Wednesday, March 31, 2010

Male Infertilty:Should we go for microsurgery wherever feasible rather than Assisted Reproductive Technology

There has been atleast 6 studies since 1973 which unambiguously show decrease in average sperm count as we are stepping into 21 st century.There has been estimated 5.2 million decrease in sperm count each year and the motilty has been reduced by 0.5% per year.This can be attributed to life style changes-smoking,substance abuse, increasing psychogenic stress,increasing prevalence of metabolic syndrome(obesity,hypertension),exposure to industrial/mutagenic pollutants and herbicides etc.This means more and more males will become infertiles and resort to medical/surgical or Assisted reproductive treatment.

Over the past 30 years,the treatment of infertility has seen the development of revolutionary new assisted reproduction technologies.First in 1978 Loius Brown - first baby to be concieved by In-Vitro Fertilisation and then it was micro-assisted Reproduction using techniques such as Intra-cytoplasmic sperm injection.

These highly complex technologies are used with increasing frequency in the treatment of couples around the globe;more than 1 million abies worldwide have been concieved by this manner.
These technologies bypass natural barriers so their is a risk of unwanted genetic traits being passed on to next generation .Researchers firmly believe that perhaps 75% of all infertility patients have a genetic basis.Then there is financial costs involved apart from mental agony if multiple cycles are required.
IVF and ICSI has been now routinely advised to all infertile males when medical management or Intra-Uterine Insemination fails.If evaluated properly the infertile males can be offered microsurgical treatment for allowing them to utilise a chance to parent their own biological children without or with a minimal aid of assisted reproduction.

Basically the infertile males can be grossly divided into two types of problems in sperm deficit in semen: Obstructive(defect in transport) or Non-Obstructive(defect in production).
In obstructive sperm problems, the bloackage can be treated in appropriate case by microsurgical reconstruction of the blocked passage(micro-surgical vaso-epididymostomy,microsurgical vasovasostomy).The chance of sperm reappearance rate can be as high as 80%.But unlike western populations; my observations about microsurgical success in India is less, probably because of the blockages here are more commonly due to infection.Infective blockages can be very difficult to treat even with microsurgery.
Microsurgery gives a magnification of 25-30 times.This magnification is highly necessary in reconstruction of vas/epididymis(male seminal pathway) as the naked eye cannot even visualise them properly so reconstructing them would be a remote possibility.

The advantage of microsurgical reconstruction is that once successful;natural conception is possible or minimal aid of Asssisted reproduction is necessary.I call it as one plus one free package as unlike IVF the couples donot have to resort to again same procedure for the second baby.
The multiple data have revealed cost effectiveness of microsurgical reconstruction over the routine sperm retrieval for IVF and ICSI.
For unobstructed oligospermia(problem with production); microsurgery has significant role in varicocecele(15-40% causative factor in male infertility).It can give success rate of almost 60%(pregnancy rate) in varicocele(although this issue is controversial- two randomised controlled trials have proven a role for surgery in varicocele related infertility).

One more area where it has a role is in some cases of male infertility that are advised donor insemination or adoption because of advanced testicular damage.In such cases microsurgical sperm retrieval(Micro-dissection TESE) can be utilised to find sperm in testis and this sperm can be used for Test Tube Baby process.The routine testicular sperm aspiration or biopsy may not yield sperms in grossly damaged testis but microsurgery can still offer a hope in such cases.

So I stress upon proper evaluation of male factor in infertility and offering them microsurgery in suitable cases before giving them an option for Assisted Reproduction Technology.


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