The document outlines surgical techniques for treating male infertility including varicocelectomy, sperm retrieval, vasovasostomy, and vasoepididymostomy. It discusses the indications and outcomes of microsurgical varicocelectomy and reviews studies showing it can improve sperm parameters, fertility with ICSI, and spontaneous pregnancy rates. The success rates of different surgical reconstruction techniques for vasal and epididymal obstructions are presented. Transurethral resection of ejaculatory ducts is described as a treatment for ejaculatory duct obstruction that can improve semen quality and fertility.

1. Sandro C. Esteves, MD., PhD.
Director, ANDROFERT
Andrology & Human Reproduction Clinic
Campinas, BRAZIL
Surgical Techniques in
Male Infertility
Reproductive Andrology Surgery Workshop 2014
Al Jahra Hospital, KUWAIT
ISO 9001:2008

2. Lecture Outline
Overview
Varicocelectomy
Sperm retrieval techniques for ART
Transurethral resection of ejaculatory duct
Vasovasostomy and vasoepididymostomy
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3. Miyaoka & Esteves. Adv Urol 2012
Agarwal, Esteves, Hamada. Nature Urol Rev 2013
Varicocele
35% subfertile men
Lower sperm count and quality
Lower sperm function
Elevated oxidative stress
Elevated sperm DNA damage
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4. Varicocele Treatment for
Infertility
Indications
Infertile couples
Normal female or treatable
female infertility
Abnormal semen analysis
and/or sperm function test
(all criteria met)
ASRM Practice Committee, Fertil Steril 2008
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5. Marmar et al., Fertil Steril 2008
Varicocele Surgery and
Spontaneous Pregnancy
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6. Varicocelectomy
Miyaoka & Esteves. Adv Urol 2012
Technique
Recurrence
Postop
Hydrocele
Retroperitoneal
(Palomo)
7-35%
6-10%
Laparoscopy
2-7%
0-9%
Embolization
2-24%
NR
Inguinal
(Ivanissevich)
0-37%
7%
Microsurgical
Subinguinal
0-1%
0-1.6%
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7. ANDROFERT
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8. Intraoperative VTI 20 MHz Microvascular
Doppler
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Courtesy of Dr. M. Cocuzza

9. Microsurgical Varicocelectomy &
Intraoperative Doppler
Cocuzza et al, Fertil Steril ; Mar, 2009
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10. Fertility
Improvement
ICSI
Outcomes
Sperm Retrieval in
Azoospermia
Fertility
Restoration
Spontaneous
Pregnancy
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11. Varicocele treated
prior to ICSI (N=80)
ICSI with
untreated
varicocele (N=162)
SC Esteves, FV Oliveira, RP Bertolla
ANDROFERT and Division of Urology, São Paulo Federal University, BRAZIL
The Journal of Urology; Vol. 184: 1442-6, 2010
Clinical Outcome of Intracytoplasmic Sperm Injection in
Infertile Men With Treated and Untreated Clinical
Varicocele
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12. Esteves & Glina
Weedin et al.
Meta-Analysis
No.
17
233
Mean age (yrs)
34.2
30.1
Motile sperm postop ejaculate; N (%)
6/17 (35.3)
91/233 (39.0)
Sperm count postop (mean; x106/mL)
0.8 (0.1-1.8)
1.6 ± 1.2
Interval between microsurgery and sperm (mo.)
5 (3-9)
NR
Results by testicular histopathology; N (%)*
Hypospermatogenesis
Maturation arrest
Sertoli-cell only
5/6 (83.3)
3/5 (75.0)
0/6 (0.0)
30/55 (54.5)
24/57 (42.0)
5/44 (11.4)
Spontaneous pregnancy; N (%)
1 (5.8)
14 (6.0)
Mean follow-up (months)
18.9
13.3
Adapted from: Esteves SC: Varicocele. In: S.J. Parekattil and A. Agarwal
(eds.), Male Infertility, 2012
Varicocele Repair in Azoospermia
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13. K Inci, M Hascicek, O Kara et al.
Department of Urology, Hacettepe University, Ankara, Turkey
The Journal of Urology Vol. 182,1500-5, 2009
53%
30%
Successful Sperm Retrieval
Treated Varicocele
Untreated Varicocele
OR: 2.63 (95% CI: 1.05-6.60; P=0.03)
Microsurgical
varicocele repair prior
to sperm retrieval
ICSI (N=66)
Sperm retrieval in
the presence of
varicocele (N=30)
Sperm Retrieval and Intracytoplasmic Sperm Injection in
Men With Nonobstructive Azoospermia, and Treated and
Untreated Varicocele
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14. Epididymis
Ejaculatory
duct
Vas
deferens
Surgery in Obstructive
Azoospermia
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15. Esteves et al. Surgical treatment of male infertility in the era of
intracytoplasmic sperm injection – new insights. Clinics 2011; 66:1462-77
Vas Deferens Obstruction
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16. Vasovasostomy
Macroscopic vs microscopic
49
88
32
59
0
10
20
30
40
50
60
70
80
90
100
Macro
Micro
patency (%)
pregnancy (%)
Derrick
1973
Lee & McLoughlin
1980
Soonawala, Lal
1984
Middleton
1987
Meinertz
1990
Kabalin
1991
Owen
1977
Silber
1977
Lee & McLoughlin
1980
Cos et al.
1983
Requeda et al.
1983
Owen & Kapila
1984
Soonawala, Lal 1984
Lee
1986
VVSG
1991
Fox
1994
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17. Author
N
Technique
Patency
(%)
Pregnancy
(%)
Vasovasostomy Technique
Belker et al. 1991
1247
Single-layer
89
57
Two-layer
86
51
Boorjian & Lipkin 2004
159
Two-layer
95
83
Chan & Goldstein 2004
1048
Two-layer
99
54
Kolettis et al. 2006
34
Single and two-
layer
76
35
Esteves et al. Surgical treatment of male infertility. Clinics 2011; 66:1462-77
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18. Preop:
Obstruction interval
Presence of granuloma
Hydrocele
Intra-op:
Surgeon expertise
Fluid aspect (macro)
Fluid assessment for presence of sperm
Vasovasostomy & Vasoepididymostomy
Prognostic factors
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19. < 3 3 - 8 9 - 14 15
0
20
40
60
100
80
Patency
Pregnancy
Adapted from Belker et al. J Urol. 145: 505-511, 1991
Obstruction interval (yrs)
86
89
56
74
525
600
253
478
205
261
92
209
32
45
11
37
97%
76%
88%
53%
79%
44%
71%
30% 40%
ART
Pregnancy
Results
Microsurgical Vasovasostomy
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20. Thomas AJ, in Surgery for Male Infertility, 2006
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21. Epididymis Obstruction
Esteves et al. Surgical treatment of male infertility in the era of
intracytoplasmic sperm injection – new insights. Clinics 2011; 66:1462-77
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22. %
Belker et al. Vasovasostomy Study Group. J Urol 145, 1991
27%20%14%9%
30
44
53
76
0
5
10
15
20
25
30
<3 3-8 9-14 >/= 15
0
10
20
30
40
50
60
70
80Epididymal obstruction
Pregnancy (%)
Obstruction interval (yrs)
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Vasectomy interval and epididymis
obstruction

