Microdissection testicular sperm extraction: preoperative patient optimization, surgical technique, and tissue processing

The Outcomes of Onco-Testis Sperm Extraction at the Time of Radical Orchiectomy

OBJECTIVE

To evaluate outcomes of onco-testis sperm extraction (TESE) and to define potential predictors of successful surgical sperm retrieval (SSR).

METHODS

For this study, we examined all men (i) diagnosed with a testicular mass, (ii) who had azoospermia, and (iii) who underwent a radical orchiectomy and onco-TESE. Our institutional database of testicular cancer (TCA) patients was reviewed. Demographics, baseline endocrine and oncological characteristics, and treatments received were recorded. The onco-TESE Technique was performed at the time of radical orchiectomy before the specimen was sent for formal histopathological assessment. Onco-TESE was considered successful if viable sperm was found. Logistic regression assessments were performed to evaluate predictors of successful onco-TESE.

RESULTS

Thirty-eight men with a median age of 35 were included in the analysis. Median baseline total testosterone, LH, and FSH levels were 419ng/dL, 10.9mU/mL, and 27mU/mL, respectively. The median pre-TESE testicular volume was 11 mL. Of men who underwent radical orchiectomy, 58% had unilateral tumors at the time of the procedure. 42% had bilateral tumors, which were synchronous in 25%, and asynchronous tumors in 75%. Pathologically, 76% had germ cell tumor (83% had pure seminoma, and 17% had mixed germ cell tumor). At onco-TESE, 24% of the patients had successful SSR. No variables had a statistically significant association with successful SSR.

CONCLUSION

Onco-TESE represents a useful option for testis cancer patients who wish for future paternity, with a quarter of such patients having sperm found.

Artificial intelligence interpretation of touch print smear cytology of testicular specimen from patients with azoospermia

PURPOSE

Identification of mature sperm at microdissection testicular sperm extraction (mTESE) is a crucial step of sperm retrieval to help patients with non-obstructive azoospermia (NOA) proceed to intracytoplasmic sperm injection. Touch print smear (TPS) cytology allows immediate interpretation and prompt sperm identification intraoperatively. In this study, we leverage machine learning (ML) to facilitate TPS reading and conquer the learning curve for new operators.

MATERIALS AND METHODS

One hundred seventy-six microscopic TPS images from the testicular specimen of patients with azoospermia at Taipei Veterans General Hospital were retrospectively collected, including categories of Sertoli cell, primary spermatocytes, round spermatids, elongated spermatids, immature sperm, and mature sperm. Among them, 118 images were assigned as the training set and 29 images as the validation set. RetinaNet (Lin et al. in IEEE Trans Pattern Anal Mach Intell. 42:318-327, 2020), a one-stage detection framework, was adopted for cell detection. The performance was evaluated at the cell level with average precision (AP) and recall, and the precision-recall (PR) curve was displayed among an independent testing set that contains 29 images that aim to assess the model.

RESULTS

The training set consisted of 4772 annotated cells, including 1782 Sertoli cells, 314 primary spermatocytes, 443 round spermatids, 279 elongated spermatids, 504 immature sperm, and 1450 mature sperm. This study demonstrated the performance of each category and the overall AP and recall on the validation set, which were 80.47% and 96.69%. The overall AP and recall were 79.48% and 93.63% on the testing set, while increased to 85.29% and 93.80% once the post-meiotic cells were merged into one category.

CONCLUSIONS

This study proposed an innovative approach that leveraged ML methods to facilitate the diagnosis of spermatogenesis at mTESE for patients with NOA. With the assistance of ML techniques, surgeons could determine the stages of spermatogenesis and provide timely histopathological diagnosis for infertile males.

