Congenital and other structural defects, scar
tissue and blockages from prior surgeries and infection can contribute to male
infertility. One problem in particular, a condition called azoospermia, or
lack of sperm in the semen, may be amenable to surgical therapy. There are two
subtypes of azoospermia, obstructive (with normal sperm production) and
non-obstructive (with decreased or absent sperm production).
Obstructive azoospermia can be
caused by vasectomy,
the elective sterilization procedure; absence of the vas
deferens, which carries sperm to the ejaculatory duct, and by scar tissue
resulting from surgery. Non-obstructive azoospermia is linked to
no or poor sperm production. Many cases involving either form of azoospermia
can be addressed successfully with relatively new surgeries that rely on
sophisticated microscopes and delicate instruments to restore normal function
to the male reproductive system.
These procedures include vasovasostomy
to reverse vasectomies, microsurgical
epididymal sperm aspiration (MESA) and testicular
sperm extraction (TESE) to remove sperm from tissue and varicocelectomy
to correct a condition that may hamper sperm production. Should you require
surgery, you will be referred to a urologist. He or she will provide you with
more information about these procedures.
Vasectomy Reversal (Vasovasostomy and
Vasectomy is an elective surgical
sterilization procedure that eliminates sperm from the ejaculatory fluid by
cutting and tying off the ends of the vas deferens (the vas), the tube through
which sperm passes from the epididymis
to the ejaculatory duct. In many cases, the vas can be restored and
re-attached during a microsurgical process called vasovasostomy, an outpatient
procedure performed under general or local anesthesia. If damage to the
epididymis has occurred, vasoepididymostomy is required to restore sperm flow.
Regardless of the method used, vasectomy reversals have a very substantial
success rate for reversing obstructive azoospermia.
More About Vasovasostomy
Vasovasostomy is performed through two small incisions on each side of the
scrotum near the original vasectomy site. Using a microscope as a guide, your
doctor locates both ends of the vas and collects a drop of semen from one of
them. The fluid is examined for thickness and the presence of healthy sperm,
which should continue to be produced by the testis after vasectomy. If the
semen and sperm are normal, the ends of the vas are reattached, restoring the
More About Vasoepididymostomy
A secondary blockage or "blowout" of the epididymis may have
occurred if there has been a long duration since vasectomy, or if the
vasectomy was performed close to the epididymis. In this case, vasovasostomy
would not be successful in restoring sperm to the ejaculate. Vasoepididy-mostomy
involves stitching the inner and outer layers of the vas directly to the
epididymis and its inner tubule at a point above the obstruction so semen can
bypass the blockage and reach the ejaculatory duct.
Like vasovasostomy, vasoepididymostomy is performed through small incisions on
each side of the scrotum near the original vasectomy site. The outpatient
procedure requires general anesthesia or spinal anesthesia. A semen
analysis is generally performed four to six weeks after surgery.
Sperm Extraction Procedures (MESA and TESE)
Some males have few or no sperm in their
ejaculate (obstructive azoospermia) as a result of vasectomy,
congenital absence of the vas deferens or epididymis, prior failed surgery or
epididymal scarring from infection. In these cases, microsurgical
epididymal sperm aspiration (MESA) or testicular
sperm extraction (TESE) may be successful in obtaining enough sperm to use
in conjunction with in
vitro fertilization (IVF). Both procedures involve the direct collection
of sperm, which is processed in the laboratory for intracytoplasmic
sperm injection (ICSI). During ICSI, a single sperm is injected into the
core of an egg retrieved during IVF.
More About MESA
MESA is a very effective procedure for obstructive azoospermia because it
usually yields high numbers of sperm for IVF. Epididymal sperm usually freezes
well; therefore, after MESA, it is possible that you will not have to undergo
additional procedures for subsequent IVF cycles if enough sperm are collected.
During this outpatient procedure, and while you are under anesthesia, your
physician will make a small incision in the skin of the scrotum. MESA relies
on an operating microscope to isolate the epididymis and locate the tiny
epididymal tubules storing the sperm. An epididymal tubule is opened and its
fluid examined for sperm. If present, both the fluid and sperm are removed and
processed in the laboratory. If none or very few are found, additional tubules
are opened. Once they are examined, the tubules are closed and any sperm that
are not needed for IVF, and meet certain criteria, are frozen
and stored in the laboratory.
More About TESE
Testicular tissue dissection
TESE is an open biopsy procedure used for
sperm extraction. Like MESA, it is performed in an outpatient setting. The
procedure is an effective means for sperm collection and there are sometimes
circumstances that make it the procedure of choice over MESA (i.e., cases of
non-obstructive azoospermia where no sperm are present in the epididymis).
TESA usually yields fewer sperm than MESA and testicular sperm is more
difficult to process in the laboratory. Many facilities also believe that
testicular sperm does not freeze as well as sperm taken from the epididymis.
While you are under anesthesia, your doctor will make a small incision in the
scrotal skin. A small piece of tissue is removed, placed in a special medium
and processed in the laboratory to release any sperm.
Varicocele Repair (Varicocelectomy)
A varicocele is a collection of abnormally
swollen (varicose) veins around the testes. They can interfere with the
ability of the testicles to cool off, possibly affecting sperm production.
Varicocele repair also is an outpatient surgical procedure.
While you are under anesthesia, a small incision is made in the lower abdomen
or groin area. Some doctors use a microscope to better visualize the
varicocele and help avoid testicular damage. During varicocelectomy, the
doctor ties off the swollen veins so blood no longer pools, allowing the
testicle to better maintain proper temperature.