Expertise & Special Interests
One out of every eight couples struggles with infertility, and half of all infertile couples have a contributing male factor. Causes can include varicoceles, testicular production problems, genetic, hormonal, environmental, or lifestyle factors. The goals for treating male infertility include identifying serious or life-threatening medical problems, diagnosing the underlying cause, and correcting or improving medical issues that impair sperm production using a combination of lifestyle modifications, medical therapy (prescriptions), and surgery. These goals optimize sperm health and delivery for natural conception and/or assisted reproduction, including IVF and IUI.
Abnormal Semen Analysis
Every male partner in an infertile couple should undergo a semen analysis. This should be analyzed by a certified andrology laboratory within one hour of collection and repeated a second time if abnormal. An abnormal semen analysis should always be evaluated by a fertility specialist, ideally a reproductive urologist.
About 15% of men who undergo vasectomy regret it, and 5% will desire reversal. The most important factor determining reversal success is the experience of the surgeon. The surgeon should be a fellowship-trained reproductive urologist who can perform both vasovasostomy (VV) and epididymovasostomy (EV). The surgeon should use an operating microscope to aid visualization during the surgery. A skilled surgeon can reverse a vasectomy on most men regardless of the amount of time that has elapsed since the vasectomy, even significantly longer than 10 years. The second most important factor for success is the age and fertility status of the female partner, with natural pregnancies most likely when the female partner is under 40 years of age. The option of banking sperm during vasectomy reversal is an added benefit not offered by many clinics. This allows for a backup plan. Dr. Coward is a fellowship-trained microsurgeon with over 10 years of experience who routinely performs both VV and EV vasectomy reversals using an operative microscope with simultaneous sperm banking.
A varicocele is an often asymptomatic dilation of the veins above one or both testicles which is the most common cause of an abnormal semen analysis. Repair of a varicocele(s) results in significant improvements in sperm quality for over two thirds of men, and one third of couples conceive naturally aafter varicocele repair. When varicoceles are repaired, assisted reproductive technology (ART) such as IVF and IUI are almost twice as likely to be effective due to the improved sperm quality.
Azoospermia is defined by two centrifuged semen samples not containing any sperm. Occuring in about 1% of all men and 10% of infertile men, azoospermia can either be obstructive or non-obstructive. A common misconception is that azoospermia is not treatable. The truth is that the vast majority of azoospermic men can become fathers.
There are multiple different techniques for sperm retrieval, each of which are used in specific situations. Considerations may include whether the patient has obstruction or not, whether epididymal or testicular sperm is desired, whether the couple desires to extract enough sperm for sperm banking, and if the procedure is being performed due to elevated sperm DNA fragmentation or failed IVF. Sperm can be extracted through procedures such as TESE, MESA, TESA, PESA, and micro-TESE. Dr. Coward offers and performs every type of sperm retrieval available and tailors the surgical plan to the patient’s anatomy and goals. Most of these procedures can be performed awake in the office with local anesthesia.
Microdissection Testicular Sperm Extraction
For men with non-obstructive azoospermia, which means that sperm production is so low that no sperm is visible in the ejaculate, the gold standard approach to sperm retrieval is called micro-TESE. Micro-TESE stands for microdissection testicular sperm extraction. The patient is asleep with deep sedation, and an operative microscope is used to identify dilated tubules which contain sperm. The use of micro-TESE improves the likelihood of finding sperm about three times higher than conventional or standard TESE.
The least invasive form of vasectomy is called the no-scalpel, no-needle vasectomy. The patient experiences minimal pain as the anesthesia is placed with a spray rather than a needle. The vasectomy is performed through a single tiny puncture site which closes on its own without even a single suture. The patient is able to drive himself to and from the procedure which is completed in approximately 20 minutes. The no-scalpel, no-needle vasectomy has a lower risk of complications than a traditional vasectomy. Dr. Coward is the only fellowship-trained male fertility specialist in the region who offers a true no-scalpel, no-needle vasectomy.