Overview
Infertility is the inability to conceive after at least one year of unprotected intercourse. Since most people are able to conceive within this time, physicians recommend that couples unable to do so be assessed for fertility problems. In men, hormone disorders, illness, reproductive anatomy trauma and obstruction, and sexual dysfunction can temporarily or permanently affect sperm and prevent conception. Some disorders become more difficult to treat the longer they persist without treatment.

Sperm Development (spermatogenesis) takes place in the ducts (seminiferous tubules) of the testes. Cell division produces mature sperm cells (spermatozoa) that contain one-half of a man's genetic code. Each spermatogenesis cycle consists of six stages and takes about 16 days to complete. Approximately five cycles, or 2 Ѕ months, are needed to produce one mature sperm. Energy-generating organelles (mitochondria) inside each sperm power its tail (flagellum) so that it can swim to the female egg once inside the vagina. Sperm development is ultimately controlled by the endocrine (hormonal) system that comprises the hypothalamic-pituitary-gonadal axis.  Because sperm development takes over 2 months, illness that was present during the first cycle may affect mature sperm, regardless of a man's health at the time of examination.

Incidence and Prevalence
According to the National Institutes of Health, male infertility is involved in approximately 40% of the 2.6 million infertile married couples in the United States. One-half of these men experience irreversible infertility and cannot father children, and a small number of these cases are caused by a treatable medical condition.

Causes and Risk Factors
The primary causes of male infertility are impaired sperm production, impaired sperm delivery, and testosterone deficiency (hypogonadism). Infertility can result from a condition that is present at birth (congenital) or that develops later (acquired). Causes of infertility include the following:

Procedural Overview
These procedures are performed to harvest sperm for invitro fertilization procedures to attain pregnancy. The MESA is a microscopic epididymal sperm aspiration, the TSA is a testicular sperm aspiration and the testis biopsy obtains testicular tissue to find individual sperm. The MESA and TSA or TESE use fine needles that are inserted into the various structures that sperm travel and aspirated. Very little seminal fluid is required since only one live sperm per cycle is required for intracytoplasmic sperm insertion (ICSI). These procedures are completed using a scrotal incision and can be completed in the office setting or in the hospital operating room.

Pre-Operative Instructions
Before your surgery, you will be seen by the physician and the anesthesiologist, and when applicable, there is a pre-admission appointment with the hospital. Click here to read more details about these appointments, referred to as the Pre-Operative Work-Up.

Change In Health Status
Notify your surgeon if you experience any significant change in your health status: develop a cold, influenza, a bladder infection, diarrhea, or other infection, before your surgery.

Pre-Operative Medication Instructions
Unless specifically instructed otherwise by your surgeon or anesthesiologist, please observe the following guidelines for taking your medicines before surgery:

1. One Week Prior to Surgery:
   - STOP all aspirin and all aspirin-containing medicines (e.g., Anacin, Excedrin, Pepto-Bismol). Check any cold or pain medication bottles to make certain aspirin is not contained.
2. Two Days Prior to Surgery:
   - STOP all nonsteroidal anti-inflammatory medications (e.g., etodolac [Lodine], fenoprofen [Nalfon], ibuprofen [Advil, Motrin, Nuprin], ketorolac [Toradol], maproxen [Aleve], meclofenarnate [Meclomen], mefenamic acid [Ponstel], naproxen [Anaprox, Naprosyn].
3. Day Before Your Surgery:
   Normally this is when you would start the pre-operative Bowel Preparation appropriate for this surgery. As this procedure is not close to the bowel and injury is extremely unlikely, there is no bowel prep required for the procedure.
4. On the Morning of your Surgery:
   • DO NOT TAKE digitalis medicines (e.g., Crystodigin, Digoxin, Lanoxin).
   • DO NOT TAKE oral antidiabetes medicines (e.g., chlorpropamide [Diabinese], glyburide [DiaBeta, Glynase, Micronase], glypizide [Glucotrol], tolazamide [Tolinase], tolbutamide [Orinase].
   • DO TAKE one-half of your usual morning. INSULIN dose. DO NOT TAKE your morning INSULIN dose if you are driving a great distance the morning of surgery or if your surgery is scheduled for the afternoon.
   • DO TAKE, with a small sip of water, ALL of your other usual morning doses of regularly prescribed medicines. Use your asthma inhalers and bring them with you to the hospital.

