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Y a-t-il encore une place pour la chirurgie dans le traitement de l'infertilité masculine?

Resume

Les progrès récents de la prise en charge biologique de l'infertilité masculine ont surtout porté sur les méthodes d'assistance médicale à la procréation. Parallèlement les techniques chirurgicales se sont améliorées, en particulier avec l'apport de la microchirurgie. Le traitement du varicocèle représente la situation où la place de la chirurgie est la moins claire. Elle ne permet pas en particulier d'obtenir une augmentation du nombre de grossesses, malgré une amélioration fréquente des paramètres du sperme. Le traitement chirurgical de la cryptorchidie ne se discute plus après échec d'un traitement hormonal. Le traitement de l'azoospermie excrétoire repose sur des anastomoses microchirurgicales nécessitant une équipe entraînée. Ses meilleurs résultats sont obtenus dans les obstructions congénitales et ne doivent pas être appréciés avant 1 an postopératoire. De même la reperméabilisation déférentielle permet d'obtenir 50% des grossesses en cas de technique microchirurgicale parfaite. La dégradation des résultats avec le temps, impose une mise de sperme en banque de façon systématique avant la réalisation d'une vasectomie. Les obstructions des canaux éjaculateurs peuvent nécessiter le recours à des gestes endoscopiques. Enfin les microponctions épididymaires ont permis de réaliser quelques fécondations. Mais les succès de l'ICSI à partir de prélèvements chirurgicaux épididymaires ou déférentiels conduisent à élargir et à revoir considérablement les indications et les protocoles opératoires. Les indications sont à préciser, et l'analyse génétique est indispensable. Mais la qualité des conceptus obtenus reste la grande interrogation des années à venir.

Abstract

Considerable progress has been recently made in the biological treatement of male infertility. In parallel surgical techniques improved with the main impact of microsurgery. Varicoceles represent the pathology where surgery has the more questionable place. In fact it usualy increases the quality of the sperm, but has no impact on the pregnancy rate. Surgery is unquestionable for cryptorchidism after a failure of the hormonal treatment. Surgical treatment for excretory azoospermia is based on microsurgery performed by a well trained team. The results are better when the obstruction has a congenital origin, and a year is requiered for the clinical evaluation. Microsurgery allows to obtain a 50% prenancy rate after vasovasostomy performed after a vasectomy. But a sperm banking must be systematically done before vasectomy, due to the deterioration of the quality of the restults with time. The ejaculatory duct obstruction may lead to endoscopic procedures. Finally epididymal or vas sperm collection has allow to obtain some pregnancies. But the success of ICSI from surgical epididymal or deferential fluid calls for a completely new approach to the range of indications and surgical protocols. The indications must be clearly defined, the need for a genetic screening is mandatory. And the quality of the obtained pregnancies remains the main question for the next years.

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Navratil, H., Mottet, N. & Costa, P. Y a-t-il encore une place pour la chirurgie dans le traitement de l'infertilité masculine?. Androl. 6, 176–183 (1996). https://doi.org/10.1007/BF03034447

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Mots clés

  • Infertilité masculine
  • chirurgie infertilié
  • ICSI

Key words

  • male infertility
  • surgery of male infertility
  • ICSI