Male Infertility

1 What is Male Infertility?

Infertility is a term doctors use if a man hasn't been able to get a woman pregnant after at least one year of trying.

Causes of male infertility include:

  • Physical problems with the testicles
  • Blockages in the ducts that carry sperm
  • Hormone problems
  • A history of high fevers or mumps
  • Genetic disorders
  • Lifestyle or environmental factors

About a third of the time, infertility is because of a problem with the man. One third of the time, it is a problem with the woman. Sometimes no cause can be found.

If you suspect you are infertile, see your doctor. There are tests that may tell if you have fertility problems. When it is possible to find the cause, treatments may include medicines, surgery, or assisted reproductive technology. Happily, many couples treated for infertility are able to have babies.

2 Symptoms

In most cases, there are no obvious signs and symptoms of male infertility. Intercourse, erections and ejaculation will usually happen without difficulty. The quantity and appearance of the ejaculated semen generally appears normal to the naked eye.

Medical tests are needed to find out if a man is infertile.

3 Causes

Male infertility can be caused by a number of health issues and medical treatments. Some of these include:

Sperm Production Problems:

  • Chromosomal or genetic causes
  • Undescended testes (failure of the testes to descend at birth)
  • Infections
  • Torsion (twisting of the testis in scrotum)
  • Varicocele (varicose veins of the testes)
  • Medicines and chemicals
  • Radiation damage
  • Unknown cause

Blockage of Sperm Transport:

  • Infections
  • Prostate-related problems
  • Absence of vas deferens
  • Vasectomy

Sexual Problems (erection and ejaculation problems):

Hormonal Problems:

  • Pituitary tumours
  • Congenital lack of LH/FSH (pituitary problem from birth)
  • Anabolic (androgenic) steroid abuse

Sperm Antibodies:

  • Vasectomy
  • Injury or infection in the epididymis
  • Unknown cause

4 Making a Diagnosis

Making a diagnosis of male infertility is done by performing several tests and procedures.

In any fertility work-up, both male and female partners are tested if pregnancy fails to occur after a year of regular unprotected sexual intercourse. It should be done earlier if a woman is over age 35 or if either partner has known risk factors for infertility. A work-up can not only uncover the causes of infertility but also detect other potentially serious medical problems, including genetic mutations, cancer, or diabetes.

Fertility History

The doctor will ask about any medical or sexual factors that might affect fertility:

  • Frequency and timing of sexual intercourse
  • Duration of infertility and any previous fertility events
  • Childhood illnesses and any problems in development
  • Any serious illness (such as diabetes, respiratory infections, cancer, or previous surgeries)
  • Sexual history, including any sexually transmitted diseases
  • Any exposure to toxins, such as chemicals or radiation
  • History of any medications and allergies
  • Any family history of reproductive problems

Physical Exam

A fertility specialist, usually an urologist, will perform a physical examination. A physical examination of the scrotum, including the testes, is essential for any male fertility work-up. It is useful for detecting large varicoceles, undescended testes, and absence of vas deferens, cysts, or other physical abnormalities.

  • Varicoceles large enough to possibly interfere with fertility can be felt during examination of the scrotum. In such cases, they are described as feeling like ""a bag of worms."" They disappear or are greatly reduced when the patient lies down, so the patient should be examined for varicocele while standing.
  • Checking the size of the testicles is helpful. Smaller-sized and softer testicles along with tests that show low sperm count are strongly associated with problems in sperm formation. Normal testicles accompanied by a low sperm count, however, suggest possible obstruction. The doctor may also take the temperature of the scrotum with a test called scrotal thermography.
  • The doctor will also check the prostate gland for abnormalities.
  • The penis is checked for warts, discharge from the urinary tract, and hypospadias (incorrect location of the urethra opening).

Post-Ejaculatory Urine Sample

A urine sample to detect sperm after ejaculation may rule out or indicate retrograde ejaculation. It also may be used to test for infections.

