Mr. Smith asked me to explain the different methods of treating varicose veins in the scrotum known as a varicocele. There are a few:
- A surgeon makes a small incision in the groin, and ties or clips the veins. The surgeon may use an operating microscope or wear glasses with magnifying lenses to preserve small arteries supplying blood to the testis.
- A surgeon uses a telescope called a laparoscope to find the veins inside the abdomen and tie or clip them.
- A radiologist threads a small tube through the veins and injects material to plug them.
Most surgeons who specialize in male fertility prefer to use an operating microscope or wear glasses with magnifying lenses to perform the procedure, but excellent results can be obtained with either laparoscopy or radiology. A man should ask his doctor about his or her experience, what he or she prefers and why.
This series of pictures shows what the procedure looks like under the operating microscope. The surgeon uses a small probe to listen to the veins as they sound different than arteries. In this procedure, titanium clips were used to block the veins, but surgical suture can also be used.
Thanks, Mr. Smith, for asking a great question!
Has it really been over three months since my last post? Between becoming one of the next Co-Editors in Chief of Fertility and Sterility, preparing for a review of our urology training program and finishing my latest book (Thank You, Chapter Authors!) I guess that I’ve let my blogging slip a bit. Fortunately, thanks to my Italian co-faculty’s discovery of the Saeco Vienna Plus espresso maker at Costco, I’m back at the keyboard.
I turned off the two-week limit for comments, and so far, that’s been a good idea. People are commenting on older posts (like How Clomid Works in Men) with good questions and thoughtful points. For new commenters, please read the FAQ. I can’t answer questions about specific patients. Those are best left to a live visit with a doctor with an interest in male reproductive medicine. One great resource is the American Society for Reproductive Medicine’s Society for Male Reproduction and Urology page and the ASRM’s find a doctor search page, (just click on the “Society for Male Reproduction and Urology (SMRU)” button in the “Find Member by Affiliated Society:” section.) Another excellent way to find a specialist who treats men with reproductive issues is to use the American Urological Association’s Society for the Study of Male Reproduction’s search engine.
This blog post was inspired by several patients who asked after I explained surgical sperm retrieval, if there was somewhere they could go for more information. I realized that I hadn’t written about such a common issue.
Just as a carpenter has many ways to make a cabinet, a surgeon can tackle a problem in a number of ways. And just as two cabinets may differ, different surgical problems demand different approaches. Such is the case in retrieving sperm from the testis.
Most of the time, taking sperm directly from the testis is necessary when a man has azoospermia, where no sperm is found in the ejaculate. Azoospermia takes two basic forms, obstructive and non-obstructive. As the name implies, obstructive azoospermia is due to a blockage in the tubes and structures that convey sperm from the testis to the outside world. In the best case, a surgeon can fix the errant anatomy, allowing a couple to conceive children without further ado. But because the tubes are so tiny, sometimes the tubes can’t be reconnected with surgery, and the alternative is to take sperm from the testis for it to be used in in-vitro fertilization.
The other form of azoospermia, non-obstructive, arises when the factory making sperm in the testis isn’t working quite right. Sometimes, the cells starting sperm are missing entirely, a condition known as “Sertoli cell only syndrome”. Occasionally, sperm may be rolling along their assembly line, a process that takes two to three months to complete, and stop mid-production. When that happens, it’s called “maturation arrest“. But frequently, sperm can be found in small amounts in the testis and can be retrieved using surgery.
Because it isn’t mature, sperm from the testis can only be used with in-vitro fertilization and intra-cytoplasmic sperm injection.
How can a surgeon remove sperm? He or she can take it from the testis itself, or the epididymis, the tiny coiled tube lying on the back of the testis where sperm mature. The surgeon can insert a needle into the testis or epididymis, he or she may make one or several small incisions into the testis or use microsurgery to retrieve sperm from either the testis or epididymis. In the case of obstructive azoospermia, it doesn’t seem to matter which technique is used. There’s plenty of sperm wherever it’s sought, and any method will do to retrieve it. When a man has obstructive azoospermia, I usually recommend taking a small piece from the testis, as the sperm may be frozen and is good for a number of in-vitro fertilization cycles so that the man doesn’t need to go through a procedure for every cycle, and can be there for his wife during her procedures.
We’ve found that frozen sperm is just as good as fresh. in fact, the chances for fertilization are the same for fresh and frozen sperm, and the chance for pregnancy may even be a little better for frozen sperm than for fresh.
Frozen sperm should literally last forever. It’s in liquid nitrogen, which is so cold that the building blocks making sperm don’t decay. Freezing sperm gives a couple time to plan when in-vitro fertilization is done.
When he has non-obstructive azoospermia, a man’s options are more limited. A surgeon can use the operating microscope to comb through the testis looking for areas that may contain sperm, a procedure known as “microsurgical testis sperm extraction“. Other techniques include making several small incisions in the testis or piercing the testis with a needle in a dozen or so different spots. When a man has non-obstructive azoospermia, I usually recommend microsurgical testis sperm extraction. More areas of the testis can be examined, and I can see the places that most likely contain sperm.
We’ve observed that prescribing a man with non-obstructive azoospermia clomiphene citrate for a few months before surgical retrieval seems to increase the chance to retrieve sperm. In many men, sperm appears in the ejaculate and surgery isn’t needed. If a couple has a few months, taking clomiphene before surgical sperm retrieval might be a good idea.
In short, a surgeon has many ways to retrieve sperm when necessary. The choice depends on the preference of the surgeon and the couple, and what’s going on inside the testis. I’ve listed the surgical techniques available, and my typical recommendations.