The Andrological Landscape in the Twenty-First Century: Making Sense of the Advances in Male Infertility Management for the Busy Clinicians

Male infertility represents a significant global problem due to its essential health, social, and economic implications. It is unsurprising that scientific research is very active in this area and that advances in the diagnostic and therapeutic fields are notable. This review presents the main diagnostic advances in male infertility, starting from the changes made in the latest WHO Manual of semen analysis and discussing the more molecular aspects inherent to "omics". Furthermore, the usefulness of artificial intelligence in male infertility diagnostics and the latest advances in varicocele diagnosis will be discussed. In particular, the diagnostic path of male infertility is increasingly moving towards a personalized approach to the search for the specific biomarkers of infertility and the prediction of treatment response. The treatment of male infertility remains empirical in many regards, but despite that, advances have been made to help formulate evidence-based recommendations. Varicocele, the most common correctable cause of male infertility, has been explored for expanded indications for repair. The following expanded indications were discussed: elevated sperm DNA fragmentation, hypogonadism, orchalgia, and the role of varicocele repair in non-obstructive azoospermia. Moving forward with the available data, we discussed the stepwise approach to surgical sperm retrieval techniques and the current measures that have been investigated for optimizing such patients before testicular sperm extraction. Finally, the key points and expert recommendations regarding the best practice for diagnosing and treating men with infertility were summarized to conclude this review.

MicroRNAs in Male Fertility

Around 50% of all occurrences of infertility are attributable to the male factor, which is a significant global public health concern. There are numerous circumstances that might interfere with spermatogenesis and cause the body to produce abnormal sperm. While evaluating sperm, the count, the speed at which they migrate, and their appearance are the three primary characteristics that are analyzed. MicroRNAs, also known as miRNAs, are present in all physiological fluids and tissues. They participate in both physiological and pathological processes. Researches have demonstrated that the expression of microRNA genes differs in infertile men. These genes regulate spermatogenesis at various stages and in several male reproductive cells. Hence, microRNAs have the potential to act as useful indicators in the diagnosis and treatment of male infertility and other diseases affecting male reproduction. Despite this, additional research is necessary to determine the precise miRNA regulation mechanisms.

[Testicular and epididymal sperm extraction surgery]

BACKGROUND

Testicular and epididymal sperm extraction surgery is a frequent procedure. However, to date, there has been no French consensus on the technique to be preferred in the various situations of male infertility and on the best way to perform them. We therefore decided to proceed with a formalized expert consensus, using the method recommended by the French National Authority for Health. The aim was to provide the French urology community with practical advice on how best to perform these procedures.

METHODS

Twenty-six international experts met online for the consensus. A research committee carried out a comprehensive literature review and prepared the 55 statements submitted to the rating group. After 2 rounds of scoring, 50 recommendations were validated in March 2023, having achieved a consensus of more than 85% among the experts.

RESULTS

The consensus covered (1) preparation for sperm extraction surgery, (2) the different sperm extraction surgery techniques (Microsurgical epididymal sperm aspiration [MESA], Percutaneous epididymal sperm aspiration [PESA], Conventional Testicular Sperm Extraction [TESE], Microsurgical Testicular Sperm Extraction [micro-TESE]), (3) advice to be given to the patient concerning the postoperative period, before presenting the results of the sperm extraction surgeries.

CONCLUSIONS

The expert consensus meeting on the performance of sperm extraction surgery presented a set of clinical guidelines based on the available literature and expert opinion. These guidelines should have a favourable effect on the development of this activity in France.

Stepwise mini-incision microdissection testicular sperm extraction in NOA patients with a history of cryptorchidism: a case-control study

BACKGROUND

Although the orchiopexy is recommended for cryptorchidism to preserve male fertility, non-obstructive azoospermia (NOA) may occur in adulthood. Fortunately, a great many of azoospermic men may obtain sperm by microdissection testicular sperm extraction (mTESE). Due to the potential injuries caused by testicular diagnostic biopsy and vascular damage at the time of orchidopexy, minimal invasiveness is particularly important during mTESE, aims to reduce the surgical damage and avoids secondary testicular failure. This comparative study aims to investigate the efficacy of stepwise mini-incision mTESE technique by comparison with standard mTESE in the treatment of NOA patients with a history of cryptorchidism.

RESULTS

A total of 73 mTESE procedures were divided into two groups: Group 1 included 37 cases performed by stepwise mini-incision mTESE, while Group 2 included 36 cases with standard mTESE. The overall sperm retrieval rate (SRR) in the two groups was 68.5% (50/73), with no significant difference in SRR between Group 1 (78.4%, 29/37) and Group 2 (58.3%, 21/36) (P = 0.1). In addition, 46.0% of the patients (17/37) obtained sperm in the first mini-incision step in Group 1, which was also equal to an overall SRR in Group 2 (58.3%, 21/36) (P = 0.3). The operation time in Group 1 (72.6 ± 33.9 min) was significantly shorter than that in Group 2 (90.4 ± 36.4 min) (P = 0.04). Patients with an orchidopexy age no more than 10 years old had a higher SRR (79.5%, 31/39) than others (55.9%, 19/34) (P = 0.03). There were no postoperative complications including wound infection, scrotal hematoma, persistent pain, and testicular atrophy during a follow-up period of at least 6 months.