Semen Analysis

The basic test to evaluate a man's fertility is a semen analysis. The sperm collection test for men who can produce semen involves the following steps:

  • A man should abstain from ejaculation for several days before the test because each ejaculation can reduce the number of sperm by as much as a third. To ensure an accurate sample, most doctors recommend abstaining from ejaculation for at least 2 days, but not more than 5 days, prior to semen collection.
  • A man collects a sample of his semen in a collection jar during masturbation either at home or at the doctor's office. Proper collection procedure is important, since the highest concentration of sperm is contained in the initial portion of the ejaculate. Specially designed condoms are also available that enable collection of a sample during sexual intercourse. (Regular condoms are not useful, since they often contain substances that kill sperm.)
  • The sample should be kept at body temperature and delivered promptly. If the sperm are not analyzed within 2 hours or kept reasonably warm, a large proportion may die or lose motility.
  • A semen analysis should be repeated at least three times over several months.
  • The sperm count test is performed if a man's fertility is in question. It is helpful in determining if there is a problem in sperm production or quality of the sperm as a cause of infertility. The test may also be used after a vasectomy to make sure there are no sperm in the semen.

The man and woman should both be present when the doctor discusses the results of this analysis so that both partners understand the implications. The analysis report should contain results of any abnormalities in sperm count, motility, and morphology as well as any problem in the semen. However, semen analysis alone is not necessarily a definitive indicator of either infertility or fertility.

  • A semen analysis will provide information on:
  • Amount of semen produced (volume)
  • Number of sperm per milliliter of semen (concentration)
  • Total number of sperm in the sample (count)
  • Percentage of moving sperm (motility)
  • Shape of sperm (morphology)

Semen Volume and Concentration:

The seminal fluid (semen) itself is analyzed for abnormalities. The color is checked and should be whitish-gray.
The amount of semen is important. Most men ejaculate 2.5 - 5 milliliters (mL) (1/2 - 1 teaspoon) of semen. Either significantly higher or lower amounts can be a sign of prostate problems, blockage, or retrograde ejaculation.
The semen will be tested for how liquid it is. Abnormal results may suggest prostate gland problems or lack of sperm.

Other factors may also be measured:

  • An absence of semen fructose (sugar) may indicate obstruction in the vas deferens or epididymis.
  • Low levels of a substance called inhibin B, which is produced only in the testes, may indicate blockage or other defects in the seminiferous tubules.
  • Low levels of another compound, alpha-glucosidase, may also indicate blockage in the epididymis.

Sperm Count:

A low sperm count should not be viewed as a definitive diagnosis of infertility but rather as one indicator of a fertility problem. In general, a normal sperm count is considered to be 20 million per milliliter of semen.

Sperm Motility:

Motility (the speed and quality of movement) is graded on a 1 - 4 ranking system. For fertility, motility should be greater than 2.

  • Grade 1 sperm wriggle sluggishly and make little forward progress. (Sperm that, in fact, clump together may indicate that antibodies to the sperm are present.)
  • Grade 2 sperm move forward, but they are either very slow or do not move in a straight line.
  • Grade 3 sperm move in a straight line at a reasonable speed and can home in on an egg accurately.
  • Grade 4 sperm are as accurate as Grade 3 sperm, but move at a very rapid speed.

More than 63% of sperm should be motile for normal fertility, but even men whose motile sperm constitutes only about a third of the total sperm count should not rule out conception.

Testing for sperm motility is important for predicting the success of assisted reproductive technologies and which men might be candidates for the intracytoplasmic sperm injection (ICSI) fertilization technique, in which the sperm is inserted directly into the egg and motility plays almost no role.

Sperm Morphology:

Morphology is the shape and structure of the sperm. Determining the morphology of the sperm is particularly important for the success of the fertility treatments in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).

Blood Tests.

Blood tests are used for measuring several factors that might affect fertility:

Hormonal Levels:

Men produce both male hormones (testosterone) as well as pituitary hormones (FSH and LH). Tests for these hormone levels are indicated if semen analysis is abnormal (especially if sperm concentration is less than 10 million per milliliter) or there are other indications of hormonal disorders.

  • Blood tests for testosterone and follicle-stimulating hormone (FSH) levels are usually taken first.
  • If testosterone levels are low, then luteinizing hormone (LH) is measured.

Low levels of FSH, LH, and testosterone may indicate a diagnosis of hypogonadotropic hypogonadism. Very high FSH levels with normal levels of other hormones indicate abnormalities in initial sperm production. Usually this occurs only if the testicles are severely defective, causing Sertoli cell-only syndrome, in which sperm-manufacturing cells are absent.

Other hormones, such as prolactin, estrogen, or stress hormones may be measured if there are symptoms of other problems, such as low sexual drive or the presence of breasts.

