Clinical features and microsurgical reconstruction of congenital unilateral absence of the vas deferens with obstructive azoospermia: a tertiary care center experience / 亚洲男科学杂志(英文版)

Patients with congenital unilateral absence of the vas deferens (CUAVD) manifest diverse symptoms from normospermia to azoospermia. Treatment for CUAVD patients with obstructive azoospermia (OA) is complicated, and there is a lack of relevant reports. In this study, we describe the clinical features and evaluate the treatments and outcomes of CUAVD patients with OA. From December 2015 to December 2020, 33 patients were diagnosed as CUAVD with OA in Shanghai General Hospital (Shanghai, China). Patient information, ultrasound findings, semen analysis, hormone profiles, and treatment information were collected, and the clinical outcomes were evaluated. Of 33 patients, 29 patients were retrospectively analyzed. Vasoepididymostomy (VE) or cross VE was performed in 12 patients, the patency rate was 41.7% (5/12), and natural pregnancy was achieved in one of the patients. The other 17 patients underwent testicular sperm extraction as the distal vas deferens (contralateral side) was obstructed. These findings showed that VE or cross VE remains an alternative treatment for CUAVD patients with OA, even with a relatively low rate of patency and natural pregnancy.

Should azoospermic patients with varicocele disease undergo surgery to recover fertility? / Pacientes com azoospermia e varicocele devem ser submetidos à cirurgia para recuperar a fertilidade?

Summary Introduction: Varicocele disease is well-known cause of infertility in men. The presence of spermatic varices veins create a hostile environment to spermatogenesis. It results in reduced quality of the sperm production and in some cases can determine a total absence of sperm. The varicocelectomy procedure in patients with non-obstructive azoospermia (NOA) can raise the rates of sperm in the semen analysis. A positive rate for sperm, even if very low, may be sufficient to enable the capture of sperm intended for in-vitro fertilization without the use of donor sperm. Objetive: To evaluate the raise of sperm in NOA patients with varicocele disease who were submitted to a bilateral procedure to recovery sperm production. Method: We analized the sperm results of 25 NOA patients who undergone to a bilateral varicocelectomy procedure. Results: From a total of 25 patients, three (12%) recovered sperm count four months after procedure. One year after the procedure, five (20%) patients recovered sperm production. Conclusion: Patients with varicocele disease and azoospermia, without genetic changes or obstruction of the spermatic tract, should undergo surgical procedure to recover sperm.

Resumo Introdução: A varicocele é sabidamente uma das causas de infertilidade nos homens. A presença de veias espermáticas dilatadas pode criar um ambiente hostil para a espermatogênese. Isso é causa de baixa qualidade e quantidade da produção do esperma; em alguns casos, pode determinar uma ausência total de espermatozoides. O procedimento de varicocelectomia em pacientes com azoospermia não obstrutiva pode aumentar as taxas de espermatozoides na análise do sêmen. Uma taxa positiva para o esperma, mesmo se muito baixa, pode ser suficiente para permitir a coleta e destinar-se ao processo de fertilização in vitro. Isso sem a necessidade de usar esperma de doador. Objetivo: Avaliar o aumento de espermatozoides em pacientes com varicocele associada à azoospermia não obstrutiva. Método: Foram analisados os espermas de 25 pacientes azoospêrmicos não obstrutivos submetidos a procedimento de varicocelectomia bilateral com magnificação microcirúrgica. Resultados: De um total de 25 pacientes, em três (12%) ocorreu recuperação da contagem de espermatozoides quatro meses após o procedimento. Após um ano de procedimento, em cinco (20%) ocorreu a recuperação. Conclusão: Pacientes com ausência de espermatozoides e varicocele, sem alterações genéticas, devem ser submetidos a tratamento cirúrgico a fim de recuperar a produção de espermatozoides.

