Male Infertility Science Lecture Series (Lecture 5: Scattergun Weapon – Microsurgery for Male Infertility Patients)
In the well-known “said Tang”, the last move of Qin Qiong’s ancestral mace method is the killer mace, equivalent to Luo Cheng’s back to the horse pistol stance, scattered hand mace is the main weapon in the cold weapon era
The main weapon can’t win or be chased by the enemy to a desperate situation, suddenly back to the mace to the enemy a fatal blow, defeat as victory, scattered hand mace has high technical content, power, critical moment use, unexpected, a move to the enemy and defeat
The characteristics of a spermatorrhea are: high technical content, great power, use at the critical moment, surprise, one move to control the enemy and counter defeat. In the past, azoospermia patients could only achieve their goal by using other people’s sperm or adopting a child, however, after all, not their own biological offspring, the emergence of the second generation of IVF technology (i.e. intracytoplasmic single sperm injection technology, also known as ICSI technology), as long as several sperm from the testes can make male azoospermia patients round the dream of obtaining their own biological offspring, but IVF technology Microsurgery (microscopic vas deferens-vas deferens anastomosis, microscopic vas deferens-epididididymal anastomosis) for patients with non-obstructive azoospermia has solved this problem. Although microsurgery has been introduced into China for only fifteen years, it is a powerful weapon in the field of male infertility treatment, adding color to male infertility treatment.
A case introduction
Case 1: Male infertility patient
The patient had no sperm in three routine semen centrifugal examinations, and the reproductive hormone examination showed that follicle-stimulating hormone and luteinizing hormone were significantly elevated, and the karyotype was 47XXY.
The patient was advised to use donor sperm or adopt a child, but the patient dreamed of having a biological offspring. The patient came to our hospital and tried microscopic sperm retrieval combined with intracytoplasmic single sperm injection, which resulted in finding sperm under the surgical microscope, and the patient’s spouse soon became pregnant.
Case 2: Male infertility patient, 32 years old, the patient had a daughter and used vasectomy for contraception 5 years ago, the patient now wants to have a second child and came to our hospital, we performed microscopic vas deferens-vasectomy on the patient, after the operation the sperm in the patient’s semen improved from none to nearly normal.
Case 3: Male infertility patient, 32 years old, the patient was azoospermic, a large number of sperm was seen by testicular puncture, the external genitalia of the patient were normal, we successfully performed microscopic vas deferens-epididididymal anastomosis on the patient, a large number of sperm was seen in the semen of the patient after the operation, and his spouse soon became pregnant.
II Case study.
Patients with testicular spermatogenic failure are those with microtesis and testicular puncture without mature spermatozoa. Microtesis is generally referred to as Klinefelter’s syndrome due to the failure to separate the neutral chromosomes during meiosis (40% occur during spermatogenesis and 60% during oogenesis); chimeric Klinefelter’s syndrome is due to the failure to separate the neutral chromosomes during mitosis of the fertilized egg, and chimeric Klinefelter’s syndrome accounts for approximately 10 The incidence of Klinefelter syndrome ranges from 1/1000 to 1/500. The Klinefelter syndrome phenotype is male, and the typical clinical manifestations are
small, hard testes (median testicular volume of 4 ml), gynecomastia and hypergonadotropic gonadotropins. Some studies suggest that the incidence of breast cancer is more than 50 times higher in patients with Klinefelter syndrome than in normal men. Serum testosterone levels are reduced in 50% to 75% of typical Klinefelter syndrome patients, and serum FSH and serum LH levels are elevated in 90%. Estradiol is elevated due to aromatization of androstenedione in the surrounding adipose tissue, and the increased estradiol/testosterone ratio causes gynecomastia.
Testicular biopsy shows generalized sclerosis of the varicocele with occasional individual varicocele containing supporting cells and spermatozoa. Such patients need to address two aspects: low androgen problems, patients such as low testosterone, it is recommended to supplement testosterone’s, the purpose of testosterone supplementation is not to improve fertility, but for their own health (sexual life and other body systems health problems); fertility problems: if there is sperm in the semen, then IVF can be done to achieve fertility, but there are risks, the day of sperm retrieval, the male partner has the risk of not being able to retrieve sperm, only temporarily freeze the woman’s egg cells, and, it is generally recommended to take the third generation of IVF technology (pre-implantation genetic diagnosis (PGD), that is, before embryo transfer, take one cell of the embryo for screening to avoid the transmission of genetic diseases from the father or mother to the next generation), if there is no sperm, then generally can only use the sperm in the sperm bank to achieve the purpose of fertility; adoption of children; some patients can consider Microscopic sperm retrieval, where it is possible to find sperm using an operating microscope and then achieve fertility through IVF techniques.
For azoospermia patients with microspermia or testicular biopsies that do not find sperm, microscopic sperm retrieval makes it possible to find sperm in the testicles again to achieve the possibility of having their own biological offspring, and may cause less damage to the testicles.
In microsemination, the surgical microscope can magnify the field of view 20-25 times to find sperm in the thicker, more opaque varicocele, greatly improving the efficiency of finding sperm.
