Male Fertility Following Inguinal Hernia Repair

Abstract

Tension-free mesh hernia repair has become the standard procedure in inguinal hernia repair. The incidence of inguinal hernias has steadily decreased following mesh and laparoscopic techniques, but the potential risk of fertility disorders after surgery remains a controversial issue. The aim of this chapter was to establish the clinical impact of open (mesh and/or without mesh) and laparoscopic hernia repair on male fertility. The results of the research published to date do not allow clear conclusions and guidelines in hernia surgery for young patients of reproductive age. Evidence is inevitably difficult to find because of the wide range of causes of infertility and their complexity. However, the choice of method and the possible impact on fertility should be discussed with the patient before surgery. Additionally, preoperative and postoperative semen analysis will help exclude or confirm its impact on patient fertility in the future.

1. Introduction

The World Health Organisation (WHO) has determined the common definition of infertility as the inability to achieve spontaneous pregnancy during at least 1 year of regular, unprotected sexual intercourse. It can affect both women and men, while the male factor is approximately 20–30%, the female factor 50% and a combination of both around 20–30%; therefore, the correct factor that causes categorisation is required to be investigated in both partners simultaneously, which enables a proper management. According to the WHO publication from 2022, related to global prevalence of infertility, one in six people has experienced infertility in their lifetimes. In general, the male factor (including the ‘both’ group) is approximately 50% globally (Western Europe (EU) 50%, Central EU 56% and Eastern EU 37%) [1, 2]. Infertility can be divided into primary—when spontaneous conception never occurred during the patient’s life despite regular attempts at conceiving a child for at least 1 year, and secondary—in case of pregnancy in the past with the same or a different partner as present. The aetiology of this disease is compounded, while the main causes can be divided into lifestyle, genetic, hormonal, systemic disease and varicocele. Idiopathic male infertility defined by disorder without identifiable cause, arising spontaneously, reaches 50% of all cases. Azoospermia is a condition in which there are no spermatozoa in the ejaculate, and it is one of the most frequent symptoms in semen analysis paired with the infertility. It can be divided into obstructive (when testes have the ability to produce normal sperm but there is obstruction of the ejaculatory route at the epididymal, vas deferens or ejaculatory duct level) and non-obstructive (when there is a clear problem with the spermatogenesis process). According to the European Association of Urology (EAU) 2023 Guidelines infertility among male patients can be the result of: varicocele in the mechanism of increased scrotal temperature (with an incidence of 14.8% of all infertility causes in unselected vs. 10.9% in patients with azoospermia), cryptorchidism (8.4% vs. 17.2% with azoospermia), vasectomy (0.9% vs. 5.3% with azoospermia), cystic fibrosis (0.5% vs. 3% with azoospermia) and idiopathic infertility (30% vs. 13.3% with azoospermia). Apart from previously presented disorders, fertility disorders may be the result of, underestimating among men, genitourinary tract infections that are not always manifested symptomatically, but sometimes only as abnormal semen parameters in sperm analysis, concomitant with positive semen culture and elevated inflammatory markers [3, 4]. The interest of this chapter is certainly the theory of possible formation of fertility disorders due to hernia repair surgery.

2. Patient evaluation

The medical interview focusing on fertility disorders contains an investigation of potential risk factors and lifestyle patterns, including partner fertility, family history of oncological and systemic diseases, coexisting diseases (such as especially hypertension, diabetes mellitus, obesity and genitourinary tract infections), the presence of erectile and ejaculatory dysfunctions, previous surgical interventions (together with testicular trauma or torsion), congenital anomalies (mainly cryptorchidism), exposure to gonadotoxins (e.g. anabolic drugs, chemotherapeutics) and radiation [4].

