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.

Over the past 20 years, there has been growing interest in understanding the genomic integrity of human spermatozoa and the clinical relevance of sperm chromatin and DNA defects. We have learned that the etiology of human sperm DNA damage is multi-factorial and that sperm DNA defects are associated with abnormal semen parameters. While we have observed that tests of sperm DNA integrity are correlated with reproductive outcomes, use of these complementary biomarkers in the management of male infertility remains controversial. In this chapter, we review the etiologic factors associated with sperm DNA damage and the utility of these tests in clinical practice. We also review the treatment options for infertile men with sperm DNA damage.

Reproductive problems in the male contribute significantly to subfertility in heterosexual couples but can also impact on the ability of single or homosexual men to take part in donation or surrogacy. The main causes of reproductive problems in males can be classified as either (1) pre-testicular (those affecting the regulatory hormonal pathway); (2) testicular (those which relate to impaired testicular function); and (c) post-testicular, where there is a blockage of the male genital tract or other problems with associated ejaculation or sperm delivery; however, it is possible that there can be more than one cause. The main diagnostic procedures include physical examination, followed by semen analysis and, in some instances, endocrine tests (follicle-stimulating hormone and testosterone), genetic tests (karotyping, Y chromosome microdeletion testing and cystic fibrosis testing) and radiological investigations. In the case of secondary hypogonadism, medical treatment with human chorionic gonadotropin can improve sperm quality but in the majority of azoospermic men only various surgical interventions to recover sufficient sperm for intracytoplasmic sperm injection are of proven value.

Varicocele is the most common surgically correctable factor identified in infertile men. The negative impact of varicocele on testicular function, semen parameters and fertility potential have been well recognized for decades. Despite this, the role of varicocele repair in managing infertility remains controversial, especially since the advent of assisted reproductive technologies (ART). This chapter details the current status of varicocele in male infertility. We describe the anatomy, pathophysiology and diagnostics of varicocele and discuss the methods of repair. We then take a critical look at the efficacy and clinical utility of varicocele repair in infertile couples, with an emphasis on clinical benefits for couples undergoing ART.