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Medical therapy is indicated for patients with specific disorders such as ejaculatory dysfunction, hormonal abnormalities, and infections. Ejaculatory dysfunction may take the form of complete failure to emission and/or retrograde ejaculation. Causes of ejaculatory dysfunction include spinal-cord injury, diabetes mellitus, retroperitoneal surgery, multiple sclerosis, bladder-neck and prostate surgery, psychogenic, and idiopathic. Medical therapy for ejaculatory dysfunction may be initiated. When medical therapy fails or is not indicated, ejaculatory dysfunction is often successfully treated with vitratory stimulation of electroejaculation. Electroejaculation, the application of transrectal electrical current to stimulate the pelvic nerves, results in approximately 90% of patients producing a retrograde and/or antegrade semen specimen. These specimens are often suboptimal in quality and are then used in conjunction with intrauterine insemination or more advanced assisted reproductive technology.
 

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Varicoceles are dilated veins in the scrotum surrounding the testes. Approximately 15% of all men have varicoceles and for most men, they do not seem to impair testicular function. However, about 40% of all men with infertility have varicoceles and it is generally believed that their presence, impairs sperm production. Although the precise pathophysiological mechanisms of the varicocele effect have not been delineated, many investigators believe that a secondary increase in testicular temperature causes impaired spermatogenesis. Whatever the cause, many studies have demonstrated that.

A varicocele is made up of enlarged veins within the scrotum. They are similar to varicose veins of the legs. Varicoceles are found in about 15% of the normal male population and about 40% of men with infertility. Most evidence indicates that varicoceles can hinder sperm production often resulting in infertility. It is important to remember that female factors can also contribute to infertility. Therefore, successful outcomes can depend on both partners being treated. Both you and your partner should have complete evaluations before any treatment choices are made.

Not all men with varicoceles are infertile. However, most infertile men with varicoceles have improvement of semen quality after varicocele repair, and some infertile men with varicoceles are able to achieve a conception after varicocele repair. Varicoceles are found by doctors on physical examination. Further tests include at least two semen analyses which may be performed to find out whether the varicocele is associated with infertility. Once an evaluation is completed, your doctor can tell you about treatment options that are available for you and your partner. To the doctor, a varicocele feels like a bag of worms when you are in the standing position.

If you are your partner are trying to conceive a child and you have been told you have a varicocele, you should think about treatment when the following are present:
 

There are a number of surgical options, and your doctor will discus with you the details of these approaches. Surgical repair of a varicocele is done in an outpatient surgical center with general or local anesthesia. The operation takes about an hour. Surgery for surgical correction of a varicocele is successful in 90% of cases and about 60% of men have improved sperm count and motility after repair of the varicocele. About 40% of couples will subsequently initiate a pregnancy following varicocele repair. Many urologists prefer an operative approach that employs microscopic techniques. The use of this higher magnification better ensures prevention of damage to other important structures with effective ligation of those veins contributing to the varicocele.
 

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Microsurgical reconstruction of the male reproductive tract is often a successful treatment when an obstruction exists and is performed to reverse a vasectomy. After vasectomy reversal, sperm return to the semen in about 70 to 95% of men and pregnancy without assisted reproductive technology occurs in 30-75% of couples.

The chance for pregnancy following reconstructive surgery depends on many factors, most importantly the age and fertility status of the female partner and the number of years between the vasectomy and its reversal. The longer you wait to reverse a vasectomy, the less the chances are for successful reversal. Still, there is no absolute number of years beyond which a reversal is not an option for consideration. Contrary to what is commonly believed, the chance for success with a vasectomy reversal does not suddenly decline after ten years or after any other specific number of years. Microsurgical reconstruction is a two to four hour operation and can be performed as an ambulatory procedure. Identifying and treating reversible conditions may improve the male partnerÕs fertility and allow for conception through natural intercourse. Many complex factors go into the decision to use microsurgical reconstruction of the male reproductive system versus sperm retrieval with ICSI. Microsurgical reconstruction of the male reproductive system often is more cost effective than sperm retrieval with IVF/ICSI. Microsurgical reconstruction allows couples to have subsequent children without additional medical treatment. On the other hand, there are situations in which sperm retrieval with IVF/ICSI is a better choice. For example, couples in whom there is more male and female factor infertility are usually better treated by sperm retrieval and ICSI. The fertility status of the female partner is another important consideration. For example, the woman's age is important. Although individuals vary greatly, a woman's fertility begins to decline after the age of about 35. This means that the chance for success with both microsurgical reconstruction and sperm retrieval with ICSI decreases with increasing female partner age, especially beyond age 37.

It is important to understand that after a successful microsurgical vasectomy reversal, the average interval until pregnancy is about one year while a successful ICSI cycle pregnancy occurs within one to two months of starting hormonal therapy. The choice of either sperm retrieval with IVF/ICSI or microsurgical reconstruction should also be influenced by the pregnancy rates achieved with ICSI by the IVF laboratory with which you are working in the local community.

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It is currently estimated that about 1% of men who have undergone a vasectomy will eventually want reversal surgery. A vasectomy reversal is a surgical procedure that restores the flow of sperm through the vas deferens. It is usually performed by an experienced microsurgeon using specialized instruments including an operating microscope. A vasovasostomy is the operation most frequently performed for a vasectomy reversal and involves communicating the severed ends of the vas deferens. However, if following a vasectomy an obstruction has occurred in the epididymis, a vasoepididymostomy must be performed which involves communicating the vas deferens to the section of the epididymis that contains mature and motile sperm. With recent advances in microsurgical techniques, instruments and suture materials, success rates have increased dramatically. Following microsurgical vasovasostomy, sperm appears in the semen in approximately 85 to 97% of men and approximately 50% of couples subsequently achieve a pregnancy.