On medical examination, attention is paid to the presence/absence of gonads in the scrotum, size, consistency, abnormal masses of the testes (thick, cohesive ones suggest cancer), penis (including strictures negatively affecting ejaculation, due, for example, to phimosis, hypospadias, epispadias and other abnormalities such as acquired curvature of the penis—Peyronie’s disease) as well as the presence of gynaecomastia, female pattern hair, fat and muscle distribution, possibly indicating hormonal disorders. Visible varicoceles (abnormal enlargement of the pampiniform plexus veins greater than 2–3 mm in diameter) are also observed at this stage of evaluation as one of the main known causes of fertility disorders. They are examined using the Valsalva manoeuvre in both the supine and standing positions and look like a bag of worms above the gonad [4, 5]. Varicoceles are more common on the left side due to anatomical conditions, but in an advanced stage they can occur bilaterally. Only the manifestation on the right side of this disease may indicate the tumour of the retroperitoneal site, which causes pressure on the testicular vein that disrupts the flow of testicular blood to the inferior vena cava [6].

Male infertility is strictly associated with abnormal semen parameters. Semen analysis is an important first-line test for guiding the clinician to identify the cause of fertility disorders. The semen parameters have been standardised by the WHO in the sixth edition of the WHO Manual for the Examination and Processing of Human Semen and published in 2021. Semen analysis standards have been lowered in recent years not only due to the decrease in semen quality due to the greater amount of stress among men related to pollution and lifestyle changes, but also partly as a consequence of the development of testing technology that allows the detection of increasingly subtle sperm disorders. The basic examination includes total sperm number, sperm concentration, semen volume, total motility, progressive motility, vitality (live spermatozoa) and sperm morphology (normal forms) (Table 1). Extended semen examination additionally consists of tests aimed at counting peroxidase positive leukocytes, markers of genitourinary tract inflammations (for example, pH), antibodies of sperm, mixed antiglobulin reaction (MAR) test (motile spermatozoa with bound particles), immunobead test (motile spermatozoa with bound beads), zinc, fructose, neutral α-glucosidase and fragmentation of sperm DNA. The advanced semen examination has also been differentiated and contains tests such as reactive oxygen species (ROS), acrosome reaction and sperm chromatin stability and structure. Consonant with WHO in the case of normal semen analysis, there is no need to perform re-test, while if the test is abnormal, the second confirmational one should be performed. Two basic tests with abnormal semen parameters qualify the patient for further extended (and advanced if needed) semen examinations and their evaluation by an andrologist [7, 8].

Parameter of semen analysis	WHO 2021 reference limit (95% CI)
Semen volume (mL)	1.4 (1.3–1.5)
Total number of sperm (106/ejaculate)	39 (35–40)
Sperm concentration (106/ml)	16 (15–18)
Total motility (PR + NP, %)	42 (40–43)
Progressive motility (PR, %)	30 (29–31)
Vitality (live spermatozoa, %)	54 (50–56)
Sperm morphology (normal forms, %)	4 (3.9–4.0)

Table 1.

Basic semen examination standards according to WHO 2021. CI- confidence interval.

In the management of fertility disorders, the imaging test, which is ultrasound (US), also plays the crucial role. Due to its accessibility and non-invasive character, it allows to visualise abnormalities in the genitourinary tract at an early stage of the diagnostic process. It also allows the measurement of testicular volume, detection of abnormalities in epididymis, hydrocele, testicular neoplasms and non-optically visible varicoceles with the ability to measure its diameters. Moreover, it illustrates the vascularity in Colour Doppler Mode strictly correlating with testicular blood perfusion, which is enhanced in orchitis, epididymitis, and in some neoplasms, and reveals echotexture and calcifications related to testicular tumours. Research data show that there is a higher risk of testicular cancer among infertility sufferers than among fertile men; therefore, every patient with infertility disorders is examined in scrotal US in relation to the presence of neoplasia. Additionally, the scrotal US may expose the distal and proximal part of the vas deferens (the median part cannot be visualised). The extension of the distal section of vas deferens indicates obstruction at some level, while the absence of vas deferens indicates the presence of the cystic fibrosis transmembrane regulator (CFTR) gene and should prompt the physician to perform a kidney ultrasound to look for other defects or agenesis. Transrectal ultrasound (TRUS) can reveal abnormalities in the ejaculatory ducts such as stricture due to the median cyst of the prostate and allows one to count the volume of the seminal vesicles, where their dilatation suggests obstruction in the ejaculatory ducts. Seminal vesicles agenesis, similar to vas deferens agenesis, indicates the presence of the CFTR gene and further investigation is needed in such cases [4, 9, 10].