CONCLUSIONS

In conclusion, our study suggests that the stepwise mini-incision mTESE could be a promising approach for sperm retrieval in NOA men with a history of cryptorchidism. While the technique may potentially reduce operation time and surgical invasiveness, further research is needed to validate these findings on a larger scale. The results also suggest that age at orchidopexy may affect SRR and have important implications for the management of cryptorchidism.

Staged Laboratory Processing of Testicular Tissue in Non-Obstructive Azoospermia May Rescue Retrieving an Existing Sperm: A Case Report and Literature Review

Non-obstructive azoospermia (NOA) is the most difficult form of male infertility to manage. It usually requires sperm retrieval from the testis, which is most challenging due to sperm rarity. Here, we describe the recovery of testicular sperms that had been missing and whose original retrieval results were negative. Salvage microsurgical testicular sperm extraction and sperm testing were performed on a 36-year-old male with NOA. Neither in the operation room nor after an inspection in the embryology laboratory were any sperm detected. The obtained tissue was advised to be frozen because the patient data and surgical microscopy predicted a favorable outcome, and the tissue processing was done in an inappropriate environment. About 1 month later, the specimen was thawed, crushed, and re-examined. Successful oocyte fertilization resulted from an effective detection of sperms and their direction to intra-cytoplasmic sperm injection. This is the first case report that, to the best of our knowledge, describes the stepwise laboratory processing of testicular tissue and its capacity to recover lost sperms in challenging NOA cases and under less-than-ideal working conditions.

Testicular Apoptosis and Proliferation in Relation to Body Mass Index and m-TESE Success in Nonobstructive Azoospermic Men

Male infertility occurs due to the disruption of the balance of proliferation and apoptosis in the testicular tissue. It is important to show the effect of increased body mass index, which is one of the factors that disrupts this balance of apoptosis and proliferation, not only at the blood hormone level but also at the tissue level. For this reason, the present study is aimed at demonstrating the relation between body mass index and cell turnover in the testis using immunohistochemical methods. In the present study, patients were grouped as normal, overweight and obese, and as m-TESE positive and negative. The sperm retrieval rate with microsurgical testicular sperm extraction (m-TESE) was 41.67%. Histological diagnosis of testicular tissues was made with hematoxylin and eosin and Masson’s trichrome staining. Apoptosis and proliferation in the testicular tissue were demonstrated by TUNEL and PCNA immunohistochemical methods, respectively. It was concluded that BMI had no significant effect on reproductive hormone profile (FSH, LH, and testosterone), m-TESE success, apoptosis, and proliferation in testicular tissue in nonobstructive azoospermic men. In addition TUNEL positivity and proliferative index was found to be significantly correlated with testicular histology and m-TESE outcome.

Human in vitro spermatogenesis as a regenerative therapy - where do we stand?

Spermatogenesis involves precise temporal and spatial gene expression and cell signalling to reach a coordinated balance between self-renewal and differentiation of spermatogonial stem cells through various germ cell states including mitosis, and meiosis I and II, which result in the generation of haploid cells with a unique genetic identity. Subsequently, these round spermatids undergo a series of morphological changes to shed excess cytoplast, develop a midpiece and tail, and undergo DNA repackaging to eventually form millions of spermatozoa. The goal of recreating this process in vitro has been pursued since the 1920s as a tool to treat male factor infertility in patients with azoospermia. Continued advances in reproductive bioengineering led to successful generation of mature, functional sperm in mice and, in the past 3 years, in humans. Multiple approaches to study human in vitro spermatogenesis have been proposed, but technical and ethical obstacles have limited the ability to complete spermiogenesis, and further work is needed to establish a robust culture system for clinical application.