The overall probability of finding spermatozoa is 63% (more detailed information shows that in azoospermic patients with hypospermia, the probability of finding spermatozoa is 81%, maturation block is 42%, and support cell only syndrome is 24%), much higher than the 45% of traditional testicular puncture, and less damage to the testis. The average number of spermatozoa found in 720 mg of testicular tissue is 64,000, while the traditional testicular puncture technique avoids damage to important blood vessels in the testis. Foreign studies on Creutzfeldt-Jakob disease have shown that about 50% of non-chimeric Creutzfeldt-Jakob syndrome patients without sperm in the semen can be found by microsemination; even in patients with Creutzfeldt-Jakob syndrome using the ICSI technique, the offspring generally have normal chromosomes (49/50 in the foreign literature), but it is not known whether normal sperm in Creutzfeldt-Jakob syndrome patients originate from normal spermatogonia or whether they are corrected by meiosis; Creutzfeldt-Jakob The sperm acquisition rate in patients with Kirschner syndrome is almost the same as that in patients with general non-obstructive azoospermia, about 47% (50/106) in Kirschner syndrome and 50% (188/379) in patients with general non-obstructive azoospermia, but the insemination rate after ICSI technique is lower than that in patients with general non-obstructive azoospermia, 57% and 65%, respectively, and the pregnancy and miscarriage rates are about the same, 55 and 53% and The pregnancy and miscarriage rates were similar, at 55 and 53%, and 12 and 11.5%, respectively.
The incidence of azoospermia is about 1% in the male population and 10%-15% in the male infertility population.
The incidence of azoospermia is about 1% in the male population and 10%-15% in the male infertility population. Obstructive azoospermia accounts for about 40% of patients with azoospermia and is divided into ejaculatory obstruction (about 1 to 3%), vas deferens obstruction, epididymal obstruction (about 30% to 67%) and intra-testicular obstruction (about 15%). In patients with non-obstructive azoospermia, fertility can only be achieved by testicular/epidididymal sperm retrieval combined with single sperm injection. If obstructive azoospermia occurs in the ejaculatory duct, we can open the obstruction through spermoscopy; if obstructive azoospermia occurs in the vas deferens, such as after vasectomy, microscopic vas deferens-vas deferens anastomosis can be performed, and the postoperative recanalization rate is 99.5%, but the pregnancy rate is only 54%, probably due to immune factors, and even if the female factor is excluded, the pregnancy rate is still only 64%. If the obstruction occurs in the epididymis and the spermatogenic function in the testis is good, vasectomy can be performed. The European Guidelines for the Treatment of Male Infertility state that in patients with non-obstructive azoospermia suitable for vasectomy, the postoperative recanalization rate is 60% to 87% and the cumulative pregnancy rate is 10% to 43%.
Combined with the cases for analysis.
Case 1: The patient’s karyotype is 47XXY and the testes are small, about the size of a peanut rice. The patient was very persistent in having biological offspring because the author suggested the patient to try microscopic sperm retrieval, a scattered technique in the field of male medicine, which resulted in finding sperm under the operating microscope and fulfilling the patient’s dream with the help of ICSI technology.
Case 2: The patient was a post-vasectomy patient, a typical patient with obstructive azoospermia, and the obstruction was in the vas deferens, and the patient also achieved good results using microscopic vas deferens-vasectomy anastomosis.
Case 3: This patient was a patient with obstructive azoospermia. The patient’s examination showed that the testes and vas deferens were normal and the epididymis was very full, so the author initially judged that the patient was a patient with obstructive azoospermia and the obstruction was in the epididymis, and the intraoperative investigation confirmed the author’s preoperative judgment, so the microscopic vas deferens-epidididymal anastomosis was performed, and the patient also achieved good results after the operation, and his spouse became pregnant soon.
III Summary
Microsurgery is the weapon of urological male surgeons, and it is a beautiful weapon in the field of male infertility treatment.
Microsurgery is a beautiful sight in the field of male infertility treatment. Microscopic sperm extraction allows azoospermia patients whose testicular biopsy does not reveal sperm or microspermia patients who have no sperm in about half of their semen to find sperm in the testicles again and then use
The technique can be used to achieve fertility. For patients with obstructive azoospermia, if the obstruction is in the ejaculatory duct, we can open the obstruction through vesicoscopic surgery; if the obstruction is in the vas deferens, such as after vasectomy
If the obstruction occurs in the vas deferens, such as after vasectomy, microscopic vas deferens-vas deferens anastomosis can be performed, and the postoperative recanalization rate is 99.5%, but the pregnancy rate is only 54%, probably due to the immune factor, and even if the female factor is excluded, the pregnancy rate is still only 64%; if the obstruction occurs in the epididymis, and the sperm production function in the testis is good, vas deferens-epididididymal anastomosis can be performed, and the postoperative recanalization rate is 60%~87%, and the cumulative pregnancy rate is The cumulative pregnancy rate is 10%~43%.