pISSN: 2287-4208 / eISSN: 2287-4690

Review Article
World J Mens Health 2012 August 30(2): 108-113
http://dx.doi.org/10.5534/wjmh.2012.30.2.108

Advances in Surgical Treatment of Male Infertility

Hyo Serk Lee, Ju Tae Seo
Department of Urology, Cheil General Hospital, Kwandong University College of Medicine, Seoul, Korea

A male factor is the only cause of infertility in 30% to 40% of couples. Most causes of male infertility are treatable, and the goal
of many treatments is to restore the ability to conceive naturally. Varicoceles are present in 15% of the normal male population
and in approximately 40% of men with infertility. Varicocele is the most common cause of male infertility that can be corrected
surgically. In males with azoospermia, the most common cause is post-vasectomy status. Approximately 6% of males who
undergo vasectomy eventually seek reversal surgery. Success of vasectomy reversal decreases with the number of years between
vasectomy and vasovasostomy. Other causes of obstructive azoospermia include epididymal, vasal or ejaculatory duct
abnormalities. Epididymal obstruction is the most common cause of obstructive azoospermia. Patients with epididymal
obstruction without other anatomical abnormalities can be considered as candidates for vasoepididymostomy. With
microsurgical techniques, success of patency restoration can reach 70∼90%. In case of surgically uncorrectable obstructive
azoospermia, sperm extraction or aspiration for in vitro fertilization is needed. Nonobstructive azoospermia is the most
challenging type of male infertility. However, microsurgical testicular sperm extraction may be an effective method for
nonobstructive azoospermia patients.

Key Words: Infertility, Diagnosis

INTRODUCTION restore the ability to conceive naturally. The dramatic re-

cent improvements in the management of male infertility
Approximately 15% of couples cannot conceive a child are largely attributable to improved surgical techniques
after 1 year of regular, unprotected intercourse. A male and assisted reproductive technology (ART).2 Specifically,
factor is the only cause of infertility in 30% to 40% of in vitro fertilization (IVF) and intracytoplasmic sperm in-
couples.1 For the treatment of male subfertility, the causa- jection (ICSI) allow us to overcome even the most severe
tive factor remains unknown in 40% of men presenting defects in spermatogenesis for which only a few treat-
with a male factor. However, most causes of male in- ments are available.3 These advances have also added im-
fertility are treatable and the goal of many treatments is to portant reproductive options for men with non-ob-

Received: Aug 3, 2012; Revised: Aug 6, 2012; Accepted: Aug 9, 2012

Correspondence to: Ju Tae Seo
Department of Urology, Cheil General Hospital, Kwandong University College of Medicine, 17, Seoae-ro 1-gil, Jung-gu,
Seoul 100-380, Korea.
Tel: +82-2-2000-7586, Fax: +82-2-2000-7787, E-mail: jtandro@cgh.co.kr
Copyright © 2012 Korean Society for Sexual Medicine and Andrology
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
 Hyo Serk Lee, Ju Tae Seo: Surgical Treatment of Male Infertility 109

