Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're highlighting procedures for male infertility. Joining me is Dr. Peter Kolettis. He's a Professor of Urology at UAB Medicine. Dr. Kolettis, thank you so much for joining us again. So in this episode today, we're going to talk about procedures. From your perspective, what are the most common procedural interventions that are currently used in the management of male infertility?

Peter Kolettis, MD: So, the most common procedures that we perform to treat male fertility are varicocele ligation, sperm retrieval to obtain sperm for IVF, and then vasectomy reversals.

Melanie Cole, MS: Okay. So, we've got these three interventions that are the main ones. How has the role of these surgical procedures evolved relative to medical or lifestyle-based interventions in the recent years? Can you give us a little sort of evolution of how these have come about. Have they changed? Are they pretty much standard throughout? Tell us a little bit about that.

Peter Kolettis, MD: Varicocele treatment has not changed significantly, I would say. Back in the '90s probably was when microsurgery was introduced to do varicocele surgery, and most of us that do varicocele surgery use a surgical microscope now. So, that has not changed significantly. The varicocele is the most commonly identified abnormality when a man's evaluated for infertility. So, it is a relatively common procedure for male infertility.

The reasons to do the procedure would be, if a man has infertility, that is inability to establish conception after a year, a varicocele that can be felt or palpable varicocele and an abnormal semen analysis. The chance for success with treating varicocele, about two-thirds of men improve their semen parameters in some way. And then overall, about 40% of men can have a pregnancy when they have treatment for their varicocele.

Melanie Cole, MS: Is this an in-office procedure? Is it done in the OR? Tell us a little bit about the procedure itself. Is it laparoscopic? Is it sometimes done as an open surgery?

Peter Kolettis, MD: It's done with an open surgery, but it's a small incision just above the scrotum to get access to the spermatic cord. So, there is anesthesia. I use general anesthesia. Some people could use a local anesthetic plus sedation, but there is some anesthesia involved and it is done in the operating room because of the need for the microscope, the surgical microscope, and then all of the equipment. It's outpatient surgery. It takes about an hour to an hour and a half to do. Recovery time is about a week for returning their full activity.

Melanie Cole, MS: What have you seen as far as complications? How long it takes the man to become sexually active again? Tell us a little bit about the quality of life right after this procedure.

Peter Kolettis, MD: Well, for one week, I limit the man's activity, so no lifting or straining, no sexual activity for a week. But after a week, they're able to resume full activities. The first semen analysis we do three months later to see if there's any improvement in the semen parameters. But really only for one week is there any activity restrictions required.

Melanie Cole, MS: Dr. Kolettis, since you mentioned the different procedural interventions, how do you and the patient and the couple work together with a shared decision-making to decide which procedure might be best for that man?

Peter Kolettis, MD: With respect to varicocele, the goal is to improve their semen parameters, sperm count, sperm motility, et cetera, such that they're able to establish conception naturally. The alternatives to fixing the varicose would be to proceed to one of the advanced fertility treatments such as IVF, which depending on details, for the particular couple that may have a better chance for their getting pregnant.

Similarly with vasectomy reversal, the goal is to have a couple be able to establish conception naturally to have sperm return of the semen and conceive naturally and avoid more advanced complicated fertility treatments for fertility. Some men may choose to not have the vasectomy reversal performed, but that's the goal of the vasectomy reversal.

And then, finally, the third procedure we mentioned was retrieving sperm. If you do any kind of procedure to retrieve sperm, you have to do IVF. You can't do anything else with those sperms. So in order for the couple to proceed with that, they have to know that they are ready to do IVF or comfortable doing IVF.

Melanie Cole, MS: So, I'd like you to expand on that, what you were just saying for just a second. When you're talking about surgical sperm retrieval, how do you coordinate and optimize that coordination between that surgical sperm retrieval and the IVF cycles? Are you working with fertility specialists? What's your role in this coordination?

Peter Kolettis, MD: So, my role is to evaluate and treat the man in the infertile couple. The fertility gynecologists, they evaluate and treat the man's partner. And then, the reproductive endocrinologists, they're involved in running a laboratory where the gametes, the sperm and eggs, are manipulated. Their team is with us in the operating room when we do this sperm retrieval procedures so that we can know if we're able to retrieve sperm, how much sperm or approximately how much sperm we have, and knowing if we need to continue to sample the testis to obtain more sperm or not. And in general, we freeze the sperm so that then the IVF cycle, the retrieval of the eggs and all of the steps there are separated from the man's sperm retrieval procedure.

So, my role-- again, to summarize my role-- is evaluating and treating the man. And then, the reproductive endocrinologist, the fertility gynecologist, they evaluate and treat the man's partner and then they oversee the laboratory for the manipulation of the sperm and eggs.

Melanie Cole, MS: So, it's a real multidisciplinary approach with your reproductive endocrinology colleagues. Speak a little bit about how you all work together as far as the patient themselves. Do they see you determinate, then they go see their fertility specialists? Are you all working together as a team? Tell us a little bit about how this all works, the flow for you.

Peter Kolettis, MD: It's definitely a team approach. So, I evaluated and treat the man as we said. And then, we coordinate the care for the couple with the reproductive endocrinologist. And it depends on the particular case for the couple, what might be required for the man's partner. But yeah, it's definitely done as a team and that really optimizes the evaluation and the treatment so that procedures can be coordinated, treatments can be coordinated, communication between us is really, really critical to allow us to provide the best care. it's all within the center here at UAB.

Melanie Cole, MS: Such a comprehensive approach and so important what you're discussing here. So, how do you counsel patients-- before we get ready to wrap up-- about realistic expectations for any of these fertility outcomes after these procedures, whether it's vasectomy, reversal, or varicocele? How do you speak to them and let other providers know that are counseling their patients about these realistic expectations?

Peter Kolettis, MD: Well, we discuss what factors determine success. So for sperm retrieval, we can do some testing ahead of time, which may or may not help us predict the chance for finding sperm. And sometimes that allows us to give additional information to counsel the couple. Sometimes, we don't get any more information or have any better ability to predict success

And so, we have to make sure the patients understand. And there's always this element of uncertainty when one does these sperm retrieval procedures. But the couples in this position. Really, this is their only option in order to have their own biological children. So, they have to be motivated and prepared to do this. And there's a lot of discussion between the partners, of course, that goes on before they attempt something like this. For vasectomy reversal, the key factors for success, the time since vasectomy, the surgical technique, and then some of the findings at the time of surgery, such as the appearance of the fluid that we see when we cut the vas deference. So, some of those factors are known ahead of time. We discuss that with the man. And then also, discuss some of the intraoperative findings can affect results and affect the actual procedure performed.

Melanie Cole, MS: Dr. Kolettis, do you have some final thoughts for other providers on what you and your team are doing as far as procedural interventions for male infertility at UAB Medicine?

Peter Kolettis, MD: Between the reproductive endocrinologist and myself we're able to evaluate and treat couples and offer them all of the latest innovations in fertility treatment. And also, some of the types of procedures that have been around for many years, such as varicocele ligation and vasectomy reversal. But we're able to work together as a team and provide the best care and give the couple the greatest number of options.

Melanie Cole, MS: Thank you so much, Dr. Kolettis, for joining us today. You've given us great information about those procedures and the work that you're doing at UAB Medicine. Thank you again. And for more information, you can visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.