The evaluation of the full infertile patient also includes hormonal level tests (e.g. high levels of follicle stimulating hormone (FSH) and luteinising hormone (LH) with a low testosterone level refer to hypergonadotropic hypogonadism suggesting gonadal dysgenesis) and genetic testing (chromosomal abnormalities—sex chromosome as well as autosomal, cystic fibrosis gene mutations—e.g. the most common microdeletions of F508 ‘Y’ spermatogenesis gene—AZFa, AZFb, AZFc, aneuploidy in sperm or particularly sex chromosome aneuploidy) [11, 12, 13, 14].

3. Treatment options

The management of fertility disorders depends on their cause. As previously mentioned, the aetiology of infertility is complex, therefore only a correct, precise evaluation of the patient and extended diagnostic process is needed. Generally, treatment options can be divided into invasive and conservative.

The conservative approach first includes lifestyle changes. Male fertility is undoubtedly positively correlated with a healthy lifestyle and overall human well-being. There is some evidence in the literature that increased body mass index (BMI), excessive alcohol consumption and smoking have a negative impact on semen quality [15, 16]. Observational studies report that men with obesity, after loss of 17.2–25.4% of body weight, have an improvement in semen volume, total sperm count, testosterone level and sperm morphology than before [17]. Moreover, moderate physical activity has a positive effect on sperm concentration and progressive motility [18]. Moderate swimming exercises in the pool can not only lower the scrotal temperature (especially in the case of varicoceles) and thus positively influence spermatogenesis, but also reduce the species of oxidative stress in the testes, which was confirmed experimentally [19]. The most effective obesity treatment is bariatric surgery, which, on the one hand, provokes a 6-month lasting reduction in sperm concentration and, on the other, normalises the levels of reproductive hormones and improves general quality of life [20, 21]. In summary, lifestyle changes should be promoted in all male patients with fertility disorders regardless of the cause.

When it comes to conservative treatment, apart from lifestyle changes, hormonal therapy should be considered. Fertility problems may reflect the malfunction of the hypothalamic–pituitary-gonadal (HPG) axis, which is responsible for the regulation of the main testicular functions: spermatogenesis and testosterone production. The HPG axis controls FSH and LH secretion and maintains the proper level of testosterone in male gonads. LH acts on Leydig cells that release testosterone. Intratesticular testosterone, together with FSH, stimulates Sertoli cells to demarcate the wall of the seminiferous tubules, which allows the development of male germ cells. However, in men with normal levels of reproductive hormones, exogenous administration of testosterone and other androgens has a negative impact on spermatogenesis because it inhibits negative feedback of lower testosterone levels, which normally enhances LH secretion on the HPG axis. In this situation, through suppression of LH, endogenous intratesticular testosterone production is reduced [22, 23]. HPG axis disorders can also be a result of different systemic or neoplastic diseases along with pharmaceutical therapies. Depending on which level of HPG axis secretion we want to boost or suppress, different hormonal treatments are implemented. In the treatment of male infertility caused by the inability of hypothalamus hormones to secrete (hypogonadotropic hypogonadism), the agents used primarily are gonadotropin-releasing hormone (GnRH), gonadotropins. The other group, dopamine agonists, is administered to patients with hyperprolactinaemia as a result of pituitary gland prolactinoma [23]. Aromatase inhibitors, which lower oestrogen levels, are used especially in obese infertile men with oligozoospermia or azoospermia. In such patients, peripheral hormonal conversion from androgens to oestrogens in fatty tissue is enhanced, leading to HPG axis malfunction. Selective oestrogen receptor modulators (SERMs) are drugs that act as agonist or antagonist. For example, clomifene citrate increases hypophysical LH and FSH secretion, which also contributes to an improvement in testosterone level. SERMs are one of the applicable treatment options for idiopathic fertility [23, 24].

