Microscopic Epididymal Sperm Aspiration Research Articles

Surgery for Obstructive Azoospermia

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.

Microscopic Epididymal Sperm Aspiration (MESA) Should be Employed Over Testicular Sperm Extraction (TESE) Sperm Retrieval Surgery for Obstructive Azoospermia (OA).

Testicular sperm extraction (TESE) has been widely used as a sperm extraction surgery for azoospermia even for obstructive azoospermia (OA) because it does not require surgical skill. However, there are postoperative pain issues, and subsequent testicular atrophy and decreased testosterone levels may occur with TESE. This study examines the usefulness of microscopic epididymal sperm aspiration (MESA) for OA. We studied 108 patients diagnosed with OA and treated with MESA at our institute between April 2004 and December 2021. The MESA was performed using a micropipette with a micropuncture technique under an operative microscope. When no sperm were present or motility was not observed, additional punctures to the epididymal tubule were performed. Motile sperm were recovered in all cases (108 cases). Of these, intracytoplasmic sperm injection (ICSI) using frozen-thawed sperm was performed in 101 cases and the normal fertilization rate was 76.2%. A total of 436 embryo transfer (ET) cycles were performed. The implantation rate per transfer cycle was 47.9%, the clinical pregnancy rate was 41.0%, and the live birth rate was 23.7%. The per-case live birth rate was 84.8%. MESA-ICSI has a very good fertilization rate, clinical pregnancy rate, and delivery rate. Furthermore, the patient's postoperative pain is less, the number of sperm collected is larger, the burden on the embryologist who processes the collected sperm is less, and ICSI can be easily attempted after frozen-thawed sperm. MESA rather than TESE should be employed for the OA subjects.

Infertility treatment for patients having a microdeletion of azoospermic factor (AZF).

In genetic causes of male infertility, Y chromosome microdeletions are the second most common after Klinefelter's syndrome. Although sperm recovery rate is relatively high for subjects with azoospermic factor (AZF) c chromosome microdeletion, intracytoplasmic sperm injection (ICSI) results using retrieved sperm has been reported to be poor. We retrospectively examined the infertility treatment for subjects with AZF microdeletion. From October 2017 to September 2020, chromosomal examination of 67 azoospermic subjects and 12 cryptozoospermia were performed. Of these, twenty-three subjects (29.1%) had AZF microdeletion. Twelve subjects with AZFc microdeletion and one subtype with unknown classification (Ym-9; P3 deletion) received sperm retrieval surgery due to azoospermia. Two subjects obtained motile sperm by microscopic epididymal sperm aspiration (MESA) and four subjects by microscopic testicular sperm extraction (micro-TESE). Pregnancy and healthy delivery were achieved in 6 of 14 subject (42.9%; including one twin) using ICSI. This was comparable with previous reports. Since there were two cases of obstructive azoospermia, we employed MESA to avoid testicular damage. Following observation of the testis and epididymis under operative microscope, a decision was made to perform sperm retrieval surgery to avoid unnecessary testicular damage. Furthermore, since AZFc microdeletion is passed to the next generation, long term follow-up is necessary.

"Dancing Coins?" Unexpected Finding During microsurgery and Potential Risk of Sperm Damage: Intrascrotal Calculi: A Retrospective Analysis.

