NC.com

Non-Surgical Management of Infertility

Ejaculatory stimulation

• Penile vibratory stimulation: vibrator stimulates ejaculation in anejaculatory men, ejaculation reflex pathway must be intact, usually does not work in RPLND or SCI patients
• Electroejaculation: electrical current applied via transrectal probe, usually induces retrograde ejaculation (remove sperm from bladder), does not require ejaculation reflex, requires anesthesia (very painful)

Medications

Class	Medication	Dose	Indication	Side effects
Gonadotropin agonist	Human Chorionic Gonadotropin (HCG)	1500-5000 IU 2-3x weekly Titrate up to 10K IU/week Titrate to T level	Hypogonadotropic hypogonadism	Nausea (12%) Breast enlargement/tenderness (1-10%) Headache (34%) Injection discomfort (1-10%)
	Human Menopausal Gonadotropin (HMG)	75-150 IU 2-3x weekly
Selective estrogen receptor modulator	Clomiphene citrate	25mg QD or 50mg EOD Titrate to max 100mg QD Titrate to T level		Headache (1%) Blurred vision (2%) Flushing (10%) Breast discomfort (2%) Nausea (2%) Impaired libido Gynecomastia (rare)
Aromatase inhibitor	Anostrozole	1mg daily	Hypergonadotropic hypogonadism (Kleinfelter syndrome)	Nausea (11-19%) Headache (9-10%) Hot flashes (12-26%) Chest discomfort (2-12%)
	Lestrozole	2.5mg daily
Dopamine agonist	Cabergoline	0.25mg 2x weekly Titrate up to 1mg Titrate per prolactin levels	Prolactin-secreting pituitary tumor	Headache (26%) Dizziness (15-17%) Nausea (27-29%) Constipation (7-10%)
a-agonist	Pseudoephedrine	60mg PO QID	Retrograde ejaculation	restlessness Nausea/vomiting Weakness Headache Nervousness Dizziness Palpitations

Surgical Management of Infertility

Surgical treatment

Class	Procedure	Indications	Description	Side effects
Azoospermia diagnosis	Testis aspiration	Confirm obstructive (vs nonobstructive) azoospermia	Insert biopsy needle (thru skin or skin incision) and aspirate to assess for sperm	Hematoma, hematocele, spermatocele, hydrocele
	Testis biopsy		Incise tunica albuginea, extrude tubules and remove, close incision	Low risk bleeding
Sperm retrieval	Tes(TESE)	Obstructive azoospermia	Obtain sperm via opening testis or epididymis and removing tubules	Bleeding, postop pain
	microTESE	Nonobstructive azoospermia	Obtain sperm via assessing and extracting microtubules
	Epididymal sperm extraction	Obstructive azoospermia with epididymal dilation	Obtain sperm via assessing and extracting microtubules
Improve sperm delivery	Vas reversal	Obstructive azoospermia (after vasectomy)	Obtain sperm via assessing and extracting microtubules	Hematoma (0.3%), granulomas (5%), delayed failure (5%), can consider TESE instead
	Transurethral resection of ejaculatory ducts (TURED)	Obstructive azoospermia (ejaculatory ducts)	Resect ducts to remove obstruction, can transrectally inject dye to improve identification	Restenosis, pain, epididymoorchitis (chemical/infectious), retention, incontinence, hematuria
Assisted reproductive technology	Intrauterine insemination (IUI)	Normal sperm but unable to reach egg naturally, oligospermia (5-8mil)	Inject collected/concentrated sperm into uterus (via cervix) to allow natural fertilization of egg	Minimal risks
	In vitro fertilization (IVF)	Sperm unable to reach egg, oligospermia (< 5mil)	Sperm placed in proximity to egg, natural fertilization, embryos placed within uterus for implantation	Risks of egg stimulation/retrieval Multifetal pregnancy
	Intracytoplasmic sperm injection (ICSI)	Sperm unable to fertilize egg, oligospermia (< 5mil)	Sperm directly injected into egg, embryos placed within uterus for implantation	Risks of egg stimulation/retrieval 4x risk for sex chromosome abnormalities Congenital malformations (slight increased risk) Spontaneous abortion/ectopic pregnancy

Varicoceles

• Prevalence: 15% all men, 40% subfertile men, more comon on L side, most common cause of infertility
• Grading scale (1-3): palpable with Valsalva only, palpable standing without Valsalva, visible on exam)
• Surgery recommended: palpable varicocele, infertility, and abnormal semen parameters
• Sugery maybe recommended: palpable varicocele and associated testis pain (may not improve/resolve), adolescent with varicocele + small testis (reverses testicular atrophy but may not prevent infertility)
• Surgery not recommended: non-clinically significant varicocele, even if scrotal/testis pain, non-obstructive azoospermia
• Success: pain improves in 50-90%, semen parameters improve in 70%, rates based on surgeon experience/technique, microsurgical has 1% recurrence rate and 0.4% hydrocele rate
• Varicocelectomy side effects: hematoma, hydrocele, edema, recurrence, atrophy, infection