Male Infertility

What is Male Infertility?
Approximately 15% of all couples face infertility issues. Up to 50% of infertility in couples may be due to male factors. Male infertility focuses on the male factors that may contribute to the couple's infertility issues. Infertility treatment is a team approach involving female infertility and male infertility specialists with one goal in mind - to help the couple have a child.

What causes Male Infertility?
A number of factors may lead to male infertility. These may range from genetic and physiologic to environmental causes. The careful evaluation and examination of male infertility patients to geared to assess any of these possible causes and to rectify them if possible.

Can Male Infertility be treated?
There are a number of male infertility conditions that can be treated. Our center specializes in some of the most innovative and cutting edge treatment options for male infertility. We are involved in a number of research protocols to develop new diagnostic and therapeutic options. We are committed to providing our patients with the safest and highest quality care available.

What kind of treatment options are available?
Our center has made a serious commitment to the development of new diagnostic and surgical treatment options for Male Infertility. Dr. Parekattil performed the first robotic bilateral vasoepididymostomy (complex vasectomy reversal) on July 25th, 2007. Our group also performed the first robotic TESE (procedure for sperm collection from the testicle) in July 2007.

In August 2007, our group performed the world's first 3D Target Scan Trans-Rectal imaging of the seminal vesicles and ejaculatory ducts with vasodynamics - a new modality to detect ejaculatory duct obstruction in some infertile men.

Testicular Pain

Up to 1% of all men who undergo a vasectomy, inguinal hernia surgery, groin surgery, recurrent/chronic epididymitis or pelvic trauma may develop chronic testicular or groin pain. This pain can range from a minor irritation to debilitating pain. Our program provides a one of its kind multi-disciplinary clinic focused on the treatment and elimination of such pain. We have developed and provide novel treatment options such as mapped anesthetic spermatic cord blocks and robotic microsurgical Neurolysis of the spermatic cord (since 2007). A collaborative effort with pelvic floor rehabilitation and acupuncture specialists is also available. Our Program has made a serious commitment to the development of new diagnostic and surgical treatment options for Male Infertility. We are the leading institution in robotic vasectomy reversal (since 2007), robotic TESE (procedure for sperm collection from the testicle since 2007), and 3D Targets can Trans-Rectal imaging of the seminal vesicles and ejaculatory ducts with vasodynamics - a new modality to detect ejaculatory duct obstruction in infertile men. Cutting edge functional and imaging methods for guided testicular biopsies are also available for men with no sperm in their ejaculate.

What is chronic testicular pain?
A small percentage of men who have previously undergone vasectomy, hernia surgery, kidney removal, scrotal or pelvic trauma, recurrent epididymal / testicular infections present with chronic testicular pain. This pain may range from a mild irritation to severe debilitating pain that impacts the patient's quality of life significantly.

What causes chronic testicular pain?
The reasons are not quite clear. One theory is that the sensory pain fibers running along the spermatic cord may for some reason have a very low stimulation threshold due to previous scrotal surgery (vasectomy), hernia surgery, kidney removal, scrotal or pelvic trauma and recurrent epididymal / testicular infections. This could be due to local irritation / inflammation along these nerve fibers. For this reason, we try conservative therapies initially since a number of patients have spontaneous resolution of the pain after a period of observation. This period may range from a few months to a few years. Our goal is to provide maximal comfort and relief for the patient from a quality of life standpoint with minimal risk - so if a patient has significant pain impacting their daily activities, more aggressive surgical intervention may be pursued at that point. This nerve hyper-stimulation can create extraordinary pain for the patient that is quite real, but cannot be defined as any structural abnormality by imaging modalities (these patients usually have a completely normal scrotal ultrasound). Our recommendation is generally not to perform any type of exploratory procedures on patients to remove possible staples and/or remove portions of the reproductive tract (epididymis/ testis/ scar tissue, etc) - since these additional procedures can sometimes aggravate the pain by further stimulating these already dysfunctional nerve fibers.

How is chronic testicular pain treated?
Chronic testicular pain is usually initially managed using conservative therapies initially. A complete neurologic, urologic and psychosocial workup is completed to ensure that there is no other contributing factor to this pain. If this workup is negative, a trial of oral anti-inflammatory, steroids, acupuncture and/or pelvic floor rehabilitation may be utilized. If all these techniques fail, then we have developed some unique treatment options that may offer relief:

1. Mapped segmental spermatic cord block - A precise minimally invasive delivery of local anesthetics and anti-inflammatory agents at predefined locations along the spermatic cord to assess if specific nerve fiber de-activation provides pain relief for the patient. If this resolves the pain, then the pain is likely to be of a neurologic origin due to hypersensitive pain nerve fibers. The cord block usually only provides temporary relief (hours, days or weeks - depending on the individual patient and their baseline pain characteristics). A patient who responds to the cord block (even transiently) is likely to be a good candidate for robotic neurolysis of the spermatic cord which will usually provides permanent relief.
   