Microsurgery of andrology always brings unexpected findings. Scrotal calculi are rare and unique, which are easily confused with tumor. To understand its etiology and harm, our study retrospectively analyzed the clinical characteristics of men with scrotal calculi to provide a reference for clinical practice. The clinical data of patients who underwent microscopic testicular sperm extraction (MTESE) and microscopic epididymal sperm aspiration (MESA) from January 1, 2018 to December 31, 2021 were retrospectively analyzed. Data screening was performed on cases in which calculi were found or not, and the relationship between calculi and spermatogenesis was analyzed. A total of 405 patients were recruited. After screening, 218 nonobstructive azoospermia (NOA), 83 obstructive azoospermia (OA), and 13 cryptozoospermia (CZ) patients were included in the study. Calculi were found in 3 patients [incidence was 0.74% (3/405)], in which 2 patients had obstructive azoospermia (1 was epididymal calculi, 1 was intrascrotal calculi) and 1 patient had cryptozoospermia (intrascrotal calculi). Pathological results showed that chronic granuloma with abscess infiltration appeared in epididymal tissue, basement membrane thickening and fibrosis appeared in seminiferous tubules, and fibrous hyperplasia with calcium deposition was found in scrotal calculus. White blood cells, lymphocytes, red blood cells, abstinence time and urethritis were closely related to the occurrence of calculi. While abstinence time might be a potential predictor, which increased the risk by approximately 1.2 times. Disturbance of the testicular microenvironment caused by lymphocyte infiltration may be the main reason for scrotal calculi and ultimately cause spermatogenesis disorders. Prolonged sexual abstinence was a potential risk.

P-554 Impact of genotype and phenotype on ICSI outcomes of cystic fibrosis (CF) men patients: a cohort study about 107 ICSI from 1999 to 2019

Abstract Study question Is there an impact of CFTR (cystic fibrosis transmembrane-conductance regulator) gene mutation type and/or general health condition of men with CF and the ICSI outcomes? Summary answer Neither genetic severity nor clinical severity seems to have a negative impact on the biological or clinical ICSI issues for cystic fibrosis men patients. What is known already CFTR protein regulates electrolyte and fluid transport in many tissues with exocrine function, including male reproductive tract. Mutation of CFTR gene causes CF, which affects the function of several organs, and impairs male fertility. CF is generally associated to an obstructive azoospermia because of bilateral absence of vas deferens and seminal vesicles degeneration. CFTR protein is detected in human fetus at the early developmental stages and highly expressed in testis and epididymis. CFTR provides establishment of specific fluid environment for germ cell differentiation and maturation. According to literature, it seems likely that CFTR mutations affect sperm quality and embryo development. Study design, size, duration This cohort study was conducted in the Assisted Reproduction Center of an university hospital on 52 patients, for whom a CF has been diagnosed and monitored in the same hospital. The CF diagnosis was based on CFTR genetic tests and clinical symptoms. All men were azoospermic and underwent on a microscopic epididymal sperm aspiration (MESA) and/or a testicular sperm extraction (TESE). 52 couples underwent in total 107 ICSI with frozen sperm between 1999 and 2019. Participants/materials, setting, methods Clinical data- one year preceding surgical sperm collection and freeze - related to the severity of the CF were collected: respiratory spirometry data, Pseudomonas aeruginosa colonization, number of antibiotic treatment, BMI and Pancreatic insufficiency, as well as CFTR mutations. Linear regression tests (fisher and χ²) were carried out to establish or not correlation between biological and clinical ICSI outcomes and on the other hand genotype and/ or each clinical parameter. Main results and the role of chance The mean age of patients at sperm retrieval was 31.3 years [21-55]. Mean BMI was 21.3. Patients with severe genotype represented 67.8% and likely (67.3%) with external pancreatic deficiency. P.aeroginosa colonization was revealed in 30% of cases and 45.6% patients received at least one IV antibiotic treatment. Respiratory function has been impaired in 18 cases, with a maximal expiratory volume per second < 40%. Spermatozoa were found and frozen for all patients after surgical sperm retrieval (20 MESA and 32 MESA + TESE). The mean number of epididymal motile progressive spermatozoa was satisfactory (10.2±18.83 million). Women mean age was 30 years at ICSI and female infertility was associated in 15.4%. Fertilization and cleavage rates were 66% both. Mean number of transferred and/or frozen embryos per attempt was 3. Implantation rate was 20%. A total of 50 pregnancies and 44 live births were obtained (35.5% of cumulative clinical pregnancy rate per ICSI and 29.1% of live birth rate per transfer). Fertilization rate, absence of pregnancy or absence of live birth were not affected by the genetic severity (p = 0.63, p = 0.46 and p = 0.16 respectively). Likewise, and after several univariate analyses there was no statistically significant correlation between clinical severity and ICSI outcomes. Limitations, reasons for caution Practices of assisted reproduction have constantly evolved during the study period, this concerns the controlled ovarian stimulation protocols, IVF techniques, equipment and culture media used. Our study needs to be completed by a multivariate analyse Wider implications of the findings Regarding to better quality of life of CF patients nowadays and to our results- with no significant correlation between genetic and/or clinical severity and ICSI outcomes, surgical sperm collection can be proposed only in case of a conceptional project or before transplantation and immunosuppressive agents in order to perform ICSI. Trial registration number for non-clinical trials

