FERTILITY OUTCOME AFTER REPEAT VASOEPIDIDYMOSTOMY

PURPOSE: Historically, epididymal obstruction has been treated with surgical reconstruction. We determine whether it is worthwhile for patients to undergo repeat surgical reconstruction after failed vasoepididymostomy or whether they should be advised only to undergo sperm acquisition for assisted reproductive technique. MATERIALS AND METHODS: A total of 18 patients underwent repeat vasoepididymostomy performed by a single urologist (A. J. T.). Cases were divided based on the etiology of obstruction into groups 1--prior vasectomy (4), 2--congenital (7) and 3--inflammatory (7). Data were available regarding time of obstruction between initial and repeat vasoepididymostomy, quality of epididymal fluid, levels of anastomoses, semen analyses at least 12 months after surgery for all 18 men and pregnancy rates based on more than 18 months of followup in 12. RESULTS: Mean patient age at repeat vasoepididymostomy was 40.6 years (50.5, 36 and 39.4 years for groups 1, 2 and 3, respectively). Mean interval between vasectomy and initial vasoepididymostomy was 12.3 years (range 10 to 18). Mean interval between initial and repeat vasoepididymostomy was 19 months (range 12 to 41). Of the patients 10 underwent unilateral and 8 bilateral anastomoses, for a total of 26 repeat anastomoses. Overall patency rate was 66.7% (12 of 18) with sperm in the ejaculate in 75, 85 and 43% of patients in groups 1, 2 and 3, respectively. The patency rates according to the levels of the anastomosis were 66.7, 62.5 and 100% in the caput, corpus and cauda, respectively. Natural conception occurred in 3 of 12 couples (25%, 2 caput and 1 caudal anastomosis) during a mean followup of 23 months (range 13 to 34). All 3 cases had congenital obstruction. Pregnancy was achieved in 2 group 1 cases with cryopreserved sperm extracted at repeat vasoepididymostomy, and in 1 case each in groups 1 and 2 with microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection. CONCLUSIONS: After repeat vasoepididymostomy two-thirds of men have sperm in the semen. Natural conception occurred in 25% of patients (3 of 12) followed for more than 18 months. Inability to establish pregnancy in the remaining 7 of 9 patients with sperm in the semen with a followup longer than 18 months may be due to epididymal dysfunction or partial obstruction and subsequent poor sperm quality. Aspiration of motile sperm and cryopreservation were possible in 11 of 18 cases at repeat vasoepididymostomy and should be recommended in case azoospermia remains or occurs after surgery. It appears worthwhile to offer patients repeat vasoepididymostomy after a failed initial procedure.     

OUTCOME OF MICROSURGICAL RECONSTRUCTION IN MEN WITH SUSPECTED EPIDIDYMAL OBSTRUCTION

Purpose

Approximately 3 to 6% of all men presenting with infertility (excluding those with a history of vasectomy) are suspected of having epididymal obstruction. However, other anatomical abnormalities within the male reproductive tract are often encountered. In this study we attempted to define the range and frequencies of anatomical abnormalities in the reproductive tract and the outcome of surgical reconstruction in men with suspected epididymal obstruction and no history of vasectomy.

Materials and Methods

Between July 1992 and July 1996, 80 azoospermic men with suspected epididymal obstruction underwent scrotal exploration. The anatomical findings and outcomes of reconstructive surgery were reviewed.

Results

Of a possible 160 reproductive tract units (2 per patient) we thoroughly examined 147 with suspected epididymal obstruction. Epididymal obstruction was found in 52.7% of the cases with other anatomical abnormalities accounting for the remaining 47.3%. Of the patients 49 (61%) had sperm identified in the epididymis on at least 1 side and underwent vasoepididymostomy, and 3 (4%) had sperm unilaterally in the proximal vas but had ipsilateral distal vasal obstruction. These 3 men underwent crossed vasovasostomy. We were more likely able to perform reconstruction in men whose obstruction was due to an infectious etiology (13 of 14, 93%) compared to either a surgical (5 of 7, 71%) or idiopathic (34 of 59, 58%) etiology. In 28 patients (35%) no sperm was identified in the epididymis or they had no other abnormalities that precluded successful reconstruction on either side. Of those patients who underwent vasoepididymostomy for epididymal obstruction 61% had sperm in the ejaculate postoperatively.