   
2. Robotic assisted microsurgical neurolysis of the spermatic cord - In patients who respond to the cord block, we perform a highly specialized robotic assisted microsurgical dissection of the nerve fibers in the spermatic cord and ligate them to hopefully achieve permanent pain relief. This technique involves a small 1-2 cm skin incision in the groin and then dissection through the spermatic cord in a minimally invasive manner. We are the leading center in the development of this technique and have achieved a complete or partial resolution of pain in up to 93% of our patients so far based on a validated pain impact score (the PIQ-6 score). This procedure is performed with real-time intra-operative Doppler identification and protection of the testicular arteries to prevent any potential testicular atrophy / injury. The robotic platform provides unparalleled 3 dimensional high definition visualization, refined surgical instrument handling (removal of any tremor) and the ability for the surgeon to utilize multiple instruments simultaneously (due to the additional robotic arm) to provide enhanced efficiency.
   
   
3. Robotic assisted microsurgical vasectomy reversal - In a small percentage of men who have previously undergone a vasectomy, there may be chronic testicular / groin pain. This pain can range from a mild irritation to debilitating pain that requires chronic pain medication use. In some of these men with specific findings of episodic pain, especially after ejaculation, or episodic pressure sensations, robotic assisted vasectomy reversal may be a treatment option. This modality is utilized if the patient does not respond to a cord block. Successful relief of pain may be achieved in up to 69% of patients undergoing microsurgical vasectomy reversal. In our preliminary small cohort of patients undergoing robotic vasectomy reversal for pain, we have achieved a higher pain resolution rate.

What can we offer patients with chronic testicular pain?
Our center provides a unique multi-disciplinary approach to the evaluation and treatment of chronic testicular pain. Our mission is to provide the most innovative and reliable treatment options available for the management of this condition in a compassionate manner.

Robotic Vasectomy Reversal for Chronic Testicular/Groin Pain
In a small percentage of men who have previously undergone a vasectomy, there may be chronic testicular / groin pain. This pain can range from a mild irritation to debilitating pain that requires chronic pain medication use. In some of these men with specific findings of episodic pain, especially after ejaculation, or episodic pressure sensations, robotic assisted vasectomy reversal may be a treatment option. We have a dedicated testicular pain / groin pain clinic dedicated to the treatment of men with this condition and have a number of treatment options.

Treatment

Robotic Testicular Sperm Extraction
For men who have no sperm in their ejaculate (also known as azoospermia), one option for the retrieval of sperm is testicular sperm extraction (TESE). There have been a number of microsurgical advances in this technique to optimize the likelihood of finding sperm at the time of the procedure. We have developed a robotic microsurgical technique for TESE that may potentially further improve these outcomes

Doppler Duplex Testicular Mapping
Previous studies have shown that in men who are azoospermic (no sperm in ejaculate) there may be areas of the testicle with better blood flow that harbor sperm that could be used in combination with assisted reproductive techniques (In-vitro fertilization - IVF) to achieve a pregnancy. Our center currently offers a study evaluating the use of a novel Doppler Duplex flow mapping device that allows us to map the testicular blood flow and possibly predict areas that may harbor sperm for extraction.

Robotic Vasectomy Reversal
Success rates after microsurgical vasectomy reversal can be as high as 98-99% depending on how many years it has been since the patient's previous vasectomy. The highest success rates are encountered in patients within 3 years of their vasectomy. As the time interval from the vasectomy increases, the success rate decreases slightly. We have had successes in men who are even over 17 years out from their vasectomy. In an effort to optimize our outcomes, we now offer robotic microsurgical vasectomy reversal. We utilize the DaVinci S High definition robotic platform as our microsurgical platform.

Some patients may have a secondary blockage in the epididymis - which is the storage container for sperm, located behind the testicle. This blockage occurs more frequently in men who are further out from their vasectomy. Thus, at the time of reversal, our team microscopically exams the fluid that comes out of the proximal vas (end of vas coming from the testicle) for sperm. If there is an epididymal blockage, there will be no sperm and thus, the distal end of the vas need to be connected directly to the epididymal tubule above the level of obstruction.

We also offer the following procedures:

• Robotic TESE
• Robotic Varicocelectomy
• PESA
• MESA
• Testis Biopsy
• Electroejactulation
• Vibratory Ejaculation
• Sperm Cryopreservation
• Retrograde Ejaculation
• Semen Analysis

Our Surgeons

Sijo Joseph Parekattil, MD

Co-Director of Robotic Surgery
Director, Male Infertility & Microsurgery
Assistant Professor of Urology
Adjunct Professor of Bio-Engineering

Dr. Parekattil is a board certified urologic surgeon with dual two year fellowship training in advanced laparoscopy/robotics for oncology and microsurgery for male infertility from the Cleveland Clinic Foundation, Cleveland. He was an Electrical Engineer (University of Michigan) prior to his medical training (New York Medical College). He strives to perform procedures combining robotics, laparoscopy and microsurgery for the treatment of prostate cancer, renal cancer and male infertility. He has been awarded numerous awards including two consecutive annual innovator awards from the Cleveland Clinic Foundation. Dr. Parekattil has been with the department since March 2007.

Appointments

To schedule an appointment with Dr. Parekattil, please contact the following numbers:
Appointments (Oncology): 352-265-8282
Appointments (Infertility): 352-265-6200
Appointments (Testicular Pain): 352-265-8240
Fax: 352-273-7515

E-mail: sijo.parekattil@urology.ufl .edu

For more information, directions to the Medical Plaza and local accommodations please visit: http://urology.ufl.edu/urocare.php