Semin Reprod Med 2009; 27(2): 159-164
DOI: 10.1055/s-0029-1202304
© Thieme Medical Publishers

Obstructive Azoospermia: A Microsurgical Success Story

Cigdem Tanrikut1 , Marc Goldstein2
  • 1Massachusetts General Hospital, MGH Fertility Center, Boston, Massachusetts
  • 2Department of Urology, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, New York
Further Information

Publication History

Publication Date:
26 February 2009 (online)

ABSTRACT

Microsurgical techniques used in the treatment of male factor infertility have provided a revolutionary adjunct to the advent of intracytoplasmic sperm injection used in conjunction with in vitro fertilization. Previously infertile couples may now parent their own biological children and, in some cases, may even conceive naturally owing to technical advances within the past decade. This article outlines the modern methods currently employed to address vasal and epididymal obstruction with special emphasis on the importance of microsurgical techniques. The multiple reconstructive and sperm aspiration techniques at our disposal for treatment of vasal and epididymal obstruction as well as the management of ejaculatory duct obstruction are reviewed. The various procedures discussed allow reproductive urologists to maximize male fertility potential in the era of assisted reproductive technologies.

REFERENCES

  • 1 Jarow J P, Espeland M A, Lipshultz L I. Evaluation of the azoospermic patient.  J Urol. 1989;  142 62-65
  • 2 Sheynkin Y R, Hendin B N, Schlegel P N, Goldstein M. Microsurgical repair of iatrogenic injury to the vas deferens.  J Urol. 1998;  159 139-141
  • 3 Kim E D, Winkel E, Orejuela F, Lipshultz L I. Pathological epididymal obstruction unrelated to vasectomy: results with microsurgical reconstruction.  J Urol. 1998;  160 2078-2080
  • 4 Kolettis P N, Thomas A J. Vasoepididymostomy for vasectomy reversal: a critical assessment in the era of intracytoplasmic sperm injection.  J Urol. 1997;  158 467-470
  • 5 Pavlovich C P, Schlegel P N. Fertility options after vasectomy: a cost-effectiveness analysis.  Fertil Steril. 1997;  67 133-141
  • 6 Hsieh M H, Meng M V, Turek P J. Markov modeling of vasectomy reversal and ART for infertility: how do obstructive interval and female partner age influence cost effectiveness?.  Fertil Steril. 2007;  88 840-846
  • 7 Fenster H, McLoughlin M G. Vasovasostomy—microscopy versus macroscopic techniques.  Arch Androl. 1981;  7 201-204
  • 8 Anger J T, Goldstein M. Intravasal “toothpaste” in men with obstructive azoospermia is derived from vasal epithelium, not sperm.  J Urol. 2004;  172 634-636
  • 9 Kolettis P N, D'Amico A M, Box L, Burns J. Outcomes for vasovasostomy with bilateral intravasal azoospermia.  J Androl. 2003;  24 22-24
  • 10 Silber S J. Microscopic vasectomy reversal.  Fertil Steril. 1977;  28 1191-1202
  • 11 Belker A M, Thomas Jr A J, Fuchs E F, Konnak J W, Sharlip I D. Results of 1469 microsurgical vasectomy reversals by the vasovasostomy study group.  J Urol. 1991;  145 505-511
  • 12 Goldstein M, Li P S, Matthews G J. Microsurgical vasovasostomy: the microdot technique of precision suture placement.  J Urol. 1998;  159 188-190
  • 13 Matthews G J, Schlegel P N, Goldstein M. Patency following microsurgical vasoepididymostomy and vasovasostomy: temporal considerations.  J Urol. 1995;  154 2070-2073
  • 14 Chan P T, Brandell R A, Goldstein M. Prospective analysis of outcomes after microsurgical intussusception vasoepididymostomy.  BJU Int. 2005;  96 598-601
  • 15 Schiff J, Chan P, Li P S, Finkelberg S, Goldstein M. Outcome and late failures compared in 4 techniques of microsurgical vasoepididymostomy in 153 consecutive men.  J Urol. 2005;  174 651-655
