Varicocele influences spermatogenesis and causes infertility. Thats why varicocelectomy is the most common surgical procedure for treatment of male infertility. This operation means ligation of internal spermatic vein and leads to improvement of semen quality. This surgery is effective in about two-thirds of cases.
The procedure requires just a small inguinal incision. There are two approaches which are a retroperitoneal and a scrotal approaches. The second one is not recommended because of the numerous small veins encountered as well as the possibility of arterial injury is greater.
Percutaneous venographic occlusion may be an alternative to surgery but small veins outside the spermatic cord are not easily embolizable with the percutaneous approach.
Another way to treat varicocele is laparoscopic techniques.
Possible complications of varicocelectomy (relevant to less than 3-5% of patients):
– hydrocele formation;
– injury to the internal spermatic artery;
– persistent or recurrent scrotal varicoceles.
Vasovasostomy and Epididymovasostomy
High rates of divorce and remarriages increase a number of vasectomy reversals. Technically, vasovasostomy can be performed anywhere along the scrotal and inguinal part of the vas. Generally, it is done in the mid or the upper part of the scrotum. Microsurgical techniques are much more effective in achieving the success than ordinary vasovasostomy. The other important factor is the surgeons experience with vasovasostomy. The quality of the vasal fluid at the time of vasovasostomy has the great impact on the surgery success. The chances of postoperative pregnancy increase up to 70% if clear copious fluid with motile sperm has been found. If no fluid is found or it is thick and "toothpasty", an epididymovasostomy is recommended. Unfortunately, epididymovasostomy success rates vary within 20-30%.
Possible factors of vasovasostomy failure:
– anastomotic stenosis;
– antisperm antibodies;
– epididymal dysfunction;
– unrecognized epididymal tubule "blow-out" with subsequent obstruction.
Further sperm manufacturing and attempts to travel through the epididymis may cause pressure-induced extravasation at any point within the epididymal tubule. A local inflammatory reaction is the result of this process that can block the movement of sperm. To get rid of this complication is possible with the help of an epididymovasostomy or vasoepididymostomy. The success of a vasoepididymal anastomosis depends on the ability to visualize the 0.2 to 0.4 mm lumen of the opened epididymal tubule exuding sperm and to approximate it accurately to the vasal lumen. Epididymal obstruction can be resulted by congenital anatomical abnormalities of the vas/epididymis, inflammatory process, or vasal obstruction. The greater the length of epididymis that the sperm traverse, the better the pregnancy rate.
Transurethral Resection of Ejaculatory Duct
People suffering from azoospermia and in some cases oligo-asthenospermia and those who have normal sized testes, and a normal testicular biopsy connected with transrectal ultrasound findings of dilated ejaculatory ducts should have transurethral resection of the ejaculatory ducts. The prostatic urethra that is lateral to the verumontanum produces the orifices of the ejaculatory ducts. The orifices of the ejaculatory ducts are discovered during anesthesia with an endoscope and they may be cut or left without a roof. Sometimes, transurethral resection of the ejaculatory ducts can lead to certain improvement in semen parameters, and successful pregnancies.