Conclusions

In nearly half the men with suspected epididymal obstruction other reproductive tract abnormalities were detected, most of which precluded successful vasoepididymostomy. Other reproductive tract abnormalities are much less likely to be found, and the outcomes of reconstruction are better if the cause of the obstruction is infectious compared to surgical or idiopathic.     

Vasoepididymostomy for Vasectomy Reversal: A Critical Assessment in the Era of Intracytoplasmic Sperm Injection

Purpose

We compared vasoepididymostomy to microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection for treatment of epididymal obstruction secondary to vasectomy.

Materials and Methods

Results in patients who underwent vasoepididymostomy for vasectomy reversal at our institution were compared to those reported previously for microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection performed for obstructive azoospermia. The pregnancy rates, delivery rates, complications, cost per procedure and cost per delivery were compared. A cost per newborn analysis was performed using pregnancy and delivery rates, and reported cost estimates for the complications of assisted reproductive techniques.

Results

A total of 55 men underwent 58 vasoepididymostomies in an attempt to restore fertility after vasectomy. Median followup was 19 months (range 0 to 115). Median obstructive interval was 12 years. There were no major complications. The patency rate after 6 months was 85%. Of the couples 20 achieved 24 pregnancies and 16 had 17 live births. The pregnancy rate at 1 year was 44%. There were 4 miscarriages and there are 3 ongoing pregnancies. The live delivery rate was 36%. Assuming a 29% delivery rate for microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection, the cost per newborn was $51,024, compared to $31,099 for vasoepididymostomy.

Conclusions

Vasoepididymostomy is more successful and more cost-effective than microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection for vasectomy reversal. It does not expose the women to complications in the treatment of a male problem and it is indicated for treatment of epididymal obstruction secondary to vasectomy. Microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection should be reserved for cases not amenable to surgical reconstruction.     

附睾输精管吻合术治疗梗阻性无精子症

目的探讨附睾输精管吻合术在梗阻性无精子症治疗中的作用。方法选择23例确诊为梗阻性无精子症并初步怀疑为附睾水平梗阻的患者进行阴囊探查，观察睾丸、附睾及输精管情况，对其中19例确定为附睾水平梗阻并在附睾液中找到活精子的患者用8-0尼龙线施行双侧或单侧附睾输精管端侧吻合术，术后随访其疗效。结果19例获随访8～34个月，9例(47％)于术后3～9个月从精液中检出活精子，其中5例配偶受孕成功。结论阴囊探查简单、易行，有助于梗阻性无精子症的诊断和治疗，附睾输精管吻合术治疗梗阻性无精子症取得初步效果，值得进一步探讨。     

Prospective analysis of outcomes after microsurgical intussusception vasoepididymostomy

OBJECTIVE: To prospectively analyse the outcomes of microsurgical vasoepididymostomy using the intussusception technique, as vasoepididymostomy is considered the most challenging reconstructive microsurgery in urology. PATIENTS AND METHODS: From 1998 to 2003, of 324 men with obstructive azoospermia who had undergone microsurgical reconstruction of the reproductive tracts, 68 (21%) had intussusception vasoepididymostomy bilaterally or unilaterally in a functionally solitary testis. The outcomes of these patients were analysed prospectively. RESULTS: The mean age was 39.8 years for the men and 31.8 years for their partners. The causes of obstruction were after vasectomy in 31%, infection in 22%, iatrogenic in 19%, trauma in 1.5%, and idiopathic in 27%. The median duration of obstruction was 18.8 years; 37% of patients had had previous failed attempts at reconstruction. The mean (range) follow-up was 15.2 (1-36) months. The overall patency (>10 000 sperm/mL) rate was 84% (53/63). Patency was achieved in 60% (38/63) of men at 1 month after surgery. The mean best sperm count was 12.8 (0.01-80) x 10(6)/mL, with a 21 (0-30)% motility. Among patients with a follow-up of > 1 year, the natural paternity rate was 40%. The median time to achieve a natural pregnancy was 14.3 (3-30) months. Pregnancy was achieved with in vitro fertilization or intracytoplasmic sperm injection in 31% of cases, all using fresh ejaculated sperm. CONCLUSIONS: A favourable patency and pregnancy rate can be achieved using microsurgical intussusception vasoepididymostomy. Even when assisted-reproductive technology is needed, fresh ejaculated sperm can be used without requiring a subsequent sperm retrieval procedure. Thus, microsurgical reconstruction of the reproductive tract should be primary therapeutic method in cases of azoospermia from epididymal obstruction.     