There are some suggestions in the literature that ROS formation and sperm DNA fragmentation can be reduced by antioxidants. It seems that they can be useful in patients with abnormally high ROS levels and DNA fragmentation. However, according to the EAU 2023 Guidelines, the role played by both of them is still unclear, because there are not sufficient data to demonstrate their therapeutic effect [4, 23].

Invasive management of male infertility comprises procedures that improve semen parameters (like varicocele correction) together with direct sperm collection from the testicle on biopsy (in case of obstructive azoospermia). Few methods of sperm retrieval evolved over the years. The retrieved sperm from this procedure can be used, after special preparation, for intracytoplasmic sperm injection (ICSI). Testicular fine-needle aspiration (TfNA) is a percutaneous insertion of the needle into the gonad under local anaesthesia. It is characterised by low costs and less tissue injury. In testicular sperm aspiration (TESA), sperm retrieval is also performed percutaneously but with a large needle (40 × 12 mm). Sperm are aspirated with the use of negative pressure created by the syringe. This procedure usually requires intravenous anaesthesia and a longer recovery (up to 24 h) but has low complication rates. Conventional testicular sperm extraction (c -TESE) is single or multiple open testicular biopsies. Samples are examined immediately after the procedure under the microscope in the laboratory. The c-TESE is fast, relatively inexpensive, and has a higher retrieval rate than the previously presented ones, but it injures testicular vascularisation and testicular tissue that may permanently or temporarily lower testosterone level. Unlike c-TESE that is performed without magnification, microdissection testicular sperm extraction (micro-TESE) is a similar procedure but carried out with the use of a microscope and a microsurgical technique during preparation to detect seminiferous tubules with greater probability of sperm in their lumen. Micro-TESE is recommended in men with non-obstructive azoospermia with an unfavourable prognosis. It has a high retrieval rate and microscopic dissection minimises testicular tissue damage. However, it is characterised by the highest costs among all sperm retrieval techniques. Open testicular mapping (OTEM) is the newest technique that involves a scrotal incision and multiple testicular punctures with a 19-G needle and syringe aspiration. The samples are then analysed under the microscope with 400× magnification to check the spermatozoa presence. If there is a lack of them in the samples, the next punctures are made. The advantage of OTEM is that there is no need for a surgical microscope and microsurgical skills along with not as extensive tissue damage as in c-TESE. This approach is a combination of two methods; it incorporates minimal invasion of micro-TESE and low costs of c-TESE [25, 26, 27].

4. Possible impact of inguinal hernia repair on fertility

Possible fertility problems after inguinal hernia repair surgery can be divided into iatrogenic vas deferens damage and inflammatory due to mesh placement.

Injury related to vas deferens may be the result of ligation, cauterisation, interruption of continuity by accidental intersection or microdamage due to intense pulling of the sperm cord. Vas deferens can also be exposed to compression and tension from tight non-mesh herniorrhaphy or scars formed by mesh insertions in hernioplasty. These factors contribute to vas deferens obstruction (or discontinuation in the case of incision), which could be reflected as oligozoospermia or azoospermia in semen analysis. The obstruction seems not only to appear early after surgery and expand to normal lumen as a result of tissue recovery after direct vas deferens damage but can also be late-onset due to the formation of adjacent tissue scars. In addition, early-onset obstruction due to severe and extensive vas deferens damage may be permanent. Paediatric and infant patients are more susceptible to vas deferens damage due to its immature tissues, which results in less strength of its wall.

