NON SURGICAL MANAGEMENT OF MALE INFERTILITY

• Correct timings of sex: Only about 25% of men actually know the exact time to have sex during the female cycle to achieve a pregnancy. The females are fertile only during a certain days of monthly cycle when eggs are produced. It generally extends from 6 days before ovulation (discharge of egg or ovum from the ovaries) till 24 hours after ovulation from. How to calculate this fertile period?
  1. Using online ovulation calculator, which calculates fertile period by using date of the menses.
  2. Home kits that detect the LH surge in the urine immediately (24 hours) prior to ovulation.
  3. Change in the texture of vaginal discharge which becomes clear, slippery and egg white like before ovulation.
  
• Treatment of erectile dysfunction or premature ejaculation: Many men, even with normal semen parameters are unable to father a child because of erection problems or premature ejaculation. This can be effectively managed using medicines in most of the patients.



SURGICAL MANAGEMENT OF MALE INFERTILTY


Surgically correctable conditions responsible for male infertility and their respective surgical procedures are:
1. Varicocele : Varicocelectomy(microscopic or laparoscopic)
2. Vas Obstruction: Vasovasosomy, Vaso-Epididymal Anastomosis(micro VEA)
3. Ejaculatory duct obstruction: TURED(Trans Urethral Resection of Ejaculatory Ducts)

VARICOCELE
What is a varicocele?
• Presence of dilated, tortuous, elongated veins around the in the scrotum. It can happen on both the sides, though left more common than the right. Why do they happen?
• They are normally present in 15% of pubertal men.
• They can happen as a result of faulty valves of the veins in the scrotum resulting in reversal of flow of blood in them.






What are the symptoms?

• Majority of small varicoceles cause no symptoms.
• There may be visible bunch of veins under the skin which increase in size on standing or straining, and reduce on lying down. It feels like feeling a ‘bag of worms’ when felt between fingers and thumb.
• Large veins may cause a dragging pain or ache in the scrotum.
• Some may present with reduction in size of the testis.
• Some present with abnormal semen parameters during evaluation of infertility.



What are the harmful effects of untreated varicocele on the body?

• Majority are completely harmless and do not require any treatment.
• It is not cancerous and is not a risk factor for any cancer.
• It can cause pain in the testis.
• Large long standing varicoceles may shrink the size of the testis.
• Some varicoceles can have harmful effects on semen parameters and lead to infertility.
• It may reduce levels of testosterone (as found in few studies) What are the harmful effects of varicocele on male fertility?
• Approximately 25% of men evaluated for infertility will have a varicocele, a much higher rate than that found in the general population (15%). 
• The temperature in scrotum is 2 degrees lower than body temperature. The dilated veins in a varicocele may decrease the effectiveness of this natural cooling mechanism and “overheat” the testis and reduce its ability to function. 
• Sperm DNA fragmentation rates is a measure of sperm quality. This can be elevated in men with varicoceles.



How are varicocele diagnosed?

• The “gold standard” way to diagnose varicoceles is by physical examination by a Urologist.
• Doppler ultrasound of scrotum.

Grading of varicoceles is from I to III, with I being the mildest.





Can varicoceles be treated with medicines?

No. They don’t shrink or disappear with medicines.
Medicines are used for pain relief or for helping improve semen parameters.



When is surgery required for a varicocele?


1. For correction of male infertility.
2. When a large varicocele leads to reduction in size of testis.
3. Pain associated with a large varicocele and not responding to painkillers



What are the various treatment options for varicoceles. How do they compare in terms of outcomes?






How should I prepare for a varicocele surgery?



• You will be admitted the day of surgery.
• 6 hours of fasting required before surgery.
• Done under spinal anesthesia or general anesthesia.
• You will be discharged the same or the next day.



What are the complications of a varicocele surgery?

Recurrence of varicocele.Incidence depends on the type of surgery. Recurrence occurs because new veins form around the original set of veins. once they are blocked. It can also occur because of incomplete blockage of veins. This might require another intervention in future.
• Injury to testicular artery, which can lead to reduction in size of the testis.
• Hydrocele formation is collection of fluid around the testis. It may require a surgical correction




When will I notice improvement, if any, after varicocele treatment?

Semen parameters are repeated after 3 months of procedure to see for the changes in semen parameters. This is because it takes 120 days for the new set of sperms to develop.



When can I return to normal sexual activity after varicocele procedure?

4 weeks after surgery or 1-2 weeks after embolisation



Can I conceive with a varicocele, even if I don’t undergo any treatment?

Varicocele may not affect sperm parameters at all. You can still father children naturally.



What will happen if varicocele left untreated?

• It may reduce the size of testis.
• It may affect sperm parameters and cause infertility
• It may reduce testosterone levels(as shown in some studies




Why is microscopic varicocelectomy better than conventional varicocelectomy?How is it performed?

• Under anesthesia, a small cut is made in the subinguinal region or near root of the scrotum, to expose the veins.
• The veins are visualized under magnification using an operative microscope.
• Using magnification, other structures in that area namely artery, lymphatics are spared and smallest of veins are also visualized. This reduces the chances of missing out any vein thereby reducing chances of recurrence and also reduces chances of complications by identifying testicular artery and lymphatics. This reduces chances of testicular shrinkage and hydrocele respectively.
• Both the sides can be operated in the same sitting.
• A dressing is placed
• You can go home the same day or at the most next day.
• You can resume normal activities in 2 to 3 days and sexual activity in a month’s time.



What are the alternatives to microscopic varicocelectomy?

• Observation – if your varicocele causes no significant problems, no treatment is needed.
• Radiological embolisation - using interventional radiology to block the swollen veins.
• Laparoscopic ("keyhole") repair – tying off the swollen veins using a telescope in your abdominal (tummy) cavity.


MANAGEMENT OF OBSTRUCTION OF SPERM CARRYING DUCTS




Surgical bypass may be possible depending on where the level of the obstruction lies. Obstruction can be present at three levels:

1. Ejaculatory ducts
2. Vas Deferens

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