显微外科技术下梗阻性无精子症术前诊断及治疗方式探讨

目的:探讨梗阻性无精子症(OA)在显微外科技术下术前诊断及其治疗策略。方法:57例不育症患者确诊为OA并初步怀疑为附睾梗阻,行阴囊探查术观察附睾及输精管梗阻情况;术中对确定为附睾梗阻并在附睾液中找到活精子的患者施行附睾输精管端侧吻合术,同时对探查至附睾头部才发现精子或术中发现双侧附睾以远输精管梗阻、缺如的患者留取精子冷冻以备卵细胞胞质内单精子注射(ICSI);术后随访其疗效。结果:53例(92.9%,53/57)行阴囊探查术确诊为附睾水平OA,47例(82.5%,47/57)完成显微手术,10例(17.5%,10/57)术中留取精子冷冻。22例(46.8%,22/47)于显微手术后1～18个月从精液中检出活动精子;5例(10.6%,5/47)配偶自然受孕成功,6例(18.5%,6/32)留取精子行ICSI后配偶怀孕。结论:在显微外科技术日益成熟下,OA的术前诊断应尽量采取无创的手段,在手术探查中进行梗阻部位的确诊及决定治疗方式。     

梗阻性无精子症的外科治疗(附56例报告)

目的:探讨梗阻性无精子症的诊断和外科治疗方法。方法:分析2004年10月至2008年11月间收治的56例梗阻性无精子症患者的临床资料,其中43例为射精管梗阻性无精子症,13例疑为附睾水平梗阻性无精子症。常规精液分析、精浆果糖和中性α葡糖苷酶测定以及经直肠超声检查(TRUS)对其进行诊断,必要时行输精管造影检查。43例为射精管梗阻性无精子症使用经尿道射精管切开术(TURED)治疗,13例疑为附睾水平梗阻性无精子症行阴囊探查术,对其中11例确定为附睾水平梗阻行双侧或单侧附睾输精管端侧吻合术,术后随访其疗效。结果:所有患者均完成手术,术后随访3～51个月。43例射精管梗阻性无精子症TURED术后,36例(83.7%)精液检查有不同程度的改善,11例(25.6%)妻子妊娠。11例附睾水平梗阻性无精子症行输精管附睾吻合术后,6例(54.5%)精液检查检出活精子,3例(27.3%)妻子妊娠。结论:精液分析、精浆果糖和中性α葡糖苷酶测定,TRUS和输精管造影是诊断梗阻性无精子症的主要方式。TURED和输精管附睾吻合术分别是治疗射精管梗阻性无精子症和附睾水平梗阻性无精子症的有效方法。     

ADVERSE EFFECTS ON VASOEPIDIDYMOSTOMY OUTCOMES FOR MEN WITH CONCOMITANT ABNORMALITIES IN THE PROSTATE AND SEMINAL VESICLE

Purpose

Following microsurgical vasoepididymostomy as many as 85% of men have sperm in the ejaculate, yet only 30 to 50% will spontaneously father children. We examined the possibility that there may be concomitant abnormalities in the prostate and seminal vesicle, which may be associated with low pregnancy rates.

Materials and Methods

Transrectal ultrasound was performed in azoospermic men with suspected epididymal obstruction, excluding those who had undergone vasectomy, to identify abnormalities of the seminal vesicles and ejaculatory ducts. Microsurgical vasoepididymostomy was attempted in all men.

Results

Transrectal ultrasound revealed ejaculatory duct dilatation in 13 of 40 men (33%), although only 3 had accompanying seminal vesicle dilatation. Two men had atrophic seminal vesicles with normal ejaculatory ducts. At surgery 8 of 40 patients (20%) were deemed to have irreparable conditions. For the 27 men followed at least 6 months postoperatively patency and pregnancy rates were 75 and 22%, respectively. Mean sperm counts plus or minus standard deviation were significantly higher in men without compared to those with seminal vesicle or ejaculatory duct abnormalities (43 ± 68 versus 5.7 ± 6.9 x 10⁶ sperm per ml., respectively), and so was the percentage of motile sperm (30 ± 16% versus 1.2 ± 2.2%, respectively). Pregnancy rates were also higher in men without (6 of 19, 32%) than with (0 of 8, 0%) seminal vesicle or ejaculatory duct abnormalities.

