Surgical Treatment of Male Surgical Treatment of Male Infertility Infertility Selahittin Selahittin Ç Ç ayan, ayan, M.D. M.D. Associate Professor of Associate Professor of Urology Urology Department of Urology Department of Urology University of Mersin School University of Mersin School of Medicine of Medicine
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Surgical Treatment of Male Infertility Selahittin Çayan, M.D. Associate Professor of Urology Department of Urology University of Mersin School of Medicine.
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Surgical Treatment of Male Surgical Treatment of Male Infertility Infertility
Selahittin Selahittin ÇÇayan, ayan, M.D.M.D.Associate Professor of UrologyAssociate Professor of Urology
Department of UrologyDepartment of UrologyUniversity of Mersin School of University of Mersin School of
Total loss of fertility possibleTotal loss of fertility possible ↓ ↓ TeTestosterone stosterone →→Erectile dysfunction, decreased lipidoErectile dysfunction, decreased lipido
Diagnose life threatened diseaseDiagnose life threatened disease 37 times higher incidence of testis cancer37 times higher incidence of testis cancer ProlactinomaProlactinoma
Detect genetic diseaseDetect genetic disease 30-100 times higher incidence of genetic 30-100 times higher incidence of genetic
abnormalitiesabnormalities
Positive effect of Positive effect of pathophysiologic specific pathophysiologic specific treatment of male infertility on treatment of male infertility on ARTART
To obviate the need for ARTTo obviate the need for ART
To downstage the level of ART needed to To downstage the level of ART needed to bypass male factor infertilitybypass male factor infertility
From IUI to spontaneous pregnancyFrom IUI to spontaneous pregnancy FF rom IVF/ICSI to IUIrom IVF/ICSI to IUI
To increase pregnancy rates with ART in To increase pregnancy rates with ART in cases who had improved sperm cases who had improved sperm morphology after the treatmentmorphology after the treatment
HistoryPhysical examinationSemen analysis (2x)
Hormonal evaluationRadiologic evaluation
TREATMENT
Evaluation of Infertile Evaluation of Infertile ManMan
Guidelines on Treatment of Guidelines on Treatment of VaricoceleVaricocele
Varicocelectomy should not be offered to Varicocelectomy should not be offered to improve fertility, since pregnancy rates improve fertility, since pregnancy rates do not increase.do not increase.
National Collaborating Centre for Women’s and Children’s Health 2005National Collaborating Centre for Women’s and Children’s Health 2005
Treatment of varicocele should be offered Treatment of varicocele should be offered to infertile men with palpable varicocele to infertile men with palpable varicocele and abnormal semen analysis.and abnormal semen analysis.
Best Policies Practice Groups of the AUA Best Policies Practice Groups of the AUA 20022002
Best Policies Practice Groups of the ASRM Best Policies Practice Groups of the ASRM 20042004
Treatment of varicocele is still Treatment of varicocele is still controversial, although it improves controversial, although it improves spontaneous pregnancy rates.spontaneous pregnancy rates.
EAU Guideline on Male infertility 2004EAU Guideline on Male infertility 2004
Selected 7 studies or abstracts (1979-2002)Selected 7 studies or abstracts (1979-2002) Inclusion-exclusion criterias: ?Inclusion-exclusion criterias: ?
Recommendation: Treatment of varicocele does Recommendation: Treatment of varicocele does not improve fertility in unexplained infertility.not improve fertility in unexplained infertility.Evers and Collin, Evers and Collin, Cochrane Database Syst Rev 2004Cochrane Database Syst Rev 2004
Varicocelectomy- Meta analiysis-Varicocelectomy- Meta analiysis-20042004
Turkish Society of Andrology: Turkish Society of Andrology: Guidelines on VaricoceleGuidelines on Varicocele
Varicocele: Diagnosis and Varicocele: Diagnosis and EvaluationEvaluation
Türk Androloji Derneği, Varikosel Kılavuzu, Türk Androloji Derneği, Varikosel Kılavuzu, 20052005
Physical examination:Physical examination:
Grade 1: Palpable with ValsalvaGrade 1: Palpable with Valsalva
Grade 2: Direct palpableGrade 2: Direct palpable
Grade 3: Visible with no Grade 3: Visible with no palpationpalpation
Endications for treatment of Endications for treatment of VaricoceleVaricocele
Selected 8 randomized clinical studiesSelected 8 randomized clinical studies Exclusion criterias from the meta-Exclusion criterias from the meta-
analysis:analysis: Subclinical varicoceleSubclinical varicocele Normal semen analysisNormal semen analysis
Inclusion criterias to the meta-Inclusion criterias to the meta-analysis:analysis: Clinical palpable varicoceleClinical palpable varicocele Abnormal semen parametersAbnormal semen parameters
3 randomized studies matching to the 3 randomized studies matching to the criteriascriterias Tedavi grubu (n: 120)Tedavi grubu (n: 120) Kontrol grubu (n: 117)Kontrol grubu (n: 117) Ficarra V et al, Eur Urol 2006Ficarra V et al, Eur Urol 2006
High ligation High ligation InguinalInguinal MicrosurgicalMicrosurgical
24 months of postop follow-up24 months of postop follow-up Spontaneous pregnancy ratesSpontaneous pregnancy rates
5 randomized clinical studies5 randomized clinical studies Treatment group (n: 396)Treatment group (n: 396) Control group (n: 174)Control group (n: 174)
Best Candidates for Best Candidates for VaricocelectomyVaricocelectomy
Palpable, large varicocelePalpable, large varicocele Normal testicular volume Normal testicular volume Normal FSH/testosterone, inhibin Normal FSH/testosterone, inhibin
BB↓↓ Total Motile Sperm> 5 millionTotal Motile Sperm> 5 million No genetic abnormalityNo genetic abnormality Short infertility durationShort infertility duration
Fretz PC Fretz PC && Sandlow JI, Urol Clin North Am, 2002 Sandlow JI, Urol Clin North Am, 2002Türk Androloji Derneği, Varikosel Kılavuzu, 2005Türk Androloji Derneği, Varikosel Kılavuzu, 2005
Improvement after Improvement after VaricocelectomyVaricocelectomy
ÇÇayan et al, Urology, 2000ayan et al, Urology, 2000 ÇÇayan et al, Urology, 2001ayan et al, Urology, 2001 Çayan et al, J Urol, 2002Çayan et al, J Urol, 2002
Varikosel tedavisinde en iyi Varikosel tedavisinde en iyi teknik hangisi?teknik hangisi?
