Surgical Options for Men With Obstructions

One of the major obstacles that present in men with oligospermia (low sperm count) and azoospermia (zero sperm count) are structural abnormalities and obstructions. These can be due to scar tissue that has formed after injuries, sexual tract infections, or past surgeries; or they can be related to cysts or tumors that have developed.

Any of these obstructions will likely yield no symptoms until male factor infertility comes into question (unless ejaculatory duct obstruction results in dry orgasms). To better understand how one small obstruction can make a dramatic difference in a male's fertility, you must first understand the necessity of each branch of the structural journey.

The Structural Journey

Once produced and nurtured within the testicles, the life of a sperm cell is a maze of tubules until it has been ejaculated. The sperm are guided toward the epididymus, which is a long, coiled tubule where the sperm learns to swim. At the end of the voyage through the epididymus, the sperm enter the vas deferens. The vas deferens is the connective tubule from the testicles to the penis.

There is no holding area for sperm in the male reproductive system. Sperm arrive at the opening to the urethra (the tube that runs through the penis for releasing both urine and ejaculate) and wait for ejaculation, much like horses at the starting gate. When ejaculation occurs, semen is expressed from the prostate gland and washes the sperm into the ejaculatory duct. The ejaculatory duct will push the ejaculate into the bulbous urethra. The sperm-rich semen is delivered from the base of the penis through the opening on the top of the penis with strong contractions.

The Surgical Solution

In the male reproductive system there are no detours or work-arounds. Sperm travels one route, much like a factory production line. The diameter of the traveling space in these tubules is microscopic, measured in hundredths of an inch. You could imagine that the slightest obstruction within this production line can seriously impede its efficiency.

Some of the more common operable conditions are:

• blocked ejaculatory duct,
• blocked or damaged epididymus,
• blocked vas deferens,
• hydroceles (areas of fluid collected around the scrotum),
• varicoceles (swollen veins in the testes that can either create pressure or overheat the testes),
• or past vasectomy (an elective procedure that severs the vas deferens as a means of birth control).

There have been dramatic advances in micro-surgical techniques for correcting tube and duct obstructions of the male reproductive tract over the past decade. Conditions that were previously considered to indicate permanent sterility are resolved routinely in an outpatient setting. The following procedures have offered many families the support that they needed to make conception possible.

Ejaculatory Duct Blockage Removal

When the ejaculatory duct is blocked, it is impossible for the ejaculate to be delivered to the bulbous urethra for ejaculation. This can lead to azoospermia and dry orgasms in extreme cases. Surgical removal of obstructions is not only available, but extremely successful. Seventy percent of men that undergo this procedure will experience restored ejaculatory capability, though only only 20-30% will go on to spontaneously conceive.

This procedure can be done either in a clinical or hospital setting. It involves local or general anesthesia and a small incision in the testes. When the incision is made, a scope is inserted to locate the ejaculatory duct and the blockage therein. When the obstruction is found, an instrument is inserted through the scope and the blockage is cut away to restore normal ejaculatory function.

Epididymostomy

The epididymus is an extremely long tubule, with much length to spare. When there is an obstruction of the epididymus the easiest way to clear it is to cut away the effected part of the tubule and reattach it to the vas deferens. This procedure is known as an epididymostomy.

Often times a large portion of the vas deferens is removed in a vasectomy. Vasectomy can also result in epididymal damage due to the pressure of continued sperm production after the fact, as severing the vas deferens removes the only escape route for the sperm that are continuing to be produced. In either of these scenarios, an epididymostomy can serve to restore the passage of sperm from the epididymus to the urethra.

In an epididymostomy, general anesthesia is given. This outpatient procedure may or may not involve cutting away blocked or damaged portions of the epididymus or vas deferens, but always involves the joining of the epididymus to the vas deferens. This micro-surgical procedure has an excellent record of over 90% success in restoring regular sperm production.

Vasovasostomy

The goal of a vasovasostomy is to reverse a vasectomy, or to resolve blocked or damaged portions of the vas deferens in a similar manner as an epididymostomy. The success rate of a vasovasostomy is not as great as a epididymostomy, as sometimes the damage that is done to the epididymus after a vasectomy is not diagnosed until after a vasovasostomy has been performed.

A vasovasostomy requires general anesthesia. If there is a blocked or damaged portion of the vas deferens, it is removed. If the procedure is being done to reverse a vasectomy, the severed ends of the vas deferens are identified. The procedure is completed by rejoining the severed ends of the vas deferens. If there is not enough length in the vas deferens to rejoin it, an epididymostomy is another alternative to restore passage from the epididymus to the urethra.

Hydrocelectomy

A hydrocele is a collection of fluid that occurs in and around the scrotum. This may occur as a result of newborn hernias. In adults, they are often attributed to blocked lymph nodes or testicular trauma. Hydroceles will often resolve themselves. Hydroceles can put pressure on the reproductive tract, and may create a barrier in one of the tubules causing temporary infertility. Only a hydrocele that is either causing a patient pain, or that is interfering with his fertility should require surgery.

In a hydrocelectomy, either local or general anesthetic is administered. The surgeon will make an incision in the scrotum through which he will drain the fluid from the hydrocele. When the hydrocele has been completely drained, the remaining sac will either be folded back behind the testicle or removed entirely. The scrotum is closed, and the procedure is complete. Nearly 100% of hydroceles do not return.

Varicocelectomy

A varicocele is not unlike a varicose vein in the testes. A varicocele occurs when blood is backed up in a vein in the testicles, causing a rise in temperature and swelling of the vein. A large varicocele can put pressure on the reproductive tract, causing blockage. More often a varicocele presents a threat to fertility by causing the temperature in the testicles to rise. When the testicles overheat it affects both sperm quality and production.

During a varicocelectomy, the surgeon will make an incision into the abdomen to insert a scope. It will be used to identify the source of the blood that is feeding the varicocele. When the problem is found, blood vessels will be clamped to restrict blood flow to the groin temporarily. The problematic varicocele(s) will be microsurgically restored to relieve swelling and restore the delicate temperature balance.

Do I Need Surgery?

Even if you have been diagnosed with one of the above conditions, other alternatives exist to help aid in your conception. Though these are the best alternatives if you wish to spontaneously conceive through “the natural method,” assisted reproductive technology (ART) has options for those that wish to avoid surgical means.

Men who are experiencing obstructions in their reproductive tract are still capable of producing sperm. Your specialist may offer to retrieve sperm directly from your testicles with a needle to be used in intracytoplasmic sperm injection (ICSI) and in vitro fertilization (IVF). Since sperm that do not travel the epididymus do not know how to swim, they can be injected directly into the female egg in ICSI. An embryo can then be created and transferred into a woman's uterus through IVF.

Some details that you may wish to consider prior to your decision are the costs of such procedures, the recovery time, and insurance coverage. Only you and your doctor can create a plan that works for your unique diagnosis and lifestyle.