"The pregnancy rate is as high as 40% with the average pregnancy occurring 6 to 9 months following a varicocele surgery".

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In this site, you will find articles specifically written by Phillip G. Wise, M.D., P.L.L.C. on Male Infertility.  Please jump to the articles that interests you.

Marriage: In Sickness and in Health... and Infertility?

Remember how you felt when you were first married, the feeling that you and your love could handle anything?  That there was nothing out there big enough to come between you?  And then came infertility... and everything seemed different.

Infertility is a force in marriage unlike any other, because is does not come as much from "outside" as from "inside".  It is not so much an outer force, as an inner one that nibbles away at areas hard to talk about: individual self-image, sexuality, and the sexual relationship, as well as emotional well-being and ways of responding to a crisis--every area of a marriage from the inside out.  And though two people may want to cope with the crisis in a united way, it just may not be possible at first.

The average couple will go through a scenario something like this:
He will cope by keeping his feelings to himself and focusing on her... She will cope by expressing over and over how awful and unfair and frustrating everything is... She pushes more and more; he retreats more and more... He feels overwhelmed by her need because he feels powerless to take away the pain; she feels abandoned when she needs him the most...

And the scene goes on night after night.  The issue is so personal.  A couple cannot help looking at their marriage differently and at themselves differently.  And as the crisis forces a spotlight on the marital relationship, the easiest thing to do is to keep dodging the light.  But that is not possible.  Boston psychiatrist Miriam Mazor sees the point clearly:  "Infertility makes couples take a harder look at each other... They begin to assess the marriage at a stage when other couples are too busy with child care to do so".  The health of a relationship must stand the glare of that spotlight and must keep standing the glare for the whole infertility crisis -- no matter how extended it may be.

What's the answer?  Communication.
There is a trick to communication, however.  The trick is to listen without criticism and advice, and with acceptance and understanding.  It is hard to assimilate such a serious life situation.  Even following a decision to change, coping patterns will be slow in transition.

However, as a couple talk they find themselves growing together.  Slowly they grasp what is happening to them.   And they may begin thinking of ways to cope together.  The husband might decide to be with his wife through as much of her part of the medical work-up as possible.  They may decide together that there are ways to soften the tension of temperature charts, the husband keeping the chart or picking between the two or three pivotal nights for instance.  Maybe they can explore other ways to share, working toward coping in a healthy partnership way.

Sometimes, though, it takes more than just "one-on-one" talking.  What may be needed is a chance to bounce ideas off of other couples, to learn that other couples have similar problems and to hear how they are responding.  Many, many couples cannot get past their denial without sharing with other couples having similar experiences.  A couple might share with another going through the same crisis, or they might want to seek support from a group such as one listed below.

Keeping a marriage healthy through this crisis may mean communicating in a new way, in a deeper way than before.  If may man looking painfully deep into oneself, into long-held understanding of one's own sexuality, beliefs about marriage, and one's own priority system.  And then it may mean listening closely to that someone held dearest as he or she works through all the painfully deep examinations too.  The united front is possible.  And surviving the emotional, mental and physical stress of infertility can forge a marital bond that can stand any stress.

For further literature write or call:

Resolve, Inc. 5 Water Street Arlington, MA  02174 617-643-2424

Infertility Network, Inc. P.O. Box 271344 Houston, TX  77277-1344 713-723-2299

Adapted from Give Us A Child: Coping with the Personal Crisis of Infertility By Lynda Rutledge Stephenson

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Varicocele

Microscopic Vasovasostomy Epididymovasostomy TESA

Varicocele
Male infertility has been found to be the major cause of a couple's inability to conceive in 50% of childless marriages. There are many causes of male infertility including: deficiencies in sperm production; blockage of the conducting system; antibodies against sperm; injury to the testicle; hormone problems; poor descent of one or both testicles; and finally the presence of a Varicocele.

In order to understand what a varicocele is, one must be aware of some basic anatomy and physiology. The testicles are the paired male genital organs that contain not only sperm but also cells that produce and nourish the sperm. These organs are located in a sac called the scrotum. The epididymis is a small, tubular structure attached to the testicle. It is a reservoir where the sperm mature and are stored. The vas deferens connects the epididymis to the prostate gland and is the tube through which sperm travel during ejaculation. The vas deferens is not situated by itself but is a part of a larger tissue bundle called the spermatic cord. The spermatic cord contains many blood vessels as well as the vas deferens, nerves, and lymphatic channels. The vein of the spermatic cord are known as the pampiniform plexus. These veins drain blood from the testes, epididymis and vas deferens, eventually becoming the spermatic veins that drain into the main circulation at the level of the kidneys. The pampiniform plexus of veins may at some time become tortuous and dilated much like a varicose vein of the leg. In fact, a scrotal varicocele is simply a varicose enlargement of the pampiniform plexus around the testicle.

The scrotal varicocele is a well recognized cause of decreased testicular function and is present in about 40% on infertile males. In order to understand the significance of this abnormality in the infertile patient, a brief review of the historical background, current concepts of its anatomy and function, and methods and results of surgical repair must be considered.

