Medical Treatment
There are several conditions affecting male fertility that can be treated with medicines or supplements. Having said this, it is important for patients to realize that there are numerous supplements available that advertise fertility benefits. Many of these have no proven benefit, however. Conditions that may be reversed with medical therapy include infection or inflammation of the genital tract, the presence of oxidants in the semen, hormonal imbalances, and many others. Supplements that do have some proven benefit can also be discussed.
In some specific cases, men can be treated with either Clomid or Anastrazole, medications used much more frequently in women. This is safe and may, in the right cases, significantly improve sperm production and function.
Surgical Treatment
Surgical treatment for male infertility consists of a few highly specialized, out-patient operative procedures. Some of these are listed below:
Varicocele surgery:
Varicocele, or varicose veins around the testicles, occur in 15% of the general male population, but 40-50% of the infertile male population. These dilated veins are thought to exert their effects by “heating” the testis with warm blood that pools in the veins. Varicoceles are easily detected on physical exam of the testicles by an experienced urologist used to evaluating fertility issues. There are some specific semen analysis findings that are commonly seen with varicoceles such as a decrease in sperm motility and morphology.
There are multiple surgical approaches to varicocele repair. Broadly speaking, these can be divided into microsurgical and non-microsurgical techniques. Non-microsurgical techniques can be safely performed through a small abdominal incision.
However, if one plans the incision in the groin or upper scrotal area (smaller incision, faster recovery time), a surgical microscope should be used as this has clearly been shown to facilitate accurate differentiation of the veins (which need to be “tied off”) from other important structures such as the artery supplying blood to the testis and lymph channels carrying lymph fluid away from the testis. It is critical to eliminate all of the veins contributing to a varicocele to prevent recurrence and to achieve the full benefit to fertility.
Likewise, it is critical to avoid injury to the artery as this is the only blood supply of the testis in this anatomic location. Inadvertent ligation of the artery will result in testicular atrophy (shrinkage) and worsening sperm counts. Ligation of the lymph channels predisposes to hydrocele formation in the future (fluid surrounding the testis). Thus, the operating microscope is essential to perform an accurate, effective and safe varicocele ligation for fertility purposes.
Dr. Nudell has performed over 1000 varicocele repair surgeries using the operating microscope. This surgery is done through a one and a half inch incision below the “underwear line” in the groin area. Surgery can be done in 1 hour and is done as an outpatient. Recovery time is minimal and most men are back at work a few days later. Heavy activity may resume in 1 week.
Microscopic epididymal sperm aspiration (MESA)
Sperm may be harvested surgically from the epididymis without attempted vasectomy reversal reconstruction. This is usually performed in men who have had an extreme time interval between vasectomy and reversal (> 25 years) or in the rare instance when there is a congenital blockage in the male genital system. This can be done either percutaneously (through the skin with a needle) or open (surgically with the operating microscope).
In general, the open technique allows for a much greater harvest of sperm to be frozen, but requires a minor surgery with a small scrotal incision. Enough sperm can usually be aspirated from one side precluding the need for a second incision. Surgery takes about 1 hour and is done as an out-patient. Once sperm is cryopreserved, it can be used at any fertility center around the country.
Testicular sperm extraction (TESE) and Micro dissection TESE
In some cases, sperm must be taken directly from the testicle for in vitro fertilization. This occurs in men with very low sperm production who have no sperm in the ejaculate in which the cause is not from a blockage of sperm flow (called nonobstructive azoospermia). It also occurs in some men with epididymal scarring, previous failed vasectomy reversal and in some 
men with congenital blockages of the sperm ducts.
TESE can be done in either the office (local anesthesia) or in the surgery center (many anesthesia options). It does not require an operating microscope. Essentially, it entails making a very small scrotal incision over the testis and removing a small piece (biopsy) of testis tissue. That tissue is immediately examined by Dr. Nudell and an embryologist to determine the presence or absence of sperm.
In some instances, multiple areas of the testis will need to by sampled (all through the same skin incision) in order to find adequate numbers of healthy sperm. In cases where only small “pockets” of sperm production may exist within the testis, a technique known as microdissection TESE would be performed.
Dr. Nudell has extensive experience in this given his microsurgical background. In these cases, this procedure has been shown to allow for the detection of viable sperm in many previously untreatable men.
Los Gatos Surgery Center fees (includes anesthesia time):
Los Gatos Surgical Center would be happy to give you a confidential price quotation in writing prior to your surgery. They can be reached at (408) 356-0454. Mention that you are having surgery with Dr. Nudell and give them the type of surgery planned. Alternatively we can supply these to you through our office depending on which type of procedure is planned.
IVF Center Fees:
If surgery is being done in an IVF center, patients should contact the IVF center for facility fees that would be applied in addition to surgeon fees.