Conclusions

Transrectal ultrasound detected abnormalities of the seminal vesicles and ejaculatory ducts are common in men with suspected epididymal obstruction. These abnormalities are associated with a poor outcome for vasoepididymostomy. We recommended that all men with suspected epididymal obstruction undergo transrectal ultrasound before any attempted reconstruction.     

Clinical observation of loupe-assisted intussusception vasoepididymostomy in the treatment of obstructive azoospermia (analysis of 49 case reports)

To evaluate the clinical outcomes of loupe-assisted intussusception vasoepididymostomy (VE) in the treatment of epididymal obstructive azoospermia (EOA), we retrospectively analyzed data from 49 patients with EOA who underwent two-suture longitudinal intussusception vasoepididymostomy (LIVE) between 2000 and 2007. The data included the surgical method, postoperative motile sperm count per ejaculation, percentage of progressive motile sperm and patency and pregnancy outcomes. There were a total of 49 men undergoing scrotal exploration, and epididymal obstruction was found in all cases. Bilateral or unilateral anastomoses were performed in 40 and 6 men, respectively. The postoperative courses of 42 patients were followed up for more than 6 months, and the courses of 38 patients were followed up for more than 1 year. The overall patency and pregnancy rates were 71.4% and 26.3%, respectively. Moreover, progressive motile sperm was more frequently present in those patients who had undergone anastomosis at cauda than at corpus or caput. Pregnancy was achieved only in those patients who had undergone anastomosis at least on one side of the cauda epididymis. We think that the loupe-assisted method, with a lower overall cost and a simplified surgical procedure, can achieve satisfactory patency outcomes and pregnancy results. Data from this paper also suggest that paternity outcomes occur more frequently after anastomoses at cauda than at corpus or caput.     

Should all urologists performing vasectomy reversals be able to perform vasoepididymostomies if required?

PURPOSE: While vasectomy reversal is a highly successful procedure 10% to 30% of reversals may fail. Despite the general consensus that an epididymal obstruction may occur following a vasectomy and that some men should undergo vasoepididymostomy (VE) rather than vasovasostomy (VV), the practice of many urologists in our region has been to offer only VV for vasectomy reversal. We examined the potential causes for vasectomy reversal failure in patients who had undergone VV without an attempt at VE. MATERIALS AND METHODS: We conducted a retrospective review of patients who had undergone redo vasectomy reversal from January 1999 to September 2001. A total of 22 patients underwent redo reversal with a minimum followup of 2 years. The medical records of all patients were then reviewed. Patients and partners seen postoperatively in the clinic were questioned regarding any pregnancy or deliveries. RESULTS: We examined 22 patients who had undergone redo vasectomy reversal. Of 22 patients 9 (40.9%) underwent repeat VV, 8 (36.3%) underwent bilateral VE for a presumed unrecognized epididymal obstruction and 5 (22.7%) had a combination of VE and VV. Of the 44 reproductive units studied 23 (52.3%) had a failed vasal anastomosis while 21 (47.7%) had an unrecognized epididymal obstruction. Based on semen analysis patency was observed in 75% of patients who had undergone vasovasostomy as a redo procedure. A patency rate of 60% was found in patients who underwent vasoepididymostomy and vasovasostomy unilaterally, and patency rates for bilateral VE were 63%. CONCLUSIONS: Our study indicates that a large proportion of men (48%) have an epididymal obstruction as the etiology for vasectomy reversal failure. We recommend that all surgeons offering vasectomy reversals be able to offer VE if required based on intraoperative findings to serve the patient adequately as well as his partner and their future fertility.     