Male factor infertility: A contemporary overview of investigation, diagnosis and management

Infertility, defined as the failure to achieve a clinical pregnancy after 1 year of regular, unprotected sexual intercourse, is a public health issue of global concern. It affects up to 12% of couples worldwide. While traditionally, research and treatment have focused on female causes of infertility, male factors contribute to up to 70% of cases and therefore deserve appropriate recognition. The purpose of this comprehensive review is to detail the diagnostic work-up, investigations and management of male factor infertility. We discuss much-debated pathologies, such as varicocele, and novel investigations, including sperm DNA fragmentation and reactive oxygen species.

Level of evidence: Not applicable

Testicular sperm characteristics in men with nonobstructive azoospermia and their impact on intracytoplasmic sperm injection outcome

OBJECTIVE

To report fertilization and clinical pregnancy rates based on sperm characteristics at the time of intracytoplasmic sperm injection (ICSI) in men with nonobstructive azoospermia (NOA) following microdissection testicular sperm extraction (mTESE).

DESIGN

Retrospective cohort.

SETTING

Tertiary hospital.

PATIENT(S)

Men with NOA undergoing mTESE between 2013 and 2016 who had successful sperm retrieval and subsequent spermatozoa available for ICSI.

INTERVENTION(S)

Sperm characteristic assessment.

MAIN OUTCOME MEASURE(S)

Fertilization and clinical pregnancy rates.

RESULT(S)

One hundred ninety-eight men with NOA and successful mTESE were included. The mean ages of the patients and their partners were 35 ± 8 and 31 ± 5 years, respectively. The overall fertilization rate was 44%, and the clinical pregnancy rate was 38%. The absence of twitching sperm motility and the presence of an acrosome defect were associated with decreased fertilization and clinical pregnancy rates on univariable analysis. On multivariable analysis, the presence of motility was associated with higher fertilization rates and greater odds of clinical pregnancy (odds ratio, 4.37; 95% confidence interval, 1.61-11.85). An abnormal acrosome was associated with reduced odds of pregnancy (odds ratio, 0.40; 95% confidence interval, 0.18-0.85). No specific anomaly or combination of sperm abnormalities precluded fertilization or clinical pregnancy with ICSI.

CONCLUSION(S)

To our knowledge, this is the first comprehensive study evaluating the importance of sperm characteristics and their impact on ICSI outcomes in men with NOA. The results suggest that no specific defect, including the use of nonmotile testicular spermatozoa, precluded a chance of clinical pregnancy. The study evaluated sperm characteristics at the time of ICSI injection; initial evaluation at the time of retrieval may differ significantly from that of spermatozoa selected for ICSI.

Medical management of non-obstructive azoospermia: A systematic review

While most men with non-obstructive azoospermia (NOA) are not amenable to medical treatment, some men can be treated effectively with hormonal therapy, prior to considering surgery. In some cases, hormonal therapy alone can treat NOA, without the need for surgery. In other cases, correction of a potential hormonal imbalance can enhance the chances of success of surgical sperm retrieval (SSR), with either conventional or microdissection testicular sperm extraction. Abnormal testicular function and low androgen levels can result from a primary dysfunction, a medical or surgical condition, or from an exogenous factor, and should be managed prior to more invasive interventions. Even men with normal androgen levels may benefit from hormonal therapy before sperm retrieval. Moreover, SSR may cause testicular injury and aggravate the pre-existing situation. If surgical extraction of sperm fails, it leaves the patients with less satisfactory options, like donor sperm or adoption. Therefore, it is the role of the infertility specialist to be vigilant and identify reversible causes of NOA, such as hormonal imbalance, prior to considering surgery. In the present paper we will systematically review the literature and highlight the available conventional medical regimens, as well as experimental ones. Abbreviations: ART: assisted reproductive technology; CAH: congenital adrenal hyperplasia; EAU: European Association of Urology; hCG: human chorionic gonadotrophin; HH: hypogonadotrophic hypogonadism; hMG: human menopausal gonadotrophin; IUI: intrauterine insemination; micro-TESE: microdissection testicular sperm extraction; NOA: non-obstructive azoospermia; OR: odds ratio; SCO: Sertoli-cell only; SERM: selective oestrogen receptor modulator; SRR: sperm retrieval rate; SSC: spermatogonia stem cell; TART: testicular adrenal rest tumour; WMD: weighted mean difference.

Tissue and sperm handling before assisted reproductive technology (ART): A systematic review

Objective

: To explore the medical literature on techniques of tissue and sperm handling after surgical retrieval for intracytoplasmic sperm injection (ICSI).