Infections:

Blood tests can determine the presence of any infections that might affect fertility, including HIV, hepatitis, and Chlamydia.

Ultrasound.

Ultrasound imaging may be used to accurately determine the size of the testes or to detect cysts, tumors, abnormal blood flow, or varicoceles that are too small for physical detection (although such small veins may have little or no effect on fertility). It can also help detect testicular cancer.

Sperm Penetration Tests.

Cervical Mucus Penetration Test: This post-coital test is designed to evaluate the effect of a woman's cervical mucus on a man's sperm. Typically, a woman is asked to come into the doctor's office within 2 - 24 hours after intercourse at mid-cycle (when ovulation should occur).

A small sample of her cervical mucus is examined under a microscope. If the doctor observes no surviving sperm or no sperm at all, the cervical mucus will then be cultured for the presence of infection. The test cannot evaluate sperm movement from the cervix into the fallopian tubes or the sperm's ability to fertilize an egg.

Micro-Penetration Assay Test:

This test checks to see if sperm can penetrate hamster eggs that have had their covering removed. If less than 5 - 20% of the eggs are penetrated, infertility is diagnosed. It may be useful for determining the best assisted reproductive treatment options for men with infertility.

Genetic Testing.

Genetic testing may be warranted in men who are severely deficient in sperm and who show no evidence of obstruction, particularly in men undergoing the intracytoplasmic sperm injection (ICSI) procedure.

Genetic testing can help identify sperm DNA fragmentation, chromosomal defects, or the possibility of genetic diseases that can be passed on to children. If genetic abnormalities are suspected in either partner, counseling is recommended.

5 Treatment

Treatment depends on what's causing male infertility. Many problems can be fixed with drugs or surgery. This would allow conception through normal sex.

The treatments below are broken into 3 categories:

  1. Non-surgical therapy for Male Infertility
  2. Surgical Therapy for Male Infertility
  3. Treatment for Unknown Causes of Male Infertility

Non-Surgical Treatment for Specific Male Infertility Conditions.

Anejaculation: Anejaculation is when there's no semen. It's not common, but can be caused by:

Drugs are often tried first to treat this condition. If they fail, there are 2 next steps. Rectal probe electroejaculation (RPE, better known as electroejaculation or EEJ) is one. Penile vibratory stimulation (PVS) is the other.

Rectal probe electroejaculation is most often done under anesthesia. This is true except in men with a damaged spinal cord. RPE retrieves sperm in 90 out of 100 men who have it done. Many sperm are collected with this method. But sperm movement and shape may still lower fertility.

Penile vibratory stimulation vibrates the tip and shaft of the penis to help get a natural climax. While non-invasive, it doesn't work as well as RPE. This is especially true in severe cases.

Assisted reproductive techniques like in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are of great value to men with anejaculation.

Congenital Adrenal Hyperplasia (CAH).

CAH is a rare cause of male infertility. It involves flaws from birth in certain enzymes. This causes abnormal hormone production. CAH is most often diagnosed by looking for too much steroid in the blood and urine. CAH can be treated with hormone replacement.

Genital Tract Infection.

Genital tract infection is rarely linked to infertility. It's only found in about 2 out of 100 men with fertility problems. In those cases, the problem is often diagnosed from a semen test. In the test, white blood cells are found. White blood cells make too much "reactive oxygen species" (ROS). This lowers the chances of sperm being able to fertilize an egg. For example, a severe infection of the epididymis and testes may cause testicular shrinking and epididymal duct blockage. The infection doesn't have to be sudden to cause problems.

Antibiotics are often given for full-blown infections. But they're not used for lesser inflammations. They can sometimes harm sperm production. Non-steroidal anti-inflammatories (such as ibuprofen) are often used instead.

Inflammation from causes other than infection can also affect fertility. For example, chronic prostatitis, in rare cases, can also block the ejaculatory ducts.

Hyperprolactinemia.

Hyperprolactinemia is when the pituitary gland makes too much of the hormone prolactin. It's a factor in infertility and erectile dysfunction. Treatment depends on what's causing the increase. If medications are the cause, your health care provider may stop them. Drugs may be given to bring prolactin levels to normal. If a growth in the pituitary gland is found, you may be referred to a neurosurgeon.

Hypogonadotropic Hypogonadism.

