Surgical Treatment for Male Infertility

When male infertility is caused by blockages or obstructions, varicoceles, prior vasectomy or even structural defects, Dr. Fenig utilizes his skill in microsurgical techniques to perform a variety of intricate surgical procedures to correct a number of conditions. These procedures include:

  • Microsurgical Varicocelectomy – a microsurgical procedure to correct a varicocele, or varicose veins in the scrotum. The procedure not only reduces the progressive damage to the testicles but may actually reverse prior damage, resulting in restoration of normal sperm levels in the semen. Data show that microsurgical varicocelectomy can improve sperm counts in 50-70% of couples. Learn more here.
  • Microsurgical Vasectomy Reversal – Dr. Fenig is one of only a few fellowship trained microsurgeons in the country with vast experience in vasectomy reversals to help couples conceive a child naturally years after a vasectomy. Learn more about this specialized procedure here.

Sperm Retrieval for In Vitro Fertilization

Another important procedure performed by Dr. Fenig to help couples dealing with male infertility conceive is sperm retrieval for use in In Vitro Fertilization (IVF). Sperm retrieval is used for men who have azoospermia and would like to use their own sperm to fertilize their partner's egg. Sperm retrieval from the testicles may be performed in patients with no sperm due to a blockage, most commonly from a vasectomy (obstructive azoospermia), or for patients with no sperm on semen analysis due to a production problem (nonobstructive azoospermia).

There are several different techniques used to retrieve sperm, including:

Percutaneous Epididymal Sperm Aspiration (PESA) and Testicular Sperm Aspiration (TESA)

Percutaneous epididymal sperm aspiration (PESA) and testicular sperm aspiration (TESA) are procedures in which sperm is collected by inserting a fine needle into the epididymis (PESA) or testis (TESA) for use in In-Vitro Fertilization (IVF).  These are commonly used for patients with a blockage in the vas deferens or congenital absence of the vas deferens which causes no sperm counts in the semen (obstructive azoospermia).  Dr. Fenig will perform a detailed history and physical examination prior to these procedures.

PESA is a relatively simple procedure that is typically used when there is a blockage of the tube through which sperm passes into the ejaculate, or when sperm is absent in the ejaculate, usually because of vasectomy, damage to the vas deferens from infection, or congenital bilateral absence of the vas deferens. The procedure involves the insertion of a very thin needle, under local anesthesia or intravenous sedation, through the scrotum and into the epidydimis, the reservoir of sperm that sits atop each testicle.  This is typically performed in advance of the IVF cycle and the sperm is frozen (cryopreserved) for later use in IVF.

TESA may be used if PESA has been unsuccessful.  Under local anesthesia, Dr. Fenig will insert a small needle into the testes to collect samples of testicular tissue with sperm.

Testicular Sperm Extraction (TESE)

Testicular sperm extraction (TESE) may be performed for patients with obstructive or non-obstructive azoospermia.  This is an outpatient surgical procedure under local anesthesia or intravenous sedation in which Dr. Fenig makes a small incision in the testis to retrieve a sample of testicular tissue.  TESE may sometimes be performed as a diagnostic testis biopsy to determine whether a patient is capable of sperm production. 

In cases of obstructive azoospermia, the testicular tissue is typically frozen ahead of the IVF cycle, but the TESE procedure may also be performed the day prior to, or the day of, IVF.  Studies have demonstrated that since patients with obstructive azoospermia make normal numbers of sperm, cryopreserved sperm is sufficient for use in IVF. 

When performed for non-obstructive azoospermia, several samples of tissue may be required to assess if there is sperm production in different regions of the testis.   This is known as testicular mapping.  When sperm is found, it may be cryopreserved for future use in IVF.

Microdissection Testicular Sperm Extraction (MicroTESE)

For men with no sperm present in the semen, microdissection testicular sperm extraction (microTESE) may be used to find sperm in the testicle. Dr. Fenig is fellowship-trained in this procedure, which is more complex than older sperm extraction techniques but yields far better results.

MicroTESE has significantly improved sperm retrieval rates in men with no measurable levels of sperm in the ejaculate, and is a more accurate procedure since the entire testis is surveyed while less testicular tissue is removed. Conventional TESE requires multiple blind testis biopsies with excision of large volumes (>700 mg) of testicular tissue and risks permanent damage to the testis. With microTESE, however, a much smaller excision is required.

Some studies have shown that the procedure can increase retrieval rates from 45% with TESE to 63% with microTESE. According to one research paper, microdissected samples yielded an average of 160,000 spermatozoa per sample from only 9.4 mg of tissue, versus 64,000 with conventional biopsy samples, which also required biopsies of 720 mg of tissue.