4
structive azoospermia (NOA), or testicular failure. able identification and preservation of arterial and lym-
Three related topics will now be addressed separately: phatic vessels, while reducing the risk for persistence or
2,7
1. varicocelectomy, 2. management of obstructive azoo- recurrence of varicocele. The application of micro-
spermia (OA), and 3. management of nonobstructive surgical techniques to varicocele repair has resulted in a
azoospermia. substantial reduction in the incidence of hydrocele for-
mation because the lymphatic vessels can be more easily
2,9
VARICOCELECTOMY identified and preserved. Studies have shown that vari-
cocele repair can improve semen parameters, testicular
Varicoceles are present in 15% of the normal male pop- function, and pregnancy rates in couples with male-factor
5 13
ulation and in approximately 40% of men with infertility. infertility associated with varicocele.
The association between male subfertility and varicocele A previous study found that men with large varicoceles
is unknown, but a meta-analysis showed that semen im- had a significantly lower sperm count than men with small
6
provement is usually observed after surgical correction. varicoceles, and that those with small varicoceles had
Varicocele repair may be considered the primary treat- nearly the same total sperm count as that of expectant
14
ment option when a man with a varicocele has suboptimal fathers. Several groups have reported only a slight im-
semen quality and the female partner does not present any provement in postoperative semen parameters without an
7
additional infertility factor. increase in the pregnancy rate after removal of subclinical
15
Repair of varicocele for treatment of male infertility is varicoceles. Therefore, the role of subclinical varicocele
8
controversial; however, any studies that have not shown in male infertility is still controversial. However, other
16,17
an improved pregnancy rate after varicocele repair were studies have found that patients treated for subclinical
small, were not stratified by grade of varicocele, and did varicocele had the same probability of success as patients
9
not control for type of repair technique. Varicocele repair with larger varicoceles, especially in the natural preg-
can reverse a pathologic condition, halt further damage to nancy rate after surgical treatment (Table 1). These studies
10,11
testicular function, and improve spermatogenesis. The revealed that varicocelectomy may be the best option in
pregnancy rates at 1 year after correction of varicocele subfertile men with subclinical varicocele resulted from
were comparable for open inguinal, laparoscopic, and improved semen quality and increased natural pregnancy
12
subinguinal microscopic varicocelectomy. The pre- rate.
ferred approaches of most experts are microsurgical in- Varicoceles are found in 4.3% to 13.3% of men with
2 18
guinal and subinguinal operations. azoospermia or severe oligospermia and can result in
The advantages of microsurgical techniques are the reli- sperm in the ejaculate of azoospermic men when severe

Table 1. Comparison of seminal parameters between the surgical group and drug group before and after treatment
Surgical group (n=20) Drug group* (n=55)
Before After p value Before After p value
Volume (ml) 2.3±1.0 2.5±0.8 0.437 2.9±1.1 2.8±1.7 0.595
Count (106/ml) 39.3±36.0 57.5±46.9 0.005 54.6±33.4 55.8±46.7 0.853
Motility (%) 38.5±18.1 32.4±10.3 0.112 43.9±18.6 43.5±24.6 0.888
Morphology (%) 52.1±26.0 44.0±26.7 0.271 38.1±35.2 35.4±20.6 0.526
Viability (%) 46.0±21.8 41.9±26.6 0.561 33.5±31.9 32.1±19.0 0.717
Pregnancy, n (%)† 12 (60) 19 (19)
Values are mean±standard deviation.
†
*L-carnitine (3 g/day orally, 3 times a day, for at least 6 months). Number of natural pregnancies after treatment.
Adapted from Seo JT, Kim WT, et al.: The significance of microsurgical varicocelectomy in the treatment of subclinical
varicocele, Fertil Steril, 2010;93:1907-10.
110 World J Mens Health Vol. 30, No. 2, August 2012

pregnancies hypospermatogenesis (HS) or maturation arrest at the sper-

Spontaneous

4,13,19
matid stage is present. Varicocele repair in patients
(n)
2
0
0
0
0

1
4
2
1
3
1
with NOA can result in motile sperm in the ejaculate and
even spontaneous pregnancy (Table 2). Repair can be per-
Pregnancies

formed successfully surgically or by percutaneous emboli-

(n)

zation of the internal spermatic vein. Motile sperm from

5
2
0
0
0

1
9
2
1
3
1
the ejaculate can be used for IVF without the need for sur-

Adapted from Weedin JW, et al. Varicocele repair in patients with nonobstructive azoospermia: a meta-analysis. J Urol 2010;183:2309-15.
NOA: non-obstructine azoospermia, FSH: follicular stimulating hormone, SD: standard deviation, postop: post-operative, NA: not available.
gical retrieval. Favorable testicular histopathology can
mean (%)
motility,
Postop

predict the appearance of sperm in the postoperative

NA

NA

NA
55
19
14
11

19

47
1
2
ejaculate. Patients with HS or late maturation arrest (MA)
have a significantly higher probability of success than
density, mean
Postop sperm

those with Sertoli cell-only syndrome or early MA. Testi-

2.20×106
1.20×106
0.04×106
0.70×106

3.81×106
3.10×106
0.87×106
0.20×106
6
0.80×10

0.36×10
NA

cular histopathology from testis biopsy can be used to de-

termine whether patients with NOA might benefit from
20
varicocele repair. Therefore, varicocelectomy offers pa-
With postop Bilateral Success Relapse
rate
(%)

tients with NOA an opportunity to have sperm for under-

22

19

29
0
0
0
0
0

going ICSI in their ejaculate and even the possibility of nat-

4
ural conception.
rate
(%)
55
43
21
23
22

47
56
50
33
33
36

Treatment strategies for male infertility have changed

dramatically over the past decade. These advances are
repairs
(%)
77
71
71
15
94

65
88
87
56
17
21

largely attributable to microsurgical varicocelectomy and

microsurgical techniques for surgical sperm retrieval and
ART, specifically ICSI. Microsurgical varicocelectomy sig-
motile
sperm
Table 2. Summary of articles of varicocele repair performed in men with NOA

