2. Herneoraphy or hydrocelectoy : while doing this surgery one must be careful about VAS

3. Transurethral or rectal surgery on seminal vesicle duct and prostate.

4. Vasoepidydimo – Anastamosis –Blocks in the epidydimus can be repaired with this procedure. But success rate is very very low.

5. Vasovasostomy : Vas can be recanalised with this procedure after vasectomy.

a. Vasovasostomy :- [reconnection of the two severed ends of the vas deferens]

6. Sperm Extraction in cases of Azoospermia to proceed with ICSI.

Percutaneous edpidymal sperm Aspiration [PESA]

Testicular sperm Extraction [TESA]

Non – Surgical Treatment

1. Specific Treatment

a. Hypogonadotropic Hypogonadism :

Causes :-

• Pituitary tumor
• Isolated gonadotropin deficiency
• Panhypo pituitarism
• Pituitary trauma
• Anbolic steroid use

Congenital Hypogonadotropic Hypogonadism :

Cause :-

• Abnormal production or secretion of GnRH by the hypothalamus.

Initial Evaluation :

• Head CT or MRI [ to rule out possibility of a pituitary tumor]
• Prolactin level

Treatment : Patients with gonadotropin deficiency – normal spermatogenesis can be restored by

• Exogenous gonadotropin or GnRH
• hCG [1,500 – 3,000 IU /sc thrice / week] 8-12 weeks after hCG therapy
• hMG [37.5-150 IU/ sc /2-4 times / week]

b. Hyperprolactinemia :- Prolactine has a negative influence on the hypothalamic secretion of gonadtotropin releasing hormone and have an inhibitory effect on LH binding to leyding cells in the testis. This hyperprolactinemia patient may have decreased serum gonadotropin and decreased testosterone level.

Causes :-

• Pituitary tumor
• Hypothyropidism
• Liver disease
• Drugs [like phenothiazine and some antidepressants]

Treatment :

• For Hypothyroidism Patient – Thyroid replacement therapy itself will bring prolactin in normal range.
• For idiopathic hyper prolactinemia patients – bromocriptine [2.5 – 7.5  mg/2-4 times /day]

c. Congenital Adrenal hyperplasia[CAH] :-
CAH patient has

• Decreased cortisol secretion due to deficiency in adrenal hydorxylase.
• Increased adrenal androgen production
• Suppression of spermatogeneis

Diagnostic test : -
Urine 17 – Ketosteroids or dehydroepiandrosterone [DHEA]
glucocorticoid replacement

d. Immunologic infertility :
Treatment – oral prednisone will decrease significant Antisperm Antibody titre  or Assisted Reproductive technigues [ART]


e. Genital Tract Infection :
Infection :

Enterobacteriaceae Chlymydia trachomatis Neisseria Gonorrhoeae Pyospermia (> 1million  WBC/ml of semen)

Testicular atrophy

Treatment :

• Culture proven antibiotic
• Non steroidal anti-inflammatory drugs.

f. Ejaculation disorders :
The ejaculatory event is comprised of seminal emission and ejaculation. Seminal emission refers to the deposition of semen into the posterior urethra by contraction of the vas deferentia and seminal vesicles. These events are mediated by the sympathetic nervous system. Ejaculation is the forceful expulsion of semen from the posterior urethra out of the urethral meatus in an antegrade fashion.

Disorder of ejaculation include :

• Retrograde ejaculation
• Anejaculation
• Retarded ejaculation
• Premature ejaculation.

Retrograde Ejaculation  :
[ abnormal backward flow of semen into the bladder with ejaculation ]

Etiology :

• Anatomic [prostatectomy, bladder neck surgery]
• Neurogenic [spinal cord injury, retroperitoneal surgery]
• Pharmacologic [use of certain drugs]
• Idiopathic

Treatment :

• Phenyl propanolamine – 75 mg bid-10 days
• Pseudoephednine hydrochloride – 60mg qid/10days
• Ephedinine sulfate – 50 mg quid/10 days
• Imipramine hydrochloride – 25 mg bid /10 days
• Recovery of sperm from urine and use for either IUI or IVF/ICSI procedure.

An ejaculation :

Etiology :

• Spinal cord injury
• Retroperitoneal lymph node dissection
• Retroperitoneal surgery. 
• Diabetes
• Multiple sclerosis
• Psychogenic or idiopathic

Treatment : Rectal probe electro ejaculation [RPE]

• Penile vibratory stimulation
• ICSI

2. Clomiphene Citrate treatment : Clomiphene citrate is a synthetic, nonsteroidal anti-estrogen that is structurally related to diethylstilbestrol (DES). It competitively binds to the estrogen receptors in the hypothalamus and pituitary, thereby blocking feedback inhibition on these organs and effectively increasing the secretion of GnRH, FSH, and LH.
Clomiphene citrate is prescribed in doses of 12.5-50 mg per day and may be given continuously or on a 25-day cycle with a 5-day "rest period" each month. Monitoring of serum gonadotropins and testosterone is essential to make certain that the testosterone level remains within the normal limits, since higher levels may have a negative influence on spermatogenesis. In addition, because a small percentage of patients experience a decline in sperm density and motility while taking this medication, frequent semen analyses are mandatory.
Controversy still exists with regard to the efficacy of clomiphene citrate for the treatment of male factor infertility. It is possible that a select group of patients responds to clomiphene therapy. It is also conceivable that by some as yet undetermined mechanism clomiphene improves pregnancy rates without improving bulk seminal parameters or sperm fertilizing capacity. Although it is difficult to predict which patients will respond to clomiphene, patients not likely to benefit from this therapy include those with elevated baseline serum FSH levels, severe oligospermia, asthenospermia, teratozoospermia or azoospermia, and those with extremely abnormal testis - biopsy is needed.

3. Specific therapy

a. Antioxidant Treatment : either invivo or invitro in sperm preparation    technique.
Antioxidants useful to reduce oxidative stress are
Carnitine     
Arginine
Zinc
Selenium
Vit B12
Vit C & E
Glutathione
CoEn.Q.10

b. Platelet –Activating Factor [PAF]
No.of endogenous biochemical factors attributed to fertility potential of spermatozoa.
One such factor is PAF. PAF treated sperm has a increased motility and better fertilization rate
PAF is unique and novel signaling phospholipid with pleiotropic biological properties like :-

          Involved in ovulation
          Increases the sperm motility
          Sperm capacitation [acrosome reaction]
          Fertilization potential
          Preimplantation embryo development
          Implantation
          Parturition
Use of exogenous PAF in sperm preparation technique will improve motility, fertilization rate, implantation rate and pregnancy rate. 

Treatment of Female:

Treatment for Female Infertility

Chart below outlines the condition and treatment for that condition.