Pre-Operative Diet Instructions
Unless specifically instructed otherwise by your surgeon or anesthesiologist, patients of all ages must observe the following diet restrictions before surgery:

1. Eight hours before the Scheduled Start of your Surgery:
   DO NOT EAT any solid foods, including juices with pulp (e.g., orange juice, nectars), lozenges, candy, chewing gum, and mints. DO NOT DRINK full liquid, such as milk, cream, and jello. You may continue to drink up to eight ounces of clear liquids until SIX hours before the scheduled start of your surgery. Clear liquids include Water, clear juices (e.g., apple, grape), black tea and black coffee.
2. Six hours before the Scheduled Start of your Surgery:
   DO NOT TAKE anything by mouth except for your usual medicines; follow the Preoperative medication instructions above.
3. Exceptions:
   DO NOT TAKE anything by mouth for eight hours, except for your usual medicines, if you are pregnant, morbidly obese, or are diagnosed with diabetes, renal failure, or stomach acid reflux with heartburn.

Patients undergoing operative or diagnostic procedures involving sedation are required to refrain from eating, drinking or taking anything by mouth for a stated period prior to their surgery or procedure. The reason for this is to prevent complications caused by nausea or vomiting while you are unconscious. Should you vomit while in the unconscious state, the risk exists that the vomit may enter into your lungs causing serious complications such as pneumonia. These complications may result in an extension of your hospitalization following your surgical procedure. It is for this reason patients are often instructed to have nothing by mouth after midnight the night prior to your operation unless otherwise instructed by an anesthetist.

Pre-Operative Cleaning Instructions (bathing and showering instructions)
Pre-operative showers are to be taken the night before and the morning of surgery just prior to your arrival. All adults are required to take a shower using either a Betadine or Hibiclens Surgical Scrub antibacterial soap. The reason is to remove as much bacteria from your skin as possible prior to your surgery. If you are allergic to these products please notify your physician or nurse. Perform your shower as follows:

1. Generously lather your body, scrub well, and rinse. Give particular attention to the area were the incision will be made for your procedure.
2. Following the morning shower, do not apply creams, body oils, lotions, perfumes, deodorants, makeup, lipstick, nail polish or any other cosmetic product to the skin or nails.
3. Do not use Hibiclens on your face. You may use any other antibacterial soap for the face.
4. Children under 5 years of age are to be given a bath using an over the counter antibacterial soap.

On The Day Of Surgery

• Take your medicines as instructed above.
• You may brush your teeth; rinse your mouth, but do not swallow the water.
• Leave all jewelry (including wedding and all other rings) and valuables (including money and credit cards) at home.
• If you wear contact lenses, glasses or hearing aids, please bring a case or container, and solution for contacts, to protect them while you are in surgery.
• Wear a minimum amount of makeup, and no mascara. Please remove the nail polish from both index fingers.
• Please bring a copy of your current medical problem list from you primary care physician (family medicine/internist).
• Minors (anyone less than 18 years old) must be accompanied by a parent or legal guardian to sign the operative consent fount

The anesthesiologist will discuss with you the anesthetic most appropriate for your medical condition and procedure prior to surgery.

After your surgery you must be escorted/driven home by a responsible adult. You may take a taxi car or shuttle if accompanied by a responsible adult who can stay with you after the driver departs.

Time To Arrive For Your Surgery
During your Pre-Admission Interview, our Registered Nurse will provide you with the correct time to arrive for check-in prior to your surgery.

Indications
Patient is a male patient with infertility (azospermia or severe oligoasthenospermia). The patient requests a diagnostic explanation for his condition or is part of an artificial reproductive techniques program and this procedure will serve to harvest viable sperm for intracytoplasmic sperm injection (ICSI). The remainder of the viable sperm will be frozen and available for future cycles

Alternatives
Alternatives include donor sperm or adoption.

Risks/Complications
The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.

The specific risks of this procedure include, but are not limited to: local hematoma formation, chronic epididymal or testicular pain or infection and failure to find viable sperm.

You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.