Obstructive azoospermia: reconstructive techniques and results

Obstructive azoospermia is a common cause of male infertility and can result from infection, congenital anomalies, or iatrogenic injury. Microsurgical vasal reconstruction is a suitable treatment for many cases of obstructive azoospermia, although some couples will require sperm retrieval paired with in-vitro fertilization. The various causes of obstructive azoospermia and recommended treatments will be examined. Microsurgical vasovasostomy and vasoepididymostomy will be discussed in detail. The postoperative patency and pregnancy rates for surgical reconstruction of obstructive azoospermia and the impact of etiology, obstructive interval, sperm granuloma, age, and previous reconstruction on patency and pregnancy will be reviewed.

The role of varicocele treatment in the management of non-obstructive azoospermia

The literature on male reproductive medicine is continually expanding, especially regarding the diagnosis and treatment of infertility due to non-obstructive azoospermia. The advent of in vitro fertilization with intracytoplasmic sperm injection has dramatically improved the treatment of male infertility due to nonobstructive azoospermia. Assisted reproduction using testicular spermatozoa has become a treatment of hope for men previously thought to be incapable of fathering a child due to testicular failure. In addition, numerous studies on non-obstructive azoospermia have reported that varicocelectomy not only can induce spermatogenesis but can also increase the sperm retrieval rate; however, the value of varicocelectomy in patients with non-obstructive azoospermia still remains controversial. The purpose of this review is to present an overview of the current status of varicocele repair in men with non-obstructive azoospermia.

Prognostic factors for sperm retrieval in non-obstructive azoospermia

Testicular sperm retrieval techniques associated with intracytoplasmic sperm injection have changed the field of male infertility treatment and given many azoospermic men the chance to become biological fathers. Despite the current use of testicular sperm extraction, reliable clinical and laboratory prognostic factors of sperm recovery are still absent. The objective of this article was to review the prognostic factors and clinical use of sperm retrieval for men with non-obstructive azoospermia. The PubMed database was searched for the Medical Subject Headings (MeSH) terms azoospermia, sperm retrieval, and prognosis. Papers on obstructive azoospermia were excluded. The authors selected articles that reported successful sperm retrieval techniques involving clinical, laboratory, or parenchyma processing methods. The selected papers were reviewed, and the prognostic factors were discussed. No reliable positive prognostic factors guarantee sperm recovery for patients with non-obstructive azoospermia. The only negative prognostic factor is the presence of AZFa and AZFb microdeletions.

Laboratory processing and intracytoplasmic sperm injection using epididymal and testicular spermatozoa: what can be done to improve outcomes?

There are two main reasons why sperm may be absent from semen. Obstructive azoospermia is the result of a blockage in the male reproductive tract; in this case, sperm are produced in the testicle but are trapped in the epididymis. Non-obstructive azoospermia is the result of severely impaired or non-existent sperm production. There are three different sperm-harvesting procedures that obstructive azoospermic males can undergo, namely MESA (microsurgical epididymal sperm aspiration), PESA (percutaneous epididymal sperm aspiration), and TESA (testicular sperm aspiration). These three procedures are performed by fine-gauge needle aspiration of epididymal fluid that is examined by an embryologist. Additionally, one technique, called TESE (testicular sperm extraction), is offered for males with non-obstructive azoospermia. In this procedure, a urologist extracts a piece of tissue from the testis. Then, an embryologist minces the tissue and uses a microscope to locate sperm. Finding sperm in the testicular tissue can be a laborious 2- to 3-hour process depending on the degree of sperm production and the etiology of testicular failure. Sperm are freed from within the seminiferous tubules and then dissected from the surrounding testicular tissue. It is specifically these situations that require advanced reproductive techniques, such as ICSI, to establish a pregnancy. This review describes eight different lab processing techniques that an embryologist can use to harvest sperm. Additionally, sperm cryopreservation, which allows patients to undergo multiple ICSI cycles without the need for additional surgeries, will also be discussed.