Partial Epididymal Obstruction as a Cause of Idiopathic Oligozoospermia: A Reproductive Urologist's Perspective following 35 Years of Surgical and Clinical Experience.

The role of partial epididymal obstruction as contributing to the development of oligozoospermia has been neglected for decades. In the early 1970s, however, Robert Schoysman, a gynecological surgeon devoted to the surgical and medical management of male factor infertility, dedicated many efforts to study such a pathology and its possible effects on male fertility. Following the studies of this pioneer in the field, we concentrated our attention to the patterns of partial and complete epididymal obstruction during surgical scrotal exploration, once made possible even in oligozoospermic men by diagnostic and therapeutic interventions, such as vasovesciculography or seminal tract washout test, at present considered obsolete and no longer feasible in light of the current guidelines. Interestingly, we found signs of partial epididymal obstruction in about 30% of oligozoospermic men with normal testicular volume and serum FSH level as well as normal spermatogenesis at testis biopsy. We, then, compared the findings of scrotal ultrasound with those of scrotal exploration and found that the ultrasound abnormalities of the epididymis were highly predictive of anatomic alteration of the gland. In the present study, we report our experience, together with a historical review of the literature, on this topic.

The effect of BMI and age on the outcomes of microsurgical vasoepididymostomy: a retrospective analysis of 181 patients operated by a single surgeon.

To design a treatment plan for patients with epididymal obstruction, we explored the potential impact of factors such as body mass index (BMI) and age on the surgical outcomes of vasoepididymostomy (VE). In this retrospective study, 181 patients diagnosed with obstructive azoospermia (OA) due to epididymal obstruction between September 2014 and September 2017 were reviewed. All patients underwent single-armed microsurgical intussusception VEs with longitudinal two-suture placement performed by a single surgeon (KH) in a single hospital (Peking University Third Hospital, Beijing, China). Six factors that could possibly influence the patency rates were analyzed, including BMI, age, mode of anastomosis, site of anastomosis, and sperm motility and quantity in the intraoperative epididymal fluid. Single-factor outcome analysis was performed via Chi-square test and multivariable analysis was performed using logistic regression. A total of 159 (87.8%, 159/181) patients were followed up. The follow-up time (mean ± standard deviation [s.d.]) was 27.7 ± 9.3 months, ranging from 12 months to 48 months. The overall patency rate was 73.0% (116/159). The multivariable analysis revealed that BMI and age significantly influenced the patency rate (P = 0.008 and 0.028, respectively). Younger age (≤28 years; odds ratio [OR] = 3.531, 95% confidence interval [95% CI]: 1.397-8.924) and lower BMI score (<26.0 kg m-2; OR = 2.352, 95% CI: 1.095-5.054) appeared to be associated with a higher patency rate. BMI and age were independent factors affecting the outcomes of microsurgical VEs depending on surgical expertise and the use of advanced technology.

The effect of BMI and age on the outcomes of microsurgical vasoepididymostomy: a retrospective analysis of 181 patients operated by a single surgeon / 亚洲男科学杂志(英文版)

To design a treatment plan for patients with epididymal obstruction, we explored the potential impact of factors such as body mass index (BMI) and age on the surgical outcomes of vasoepididymostomy (VE). In this retrospective study, 181 patients diagnosed with obstructive azoospermia (OA) due to epididymal obstruction between September 2014 and September 2017 were reviewed. All patients underwent single-armed microsurgical intussusception VEs with longitudinal two-suture placement performed by a single surgeon (KH) in a single hospital (Peking University Third Hospital, Beijing, China). Six factors that could possibly influence the patency rates were analyzed, including BMI, age, mode of anastomosis, site of anastomosis, and sperm motility and quantity in the intraoperative epididymal fluid. Single-factor outcome analysis was performed via Chi-square test and multivariable analysis was performed using logistic regression. A total of 159 (87.8%, 159/181) patients were followed up. The follow-up time (mean ± standard deviation [s.d.]) was 27.7 ± 9.3 months, ranging from 12 months to 48 months. The overall patency rate was 73.0% (116/159). The multivariable analysis revealed that BMI and age significantly influenced the patency rate (P = 0.008 and 0.028, respectively). Younger age (≤28 years; odds ratio [OR] = 3.531, 95% confidence interval [95% CI]: 1.397-8.924) and lower BMI score (<26.0 kg m-2; OR = 2.352, 95% CI: 1.095-5.054) appeared to be associated with a higher patency rate. BMI and age were independent factors affecting the outcomes of microsurgical VEs depending on surgical expertise and the use of advanced technology.

Human and animal fertility studies in cystinosis reveal signs of obstructive azoospermia, an altered blood-testis barrier and a subtherapeutic effect of cysteamine in testis.