12
12

18
5
3
7

7
9
2
7

nificantly increased the sperm retrieval rate in patients

with clinical varicocele and NOA; it may also be the treat-
ment option for subclinical varicocele. However, careful
Patients

22
28
24
13
31

17
32
14
27

19
(n)

patient counseling is important for defining the relative

risks and benefits of each approach. The recommenda-
19.6±4.5 Subinguinal

Subinguinal

Subinguinal

17.0±12.4 Subinguinal
Approach

Embolize
Embolize
Inguinal
Inguinal
Inguinal

Inguinal
Inguinal

tions must be individualized for each couple, and consid-

eration of all the factors important to potential success, in-
cluding age, must be reviewed.
20.0±16.0

14.6±10.5
20.8±12.3
mean±SD
(mIU/ml)

12.3±7.1
35.0±2.8

17.8±4.8
FSH,

14.6

MANAGEMENT OF OBSTRUCTIVE AZOOS-

NA

NA

PERMIA
Age Follow-up

Approximately 20% of men visiting for infertility have

10.3
15.0
13.4

14.7

18.9
12.0
24.8
12.0
(mo)

9.0

7.4
＞6

21
azoospermia. Of these patients, about 40% have
22
post-testicular obstruction. OA is the absence of both
NA

NA
(yr)

35
35
30
29

32
34
33
30

32

spermatozoa and spermatogenetic cells in semen and

Esteves and Glina
Cakan and Altug

Pasqualotto et al

post-ejaculate urine due to the bilateral obstruction of the

Kadioglu et al

Ishikawa et al
Mattews et al

Poulakis et al

epididymis or the seminal or ejaculatory ducts. Men with

Reference

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Kaufman
Kim et al

OA present with normal follicular stimulating hormone

Gat et al

Lee et al

(FSH) levels, normal testis size, and epididymal enlarge-

ment. Occasionally, the vas deferens is absent because of
 Hyo Serk Lee, Ju Tae Seo: Surgical Treatment of Male Infertility 111

35
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36
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1. Vasovasostomy
trieval and cryopreservation during an operation is recom-
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31
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39,40
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when performing a microscopic rather than a macro-
32 3. Sperm retrieval techniques in OA
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ovasostomy, 70% to 95% of patients have return of sperm It is controversial whether the technique of sperm re-
to ejaculate, and pregnancies are obtained without ART in trieval (open or percutaneous) or the source of sperm
7,33
30% to 75% couples. The factor that influences the rate (testicular, epididymal, vassal, or seminal vesicular) af-
of sperm returning and pregnancy is the number of years fects the pregnancy rate. Each technique and sperm
33
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34
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41
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42,43
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treatment when the female partner is advanced in age or
2. Vasoepididymostomy 7
has female infertility requiring IVF.
Patients with epididymal obstruction without other
anatomical abnormalities should be considered candi- MANAGEMENT OF NOA
dates for vasoepididymostomy. Given the expense and
potential side effects from hormonal therapy for the fe- NOA is the most challenging type, but no specific treat-
male partner, microscopic vasoepididymostomy is con- ment has been available in the past. With the advent of
sidered to be the first choice for the epididymal ob- ICSI in conjunction with sperm retrieval via testicular
structive azoospermic male. Following the development sperm extraction (TESE), many nonobstructive azoosper-
44
of microsurgical instruments and suture material, several mic patients are able to father children. TESE/ICSI is also
45
techniques for successful anastomosis have been successful as an intervention for Klinefelter syndrome.
reported. However, 20∼50% of NOA patients are not able to
46
With microsurgical techniques, restoration of patency have sperm retrieved for ART. Microsurgical TESE is an
can be achieved in 70∼90% of patients, although restora- advanced type of TESE that applies microsurgical
112 World J Mens Health Vol. 30, No. 2, August 2012

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