Mesh inserted in hernioplasty involves an inflammatory fibroblastic reaction of the monofilaments of the foreign body with adjacent tissue, strengthening the inferior wall of the inguinal canal to prevent future inguinal hernias. When the spermatic cord adheres strictly to the mesh, vas deferens and its vascularization can be involved in scar formation, which can lead to damage due to its wall inflammation and hyperplasia, as well as impaired blood perfusion. Visible vas deferens injury can be corrected during surgery, but most damages do not appear to be detectable during herniorrhaphy or hernioplasty and this could be a reason for underestimation and underdiagnosis.

In case of postoperative suspicion of obstruction, the check of vas deferens patency and the level of eventual narrowing can be done by vasography, which is, however, an invasive examination. The patient could choose, under favourable anatomical conditions and a high probability of success of the procedure, whether to undertake an attempt at his vas deferens reconstruction by a surgeon or to immediately opt for a testicular biopsy to obtain sperm for ICSI. Reconstruction of vas deferens in injuries due to inguinal hernia repair performed in childhood and manifesting later as oligo/azoospermia in adulthood is possible, but not always successful in more extended defects with impaired blood supply and secondary epididymal loss of patency, which developed over years in such cases. Sperm should be collected during reconstruction surgery. Among these men, the reconstruction attempt of vas deferens, in case of its failure, is paired with direct sperm aspiration and then cryopreservation for future ICSI [28, 29, 30, 31, 32].

The impact of inguinal hernia surgery on male fertility is one of the controversial issues concerning the implications of surgical intervention within the inguinal canal on the quality of sperm and male sexual activity. The potential impact of hernioplasty on fertility was first reported at the end of the twentieth century and the beginning of the twenty-first century. To date, published research results have analysed a wide variety of aspects of fertility assessment and external genitalia function. An additional aspect that makes an unambiguous assessment difficult is the development of surgical techniques (non-mesh versus mesh surgery, open versus laparoscopic approach and different types of materials used in tension-free surgery). Authors investigating the impact of inguinal hernia surgery on male fertility have hitherto evaluated various parameters, including testicular volume, testicular perfusion based on vascular resistive index values, sex hormone values, semen analysis and anti-sperm antibody (ASA) level.

4.1 Animal study

Few experimental studies in animals have shown that polypropylene mesh used in hernia repair stimulates a foreign body reaction that can lead to the encapsulation of spermatic cord structures and is postulated to cause symptoms of dysejaculation and genital pain during sexual activity with deleterious effects on patient sexual functions and quality of life [33]. Peiper et al. based on the results of experimental studies in the pig and rabbit reported that implantation of a polypropylene mesh in the inguinal region induces a major response of the structures of the spermatic cord, which may also influence spermatogenesis [34]. Uzzo et al. reported the effect of mesh implantation on the spermatic cord structures in a canine model including histological evaluation of the spermatic cord following surgery. The authors found dysfunction in the external genitalia in three out of six dogs operated with mesh; furthermore, the size of the vessel lumen in the cross-sectional section was significantly reduced with a marked foreign-body reaction of the soft tissue identified after mesh repair. A posttraumatic neuroma was identified suggesting nerve entrapment in the fibrous branch of the mesh, which may be the culprit in the postoperative pain observed in some patients [35]. In another animal model study, a histopathological alteration of the vas deferens was evaluated in rats exposed to polypropylene mesh. The authors reported that polypropylene mesh induces a foreign-body reaction, with histological changes in the vas deferens that cause functional obstruction, with dilatation and spermatozoid repression [36]. Contrary to these results, Damous et al. published results of an experimental study in rats after surgery with the use of bilateral polypropylene mesh. On the basis of the results, the mesh placement did not alter the morphology of the vas deferens in any of the analysed segments. The authors concluded that surgery, with or without mesh placement, did not alter morphology, wall thickness or lumen area [37]. A separate issue related to the consequences of mesh implantation in the region of the spermatic cord on an animal model was the evaluation of the effect of mesh bioprosthesis in inguinal hernia repair on testicular nitric oxide metabolism and apoptosis in rat testis. The authors reported that long-term polypropylene mesh implantation has no effect on testicular hormonal function and only a limited effect on nitric oxide levels and this effect is not sufficient to cause apoptosis in the testis that could lead to infertility [38].