Alloplastic spermatocele: poor sperm motility in intraoperative epididymal fluid contraindicates prosthesis implantation

After vasectomy reversal by vasovasostomy or vasoepididymostomy motile sperm appear commonly in the semen even when only nonmotile sperm are present in the intraoperative vasal or epididymal fluid. We studied patients with bilateral congenitally absent vasa deferentia to see if relief of obstruction by implantation of an alloplastic spermatocele also benefits sperm motility in such patients. A total of 130 alloplastic spermatoceles was implanted in 91 patients. Of 21 patients with only nonmotile sperm in the epididymal fluid intraoperatively only 1 had motile sperm in the postoperative aspirates from the alloplastic spermatocele. The quality of sperm motility in the intraoperative epididymal fluid was predictive of the quality of sperm motility in the postoperative aspirates. Conception postoperatively did not occur whenever less than 20 per cent of the intraoperative epididymal sperm was motile. Thus, poor or absent sperm motility in the epididymal fluid during planned alloplastic spermatocele implantation predicts a poor postoperative result and, therefore, contraindicates implantation of the prosthesis. Pregnancy, which occurred postoperatively in 7 of 91 wives, ended in spontaneous abortion in 3 and progressed to full-term delivery in 4.     

Obstructive infertility: changes in the histology of different regions of the epididymis and morphology of spermatozoa

In the present study, the effects of prolonged obstruction in different regions of the human epididymis on its histology and on the spermatozoa retained at the site of obstruction were assessed. Men who were confirmed of having obstruction of the epididymis underwent vasoepididymostomy (VEA) for surgical correction of the obstruction. At the time of surgery, fluid from the epididymal tubule above the site of obstruction was aspirated and examined for sperm profile. Epididymal tissue, collected at the site of obstruction, was processed for assessment of histological changes and also used to identify the site of obstruction. Prolonged obstruction of the epididymis has caused degeneration of the epididymal epithelium, gradual decrease in the diameter of the tubule and tubular lumen and increase in the intertubular connective tissue. Sperm aspirated from the caput epididymal fluid showed sluggish pattern of motility only in one out of the six subjects, whereas spermatozoa collected from the cauda epididymal fluid showed rapid linear progressive motility in one of three subjects. A major percentage of spermatozoa in the aspirated fluid showed various types of morphological abnormalities, irrespective of the site of obstruction. These results are discussed in relation to the role of the epididymis in investing spermatozoa with motility and fertilizing capacity.     

Need for sperm retrieval and cryopreservation at vasectomy reversal

PURPOSE: Controversy exists on whether to obtain sperm for cryopreservation routinely at vasectomy reversal. With recent improvements in in vitro fertilization with intracytoplasmic sperm injection, it is now possible to obtain a small amount of testicular tissue for cryopreservation in the event of reversal failure. However, to our knowledge no studies exist of who is most likely to benefit from this procedure. MATERIALS AND METHODS: We reviewed 84 consecutive vasectomy reversals performed by 1 surgeon (J. I. S.) between July 1996 and March 2000 with followup available for 77. We grouped cases by procedure as vasovasostomy, vasoepididymostomy and vasovasostomy with vasoepididymostomy as well as bilateral or unilateral. Sperm was retrieved at reversal in 15 of 46 vasovasostomy (none used), 11 of 18 vasoepididymostomy (3 used) and 13 of 20 vasovasostomy with vasoepididymostomy (none used) cases. RESULTS: The overall anastomotic patency rate after unilateral or bilateral vasovasostomy, unilateral vasovasostomy with contralateral vasoepididymostomy and unilateral or bilateral vasoepididymostomy was 96%, 83% and 57%, respectively. The natural pregnancy rate without in vitro fertilization was 57%, 50% and 14%, respectively. The most recent vasoepididymal anastomoses were performed by the Berger triangulation technique with a 78% patency and 25% pregnancy rate. Only 8% of men with banked sperm eventually used it for assisted reproductive techniques, in whom unilateral or bilateral vasoepididymostomy failed in all. CONCLUSIONS: We currently do not recommend routine sperm retrieval for cryopreservation in men who undergoing vasovasostomy. We encourage men who require bilateral vasoepididymostomy to bank sperm at reversal. In men who undergo vasovasostomy with vasoepididymostomy we base the decision on preoperative counseling and intraoperative findings.     

