Surgery for Obstructive Azoospermia

Abstract

Microsurgical technique in male infertility has progressed significantly since the introduction of intracytoplasmic sperm infection (ICSI) 30 years ago. The searching of sperm available for ICSI becomes the main tasks for reproductive andrologists. At the initial study for patients with azoospermia, it is crucial to differentiate obstructive causes from non-obstructive categories. Testis biopsy is still a gold standard testing method to confirm obstructive azoospermia (OA). For patients with OA, the choice spectrum of treatment is broad. Basically, sperm can be retrieved from anywhere upstream the blocking spot along the male reproductive tract. However, it is not always that infertile couples consider ICSI as their treatment of choice. The choice of treatment should be prioritized according to patients’ concerns. The concerns include age of female partner, the patency of oviducts, the presence of infection in the seminal plasma, DNA fragmentation index of sperm, failure of prior use of downstream sperm for in vitro fertilization (IVF) or ICSI, religious limitation, economical affordability, number of babies expected and techniques available from the surgeons. For techniques view, the surgeons should be equipped with capabilities of techniques for sperm retrieval from the testis (testicular sperm extraction, abbreviated TESE) and epididymis (percutaneous epididymal sperm extraction abb. PESA; or microscopic epididymal sperm aspiration abb. MESA). Besides, techniques of microsurgical anastomosis of vas (vasectomy reversal or vaso-vasostomy) and epididymal tubule (vaso-epididymostomy) after scrotal exploration are also required. Other special conditions of obstructive azoospermia are also included, such as congenital absence of vas deferens (CBAVD) or causes for dry ejaculation (including diabetes neuropathy, or post retroperitoneal surgery), or obstruction of ejaculatory ducts. Herein, I would like to share the experiences on treatment of various types of obstructive azoospermia, via scrotal exploration and the techniques of epididymovasostomy. Besides, different techniques of sperm retrieval like MESA and TESE are also demonstrated.