History
Varicoceles have been recognized as a clinical problem since the 16th century. Ambroise Pare (1500-1590), the most celebrated surgeon of the Renaissance, described this vascular abnormality as containing "melancholic blood."
It was not until the late 19th century that the relationship between infertility and varicocele was first proposed by the British surgeon Barfield. Shortly thereafter, other surgeons reported an association with "an arrest of sperm secretion" and subsequent restoration of fertility following varicocele repair. Through the early 1900's reports by other surgeons continued to describe the association of infertility with a varicocele. It was not until the 1950's, after a report of fertility following varicocele repair in an individual known to be azospermic (i.e. without sperm), however, that the concept gained support as a clinical entity among American surgeons. Research then continued with studies characterizing semen of men with varicoceles having degrees of impaired sperm quality. From these studies a pattern of low sperm count, poor motility, and a predominance of abnormal sperm forms was documented. This became known as the "stress pattern" of semen. Although not synonymous or specific for a varicocele, it consistently suggests early evidence of testicular damage. Clinically, urologists evaluate male infertility through the study of sperm. The sperm are evaluated for their number (sperm count), the percentage of motile forms, their forward movement and their morphology (shape and form).
Although varicoceles do appear in about 25% of normal, fertile men, their presence is significantly higher in the subfertile population. In fact, scrotal varicoceles have been found to be the most common identifiable and surgically correctable factor contributing to poor testicular function and decreased semen quality.

Anatomy of the Varicocele and Mechanism of Effect
Varicoceles are more common on the left than on the right for multiple anatomic reasons. They may vary in size and can be classified into three groups: 1) large - easily identified by inspection alone, 2) moderate - identified by palpation without bearing down or straining, and 3) small - identification only by bearing down which increases the intraabdominal pressure, further impeding drainage and thus increasing the size of the varicocele. It is important to remember, however, that the size of the varicocele is not related to the degree of changes in the sperm. Several theories have been proposed to explain the deleterious effect of the varicocele on sperm quality. These include possible effects of oxygen deprivation, heat injury or toxins. Despite considerable research, none of these theories have been unquestionably proven although an elevated heat effect caused by impaired circulation appears to be the most reproducible defect. The fact that creation of a varicocele in the experimental animal can lead to poor sperm function with elevated intratesticular temperature does give support to this concept. Regardless of the mechanism of action, varicocele indisputably is a significant factor in decreasing testicular function and changing the semen quality in a large percentage of men seen for infertility.

Diagnosis
Because of its potential role in causing significant testicular damage, it is important to identify the varicocele on physical examination. Reasons for surgical correction include the presence of significant testicular pain, impairment of testicular function, as evidenced by decreased semen quality, and loss of testicular size (atrophy). The mere presence of a varicocele does not mean that surgical correction is necessary. Usually, the varicocele is asymptomatic and the patient is seen primarily for evaluation of a possible male factor in an infertile marriage. However, the patient may sometimes complain of pain or heaviness in the scrotum.
Careful physical examination remains the primary method of varicocele detection. It is important to examine the patient in the standing position, having him perform the Valsalva maneuver, i.e., take in a deep breath and bear down to magnify a small varicocele. When small varicoceles are difficult to diagnose, more objective means can be used such as the Doppler Stethoscope and venography. The Doppler technique is painless and evaluates the motion of blood in the peritesticular veins using soundwaves. Venography requires a small incision in the groin, insertion of a needle into a groin vein and injection of "dye" (contrast solution) which will flow into the spermatic vein. This technique is relatively pain-free, performed on an outpatient basis and allows direct visualization of the varicocele by x-ray.

Surgery and its Results
Once a varicocele is diagnosed, reasons for surgical correction include: testicular discomfort or pain unrelieved by routine, symptomatic treatment; testicular atrophy (loss of size); or the possible contribution to unexplained male infertility. There are four commonly used surgical approaches for the correction of a scrotal varicocele. These are the transinguinal (groin), the retroperitoneal (abdominal), laparoscopic and microscopic approach. The transinguinal and retroperitoneal approaches were the operations of choice for many years. Recent advances in surgical techniques and equipment have brought newer ways to remove the varicoceles. With the laparoscopic approach a small incision is made under the belly button and two small holes on either side of the abdomen are created. Through these ports, instruments are placed to tie off the offending veins. The advantage of the laparoscopic method is that there is much less pain involved. The disadvantage is that there is a small risk of injury to the intra-abdominal organs. With the microscopic approach, the abdomen is not entered, but a larger incision in required and placed over the top part of the scrotum. This seems to cause more pain, but there is no risk of damage to the abdominal contents. Although the mechanisms whereby varicoceles cause impairment in sperm production and semen quality remain theoretical, the statistical association between varicocele and male infertility is unquestionable. Furthermore, improvement in semen quality after varicocele correction has been repeatedly demonstrated. The resultant improvement seen in sperm motility rather than in sperm count. The pregnancy rate is as high as 40% with the average pregnancy occurring 6 to 9 months following surgery.