Cystinosis is an inherited metabolic disorder caused by autosomal recessive mutations in the CTNS gene leading to lysosomal cystine accumulation. The disease primarily affects the kidneys followed by extra-renal organ involvement later in life. Azoospermia is one of the unclarified complications which are not improved by cysteamine, which is the only available disease-modifying treatment. We aimed at unraveling the origin of azoospermia in cysteamine-treated cystinosis by confirming or excluding an obstructive factor, and investigating the effect of cysteamine on fertility in the Ctns-/- mouse model compared with wild type. Azoospermia was present in the vast majority of infantile type cystinosis patients. While spermatogenesis was intact, an enlarged caput epididymis and reduced levels of seminal markers for obstruction neutral α-glucosidase (NAG) and extracellular matrix protein 1 (ECM1) pointed towards an epididymal obstruction. Histopathological examination in human and mouse testis revealed a disturbed blood-testis barrier characterized by an altered zonula occludens-1 (ZO-1) protein expression. Animal studies ruled out a negative effect of cysteamine on fertility, but showed that cystine accumulation in the testis is irresponsive to regular cysteamine treatment. We conclude that the azoospermia in infantile cystinosis is due to an obstruction related to epididymal dysfunction, irrespective of the severity of an evolving primary hypogonadism. Regular cysteamine treatment does not affect fertility but has subtherapeutic effects on cystine accumulation in testis.

Obstructive azoospermia secondary to bilateral epididymal cystadenomas in a patient with von Hippel-Lindau.

von Hippel-Lindau (VHL) is a heritable cancer syndrome associated with findings in multiple organ systems. Male patients can be affected by epididymal cystadenomas which are benign tumors localized to the epididymis. While benign, these tumors can cause pain and in very rare circumstances can have an effect on fertility especially when present bilaterally. We present a case of a young man with obstructive azoospermia secondary to bilateral cystadenomas, with a focus on his work-up and management.

Retrospective analysis of one-year outcomes after modified single-armed suture technique for microsurgical intussusception vasoepididymostomy / 中华显微外科杂志

Objective To retrospectively analyze the one-year outcomes of modified single-armed suture technique for microsurgical vasoepididymostomy in men with epididymal obstructive azoospermia (EOA).Methods From February,2012 to November,2013,microsurgical longitudinal intussusception vasoepididymostomies using a modified single-armed suture technique in 51 men with EOA was performed.The followed-up period was designed as 1 year.The correlations between the sperm motility in epididymal fluid,unilateral or bilateral procedure,anastomotic site,and the female partner age and the patency or pregnancy rate were analyzed.Results Followups were carried out for 39 (76.5％) men.The patency was noted in 24 (61.5％) men and pregnancy was reported in 15 (38.5％) female partners,including 1 received in vitro fertilization using fresh ejaculated sperm.Motile sperms in epididymal fluid were observed intraoperatively in 14 (58.3％) patent men and 3 (20.0％) nonpatent men,respectively (P ＜ 0.05).In patent cohort,the mean ages of the pregnant and non-pregnant female partners were 26.5 and 32.7 years(P ＜ 0.05),respectively.Conclusion The modified single-armed suture technique showed favourable patency and pregnancy rates in this study.It's a practical alternative in the areas without the specialized double armed suture.

Retrospective analysis of early outcomes after a single-armed suture technique for microsurgical intussusception vasoepididymostomy.

Longitudinal intussusception microsurgical vasoepididymostomy (LIVE) increases the patency rate in men with epididymal obstructive azoospermia (EOA). Here, we retrospectively analyzed the early outcomes of our modified single-armed suture technique for LIVE in men with EOA. From February 2012 to November 2013, 51 men received the modified technique and 39 men provided at least one post-operative semen sample. The mean age was 31.4 years old for the men and 29.2 years old for their female partners. The mean duration of obstruction was 34.3 months. Patency was noted in 24 (61.5%) men and pregnancy was reported in 15 (38.5%) female partners. Motile spermatozoa in the epididymal fluid were observed intraoperatively in 14 (58.3%) patent men and 3 (20%) non-patent men, respectively (p < 0.05). In the patent cohort, the mean ages of the pregnant and non-pregnant female partners were 26.5 and 32.7 years old, respectively (p < 0.05). Our modified technique resulted in favorable patency and pregnancy rates in this study. Sperm motility in epididymal fluid and female partner age were important factors associated with the patency and pregnancy rates.

Obstructive azoospermia.

Obstructive azoospermia accounts for 40% of azoospermia and results from obstruction of the excurrent ducts (due to many causes) at any location between the rete testis and the ejaculatory ducts. The diagnosis of obstructive azoospermia (OA) requires a stepwise approach to differentiate it from nonobstructive OA and to formulate management options. Localization of the site of obstruction relies on history, physical examination, and possibly laboratory, genetic, imaging tests, and intraoperative findings. The prospects for patients with OA are excellent given recent advances in microsurgical approaches and in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). Successful outcomes are increasingly likely after microsurgical reconstruction techniques, permitting non-IVF pregnancies for many couples. When reconstruction is not an option, microsurgical sperm retrieval provides excellent outcomes for patients in conjunction with IVF and ICSI.