The evolution and refinement of vasoepididymostomy techniques

Obstructive azoospermia secondary to epididymal obstruction can be corrected by microsurgical reconstruction with vasoepididymostomy (VE). Although alternative management such as epididymal or testicular sperm aspiration in conjunction with intracytoplasmic sperm injection is feasible, various studies have established the superior cost-effectiveness of VE as a treatment of choice. Microsurgical VE is considered one of the most technically challenging microsurgeries. Its success rate is highly dependent on the skills and experience of the surgeons. Various techniques have been described in the literature for VE. We have pioneered a technique known as longitudinal intussusception VE (LIVE) in which the epididymal tubule is opened longitudinally to obtain a larger opening to allow its tubular content to pass through the anastomosis. Our preliminary data demonstrated a patency rate of over 90%. This technique has been widely referenced in the recent literature including robotic-assisted microsurgery. The history of the development of different VE approaches, the preoperative evaluation along with the techniques of various VE will be described in this article.     

Identification of motile sperm in caput epididymis. Intraoperative observations and clinical correlations.

This retrospective review of patients who underwent vasoepididymostomy demonstrates that motile sperm may be identified in the most proximal portion of the epididymis, and implies that induction of sperm motility may be independent of transit through the epididymis. Although further studies are needed, the data imply that it may not be necessary to identify motile sperm in the epididymal fluid to achieve a successful vasoepididymostomy.     

Comparison of intussusception pull-through end-to-side and conventional end-to-side microsurgical vasoepididymostomy: prospective randomized controlled study in male wistar rats

PURPOSE: Vasoepididymostomy is a technically challenging and complex microsurgical procedure. Recently a new triangulation end-to-side microsurgical technique was reported that allows intussusception of the epididymal tubule into the vasal lumen, resulting in a higher clinical patency rate of 92% with shorter operative time in preliminary clinical studies. We performed a prospective controlled randomized study comparing the patency rate, postoperative sperm granuloma rate and operating time of conventional and intussusception end-to-side vasoepididymostomy in previously vasectomized rats. MATERIALS AND METHODS: We randomized 42, 6-week-old male Wistar rats into 4 groups, including 6 into the sham operation, and 12 each into the control, conventional end-to-side and intussusception end-to-side vasoepididymostomy groups. Bilateral 2-clip vasectomy was performed in all animals except those in the sham operation group. Bilateral intussusception or conventional end-to-side vasoepididymostomy was performed in the assigned animals 2 weeks after vasectomy. Animals in the control group underwent vasectomy only. In the sham operation group the testes were mobilized out of the scrotum and then returned. Rats were sacrificed at 8, 12, 16 and 24 weeks, respectively. The anastomosis and vasectomy sites were inspected for sperm granuloma. To assess patency the abdominal end of the vas was transected and intraluminal fluid was examined microscopically at 400x magnification for the presence of motile sperm. Patency was further confirmed by performing retrograde indigo carmine vasography through the anastomoses. RESULTS: In the intussusception and conventional groups the patency rate was 91.7% and 54.2% (p = 0.004), the sperm granuloma rate was 20.8% and 58.4% (p = 0.035), and average operative time was 65.8 and 67.7 minutes (p = 0.197), respectively. CONCLUSIONS: Intussusception end-to-side vasoepididymostomy is superior to conventional end-to-side vasoepididymostomy with respect to the patency and postoperative sperm granuloma rates. Further investigations are required to confirm such findings clinically in humans.     

附睾梗阻性无精子症的手术治疗

目的 评价附睾梗阻性无精子症(EOA)的手术效果和影响因素. 方法回顾性分析51例EOA患者的临床资料.患者均在硬膜外麻醉下行阴囊探查术.放大镜辅助下,行单层纵向2针套叠式输精管附睾吻合术(LIVE).收集资料包括手术方法、随访时间、术后精子数平均值、a级精子百分率及复通率和受孕率. 结果 平均手术时间(134±36)min.49例一侧或双侧附睾有精子检出,其中1例一侧附睾对侧输精管检出精子;2例附睾未检出精子.49例附睾找到精子者中,48例行单侧或双侧LIVE,1例行单侧LIVE对侧输精管端端吻合.48例行单纯LIVE者失访4例,余44例随访7～17个月,32例精液中检出精子,复通率为72.7%;精子总数平均为(24±23)×106个;28例(87.5%)精液中检出a级精子,a级精子平均为(12.0±11.2)%.39例随访12个月,其中10例妊娠,受孕率为25.6%.术后妊娠与吻合口位置有关,本组妊娠均为吻合部位在尾部者. 结论 放大镜辅助下的LIVE操作简单、费用低,并能取得满意的复通率和受孕率;术中应考虑吻合口位置对妊娠的影响.     

