Male-factor infertility contributes significantly to the burden of infertility. Fortunately, many causes of male-factor infertility are amenable to surgical intervention. These interventions can be grouped broadly into three categories: 1) those that improve sperm delivery, including vasovasostomy, vasoepididymostomy, and transurethral resection of the ejaculatory ducts, for obstruction of the vas deferens, epididymitis, and ejaculatory ducts, respectively; 2) those that improve testicular function and optimize spermatogenesis, namely varicocelectomy; and 3) those that enable direct retrieval of sperm from either the epididymis (microsurgical epididymal sperm aspiration and percutaneous epididymal sperm aspiration) or testicle (testicular sperm aspiration and testicular sperm extraction). When used in conjunction with other assisted reproductive techniques, including IVF/ICSI, these surgical procedures have vastly improved the reproductive outlook for many subgroups of infertile men who had previous been considered completely infertile.

Infertility due to azoospermia may be overcome by surgically retrieving sperm from the epididymis or testicle followed by in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) and embryo transfer. The nature of the azoospermia (obstructive (OA) versus non-obstructive azoospermia (NOA)), the surgical approach (percutaneous versus open) and the timing of the sperm retrieval relative to oocyte retrieval for IVF/ICSI (fresh versus frozen sperm) contribute to the success of sperm retrieval and the number of viable sperm that will be available for the IVF/ICSI procedure. The goal of the surgical team should be to maximize the recovery of mature, viable sperm for ICSI while minimizing patient risk and cost. The laboratory processing the samples must minimize post-recovery cell damage, preserve sample sterility and strive to optimize the efficiency of the surgery when possible by cryopreserving excess sperm for future IVF/ICSI procedures. Lastly, these teams must work together to optimize the ease of surgery coordination with the IVF procedure. The relevant procedures for sperm preparation from epidymal aspirates or testicular biopsies will be described in this chapter.