This tab covers the surgical options for male infertility: sperm retrieval, vasography, vasectomy reversal, ejaculatory-duct obstruction, ejaculatory stimulation, varicocelectomy, and assisted reproductive technology.
Surgical Sperm Retrieval
The efferent ducts coalesce into a single epididymal tubule from the caput onward, so aspiration is safely done at the proximal head (multiple lobules), while any injury distal to the caput obstructs the whole side. Retrieval is indicated for azoospermia (obstructive or non-obstructive) or ejaculatory dysfunction:
- Epididymal — microsurgical (MESA) or percutaneous (PESA) aspiration.
- Testicular — open TESE (the gold standard; preferably micro-TESE, which retrieves the most sperm with less testosterone loss than conventional TESE; contraindicated in Sertoli-cell-only syndrome or maturation arrest), percutaneous core biopsy (blind — risks the epididymis/testicular artery, so target the midsection), or TESA (least invasive). The most common complication is hematoma.
Approach by cause: obstructive azoospermia — sperm from either testis or epididymis (equivalent outcomes); non-obstructive azoospermia — micro-TESE (~1.5× more successful than non-microsurgical extraction).
Vasography
Absolute indications (all three): azoospermia, complete spermatogenesis on biopsy, and at least one palpable vas. Principles: sample vasal fluid first and cryopreserve any motile sperm before injecting dye; use indigo carmine, not methylene blue (which kills sperm); and never inject toward the epididymis under pressure. Large fluid volume with sperm indicates obstruction toward the seminal-vesicle end, whereas a dry, spermless vas after milking indicates epididymal obstruction; a vas ending blindly suggests partial agenesis (test for CFTR).
Vasectomy Reversal
Microsurgical reconstruction anastomoses the vas to the most distal site containing sperm. Higher patency/pregnancy follow bilateral vasovasostomy, intact sperm at the reconstruction site, and a shorter obstructive interval. Counsel couples on reconstruction vs sperm retrieval + ICSI: reconstruction is preferable when the female partner has normal fertility, while IVF/ICSI is favoured with female factors or very remote vasectomy (>25 years). The contraindication is non-obstructive azoospermia.
The vasal fluid appearance guides the anastomosis:
| Vasal fluid | Procedure |
|---|---|
| Clear/thin, watery (± sperm) | Vasovasostomy |
| Thick, dry, "toothpaste-like," spermless | Vasoepididymostomy (only onto a sperm-containing tubule) |
Length for a large vasal gap is gained sequentially (separating the cord, freeing the convoluted vas without unravelling it, rerouting under the inguinal canal, and dissecting the epididymis off the testis — bridging up to 10 cm). Simultaneous vasovasostomies at two sites devascularise the intervening segment, and a crossed vasovasostomy connects a healthy testis to the contralateral unobstructed vas. Postoperatively, use scrotal support, avoid ejaculation for 3 weeks, and obtain semen analyses at 1, 3, and 6 months (redo if azoospermia persists at 6 months); cryopreserve sperm once they appear, as late stricture can occur.
Ejaculatory Duct Obstruction
Congenital EDO is the most common (acquired forms follow prostatitis or cyst compression). It presents as a low-volume, acidic, low-fructose, azoospermic ejaculate with normal FSH and biopsy and a palpable vas; TRUS shows a midline (müllerian) cyst or dilated ducts/seminal vesicles (SV AP >1.5 cm). Management is TURED (improves semen parameters in 63–83%), resecting at the verumontanum while preserving the bladder neck, sphincter, and rectum. Complications include restenosis, reflux of urine causing watery ejaculate and chemical epididymitis, retrograde ejaculation, and stricture.
Ejaculatory Stimulation
Indicated for ejaculatory dysfunction from impaired sympathetic outflow (SCI, MS, diabetes, RPLND/pelvic surgery). The technique depends on the lesion level: above T10, the ejaculatory reflex arc is intact → penile vibratory stimulation; at/below T10 → electroejaculation (then sperm retrieval if both fail). In SCI at/above T6, watch for autonomic dysreflexia (headache, hypertension, bradycardia, diaphoresis — potentially life-threatening) — pretreat with 20 mg sublingual nifedipine and monitor blood pressure.
Varicocelectomy
Not indicated for non-palpable (imaging-only) varicoceles. Consider repair in a man attempting conception who has a palpable varicocele, infertility, AND abnormal semen parameters (but not for azoospermia) — it raises pregnancy rates versus no treatment but defers ART by ≥6 months, and the evidence to repair before ART in NOA is not definitive.
Assisted Reproductive Technology
Indicated for unreconstructable obstruction (CBAVD), few viable sperm, NOA, or idiopathic infertility.
- Intrauterine insemination (IUI) — washed semen placed in the uterus at ovulation, ideally with ovulation induction; natural-cycle IUI is no better than timed intercourse for abnormal semen. A total motile count <5 million after processing predicts lower success (≥5–10 million is usually needed).
- IVF ± ICSI — IVF leaves egg and sperm to fertilise, whereas ICSI injects a single sperm and so overcomes poor sperm quality with only a few viable sperm needed. IVF gives ~33% live delivery per cycle (lower with female age >35) and ~19% twin deliveries; for surgical sperm, fresh and cryopreserved sperm give equivalent ICSI outcomes.
Self-Test
1. What are the approaches to surgical sperm extraction, and which can be used for obstructive azoospermia? Epididymal: MESA and PESA. Testicular: TESE/micro-TESE (gold standard), percutaneous core biopsy, and TESA. For obstructive azoospermia, either testicular or epididymal retrieval works (equivalent outcomes); for non-obstructive azoospermia, micro-TESE is preferred.