Secondary male infertility: the importance of the urological assessment for couples who desire children in later life.

ABSTRACTAmongst 942 out-patients who consulted our male infertility division between 2016 to 2020, 85 (9.0%) patients suffered from secondary infertility. Of these, in 59 (69.4%) subjects, the first pregnancy was achieved by natural conception. 81 subjects were evaluated for semen quality except for two subjects who at the time were undergoing cancer treatment and another of two ejaculatory dysfunction (EjD). Semen analysis revealed 16 subjects (19.8%) were azoospermic, whereas 9 (11.1%) were cryptozoospermic at median three years of infertility. Left varicocelectomy had been undertaken in a total of 17 oligoasthenozoospermic and cryptozoospermic cases in order to improve semen quality. For achieving natural pregnancy, microscopic vasoepididymostomy was performed in 3 subjects of obstructive azoospemia and patency was achieved in two of three. 11 azoospermic subjects and two of the EjD underwent sperm retrieval surgery for intracytoplasmic sperm injection (ICSI). Motile sperm recovery was obtained by microscopic epididymal sperm aspiration (5/5=100%), microscopic testicular sperm extraction (micro-TESE, 2/6=33.3%), and retrograde vasal sperm aspiration (2/2=100%). Natural pregnancy was obtained in two subjects following varicocelectomy, and in one following vasoepididymostomy. Seven pregnancies were achieved by ICSI using cryopreserved sperm and surgically retrieved sperm. Even if the first pregnancy occurred naturally, 30.9% subjects showed azoospermia or cryptozoospermia at median duration of three years. We would like to emphasize that earlier urological assessment especially semen analysis is necessary if pregnancy later in life is desired.

Superior clinical pregnancy rates after microsurgical epididymal sperm aspiration.

PurposeTo assess normal fertilization, clinical pregnancy, and live birth rates after the use of microscopic epididymal sperm aspiration (MESA).MethodsOne‐hundred‐and‐sixty azoospermic participants who underwent MESA were evaluated. The MESA was performed by using a micropuncture method with a micropipette. In cases in which motile sperm were not obtained after the MESA, conventional or micro‐testicular sperm extraction (TESE) was completed.ResultsAdequate motile sperm were retrieved in 71 participants by using MESA and in 59 out of 89 participants by using TESE. Of the total number of patients, 123 underwent intracytoplasmic sperm injection. After MESA, the normal fertilization rate was 73.5% and the clinical pregnancy rate per case was 95.7%. Healthy deliveries resulted after MESA in 65 (92.9%) cases and after TESE in 38 (71.7%) cases.ConclusionThe MESA specimen collection does not have any special requirements, such as mincing tissue disposition. The MESA also can reduce the amount of laboratory work that is needed for cryopreservation. In the authors' experience, MESA is a beneficial procedure and should be given priority over TESE.

