ spermatozoa
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Arrest may occur at primary spermatocyte / early spermatocyte stage
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Also known as sertoli cell only syndrome Here, tubules are lined by immature appearing sertoli cells only
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Diffuse and nodular leydig cell hyperplasia Tubules often contain sertoli cells only
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Completely sclerotic tubules are seen