Dahil edilme kriterleri:Dahil edilme kriterleri: İnfertiliteİnfertilite Anormal semen analiziAnormal semen analizi Palpabl varikoselPalpabl varikosel Tüm tedavi gruplarıTüm tedavi grupları
Açık cerrahi Açık cerrahi LaparoskopikLaparoskopik RadyolojikRadyolojik
Radyolojik başarısız girişim: % 13.05Radyolojik başarısız girişim: % 13.05Laparoskopik major komplikasyon: % 7.59Laparoskopik major komplikasyon: % 7.59
The best treatment modality is microsurgical repair with The best treatment modality is microsurgical repair with the lowest complication rate and the highest the lowest complication rate and the highest spontaneous pregnancy rates.spontaneous pregnancy rates.
Varicocelectomy has significant potential not only to Varicocelectomy has significant potential not only to obviate the need for ART, but also to downstage the obviate the need for ART, but also to downstage the level of ART needed to bypass male factor infertility.level of ART needed to bypass male factor infertility.
A cost effective treatment of infertility:A cost effective treatment of infertility: Upgrade to normal semen: Allow natural pregnancy (40%)Upgrade to normal semen: Allow natural pregnancy (40%) Upgrade from azoospermia to oligospermia (20-30%)Upgrade from azoospermia to oligospermia (20-30%) Allow fresh sperm for IUI or IVF/ICSIAllow fresh sperm for IUI or IVF/ICSI Even if patients remain azoospermic, it may preserve foci of Even if patients remain azoospermic, it may preserve foci of
spermatogenesis for Testicular sperm recovery (TESA/TESE)spermatogenesis for Testicular sperm recovery (TESA/TESE)
Insecticide (DDT), pesticideInsecticide (DDT), pesticide Termal (heating, hut tub, saunas), Pb, solventTermal (heating, hut tub, saunas), Pb, solvent
Treatment: Treatment: Treatment of underlying pathologyTreatment of underlying pathologySemen analysis after 3-12 monthsSemen analysis after 3-12 months
No need for additional surgical procedure for No need for additional surgical procedure for sperm retrievalsperm retrieval
Candidates for IUI or ICSI with fresh motile sperm Candidates for IUI or ICSI with fresh motile sperm from ejaculatefrom ejaculate
Upgrade from azoospermia to normal semen Upgrade from azoospermia to normal semen parametersparameters
Upgrade from azoospermia to oligospermia for IUI or Upgrade from azoospermia to oligospermia for IUI or ICSIICSI
Ejaculatory Dysfunction-Anejaculation
PVS
EEJ
TESE
Reasons for anejaculation:Reasons for anejaculation:
·· Spinal cord injury Spinal cord injury ·· Pelvic and retroperitoneal surgery Pelvic and retroperitoneal surgery ·· Psychogenic causesPsychogenic causes·· IdiopathicIdiopathic·· Multiple sclerosisMultiple sclerosis·· DiabetesDiabetes·· ProlactinomaProlactinoma
IVF/ICSI
IVF
ICI
IUI
Çayan & Turek, Fertil Steril, 2001
Overall 61.1% (11/18) of couples achieved pregnancyOverall 61.1% (11/18) of couples achieved pregnancy
Achieving natural pregnancy, while ideal, should not be the only Achieving natural pregnancy, while ideal, should not be the only measurement of treatment efficacymeasurement of treatment efficacy..
Clinicians should offer treatment that improves the long term Clinicians should offer treatment that improves the long term fertility status of the couples, not just to achieve immediate fertility status of the couples, not just to achieve immediate pregnancy.pregnancy.
Pathophysiologic specific treatment in male infertility Pathophysiologic specific treatment in male infertility has has significant potential not only to obviate the need for ART, but also significant potential not only to obviate the need for ART, but also to downstage the level of ART needed to bypass male factor to downstage the level of ART needed to bypass male factor infertility.infertility.
Effective treatment may be surgical, medical or simple lifestyle Effective treatment may be surgical, medical or simple lifestyle modifications.modifications.
Upgrade from nothing to IVF/ICSIUpgrade from nothing to IVF/ICSI Upgrade from IVF/ICSI to IUIUpgrade from IVF/ICSI to IUI Upgrade from IUI to natural pregnancy Upgrade from IUI to natural pregnancy