Surgical treatment of male infertility

A surgeon can be of practical help in the treatment of the infertile male in several ways: 1) by relieving obstruction of the vas deferens 2) by curing varicocoeles and 3) by bringing down ectopic testes. Among the 4000 men who have been seen at the Liverpool Infertility Clinic I have found 41 men with bilateral absence of the vas deferens 16 men with unilateral absence of the vas 6 men with vasa deferentia in which no lumen had developed and 1 man who had a double vas on 1 side. Treatment of congenital absence of the vasa is a difficult surgical problem. In 2 cases I have tried to form an epididymal sinus; in another I formed an artificial spermatocoele by making a tent of polythene. I have tried ligation of the body of the epididymis in human males on 5 occasions so far and in 3 cases small cysts have been formed. Attempts to aspirate these cysts for AIH have been unsuccessful. Bilateral traumatic obstructions of the vasa are less common than congenital absence. I have seen only 5 such cases all following operations for the surgical cure of bilateral hernia in infancy. Treatment of traumatic obstruction is by excision and end-to-end anastomosis of the vas. In my cases although obstruction in the seminal pathway had been present from 25 to 40 years speramatogenesis was taking place and 4 out of 5 had spermatozoa in their ejaculate after the operation. The relief of azoospermia due to bilateral blockage of the vas deferens following infection or congenital malformations is by the delicate operation of epididymo-vasostomy. The vas is found incised and its patency towards the urethra demonstrated by passing a nylon suture. The serous coat of the epididymis is incised and the tubules beneath cut across. A specimen of the exudate from this surface is examined for the presence of spermatozoa. The window in the vas is buried in the cut epididymis; to keep an open channel I leave a nylon splint running through the vas deferens and epididymis for 8 days. I have performed 326 operations on 249 azoopspermic men. 121 men had spermatozoa in the ejaculate following operation. My records show that 23 men have produced 32 pregnancies including 5 miscarriages. 48% have been cured of azoospermia but only 9% became fathers. Recently I have become aware of a genetic linkage between bronchiectasis possibly due to congential cystic disease of the lung and failure of the vasa efferentia to join together as an epididymis. I call it the Berry-Perkins-Young syndrome. (AUTHORS MODIFIED)