Hypogonadotropic hypogonadism is when the testicles don't make sperm due to poor stimulation by the pituitary hormones. This is due to a problem in the pituitary or hypothalamus. It's the cause of a small percentage of infertility in men. It can exist at birth (""congenital""). Or it can show up later ("acquired").

The congenital form, known also as Kallmann's syndrome, is caused by lower amounts of gonadotropin-releasing hormone (GnRH). GnRH is a hormone made by the hypothalamus. The acquired form can be triggered by other health issues such as:

If hypogonadotropic hypogonadism is suspected, your health care provider may want you to have an MRI. This will show a picture of your pituitary gland. You will also have a blood test to check prolactin levels. Together, an MRI and blood test can rule out pituitary tumors.

If there are high levels of prolactin but no tumor on the pituitary gland, your provider may try to lower your prolactin first. Gonadotropin replacement therapy would be the next step. During treatment, blood testosterone levels and semen will be checked. Chances for pregnancy are very good. The sperm resulting from this treatment are normal.

Immunologic Infertility.

In vitro fertilization with Intracytoplasmic Sperm Injection (ICSI) is now preferred for fertility problems caused by the immune system. This abnormality is very rare.

Reactive Oxygen Species (ROS).

Many compounds have been used to detoxify or ""scavenge"" (fix) ROS levels. The most studied of these, Vitamin E (400 IU twice daily), can work well as an antioxidant. Pentoxifylline, coenzyme Q, and Vitamin C have also been shown to lower sperm ROS. They're used much less often than Vitamin E.

Retrograde Ejaculation.

Retrograde ejaculation, semen flowing back instead of going out the penis, has many causes. It can be caused by:

  • prostate or bladder surgeries
  • diabetes
  • spinal cord injury
  • anti-depressants
  • certain anti-hypertensives
  • medications used to treat prostate enlargement (BPH)

Retrograde ejaculation is found by checking your urine for sperm. This is done under a microscope right after ejaculation. Drugs can be used to correct retrograde ejaculation.

It is often treated first with over-the-counter medications like Sudafed®. If medications don't work and you need assisted reproductive techniques (ARTs), your health care provider may try to collect sperm from your bladder after ejaculation.

Surgical Therapy for Male Infertility.

Varicocele Treatments.

Varicoceles can be fixed with minor outpatient surgery called varicocelectomy. Fixing these swollen veins helps sperm movement, numbers, and structure.

Azoospermia Treatments.

If your semen lacks sperm (azoospermia) because of a blockage, there are many surgical choices.

Microsurgical Vasovasostomy.

Vasovasostomy is used to undo a vasectomy. It uses microsurgery to join the 2 cut parts of the vas deferens in each testicle.

Vasoepididymostomy.

Vasoepididymostomy joins the upper end of the vas deferens to the epididymis. It's the most common microsurgical method to treat epididymal blocks.

Transurethral Resection of the Ejaculatory Duct (TURED).

Ejaculatory duct blockage can be treated surgically. A cystoscope is passed into the urethra (the tube inside the penis) and a small incision is made in the ejaculatory duct. This gets sperm into the semen in about 65 out of 100 men. But there can be problems. Blockages could come back. Incontinence and retrograde ejaculation from bladder damage are other possible but rare problems. Also, only 1 in 4 couples get pregnant naturally after this treatment.

Treatment for Unknown Causes of Male Infertility.

Sometimes it's hard to tell the cause of male infertility. This is called "non-specific" or "idiopathic" male infertility. Your health care provider may uses experience to help figure out what works. This is called "empiric therapy." Because infertility problems are often due to hormones, empiric therapy might balance hormone levels. It's not easy to tell how well empiric treatments will work. Each case is different.

Assisted Reproductive Techniques.

If infertility treatment fails or isn't available, there are ways to get pregnant without sex. These methods are called assisted reproductive techniques (ARTs). Based on the specific type of infertility and the cause, your health care provider may suggest:

Intrauterine Insemination (IUI).

For IUI, your health care provider places the sperm into the female partner's uterus through a tube. IUI is often good for low sperm count and movement problems, retrograde ejaculation, and other causes of infertility.

In Vitro Fertilization (IVF).