Detailed Surgery Description

Indications
Male with infertility and azospermia

Sample Procedure Dictation
The patient was placed in the supine position and then prepped and draped in the usual standard sterile manner. He was given local lidocaine anesthesia to the scrotum and given a spermatic cord block. A transverse scrotal incision was made through the skin, subcutaneous tissue, dartos layer, and the tunica vaginalis. The testicle was then delivered through the scrotal incision. The tunica vaginalis incision was extended the full length of the cavity carefully avoiding the epididymis, cord structures and the testicle. The head of the epididymis was exposed and a sample of semen was aspirated and viewed under low power microscopy. Motile sperm was identified and saved for artificial reproductive techniques. Epididymal capsule was closed with 4-0 chromic suture. The testicular appendix and epididymal appendix were both coagulated incidentally to avoid future torsion. The scrotal contents were inspected and noted to be normal. All bleeders were coagulated. The testis was placed back into the tunica vaginalis and a two-layer closure was performed with 3-0 chromic sutures. The skin was closed with running 4-0 monocryl sutures. Patient was then awaken from anesthesia without complications and transferred to the Recovery Room (RR). The patient arrived to the RR in stable condition and without complications.

The information deck will overhead page you or the "family of" when they receive the recovery call to let you know that the surgery has been completed. The overhead page system works ONLY on the Surgical Waiting Area and not throughout the hospital or the cafeteria.

We will plan to see you in the surgical waiting area after we have safely completed the early phases of the post-anesthesia recovery in the "Recovery Room" or PAR (Post Anesthesia Recovery). This may take up to an hour after the initial call. Sometimes, especially if another case is ready to start, we will call and talk to you. If for some reason, we have not come or called within 30 minutes, please ask the information desk to page us.

Your family member will be in the Recovery Room for 1-2 hours. This is standard recovery time, although the times vary with each individual. For example, spinal anesthetics take longer to "wear off," local anesthetics are much shorter acting. Under no circumstances are family members or friends allowed in the recovery room. The information deck will inform you of the patient's return to the room as soon as they receive the information that the patient has left recovery. At that time, they will give you the room number and direct you to the correct wing and floor.

  General Instructions

1. Rest today.
2. Resume your regular diet. Some nausea after anesthesia is common.
3. Drink plenty of fluids . We recommend 24-32 oz. over your usual intake daily. Avoid tea, coffee (including decaf), carbonated products and alcoholic drinks.
4. You may experience some pain and burning when you urinate. There may be blood in your urine. This will get better over 1-3 days.
5. No sexual activity for 1 week unless instructed otherwise by your doctor.
6. Please call the urology office today to schedule your follow-up appointment.
7. Please start the medications prescribed by your doctor today. Please complete the entire prescription and do not share medications with others. If there is a problem taking or getting the medication, call us.
8. If a ureteral stent was placed, you may experience frequent urination, blood in the urine and occasional discomfort. This may continue until the stent is removed.

Special Instructions for Endoscopic Procedures

1. This may cause a burning sensation with urinating for 2-3 days.
2. You may pass blood in your urine over the next 3-5 days, progressively getting better.
3. You may have some bladder irritability, urgency, frequency and or incontinence. With most of the transurethral procedures, you will be discharged with Detrol to relax your bladder.

Circumcisions, Penile or Scrotal Surgeries

1. If you had a circumcision, remove Vaseline gauze dressing on the morning after surgery. You may need to soak in a warm (not hot) tub prior to removal. Apply Bacitracin or similar ointment to the wound three times a day.
2. All other dressing should be removed the second day after surgery unless otherwise directed. You may take showers daily once dressing is removed. No tub baths for 1 week unless otherwise directed.
3. Wear scrotal support with a jock strap or snug briefs for two weeks if you have had any testicular/scrotal surgery.
4. No sexual activity until you have seen the doctor.
5. Apply an ice pack to your groin for 24 hours.

Special Instructions for Patients with Catheters

1. If you have a catheter in place, wash around it gently with soap and water. Keep the catheter taped to your thigh or abdomen to avoid inadvertent jerking or pulling. Do not disconnect the catheter from the drainage bag unless directed by your doctor.
2. Some blood might be seen in the bag. This is normal. If the urine is very bloody, and the bag does not appear to be draining well, call our office.