4.2 Human study

4.2.1 Laparoscopic versus open surgery hernia repair

Singh et al. in randomised controlled trial (RCT) compared testicular dysfunction, incidence and factors that influence chronic groin pain, and quality of life after open mesh and laparoscopic repair. A significant decrease in testicular volume was observed and less improvement in blood flow after open repair. There was also a significant reduction in serum testosterone level with a significant increase in FSH and LH level; however, there was no testicular atrophy. The incidence and severity of chronic groin pain were significantly lower after laparoscopic repair during normal and strenuous activities, although they were similar to those after open repair during rest after 3 months postoperatively [39]. In another trial, Abkulut et al. compared changes in testis volume and sex hormone levels after inguinal hernia repair (Lichtenstein vs. laparoscopic totally extraperitoneal (TEP) hernia repair techniques). Neither the Lichtenstein nor the TEP method could affect LH, FSH, and testosterone values, but TEP could lead to a decreasing effect on testis volume, but within normal limits [40]. Immunological factor is considered another potential factor that may affect fertility after mesh hernia surgery. In the general male fertile population, the positivity of ASAs is estimated to be between 0.9 and 4% [41]. Eight to ten percentage of infertile patients have immunological infertility. The effect that autoimmunization causes on the various passages of fertility is still under discussion. First of all, ASAs are supposed to cause poor penetration into cervical mucus. The conception rate in infertile couples with antibodies is almost 40% lower than in the group without antibodies. Damage to the vas deferens, testicular ischemia, and inflammatory reaction to the mesh may be possible causes of sperm antigen intolerance. In the study by Stula et al., the quantitative value of antisperm antibodies (ASA) in serum was analysed after hernia repair. After the operation, the ASA increased in most of the patients but remained in the normal range. The ASA value increased significantly by an average of 13.5% in the group of patients who were operated with the open technique. In the group of patients who underwent laparoscopic surgery, no significant change in the value of ASA was found postoperatively. In the concluding study, inguinal hernia mesh repair does not have a clinically significant influence on the immunological response [42]. Goupta et al. presented suitable results in a randomised three-arm study comparing open mesh hernioplasty, laparoscopic totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repair of the groin hernia and antisperm antibodies (ASA) levels increased after surgery in the study population, which reached statistical significance. On the contrary, patients undergoing open mesh hernioplasty showed a significant increase in ASA compared to preoperative values. In the TAPP and TEP groups, there was no significant increase in ASA in the postoperative period after 3 months. However, all these values were within the normal range of antisperm antibodies [43]. Negri et al. in their study investigated the influence of inguinal hernia repair on sperm autoimmunity. This retrospective study includes all infertile male patients with a history of unilateral or bilateral inguinal hernia surgery repair who underwent mixed antiglobulin reaction tests. Antisperm antibodies would appear to increase in patients who performed groin hernia surgery 2.45 (95% confidence interval: 1.01–5.99; p < 0.05) times more than in the unselected infertile population. The authors concluded that the MAR test could be useful in patients who have undergone previous hernia surgery, to avoid false unexplained infertility diagnoses and to direct the couple to assisted reproductive technology procedures [44].