IVF is when the egg of a female partner or donor is joined with sperm in a lab Petri dish. For IVF, the ovaries must be overly stimulated. This is often done with drugs. It allows many mature eggs to be retrieved. After 3 to 5 days of growth, the fertilized egg (embryo) is put back into the uterus. IVF is used mostly for women with blocked fallopian tubes. But it's being used more and more in cases where the man has very severe and untreatable oligospermia (low sperm count).

Intracytoplasmic Sperm Injection (ICSI).

ICSI is a variation of IVF. It has revolutionized treatment of severe male infertility. It lets couples thought infertile get pregnant. A single sperm is injected into the egg with a tiny needle. Once the egg is fertilized, it's put in the female partner's uterus. Your health care provider may use ICSI if you have very poor semen quality. It is also used if you have no sperm in the semen caused by a block or testicular failure that can't be fixed. Sperm may also be taken from the testicles or epididymis by surgery for this method.

Sperm Retrieval for ART.

Many microsurgical methods can remove sperm blocked by obstructive azoospermia (no sperm). The goal is to get the best quality and number of cells. This is done while trying not to harm the reproductive tract. These methods include:

Testicular Sperm Extraction (TESE).

This is a common technique used to diagnose the cause of azoospermia. It also gets enough tissue for sperm extraction. The sperm taken from the testicle can be used fresh or frozen ("cryopreserved"). One or many small biopsies are done, often in the office.

Testicular Fine Needle Aspiration (TFNA).

TFNA was first used to diagnose azoospermia. It is now sometimes used to collect sperm from the testicles. A needle and syringe puncture the scrotal skin to pull sperm from the testicle.

Percutaneous Epididymal Sperm Aspiration (PESA).

PESA, like TFNA, can be done many times at low cost. There is no surgical cut. More urologists can do it because it doesn't call for a high-powered microscope. PESA is done under local or general anesthesia. The urologist sticks a needle attached to a syringe into the epididymis. Then he or she gently withdraws fluid. Sperm may not always be gotten this way. You may still need open surgery.

Microsurgical Epididymal Sperm Aspiration (MESA).

With MESA, sperm are also retrieved from the epididymal tubes. This method uses a surgical microscope. MESA yields high amounts of motile sperm. They can be frozen and thawed later for IVF treatments. This method limits harm to the epididymis. It keeps blood out of the fluid. Even though MESA calls for general anesthesia and microsurgical skill, it has a lower problem rate. It's also able to collect larger numbers of sperm with better motility for banking.

6 Prevention

Many types of male infertility aren't preventable. However, you can prevent some causes of male infertility. For example:

  • The biggest preventable danger to male fertility is due to uncontrolled sexually transmitted diseases (STDs) such as syphilis, gonorrhea and Chlamydia which can cause irreparable damage to the reproductive tract.
  • Another important preventable cause of testicular damage in men is uncorrected undescended testes. Undescended testes should be surgically treated at an early age to prevent damage - preferably before the age of 2 years. This requires educating parents of young boys and doctors as well.
  • It may also be a good idea to immunize boys against mumps in childhood, thus preventing the ravage which mumps can cause to the testes in later life.
  • Drugs - including alcohol, cocaine and marijuana - are all poisons. They can reduce sex drive; damage sperm production; and interfere with ovulation - and sometimes this damage is irreparable.
  • Smoking tobacco also affects reproductive function - by depleting egg production; increasing the risk of PID; and lowering sperm counts. Often, the adverse effect is temporary, so that when these are stopped, the harmful effects on reproductive function are likely to be reversed.
  • Occupational hazards can also decrease sperm counts.
  • Many toxic drugs - including radiation, radioactive materials, anesthetic gases.
  • Industrial chemicals such as lead, the pesticide DBCP and the pharmaceutical solvent ethylene oxide can reduce fertility by impairing sperm production.
  • Intense exposure to heat in the workplace (for example, long-distance truck drivers exposed to engine heat; and men working in furnaces or in bakeries) can cause long-term and even permanent impairment of sperm production.