The scrotal varicocele remains the most correctable factor when treating poor semen quality. Therefore, when present in the infertile male with abnormalities of semen quality, surgical correction should strongly be considered. The side effects following varicocele repair are remarkably low, and successful surgery will often increase the incidence of eventual pregnancy in the infertile couple.

 

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Varicocele

Epididymovasostomy TESA

Microscopic Vasovasostomy
Increasingly more men are presenting to the urologist for vasectomy reversals. This is the most commonly due to remarriage of an individual who has previously had a vasectomy and now desires the initiation of a subsequent pregnancy. Vasectomy reversals are also requested by men who have been in a long-standing stable relationship and who have merely "changed their mind." Also, we do see the occasional unfortunate individual who has lost a child and is attempting to initiate another pregnancy. Fortunately, microsurgery has advanced significantly in the past several years so that reversing a once thought permanent sterilization (vasectomy) is now highly possible.

It should be remembered that much of the success of a vasectomy reversal depends on two factors: (1) The skill of the surgeon and (2) the findings at the time of surgery. Regarding surgical skills, certainly the individual who operates more frequently will increase his technical expertise. Although a microscopic vasovasostomy is not always necessary to produce an effective outcome, it certainly aids the microsurgeon in performing a successful reconnection (anastomosis) of the previously vasectomy. I use a two-layer anastomosis utilizing microscopic sutures and the latest microsurgical equipment and operating microscope. I prefer to have my patients operated on as an outpatient, this affords them the opportunity of returning to their home or a nearby hotel without actually being admitted directly to the hospital, thus saving considerable expense and making the overall experience much more pleasant.

Operating time for a vasovasostomy or epididymovasostomy is approximately 3 hours. Most patients are given a prescription for Valium and Vicodin to be taken one hour prior to their arrival in the office. The reconstruction is done under local anesthesia in the office, at a considerable savings to the patient. On rare occasions surgery can be done at a hospital or surgery center. I prefer out-of-town patients to stay in Grand Rapids one day following surgery and then to return to their respective homes. My patients receive mild analgesics for five postoperative days. They may return to work after a few days, but are advised to wear a scrotal support and to avoid lifting and ejaculation for ten days. Postoperative care should include an evaluation of wound healing at 10 days and a semen analysis at 6 weeks. Monthly semen analyses are then obtained for approximately 4-6 months, semen analysis often reveals adequate sperm density with poor motility. By six months, the count is usually good and motility is markedly improved. At this time sperm banking is advised for insurance against future reduction of sperm.
More than 90% of patients who have sperm in the testicular vas at the time of surgery will have sperm in the ejaculate. The reported pregnancy rate, however is approximately 45% to 60%. Possible anatomic explanations for this impaired fertility include formation of sperm granuloma, obstruction of the proximal vas or epididymis and surgical misalignment of the lumena at the site of the reanastomosis. Functional failure may also be involved and includes changes in epididymal or testicular physiology, poor prevasectomy semen quality, aperistalsis of the vas due to sympathetic nerve damage, abnormalities in the partner's fertility potential, and the presence of sperm agglutinating or sperm immobilizing antibodies. In addition, it has become evident that the post vasectomy fertility rate slowly, but progressively, decreases with increasing time between vasectomy and reanastomosis.

Epididymovasostomy
The technique for epididymovastomy is similar to that for vasovasostomy. Two techniques may be employed, the end-to-side, or the end-to-end anastomosis. In the former technique, a single epididymal tubule is teased away from the mass of tissue, incised longitudinally, and fluid expressed. This fluid is examined for spermatozoa. if none are present, then another more proximal tubule is chosen and the procedure is repeated. When sperm are identified the anastomosis is carried out by suturing the cut end of the vas to the incised tubule with 10-0 nylon. Alternatively, the entire epididymis is transected just proximal to the site of suspected obstruction and gently squeezed while being observed microscopically to allow detection of the individual tubule exuding the sperm. The fluid is checked for spermatozoa and if none are present, a more proximal transection is made. The anastomosis is then performed with 10-0 nylon, a suture as fine as hair. The single epididymal tubule is sutured to the mucosa of the vas, usually with four quadrant sutures. A second out layer of sutures reinforces the wall of the vas to the epididymis. The more traditional macroscopic technique of suturing the spatulated vas to a "window" in the epididymal tissue from which viable sperm have been identified is an alternative consideration. However, recent reports indicate that the microsurgical approach offers a somewhat better prognosis. Postoperative care is similar to that for the vasectomy.

Whichever technique is used, it is wise to remember that the more distal the epididymal anastomosis, the more completely sperm can mature. It has been reported that when the same anastomotic technique is used, an 11% pregnancy rate can be expected with the obstruction at the caput while a 30% pregnancy rate has been cited for caudal obstruction. As in the vasovasostomy, meticulous hemostasis is necessary; furthermore, a watertight closure is needed to decrease the possibility of sperm granuloma formation with subsequent anastomotic breakdown or stenosis.

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