4.2.2 Laparoscopic totally extra peritoneal (TEP) versus transabdominal preperitoneal (TAPP) hernia repair

Bansal et al. suggested no changes in testis and sexual function after TAPP compared to TEP. According to the report, changes in male fertility are not related to the techniques used in TAPP or TEP. However, the authors considered that hands-on ligation of spermatic cord structures during the procedure may alter the aetiology of testicular dysfunction after open mesh repair [45]. A prospective randomised study of sexual function and semen analysis following TEP and TAPP inguinal hernia repair showed that both methods are comparable in terms of sexual function and effect on semen analysis. Antisperm antibody levels were insignificant both preoperatively and 3 months postoperatively in the study population and there was no significant difference between the two methods [46]. Based on the study by Gupta et al., most of the parameters of semen analysis improved significantly from preoperative to post-TEP or post-TAPP period. Semen volume, total sperm concentration, sperm count, and vitality improved significantly during the postoperative period at 3 months. However, progressive motility decreased slightly. Non-progressive motility did not show any change from the preoperative to postoperative period. On comparison of the laparoscopy approach (TAPP + TEP) vs. open, no parameter showed any statistically significant difference [43].

4.2.3 Lightweight versus heavyweight mesh for inguinal hernia repair

Patients operated on with a lightweight mesh (VyproII® or TiMesh®) exhibited a decreased sperm motility compared with heavyweight mesh (Marlex®) patients, respectively −9.5% and − 5.5% versus +2%. When the results after uni- and bilateral hernia repair were analysed separately, this difference only remained significant in the bilateral hernia subgroup: −10% for VyproII® and − 17% for TiMesh® versus +1% for Marlex®. The authors concluded that the use of lightweight meshes for laparoscopic inguinal hernia repair in male patients negatively influences sperm motility, without any benefit on quality of life [47]. Peeters et al. in a forthcoming study analysed the effects of lightweight meshes on laparoscopic repair of inguinal hernia on male fertility aspects, at 3-year follow-up. They did not report significant differences between the percentage of lightweight mesh (VyproII® and TiMesh®) versus Marlex® patients with a decreased sperm motility or concentration at 3 years of follow-up (−8.5% and −8% vs. −2.8%, respectively). Furthermore, no significant changes were observed in the number of patients with decreased sperm motility or concentration 3 years after surgery compared to 1 year after operatively [48].

4.2.4 Non-mesh versus mesh inguinal hernia repair

Based on Kordzadeh et al. pooled analysis, sperm motility could be affected following the inguinal hernia repair technique, but this is limited to the immediate postoperative period (<48 h). Obstructive azoospermia was observed in 0.03% of open hernia and 2.5% of bilateral mesh laparoscopic hernia repair. Male infertility was detected in 0.8% of open hernia repair (mesh) with no correlation to the type of mesh. The authors concluded that the repair of the inguinal hernia without mesh has no impact on male fertility and obstructive azoospermia [49].

Dong et al. in systemic review investigated 29 related trials with a total of 36,552 patients, including 7 randomised controlled trials (RCTs) with 616 patients and 10 clinical trials (1230 patients) with mesh or non-mesh repairs. They suggested that mesh hernia repair in an open or laparoscopic procedure has no significant effect on male fertility [50].

5. Conclusions

Undoubtedly, infertility, due to the increase in its prevalence in the population in recent years, has become one of the civilisation diseases. Therefore, of great importance is the identification of the causes of this disease.

There were theories of a negative impact on male fertility by inguinal hernia repair surgery. However, most of the research results available so far have not confirmed that hernioplasty procedures contribute to male infertility. Evidence is inevitably difficult to reach because of a wide range of causes of infertility and their complexity. However, the choice of method and the possible impact on fertility are worth discussing with the patient before surgery. Furthermore, preoperative and postoperative semen analysis will help exclude or confirm its impact on patient fertility in the future.

The role of surgeon during procedure is to raise awareness of the possibility of vas deferens injury and obstruction formation, which can be avoided by delicate and careful mobilisation of the spermatic cord without grasping, exposure to coagulation and any additional compression. Although there is no proof of whether any kind of mesh negatively impacts male fertility, obstruction of the vas deferens due to fibroblastic scar formation may be taken into account in follow-up in case of poor results of the semen analysis. Prevention may be achieved by avoiding excessive spermatic cord compression by the mesh to reduce the development of pathologic tissue adhesions.

Conflict of interest

The author declares no conflict of interest.