7 Lifestyle and Coping

Following lifestyle modifications are necessary in order to cope with male infertility:

  • Timing and Monitoring Sexual Activity for Best Results: Both male and female hormone levels fluctuate according to the time of day, and they also vary from day to day and month to month. Some timing tips might be helpful.
  • Fertility and Seasonal Changes: Some studies have reported higher sperm counts in the winter than in the summer. For women, fertility rates as measured by treatment success are highest in months when days are longest.
  • Monitoring Basal Body Temperature: To determine the most likely time of ovulation and therefore the time of fertility, a woman should take her body temperature, called her basal body temperature. This is the body's temperature as it rises and falls in accord with hormonal fluctuations. By studying the temperature patterns after a few months, couples can begin to anticipate ovulation and plan their sexual activity accordingly.
  • Frequency of Intercourse: It is not clear how often a couple should have intercourse in order to conceive. Some doctors think that having sex more than 2 days a week adds no benefits. In addition, frequent sexual activity lowers sperm count per ejaculation. Some studies have indicated, however, that having intercourse every day, or even several times a day, before and during ovulation, improves pregnancy rates. Although sperm count per ejaculation is low, a constantly replenished semen supply is more likely to result in a fertilized egg.
  • Dietary Considerations: Everyone should eat a healthy diet rich in fresh fruits, vegetables, and whole grains. Replace animal fats with monounsaturated oils, such as olive oil. Certain specific nutrients and vitamins have been studied for their effects on male infertility and sperm health. They include antioxidant vitamins (vitamin C, vitamin E) and the dietary supplements L-carnitine and L-acetylcarnitine. To date, there is no conclusive evidence that they are effective.

Other Lifestyle Changes

Other tips for helping fertility include:

  • Avoid cigarettes and any drugs that may affect sperm count or reduce sexual function.
  • Overweight men should try to reduce their weight as obesity may be associated with infertility.
  • Get sufficient rest, and exercise moderately but regularly. (Excessive exercise can impair fertility.)
  • Stress may contribute to reduced sperm quality. It is not known if stress reduction techniques can improve fertility, but they may help couples endure the difficult processes involved in fertility treatments.
  • Although studies indicate that tight underwear and pants pose no threat to male fertility, there is no harm in wearing looser clothing.
  • To prevent overheating of the testes, men should avoid hot baths, showers, and steam rooms.
  • Avoid use of sexual lubricants (Astroglide, KY-jelly) as they may affect sperm motility.

Dealing with Stress:

The fertility treatment process presents a roller coaster of emotions. There are almost no sure ways to predict which couples will eventually conceive. Some couples with multiple problems will overcome great odds, while other, seemingly fertile, couples fail to conceive. Many of the new treatments are remarkable, but a live birth is never guaranteed. The emotional burden on the couple is considerable, and some planning is helpful:

  • Decide in advance how many and what kind of procedures will be emotionally and financially acceptable and attempt to determine a final limit. Fertility treatments are expensive. A successful pregnancy often depends on repeated attempts.
  • Prepare for multiple births as a possible outcome for successful pregnancy (especially if assisted reproductive technologies are used). A pregnancy that results in a multiple birth introduces new complexities and emotional problems.
  • Determine alternatives (adoption, donor sperm or egg, or having no children) as early as possible in the fertility process. This can reduce anxiety during treatments and feelings of disappointment if conception does not occur.

8 Risks and Complications

There are several complications associated with male infertility.

Hydrocele formation is the most common complication reported after non-microsurgical varicocelectomy, with an average incidence of about 7%.

Hydroceles form secondary to ligation of the testicular lymphatics. At least half of all post-varicocelectomy hydroceles grow to a size that produces sufficient discomfort to warrant surgical hydrocelectomy.

The effect of hydrocele function on spermatogenesis and fertility is unknown. Theoretically, large hydroceles may impair testicular function by insulating the testis and preventing normal thermoregulation. Use of the operating microscope has essentially eliminated the development of hydroceles following varicocelectomy.

Testicular artery ligation is also a common complication of non-microsurgical varicocelectomy although its true incidence is unknown. Injury or ligation of the testicular artery may cause testicular atrophy, impaired spermatogenesis, or both.

Animal studies indicate that testicular atrophy occurs anywhere from 20% to 100% of the time following testicular artery ligation. Optical magnification and/or the use of a fine tipped Doppler probe facilitate identification and preservation of the testicular artery.

The incidence of varicocele recurrence following surgical repair varies from 1% to 45%. The incidence of recurrence depends upon the type of procedure performed and the use of magnification.

Venographic studies have shown that recurrent varicoceles are caused by periarterial, parallel inguinal, midretroperitoneal, gubernacular and transcrotal collateral veins.

The only approach equipped to deal with these vessels is the inguinal or subinguinal microscopic technique with delivery of the testis.

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