23. Author
N
Technique
Patency
(%)
Pregnancy
(%)
Vasoepididymostomy
Silber 1978
139
Termino-lateral
78
56
Thomas 1987
137
Termino-lateral
79
50
Berger 1998
12
Triangulation
92
NR
Marmar 2000
9
Modified triangulation
78
22
Chan et al. 2005
68
Triangulation
84
40
Schiff et al. 2005
153
Termino-terminal
73
NR
Termino-lateral
74
Intussusception (3-suture)
84
Intussusception (2-suture)
80
Esteves et al. Surgical treatment of male infertility. Clinics 2011; 66:1462-77
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24. Epididymis
Ejaculatory
duct
Vas
deferens
Surgery in Obstructive
Azoospermia
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25. Clinical features:
Obstructive azoospermia
Hypospermia (<1.5 mL)
Acidic semen pH: <7.2
Congenital
Prostatic cyst
(Muller)
Ejaculatory duct
cyst (Wolf)
Acquired
Iatrogenic
Post-infection
AP diameter (TRUS): >1.5 cm
Ejaculatory Duct Obstruction
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26. Transurethral Resection of
Ejaculatory Duct (TURED)
Netto Jr, Neves, Esteves. J Urol. 1998;159: 2048-53
Case series
Etiology
Semen quality
Improvement (%)
Pregnancy (%)
Acquired
37.5 (3/8)
12.5 (1/8)
Congenital
83.0 (5/6)
66.0 (4/6)
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27. Lecture Outline
Overview
Varicocelectomy
Sperm retrieval techniques for ART
Transurethral resection of ejaculatory duct
Vasovasostomy and vasoepididymostomy
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28. Sperm Retrieval in Azoospermia
Normal sperm production
Mechanical blockage
Vasectomy, Post-infectious,
Congenital
Sperm production deficient or
absent
Cryptorchidism, Radiation,
Chemotherapy, Trauma,
Genetic, Orchitis, Varicocele,
Gonadotoxins, Unexplained
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29. Azoospermia
Differential Diagnosis
Azoospermia
Obstructive
Non-
obstructive
Subtypes
Hypo-
hypo
Testicular
failure
Spermatogenesis
Disrupted
Normal
Clinical Picture
High FSH/LH (NL)
Low TT (NL)
Small testis (NL)
FSH/LH <1.2 mUI/mL
Low TT
Small testis
Poor virilization
NL testis
NL FSH, LH, TT
Mechanical block
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30. Obstructive Azoospermia
Technique
Acronym
Percutaneous Epididymal
Sperm Aspiration
PESA
Microsurgical Epididymal
Sperm Aspiration
MESA
Testicular Sperm
Aspiration
TESA
Esteves & Agarwal. Sperm Retrieval Techniques.
Cambridge University Press, 2011
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31. http://androfert.com.br/videos
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32. http://androfert.com.br/videos
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33. 100% 96.6% 96.3%
CBAVD Vasectomy Post-­‐infection
OBSTRUCTIVE
AZOOSPERMIA
78.1
%
97.3
%
Successful Retrievals
PESA + rescue TESA
PESA alone
Esteves et al. J Urol. 2013
146 patients
Sperm retrieval in CBAVD
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34. Esteves et al. J Urol. 2013
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35. Esteves et al. J Urol. 2013
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36. Esteves et al. J Urol. 2013
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37. Testicular torsion; Trauma
Post-inflammatory (eg. mumps orchitis)
Exogenous factors (steroids, cytotoxic drugs, irradiation)
Testicular Cancer
Systemic diseases (liver cirrhosis, renal failure)
Varicocele
Congenital
Testicular dysgenesis/cryptorchidism
Genetic abnormalities (eg. Klinefelter syndrome, Yq microdeletions)
Acquired
Idiopathic (unknown etiology)
Untreatable
condition
Sperm
Retrieval
and ICSI
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Non-Obstructive Azoospermia