The efficacy of repeat percutaneous epididymal sperm aspiration procedures

PURPOSE: The development of intracytoplasmic sperm injection spawned new methods of sperm retrieval for men with obstructive azoospermia who did not want to undergo reconstruction of the seminal tract. There is a wide array of different procedures that may be performed in these cases, for instance percutaneous epididymal sperm aspiration (PESA) and microepididymal sperm aspiration. However, concerns regarding the presence of sperm in a second PESA attempt due to possible fibrosis have been suggested by many authors. We evaluate if it is worthwhile to repeat percutaneous epididymal sperm aspiration. MATERIALS AND METHODS: The records of 20 patients (23 attempts) who underwent repeat PESA from January 1996 to September 2000 for assisted reproductive technique purposes were reviewed. In all patients the repeat procedure was performed on the same side as the previous PESA. Data were collected on patient age, presence of motile sperm during PESA, epididymal side, pregnancies and abortion rates. RESULTS: Mean patient age +/- SD was 32.4 +/- 5.6 years. One patient was excluded from our analysis due to lack of information on the chart regarding the side of the procedure. Repeat PESA was performed in the right epididymis in 12 attempts and in the left in 10. Of the remaining 19 patients 14 (73.68%) did not and 5 (26.3%) have sperm in the epididymal fluid. In these 5 patients 8 repeat PESA procedures were performed (3 procedures in 1 and motile sperm was always found (8 of 22 attempts, 36.4%). Three patients achieved pregnancy with the motile sperm retrieved from the repeat PESA (3 of 8 repeat attempts, 37.5%). No abortions were detected. CONCLUSIONS: More than a third of repeat PESA attempts resulted in the presence of motile sperm. Before performing testicular sperm aspiration or extraction in patients who have undergone previous PESA without achieving pregnancy, repeat PESA may be done. Further attempts should be added in the future to confirm these results.     

Histology of the epididymis in men with obstructive infertility

The histology of different regions of human epididymis in men undergoing vasoepididymostomy to correct epididymal obstruction was studied. The data indicate major degenerative changes in intertubular connective tissue and in the epididymal epithelium. These include increase in connective tissue thickness and its infiltration by leucocytes in some cases, decrease in tubular diameter, degeneration and/or vacuolation of cytoplasm of nonciliated cells of efferent duct and principal cells of epididymis and presence of multinucleate giant cells in the epididymal lumen. These histological abnormalities are discussed in relation to the role such epididymis can play in sperm maturation following vasoepididymostomy.     

Microscopic evaluation of the vasal fluid for sperm at the time of vasectomy reversal: Do we really need to check?

IntroductionDuring vasectomy reversal, intraoperative microscopic evaluation of the vasal fluid for sperm presence/quality can inform of the possibility of epididymal obstruction and need for a vasoepididymostomy (VE). In an effort to validate the utility of microscopic vasal fluid evaluation, the current initiative correlates gross vasal fluid characteristics with sperm presence and quality in a large series of VRs.MethodsA total of 1267 vasectomy reversals yielded a total of 2522 vasal-units (right/left sides) for analysis. During vasectomy reversal, vasal fluid was sampled from the testicular-end vas and the fluid was characterized (thick-paste/opaque/translucent/clear). Each aspirate underwent microscopic evaluation for sperm quality and was categorized as: motile sperm/intact-non-motile sperm/sperm parts/no sperm. The predictive utility of the gross vasal fluid characteristics with respect to microscopic sperm presence and quality was analyzed.ResultsAmong the 2522 vasal units analyzed, the side-to-side (left-right) concordance of vasal fluid quality and microscopic vasal sperm quality was 72% and 52%, respectively. When thick-pasty fluid was observed, no sperm were seen in the samples in 53% of cases, and if present, only non-motile sperm were observed. Even in the setting of more favorable vasal fluid characteristics (clear, translucent, and opaque fluid), no sperm were seen in 6–11% of cases, suggesting the possibility of epididymal obstruction and the need for VE.ConclusionsIntraoperative microscopic evaluation of the vasal fluid for sperm is a necessary practice during vasectomy reversal to optimize surgical outcomes. Reliance on gross vasal fluid characteristics in isolation may lead to unrecognized epididymal obstruction, and the need for a VE, in approximately 11% of cases.