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Microsurgery for Male Infertility

  • Yifan Meng
  • Manaf Alom
  • Kiran Sharma
  • Tobias S. Köhler
  • Landon W. TrostEmail author
Chapter

Abstract

Introduction: Microsurgery for male fertility has been performed for decades, with the most common procedures being micro epididymal sperm aspiration (MESA), microdissection testicular sperm extraction (microTESE), varicocelectomy, and vasectomy reversal (VR). These procedures are required in the appropriate management of male fertility. The objective of the current chapter is to review indications, technical steps, outcomes, and the role of these procedures in contemporary practice.

Materials and Methods: The chapter is organized to review clinical indications, surgical steps, and outcomes of each of the four microsurgical male fertility procedures. Additionally, logistical factors are reviewed including appropriate equipment selection, utility and outcomes of robotic-assisted techniques, and office-based approaches. Where appropriate, a summary of literature is provided using a Pubmed search from inception through October 2018.

Results: Optimal microsurgical outcomes depend on appropriate instrument and suture selection, with improved VR outcomes noted in cases utilizing an operating microscope over loupe magnification. In men with obstructive azoospermia, sperm retrieval outcomes may be improved with MESA over alternative techniques, while microTESE may have slightly higher retrieval rates compared to TESE in cases of non-obstructive azoospermia. Varicocelectomy has been shown to improve outcomes in nearly all fertility-related indications among men with clinically-palpable varicoceles, with the microsurgical approach consistently demonstrating improved outcomes compared to other techniques. VR remains a highly successful operation with appropriate patient selection and surgeon experience and represents a cost-effective therapy. Robotic-assisted techniques demonstrate equivalent outcomes to traditional approaches, although its role remains debatable outside of intracorporeal vasoplasty indications. Recent trends have also moved towards office-based approaches, with all microsurgical fertility procedures being successfully performed with equivalent outcomes at a reduced cost when compared against traditional OR cases.

Conclusions: Microsurgical procedures remain central to the management of male factor infertility. Although surgical techniques have only minimally changed over time, advances in technology and outcome reporting have more clearly defined appropriate clinical indications and narrowed the optimal surgical approach for each scenario.

Keywords

Vasectomy reversal Micro epididymal sperm aspiration Microdissection testicular sperm extraction Varicocelectomy MicroTESE 

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Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Yifan Meng
    • 1
  • Manaf Alom
    • 2
  • Kiran Sharma
    • 2
  • Tobias S. Köhler
    • 2
  • Landon W. Trost
    • 2
    Email author
  1. 1.Washington University School of Medicine Division of UrologySt. LouisUSA
  2. 2.Mayo ClinicRochesterUSA

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