38. Non-Obstructive Azoospermia
Technique
Acronym
Success
Testicular
Sperm
Aspiration
TESA
15-50%
Testicular
Sperm
Extraction
TESE
20-60%
Microsurgical
Testicular
Sperm
Extraction
Micro-
TESE
40-67%
Esteves & Agarwal. Sperm Retrieval Techniques.
Cambridge University Press, 2011
TESE
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39. 30-50% cases: minimal
production within the testis,
but not enough for sperm to
appear in ejaculate
Goal is to identify site of
production and retrieve
sperm for ICSI
Geographic location
unpredictable
Esteves SC & Agarwal A. Sperm Retrieval Techniques; In: Gardner D et al (Eds.), Human Assisted
Reproductive Technology. Cambridge University Press, pp. 41-53, 2011
Which
is
the
best
sperm
retrieval
technique
in
NOA
?
Non-Obstructive Azoospermia
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40. Schlegel 1999
Amer et al. 2000
Okada et al. 2002
Okubu et al. 2002
Tsujimura et al. 2002
Ramon et al. 2003
Esteves et al. 2011
43%-53%
25%-41%
ControlledSeries
Sperm
retrieval
in
NOA
which
is
the
best
technique?
TESE
Esteves et al. Sperm retrieval Techniques. Int Braz J Urol 2011
SR Techniques in NOA
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41. Microsurgical vs Single-Biopsy TESE in
NOA according to testicular histology
45%
93%
64%
20%25%
64%
9% 6%
Overall
Hypospermatogenesis
Maturation Arrest
Sertoli-cell Only
Sperm Retrieval Success Rates
Micro-TESE
single-biopsy TESE
Controlled series (N=60)
Verza Jr & Esteves. Fertil Steril 2011
Histology categories
pairwise
Comparisons: p<0.0001
Method
P=0.0005
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42. http://androfert.com.br/videos
Esteves SC, Int Braz J Urol 2013
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43. Esteves et al. Asian J Androl. 2014; doi: 10.4103/1008-682X.126015
Sperm Retrieval and ICSI Results
41.4 47 43.3
20
100
64 61
34.2
Sperm retrieval
(%)
2PN Fertilization
(%)
Top Quality
Embryos (%)
Live Birth (%)
Non-obstructive
Obstructive
OR=0.033
95% CI: 0.007-0.164; p<0.001
OR=0.38
95% CI: 0.23-0.61; p<0.001
P<0.01
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44. 35.7
244.6
6.3
3.2
36.9
273.3
2.0
1.2
37.0
257.7
2.5
1.7
Gestational age
(wks)
Birth weight
(gramsx10)
% Perinatal death
% Birth defects
NOA (n=63)
Ejaculated Sperm (n=247)
Obstructive Azoospermia (n=117)
P = NS
Esteves & Agarwal. Reproductive outcomes including neonatal data of sperm
injection in men with obstructive and nonobstructive azoospermia: case series
and systematic review. Clinics 2013
Health of Babies Born in NOA
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45. Lecture OutlineSummary
Varicoce repair
Subinguinal microsurgical technique
Sperm retrieval techniques for ART
PESA, TESA, MESA, micro-TESE
Transurethral resection of ejaculatory duct
TURED
Vasovasostomy and vasoepididymostomy
Microsurgical techniques
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46. Thank you