Methods

: A search was performed in PubMed and Google Scholar databases, according to a modified Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guideline, considering the studies investigating tissue handling and sperm selection techniques for ICSI.

Results

: Overall, 42 articles were included in this study, investigating sample handling, methods for sperm selection, and the use of chemical compounds to improve sperm motility and fertilisation rates.

Conclusion

: The ideal sperm handling method should provide a high sperm count, high vitality and appropriate sperm function, without side-effects. In this review the most common and useful techniques are described and the best combination strategies discussed in clinical scenarios.

Microdissection testicular sperm extraction (micro-TESE) in men with infertility due to nonobstructive azoospermia: summary of current literature

PURPOSE

Nonobstructive azoospermia (NOA) is associated with intrinsic testicular defects that severely impair sperm production. Although NOA invariably leads to infertility, focal sperm production may exist in the testicles of affected patients, which can be retrieved and used for intracytoplasmic sperm injection (ICSI) to generate healthy offspring. However, geographic locations of testicular sperm producing-areas are uncertain, making microsurgical-guided sperm retrieval (microdissection testicular sperm extraction; micro-TESE) an attractive method to identify and retrieve sperm in patients with NOA due to spermatogenic failure. Given the widespread use of micro-TESE, its effectiveness in harvesting sperm and related potential complications need to be clarified.

METHODS

We queried PubMed/MEDLINE for studies published in English, from inception to May 2021, concerning the effect of micro-TESE on sperm retrieval rate (SRR), complication rate and ICSI pregnancy rate-using retrieved testicular sperm in subfertile couples where the male had NOA.

RESULTS

We found 116 articles, including 70 original papers, 32 review articles, and 14 systematic reviews. The evidence accounted for 4895 patients. Micro-TESE retrieved sperm in 46.6% of men with NOA, but SRRs varied considerably (18.4-70.8%) and were mainly related to the treated population characteristics. Concerning the general population of NOA patients who have not undergone previous sperm retrieval (naïve population), the SRR by micro-TESE was 46.8% (1833 of 3914 patients; range 20-70.8%; 28 studies). In studies reporting SR by micro-TESE for men who had failed percutaneous testicular sperm aspiration or non-microsurgical testicular sperm extraction, the SRR was 39.1% (127 of 325 patients; range 18.4-57.1%; 4 studies). Data on adverse events indicated that micro-TESE was associated with low (~ 3%) short-term postoperative complication rates. The fertilizing ability of testicular sperm retrieved by micro-TESE and used for ICSI was adequate (~ 57%), whereas clinical pregnancy and live birth were obtained in 39% and 24% of couples who had an embryo transfer, respectively. The health of the resulting children seems reassuring, but the evidence is limited. The procedure increases sperm retrieval success compared to non-microsurgical retrieval methods, particularly in men with Sertoli cell-only testicular histopathology.

CONCLUSION

We concluded that micro-TESE is an effective and safe method to retrieve sperm from men with NOA-related infertility, with potential advantages over non-microsurgical methods. Nevertheless, high-quality, head-to-head comparative randomized controlled trials by sperm retrieval method, focusing on SRR, live birth rate and assessing long-term adverse events and health of children conceived using testicular sperm from NOA patients are lacking. Therefore, further research is required to determine the full clinical implications of micro-TESE in male infertility treatment.

Evaluating the quality of reported outcomes for microsurgical TESE in men with non-obstructive azoospermia: A methodological analysis

BACKGROUND

Publications of microsurgical testicular sperm extraction (mTESE) techniques and outcomes are heterogeneous, which may limit creation of best surgical practices.

OBJECTIVE

To study the quality and heterogeneity of published mTESE outcomes via a methodological analysis.

MATERIALS/METHODS

A systematic methodological analysis of all published literature on the use of mTESE in men with non-obstructive azoospermia from 1999 to the July 2020 was performed. PubMed and MEDLINE searches were performed using the search terms "microdissection TESE OR microsurgical TESE." Publications were evaluated on their reporting of pre-operative factors, intraoperative techniques, surgical and clinical outcomes, and adverse events.

