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Video: Dr. Silber explains vasectomy reversal in detail: what works, what doesn't work, and why.

Two of Dr. Silber's patients relate their experiences receiving care at the Infertility Center of St. Louis.

Male Infertility

There is no more confused medical care in our field than what is delivered by many urologists to the couple that suffers from "male infertility." In fact, many couples are told to delay the IVF treatment they should have had sooner (because of the wife's advancing age) in order just to wait for some dubious treatment of the male partner to increase his sperm count. Numerous control studies have demonstrated that administering clomid or nutritional supplements to the male does nothing to improve his sperm count, and the often suggested testosterone supplements just lowers rather than raises his sperm count, and may even render him totally sterile.

In addition, many husbands in infertile marriages are sent to urologists who then almost always in some communities recommend "varicocoelectomy." This is a procedure to tie off a varicose vein of the testicle. More than 15% of all men on the planet have a varicose vein of their left testicle, and most of these men are quite fertile. It is a completely benign and normal variant of testicular anatomy. Yet often the husband is subjected to this completely meddlesome surgery, often on both sides, despite the absence even of a varicocoele, and despite its ineffectiveness in improving his sperm count. It is however ironically quite effective in delaying the treatment the couple really needs all the while the wife's eggs keep getting older. Furthermore, if done clumsily, bilateral varicocoelectomy can reduce the husband's merely low sperm count down to a zero sperm count.

Let's give a few examples:

I recently saw a physician couple (he was an anesthesiologist and she was an OB-GYN) who had needed IVF because the wife was already 40 years old (old eggs) and the husband had a very moderately low sperm count of 21,000,000 sperm per cc.They went to a very famous IVF center, which wanted the husband, mind you a physician, to be seen by a urologist before they went to the IVF. The urologist proceeded to order many thousands of dollars of absolutely unnecessary testing, including hormone assays, scrotal ultrasound, and sperm "DNA fragmentation," all of which added to the urologist's income. After all these worthless tests, he recommended bilateral varicocoelectomy, even though in truth the patient did not even have a varicocoele. (Even if he did have bilateral varicocoeles, this would have been a useless procedure.) Post-operatively the husband, mind you a physician, now had zero sperm count instead of 21,000,000 per cc.

Another recent example is a man who had a perfectly normal sperm count, and the couple was about to undergo IVF at a well known IVF clinic which recommends, for some inexplicable reason, that the husband see a urologist "just to make sure" everything was OK. Again, after a series of useless but expensive "andrological" tests, the urologist came up with a most terrible meddlesome recommendation. He told the couple they would have better results with the IVF if instead of using his normal ejaculated sperm, they should perform a testicle biopsy and use testicular sperm, which in truth would give worse results than the ejaculated sperm. Not withstanding this terrible advice, he suggested that first they should do a bilateral varicocoelectomy, even though the sperm count was normal and the wife was in her 40's.

So what is appropriate treatment for male infertility in an infertile couple? For most men with low sperm counts, there is no treatment which will raise the sperm count, since sperm counts are genetically determined. It is best in cases of low sperm count to go directly to IVF and ICSI (which is injecting sperm into the egg) before the wife becomes so old that her older eggs become a compounding problem.

Azoospermia and Vasectomy Reversal

However, there are many infertile couples in whom the male is completely azoospermic (that is, no sperm at all in the ejaculate). For these cases, the urologist is actually needed, but again often his treatment is poorly performed. For example, I recently saw a couple from Texas that needed a vasectomy reversal procedure. He had had a vasectomy in the past, and needed a reversal to try to have another child. He went to a urologist in Texas who offers "money back" guarantees. I have re-operated on many of the patients of this doctor who failed reversal attempts and I know that none of them ever had their money returned as he always had room in his "contract" to wiggle out.

The doctor he saw lied to him on three counts. Firstly, he told him post-op after the vasectomy reversal that he now had sperm in his ejaculate and that the vas reconnection had been successful. But there was no sperm in the ejaculate, and when we did his re-operation a year later, we found that the two cut ends of the vas were nowhere near each other. Therefore he could never ever have had sperm in his ejaculate after his previous surgery. The second lie was that the doctor said he had found sperm in the vas fluid when he did the vas reconnection. But there were epididymal blowouts indicating there could not have possibly been sperm in the vas fluid. The third lie was that he could possibly have had a successful reversal even if a vas reconnection had been performed, because what he needed was a reconnection of the vas to the epididymis proximal to the blowout site.