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Advances in assistive reproductive technology have astonishingly increased the likelihood of achieving fertilization and are routinely incorporated into the treatment of infertile men. It is fair to state that gamete micromanipulation has dramatically and fundamentally influenced the current treatment of male-factor infertility. Intracytoplasmic sperm injection is the technique whereby a single sperm is microinjected directly into the cytoplasm of the ovum. Today, couples with severe male-factor infertility routinely utilize ICSI when undergoing IVF treatment. ICSI has become the preferred treatment for utilizing retrieved epididymal and testicular sperm. Men with congenital absence of the vas deferens as well as men with irreconstructable obstruction are routinely treated with ICSI. Significantly improved diagnostic and treatment modalities have fundamentally enhanced the prognosis for infertile men. These exciting advances have created a new approach in the treatment of male infertility and provide realistic hopes for many men who were previously told that they could never experience fatherhood.

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Electroejaculation is a procedure that is performed when a medical or psychological condition prevents a male from being able to ejaculate. Such conditions include spinal cord injury, retroperitoneal surgery that severs the sympathetic nerves to the perineum and psychological conditions. During rectal probe ejaculation, the male is positioned on his side and a doctor inserts an electrical stimulation probe into the rectum. The doctor controls the amount of electrical stimulation delivered so that an ejaculation occurs. This can be done either in the office or in the operating room with anesthesia depending on the sensory status of the patient. Alternative methods of sperm retrieval are recommended when penile vibratory stimulation and rectal probe ejaculation are unsuccessful or unavailable. Sperm are made in the testicle and travel through the epididymis and vas deferens before reaching the outside of the body. Sperm can be obtained directly from the man's reproductive tract using minor surgery. The most common method is obtaining sperm from the testicle. This may be done in an open procedure. Alternatively, a closed procedure may be done in which no incision is made and a needle is passed through the scrotal skin directly into the testicle. The number of sperm obtained from any of these procedures is small and thus an advanced ART technique such as ICSI is required.

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Intracytoplasmic sperm injection (ICSI) is the injection of a single sperm into the mature Oocyte. It is the form of in-vitro fertilization that must be used in all cases of obstruction when sperm are retrieved from the testicle or epididymis. Sperm retrieval followed by ICSI is preferable to surgical reconstruction when advanced female age is present and/or female factors that require IVF are present.

There are several methods of sperm retrieval. The choice of method depends mainly on the urologist who will perform the procedure and the embryology/IVF laboratory performing the ICSI. Sperm retrieval may be performed prior to or simultaneously with the female partner's egg retrieval. Many reproductive centers prefer to use fresh sperm obtained on the same day as the egg retrieval. For those whose azoospermia is due to obstruction, sperm retrieval can be accomplished by either a needle aspiration or microsurgical technique.

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Azoospermia is the complete absence of sperm in the semen and has many causes. Obstructive azoospermia implies that there is a blockage in the genital tract yet normal testicular production of sperm. Other causes of azoospermia are nonobstructive, meaning that there is a significant diminution in sperm production within the testicle. Obstructive azoospermia accounts for about 40% of all cases of azoospermia. Obstruction may be either congenital or acquired. Vasectomy is a common form of male contraception in that the vas deferens is cut and sealed on each side forming an acquired obstruction. It is the most common cause of obstruction in the vas. Another common cause of obstruction is a prior infection which results in scarring of the ductal structures. Congenital obstruction can be due to either a malformation or the absence of the vas deferens.

Obstruction of the male reproductive tract can often be corrected by an operation, but is some men, surgical correction is not possible. In this situation, it may still be possible for the man to father children by removing a few sperm from his reproductive system and using the sperm for in vitro fertilization with intracytoplasmic sperm injection, ICSI.

Finding the cause of the obstructive azoospermia is helpful for several reasons. It allows your physician to decide whether you are a candidate for surgical treatment. If your obstruction is not surgically treatable, your doctor might be able to suggest other treatment options for you or your partner. If there is a major medical or genetic disorder underlying the azoospermia, it may be important to identify these disorders. It is also important to know whether the genetic problem may be passed on to your children.The genetic abnormality that may be associated with obstructive azoospermia occurs in some men who are born without the vas deferens. This condition is called congenital bilateral absence of the vas deferens CBAVD. About two-thirds of men who have CBAVD have a genetic mutation that can cause cystic fibrosis if they initiate a pregnancy with a woman who has the same genetic mutation.

Therefore, if you have CBAVD, genetic testing and counseling should be sought to help you and your partner understand the risks of passing this defect to your children.

The options available to couples in whom the male partner has obstructive azoospermia include surgical correction of the obstruction, removal of sperm from the male reproductive system combined with IVF/ICSI, artificial insemination with sperm from a donor, and adoption.

The best treatment option for you depends on the cause of the obstruction as well as a number of personal factors. The reproductive, health status of your partner, social, marital, religious, cultural and financial factors and genetic factors are other important considerations. Before you choose the best treatment for you, an evaluation of both you and your partner is recommended. This evaluation will determine whether your obstruction is surgically correctable and what are the approximate chances for having a baby with each option.

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