RESULTS

Fifty-five studies met inclusion criteria. Surgical technique and sperm retrieval rates were the most reported criteria. Reporting on the presence of an embryologist intraoperatively was observed in approximately 30% of articles, while other procedural details including method of sperm quantification, quantity retrieved, and number of cryopreserved vials were observed in fewer than 10% of articles. Clinical outcomes, including pregnancy rates and live birth rates, were reported in fewer than 40% of the articles. Fetal outcomes including fetal and neonatal anomalies were rarely reported. Fetal growth restriction, preterm delivery, small or large for gestational age, and NICU admissions were never reported.

CONCLUSION

There are inconsistencies in reporting quality of mTESE outcomes, specifically a lack of information on the quantity and quality of sperm retrieved, the role of embryology intraoperatively, and clinical outcomes, such as live birth rate and fetal anomalies. These gaps may guide development of standardized reporting guidelines to better assess and compare clinical outcomes across institutions and maintain focus on couples-centric fertility outcomes in future mTESE studies.

Histology and sperm retrieval among men with Y chromosome microdeletions

In this review of Y chromosome microdeletions, azoospermia factor (AZF) deletion subtypes, histological features and microTESE sperm retrieval rates are summarized after a systematic literature review. PubMed was searched and papers were identified using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Approximately half of infertile couples have a male factor contributing to their infertility. One of the most common genetic etiologies are Y chromosome microdeletions. Men with Y chromosome microdeletions may have rare sperm available in the ejaculate or undergo surgical sperm retrieval and subsequent intracytoplasmic sperm injection to produce offspring. Azoospermia or severe oligozoospermia are the most common semen analysis findings found in men with Y chromosome microdeletions, associated with impaired spermatogenesis. Men with complete deletions of azoospermia factor a, b, or a combination of any loci have severely impaired spermatogenesis and are nearly always azoospermic with no sperm retrievable from the testis. Deletions of the azoospermia factor c or d often have sperm production and the highest likelihood of a successful sperm retrieval. In men with AZFc deletions, histologically, 46% of men demonstrate Sertoli cell only syndrome on biopsy, whereas 38.2% have maturation arrest and 15.7% have hypospermatogenesis. The microTESE sperm retrieval rates in AZFc-deleted men range from 13-100% based on the 32 studies analyzed, with a mean sperm retrieval rate of 47%.

Towards a better testicular sperm extraction: novel sperm sorting technologies for non-motile sperm extracted by microdissection TESE

Non-obstructive azoospermia (NOA) is the most severe form of male factor infertility. It is characterized by a lack of spermatogenesis in the seminiferous tubules. Microdissection testicular sperm extraction (microTESE) has significantly improved testicular sperm retrieval rates compared to conventional techniques for NOA. Following testicular biopsy, the sperm is usually non-motile and contained within seminiferous tubules requiring extensive laboratory processing to find individual sperm sufficient for artificial reproductive technologies (ART). Current techniques include mechanical and enzymatic processing which is time-consuming and often damaging to sperm. We review novel techniques that may help improve sperm retrieval rates after microTESE including microfluidics (dielectrophoretic cell sorting, spiral channel sorting, and pinched flow fractionation), fluorescence-activated cell sorting (FACS), and magnetic-activated cell sorting (MACS).

Extended indications for sperm retrieval: summary of current literature

Sperm retrieval combined with intracytoplasmic sperm injection (ICSI) is the treatment of choice for couples with untreatable azoospermia-related infertility. However, an increasing body of evidence has been mounting, suggesting that ICSI with testicular sperm instead of ejaculated sperm (when both are available) increases pregnancy outcomes in some specific scenarios. This has led to the exploration of extended indications for sperm retrieval. This review summarizes the current literature concerning sperm retrieval and ICSI for non-azoospermic men with elevated sperm DNA fragmentation, oligozoospermia, and cryptozoospermia.

Extended indications for varicocelectomy

The relationship between varicoceles and subfertility is well-established, but recent evidence suggests that varicoceles may cause global testicular dysfunction. This has led to exploration into expanding the indications for varicocelectomy. This review examines the literature regarding varix ligation as a treatment for non-obstructive azoospermia, elevated DNA fragmentation, and hypogonadism.

Introduction: Surgical treatment of male infertility: a state-of-the-art overview

Surgical treatments offer effective solutions for many couples experiencing male factor infertility. This Views and Reviews collection of articles offers a state-of-the-art overview of the surgical procedures commonly used to treat impaired male reproductive health.