So taking all three of these lies into account, we re-operated on this patient who supposedly had had a successful vasectomy reversal back home in Texas, doing a rather extensive procedure to free up all the surgically induced scar tissue, and reconnected the vas [watch video] to the epididymis on both sides. Now he truly is fertile, with normal sperm count, and has successfully impregnated his wife finally, with no need for IVF.

Azoospermia Not Caused by Vasectomy

If the azoospermia is not caused by a previous vasectomy, it is usually not correctable with reconstruction, and then sperm retrieval [watch video] with IVF and ICSI is necessary. In fact, we were the center that invented sperm retrieval with ICSI [watch video] for azoospermic men in the 1990s, and have the greatest experience and expertise with it.

There are two entirely different situations and causes for no sperm in the ejaculate (azoospermia): obstructive and non-obstructive. For obstructive azoospermia, aside from vasectomy, which is reversible with reconstructive microsurgery, there are men who were born with absence of the vas. Most of them have a mutation on their CF (cystic fibrosis) gene or chromosome 7, but do not have cystic fibrosis. They just never developed a vas deferens in fetal life, and they do not discover they have this problem until they get married, try to have children, and discover they have no sperm in the ejaculate. There is no vas to reconstruct and so the only way they can have children is to microsurgically retrieve sperm from their epididymis and inject this sperm into the wife's eggs via IVF. This procedure is virtually 100% successful.

The second type of azoospermia is "non-obstructive." This means there is not any obstruction, but the patient "appears" to have just no sperm production at all in his testes. Usually this is partly just an illusion, in that the majority of such patients do have a tiny amount of sperm production in their testes, but just not quantitatively enough sperm production to "spill over" into the ejaculate. These cases should usually, but not always, be successful in retrieving enough sperm for successful IVF and ICSI.

In both types of sperm retrieval, obstructive and non-obstructive, it is important to use precise microsurgical techniques rather than just "needle sticks" to have the highest percentage of success and also the least amount of pain or complications. Unfortunately, this is not always the case, and some husbands have fairly horrible experiences, which just shouldn't happen. For example, I just recently saw a couple who had gone through 10 IVF cycles with retrieval sperm for congenital absence of the vas at a reputable IVF clinic, with over 20 embryos transferred but no pregnancy. Each time he had the sperm retrieval done with a needle stick rather than microsurgery, and each time relatively poor quality sperm were used because the urologist could not see where in the epididymis he was poking. So he retrieved mostly older sperm with a lot of DNA fragmentation, thus explaining the wife's failure to conceive. Furthermore, he had a great deal of pain and swelling with each crude needle stick procedure making his wife frustrated when he became less and less enthusiastic with each IVF cycle at the thought of going through another one. Also, the sperm the urologist had retrieved was so poor that the laboratory would not freeze it, even though the proper approach would have been to obtain good quality sperm that would freeze well and obviate any further need for sperm retrieval.

There are countless cases I have seen of this kind of mismanagement of male infertility at office IVF centers that have no microsurgical knowledge of the male. Just recently we saw an azoospermic patient who had been diagnosed at 10 years of age with a rare condition called Kartagener's Syndrome, where their ciliated cells in the lungs and nose and even the epididymis (the tiny duct which carries sperm out of the testicle into the vas deferens) are unable to move. The tiny hair-like cilia can't wiggle and sweep the fluids along well, but modern treatment makes it a minor condition except for one thing: they have no sperm in the ejaculate.

This patient wasted years of time, energy, and money going through worthless testing, while his wife's eggs were getting older. When he finally reached our clinic, the same day I performed a microsurgical sperm retrieval under local anesthesia, which resulted in our obtaining millions of vigorous motile sperm perfect for IVF. His previous clinic had thought that his Kartagener's Syndrome would make his sperm non-motile and nonfunctional even for IVF, but clearly that was not the case. The sperm were perfectly normal. They just couldn't get out of his epididymis into the ejaculate.

Another recent example of the poor quality of male infertility treatment at many IVF clinics I saw recently was more tragic. This was a patient with non-obstructive azoospermia who was sent by his clinic to a urologist who did a useless varicocele operation on both sides in a highly scarred and difficult inguinal area, because the cause of the azoospermia was undescended testis, as well as very destructive testis biopsy on both sides. The result was that in addition to azoospermia, he now also had no testosterone production either. This poor patient became a eunuch as a result of the overzealous and poorly performed attempt at sperm retrieval he had to suffer through.

So in summary, male infertility treatment, short of IVF and ICSI, should be limited to microsurgery for azoospermia, and careful thought has to go into making your choice of where to go for such treatment.

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If you have any questions, you may call us at  (314) 576-1400.