  • 16 Boorjian S, Lipkin M, Goldstein M. The impact of obstructive interval and sperm granuloma on outcome of vasectomy reversal.  J Urol. 2004;  171 304-306
  • 17 Meinertz H, Linnet L, Fogh-Andersen P, Hjort T. Antisperm antibodies and fertility after vasovasostomy: a follow-up study of 216 men.  Fertil Steril. 1990;  54 315-321
  • 18 Schrepferman C G, Carson M R, Sparks A E, Sandlow J I. Need for sperm retrieval and cryopreservation at vasectomy reversal.  J Urol. 2001;  166 1787-1789
  • 19 Fuchs E F, Burt R A. Vasectomy reversal performed 15 years or more after vasectomy: correlation of pregnancy outcome with partner age and with pregnancy results of in vitro fertilization with intracytoplasmic sperm injection.  Fertil Steril. 2002;  77 516-519
  • 20 Kolettis P N, Thomas Jr A J. Vasoepididymostomy for vasectomy reversal: a critical assessment in the era of intracytoplasmic sperm injection.  J Urol. 1997;  158 467-470
  • 21 Pasqualotto F F, Agarwal A, Srivastava M, Nelson D R, Thomas Jr A J. Fertility outcome after repeat vasoepididymostomy.  J Urol. 1999;  162 1626-1628
  • 22 Kolettis P N, Sabanegh E S, Nalesnik J G, D'Amico A M, Box L C, Burns J R. Pregnancy outcomes after vasectomy reversal for female partners 35 years old or older.  J Urol. 2003;  169 2250-2252
  • 23 Gerrard Jr E R, Sandlow J I, Oster R A, Burns J R, Box L C, Kolettis P N. Effect of female partner age on pregnancy rates after vasectomy reversal.  Fertil Steril. 2007;  87 1340-1344
  • 24 Daudin M, BIeth E, Bujan L, Massat G, Pontonnier F, Mieusset R. Congenital bilateral absence of the vas deferens: clinical characteristics, biological parameters, cystic fibrosis transmembrane conductance regulator gene mutations, and implications for genetic counseling.  Fertil Steril. 2000;  74 1164-1174
  • 25 Stuhrmann M, Dörk T. CFTR gene mutations and male infertility.  Andrologia. 2000;  32 71-83
  • 26 Matthews G J, Goldstein M. A simplified technique of epididymal sperm aspiration.  Urology. 1996;  47 123-125
  • 27 Tournaye H, Devroey P, Liu J, Nagy Z, LIssens W, Van Steirteghem A. Microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection: a new effective approach to infertility as a result of congenital bilateral absence of the vas deferens.  Fertil Steril. 1994;  61 1045-1051
  • 28 Nudell D M, Conaghan J, Pedersen R A, Givens C R, Schriock E D, Turek P J. The mini-micro-epididymal sperm aspiration for sperm retrieval: a study of urological outcomes.  Hum Reprod. 1998;  13 1260-1265
  • 29 Craft I L, Khalifa Y, Boulos A, Pelekanos M, Foster C, Tsirigotis M. Factors influencing the outcome of in-vitro fertilization with percutaneous aspirated epididymal spermatozoa and intracytoplasmic sperm injection in azoospermic men.  Hum Reprod. 1995;  10 1791-1794
  • 30 Dardashti K, Williams R H, Goldstein M. Microsurgical testis biopsy: a novel technique for retrieval of testicular tissue.  J Urol. 2000;  163 1206-1207
  • 31 Sheynkin Y R, Ye Z, Menendez S, Liotta D, Veeck L L, Schlegel P. Controlled comparison of percutaneous and microsurgical sperm retrieval in men with obstructive azoospermia.  Hum Reprod. 1998;  13 3086-3089
  • 32 Schlegel P N, Palermo G D, Alikani M et al.. Micropuncture retrieval of epididymal sperm with IVF: importance of in vitro micromanipulation techniques.  Urology. 1995;  46 238-241
  • 33 Gil-Salom M, Minguez Y, Rubio C, De los Santos M J, Remohi J, Pellicer A. Efficacy of intracytoplasmic sperm injection using testicular spermatozoa.  Hum Reprod. 1995;  10 3166-3170
