There are a range of microsurgical procedures for men who have fertility difficulties, low sperm counts or absent sperm. Microsurgical methods enable very delicate dissection of tissues and highly accurate reconnection to repair structures such as the vas deferens or epididymis that are damaged by disease or are abnormal. While microsurgical vasectomy reversal is the most common operation, others include sperm retrieval and removal of epididymal cysts.
Surgical Sperm Retrieval
If there are no sperm seen at semen analysis or sperm wash then either testicular biopsy or sperm aspiration may be used to discover if they are present in the testis. Hopefully any sperm found can be frozen and stored, to permit use in later IVF and ICSI treatments.
There are two ways of performing both testicular biopsy and sperm aspiration. The first involves the use of very small needles placed into the testis or its collecting tubes (epididymis). This can be performed readily under local anaesthesia. The testis and surrounding structures can be numbed by placing local anaesthetic around the vas deferens near the groin in the upper scrotum. Most men opt to have some sedation as well as the local anaesthetic. The second method requires an open operation on the scrotum carried out under general anaesthesia involving a small cut in the testis and or a microsurgical collection of sperm from the collecting tubes.
In the one procedure both an accurate diagnosis and knowledge of whether treatment can be performed is obtained. Often (but not always), sperm collected at the time of these procedures can be frozen and then subsequently used for treatment (involving sperm micro-injection into eggs) and IVF at a later date.
Microsurgical removal of epididymal cysts
The epididymis is a very fine highly convoluted tube that carries sperm between the testis and the vas deferens. Essentially it is the internal lining of the vas deferens from the point where the vas deferens loses its muscular coating to the testis. It is about 6 metres long but only occupies an area of 3cm by 1cm next to the testis. It is one of the finest tubes in the human body.
Epididymal cysts are a fluid filled swellings within or next to the epididymis. Because they are intimately associated with the epididymal tubule their removal by any other than microsurgical means runs the real risk of obstruction of the epididymis and prevention of the passage of sperm - therefore affecting both sperm count and fertility.
Removal is a day surgical procedure and requires a small incision in the scrotal skin directly over the cyst or cysts. The cyst is identified and carefully dissected free from the tubules before excision.
It is very much in your best interests to have epididymal cysts removed microsurgically, as delicate and very precise methods are required to accurately and safely (from a fertility perspective) remove epididymal cysts.
Non-microsurgical techniques increase the rate of damage to the epididymal tubule and so can result in both obstruction and ultimately prevent sperm reaching semen, thus resulting in a decreased or zero sperm count.
Fallopian tube repair
The fallopian tubes are very delicate structures in which egg and sperm fertilise to produce an embryo and pregnancy. If they are obstructed then pregnancy cannot occur. The commonest cause of obstruction is due to elective sterilisation for which microsurgical fallopian tube reanastomosis is a a highly successful procedure.
Blockage of the Fallopian tubes has a number of disease related causes, the most common of which are past pelvic infection, prior surgery and endometriosis. Microsurgery has long been used to open up blocked fallopian tubes and is successful in doing so in a majority of cases.
A critical issue when considering microsurgery to repair damaged Fallopian tubes is the nature and extent of the adhesions which are blocking or binding the tubes.
Preliminary pelvic assessment using a telescope through the umbilicus known as laparoscopy will always be required. In addition, a specialised technique to assess the exact position of blockage (selective salpingography) will usually be necessary to determine if microsurgery is the best treatment.
A high level of expertise and experience is required to successfully restore fallopian tube patency. Because the fallopian tubes have many small blood vessels coursing along them, highly accurate methods are essential to prevent additional damage when operating to restore patency. The use of microscopic methods gives the surgeon a superior view of the tube and so a greater ability to explore and find the correct site to re-open the tube, while at the same time preventing further damage and subsequent adhesion formation.
Endometriosis is a complex condition where tissue that looks like the ling of the uterus (the endometrium) is present outside the uterus in the pelvis. It can affect fertility by physically damaging the reproductive organs or by altering the chemistry of the surrounding fluid and so reducing normal function. Approximately 10% of women will develop endometriosis at some time of their lives. In some cases the disease will regress spontaneously; in others it will unfortunately produce symptoms such as painful periods, painful sex, abnormal uterine bleeding or infertility. Often endometriosis is treated medications or by laparoscopic means.
Microsurgical dissection and excsion of endometriois can in certain situations be the best form of treatment for endometriosis. This is particularly so when endometriosis damages the fallopian tubes and ovaries leading to infertility.This aim of microsurgical dissection of endometriosis is to restore the damaged structures and pelvic anatomy to as close to normal as possible. If endometriosis leads to adhesion formation surrounding either the ovaries or fallopian tubes, microsurgical methods optimise the prospects of re-establishing normal fertility function by allowing precise, accurate separation of structures along normal tissue plains, minimising collateral damage and maximising normal anatomical restoration.
Microsurgical methods offer the best hope for long-term correction of potentially painful conditions and those which obstruct the passage of sperm through the male reproductive organs or cause pain.
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