The need for epididymovasostomy at vasectomy reversal plateaus in older vasectomies: a study of 1229 cases.

Vasectomy reversal involves either vasovasostomy (VV) or epididymovasostomy (EV), and rates of epididymal obstruction and EV increase with time after vasectomy. However, as older vasectomies may not require EV for successful reversal, we hypothesized that sperm production falls after vasectomy and can protect the system from epididymal blowout. Our objective was to define how the need for EV at reversal changes with time after vasectomy through a retrospective review of consecutive reversals performed by three surgeons over a 10-year period. Vasovasotomy was performed with Silber score 1-3 vasal fluid. EVs were performed with Silber score 4 (sperm fragments; creamy fluid) or 5 (sperm absence) fluid. Reversal procedure type was correlated with vasectomy and patient age. Post-operative patency rates, total spermatozoa and motile sperm counts in younger (<15 years) and older (>15 years) vasectomies were assessed. Simple descriptive statistics determined outcome relevance. Among 1229 patients, 406 had either unilateral (n = 252) or bilateral EV's (n = 154) constituting 33% (406/1229) of reversals. Mean patient age was 41.4±7 years (range 22-72). Median vasectomy interval was 10 years (range 1-38). Overall sperm patency rate after reversal was 84%. The rate of unilateral (EV/VV) or bilateral EV increased linearly in vasectomy intervals of 1-22 years at 3% per year, but plateaued at 72% in vasectomy intervals of 24-38 years. Sperm counts were maintained with increasing time after vasectomy, but motile sperm counts decreased significantly (p < 0.001). Pregnancy, secondary azoospermia, varicocoele and sperm granuloma were not assessed. In conclusion, and contrary to conventional thinking, the need for EV at reversal increases with time after vasectomy, but this relationship is not linear. EV rates plateau 22 years after vasectomy, suggesting that protective mechanisms ameliorate epididymal 'blowout'. Upon reversal, sperm output is maintained with time after vasectomy, but motile sperm counts decrease linearly, suggesting epididymal dysfunction influences semen quality after reversal.

Clinical Significance of No Appearance of Vasal Fluid on Testicular End of the Vas during Vasovasostomy / 대한비뇨기과학회지

The sperm count in semen analysis after vasovasostomy is significantly higher in men with vasal fluid in the proximal vas during the operation than in those without fluid on one or both sides(P<0.05). On 8(38.1%) of 21 sides in 12 men without vasal efflux during vasovasostomy secondary epididymal obstructions were found on scrotal exploration. Bilateral ductal obstructions were found in 3 of 9 men without vasal efflux on both sides. The cause of obstruction included spermatocele, chronic epididymal inflammation. In epididymal histology the cause of obstruction was the interstitial sperm granulomas resulting from the rupture of the epididymal duct and chronic epididymitis. We concluded that epididymal exploration is necessary in case with no sperm from testicular end of the vas on both sides.

Surgical Correction of Epididymal Obstruction / 대한비뇨기과학회지

During the period of 1964 to 1972, epididymovasoetomies were performed on 53 cases of azoospermias due to epididymal obstruction. They were operated by the technics of the ordinary side-to-side epididymovasostomy with splint, in such a manner that a minute longitudinal opening in the vas was anastomosed to a similar opening in the epididymis at a site where live sperm had been recovered, which was applied on 58 per cent of the subjects, and of the buried side-to-side anastomosis with a splint, wherein longitudinally opened vas ..was actually buried in longitudinally opened head of epididymis, which was attempted on 26 per cent of them. The following data are presented as abstraction of clinical findings and the operation outcomes: l. An average age of the subjects was 35, and that of their wives, 30. 2. An average duration intervening between the beginning of the obstruction and the performance of the operation was 9 years. 3. An average frequency of sexual intercourse per week indicated 2.5 times before the obstruction 2. 2 times after the obstruction, and 2. 1 times after the operation. 4. In the majority of the cases, the post-inflammatory obstructions were found to be the most responsible causes for azoospermia in my present study. That is, non-tuberculous epididymitis (gonorrheal and non-gonorrheal origin) was found in 70 per cent of the subjects and tuberculous origin, 25 per cent of them respectively. 5. Success rate of non-tuberculous epididymitis group is higher than that of tuberculous epididymitis counter part 6. Success rate of the buried technic group is higher than that of the ordinary technic group. 7. Success rate of bilateral oozes with sperm group is higher than that of unilateral oozes with sperm or no oozes group. 8. A total of 53 cases was operated upon for curing the obstructive azooepermias. Poet-operative semen analyses were carried out on 43 cases out of the 53. Sperm appeared in the ejaculates of 17 cases out of the 43 in repeated sperm tests 3 weeks following the operation. Accordingly, successful operations were showed in 40 per cent of the 43 cases. Seven pregnancies(16%) followed the operation. 9. The writer believes that epididymovasostomy could be said to be a worthwhile procedure for the cases of asooapermia due to the obstruction of globus minor with normal spermatogenesis. The prognosis is always good whenever the indications are strictly followed.