  • 34 Kupker W, Schlegel P N, Al-Hasani S et al.. Use of frozen-thawed testicular sperm for intracytoplasmic sperm injection.  Fertil Steril. 2000;  73 453-458
  • 35 Palermo G D, Schlegel P N, Hariprashad J J et al.. Fertilization and pregnancy outcome with intracytoplasmic sperm injection for azoospermic men.  Hum Reprod. 1999;  14 741-748
  • 36 Janzen N, Goldstein M, Schlegel P N, Palermo G D, Rosenwaks Z, Hariprashad J. Use of electively cryopreserved microsurgically aspirated epididymal sperm with IVF and intracytoplasmic sperm injection for obstructive azoospermia.  Fertil Steril. 2000;  74 696-701
  • 37 Tournaye H, Merdad T, Silber S et al.. No difference in outcome after intracytoplasmic sperm injection with fresh or with frozen-thawed epididymal spermatozoa.  Hum Reprod. 1999;  14 90-95
  • 38 Nagy Z, Liu J, Cecile J, Silber S, Devroey P, Van Steirteghem A. Using ejaculated, fresh, and frozen-thawed epididymal spermatozoa gives rise to comparable results after ICSI.  Fertil Steril. 1995;  63 808-815
  • 39 Habermann H, Seo R, Cieslak J, Niederberger C, Prins G S, Ross L. In vitro fertilization outcomes after intracytoplasmic sperm injection with fresh or frozen-thawed testicular spermatozoa.  Fertil Steril. 2000;  73 955-960
  • 40 Gil-Salom M, Romero J, Rubio C, Ruiz A, Remohi J, Pellicer A. Intracytoplasmic sperm injection with cryopreserved testicular spermatozoa.  Mol Cell Endocrinol. 2000;  169 15-19
  • 41 Griffiths M, Kennedy C R, Rai J, Wilson L, Blacklock A R, Keay S D. Should cryopreserved epididymal or testicular sperm be recovered from obstructive azoospermic men for ICSI?.  BJOG. 2004;  111 1289-1293
  • 42 Prabakaran S A, Agarwal A, Sundaram A, Thomas A J, Sikka S. Cryosurvival of testicular spermatozoa from obstructive azoospermic patients: the Cleveland Clinic experience.  Fertil Steril. 2006;  86 1789-1791
  • 43 Pryor J P, Hendry W F. Ejaculatory duct obstruction in subfertile males: analysis of 87 patients.  Fertil Steril. 1991;  56 725-730
  • 44 Popken G, Wetterauer U, Schultze-Seemann W, Deckart A, Sommerkamp H. Transurethral resection of cystic and non-cystic ejaculatory duct obstructions.  Int J Androl. 1998;  21 196-200
  • 45 Worischeck J H, Parra R O. Transrectal ultrasound in the evaluation of men with low volume azoospermia.  J Urol. 1993;  149 1341-1344
  • 46 Jarow J P. Transrectal ultrasonography in the diagnosis and management of ejaculatory duct obstruction.  J Androl. 1996;  17 467-472
  • 47 Fisch H, Lambert S M, Goluboff E T. Management of ejaculatory duct obstruction: etiology, diagnosis, and treatment.  World J Urol. 2006;  24 604-610
  • 48 Schroeder-Printzen I, Ludwig M, Kohn F, Weidner W. Surgical therapy in infertile men with ejaculatory duct obstruction: technique and outcome of a standardized surgical approach.  Hum Reprod. 2000;  15 1364-1368
  • 49 Meacham R B, Hellerstein D K, Lipshultz L I. Evaluation and treatment of ejaculatory duct obstruction in the infertile male.  Fertil Steril. 1993;  59 393-397
  • 50 Yurdakul T, Gokce G, Kilic O, Piskin M M. Transurethral resection of ejaculatory ducts in the treatment of complete ejaculatory duct obstruction.  Int Urol Nephrol. 2008;  40 369-372
  • 51 Boehlen D, Schmid H P. Novel use of fine needle aspiration of seminal vesicle for sperm retrieval in infertile men.  Urology. 2005;  66 880
  • 52 Cerruto M A, Novella G, Antoniolli Sz, Zattoni F. Use of transperineal fine needle aspiration of seminal vesicles to retrieve sperm in a man with obstructive azoospermia.  Fertil Steril. 2006;  86 e7-e9

Cigdem TanrikutM.D. 

Massachusetts General Hospital, MGH Fertility Center

55 Fruit Street, YAW-10A, Boston, MA 02114

Email: ctanrikut@partners.org