Computational Models for Prediction of IVF/ICSI Outcomes With Surgically Retrieved Sperm

Various factors may be involved in determining the outcome of IVF/ICSI. Using several linear and nonlinear mathematical models, we investigated the correlation of maternal age, type of male factor infertility, sperm retrieval techniques and sperm type with IVF/ICSI outcome. A dataset of 113 exemplars containing input features maternal age, sperm retrieval technique (testicular sperm extraction, testicular sperm aspiration and microscopic epididymal sperm aspiration), type of sperm used (cryopreserved or “fresh”), type of male factor (previous vasectomy with or without subsequent reversal, congenital absence of the vas deferens, other obstructive conditions, varicocele, non-obstructive azoospermia, miscellaneous) and output intra-uterine pregnancy achieved by IVF/ICSI was randomized into a modeling (“training”) set of 83 and cross-validation (“test”) set of 30, with similar outcome frequencies preserved in each set. We used neUROn++, a set of C++ programs we developed using the Cygwin (Red Hat) GNU C++ port for Windows (Microsoft) distributed across Pentium (Intel) platforms, to model the dataset using the linear methods linear and quadratic discriminant function analysis (LDFA, QDFA) and logistic regression (LR), and the nonlinear method of neural computation (NNET) with several investigated architectures. A 4 hidden node (HN) network was found to have the highest accuracy, compared to LDFA, QDFA and logistic regression, with a ROC area for the test set of 0.783. Reverse regression of the neural network based on Wilk’s Generalized Likelihood Ratio test revealed maternal age to be most significant (p=0.025) feature in predicting pregnancy, followed by sperm type (p=0.076). Type of male factor (p=0.47) and sperm retrieval technique (p=0.88) did not predict outcome. Tabled 1 We have investigated linear and nonlinear computational models of IVF/ICSI. The demonstration that IVF/ICSI-induced intra-uterine pregnancy correlates to maternal age and to the type of sperm used supports the use of our neurocomputational model as a predictive tool when planning for the use of assisted reproductive techniques in the presence of male factor infertility.

4000 cases of intrafallopian transfer of ova immediately after intracytoplasmic sperm injection (RAPID ICSI-ZIFT) for treatment of severe male factor infertility.

Objective: Gamete Intrafallopian Transfer (GIFT) is a well-established technique of assisted conception and as the technique of choice for infertile couple with patent fallopian tubes although Gift lost popularity because of its requirement of a fully equipped operating room and improving in-vitro embryo culture system. But it still offers a high pregnancy rate in the hands of well trained personnel probably because of more physiologic environment of the tubal epithelium. We presented probably for the first time the treatment of 100 couples with severe Male Factor infertility in 16th world congress and 54th annual meeting of ASRM 1998. We endeavor to show that Gamete Intrafallopian Transfer of ova immediately after intracytoplasmic sperm injection (RAPID ICSI ZIFT) is a treatment for severe Male Factor Infertility.Design: A retrospective study of 4000 consecutive RAPID ICSI ZIFT cases conducted in a private and university ART centers during a 54 month period from July 1996 to December 2000.Materials/Methods: 4000 couples were selected in whom severe Male Factor was the primary infertility diagnosis. Semen was collected after masturbation (N#2300), microscopic epididymal sperm aspiration (MESA) (N#460), percutaneous sperm aspiration from the epididymis (PESA) (N#830) or testical (TESA) (N#215) and vibratone assisted ejaculation (N#195). 2480 semen samples collected, exhibited two or more suboptimal sperm parameters. 2200 samples contained sperm concentration which were < 3 mil, 2000 samples with 15% forward progressive sperm and suboptimal morphology in 2440 samples. Females 25 to 45 years of age exhibited tubal patency as determined by hystrosalpingogram and laparascopy. All patients had been stimulated with LH/RH agonist Buserlin (Suprefact) HMG combinations in the form of a long protocol and transvaginal ultrasound guided oocyte retrieval, ICSI and laparascopic tubal transfer.Results: In average 10 oocyte per collection was retrieved and a mean of 5.5 post ICSI-OVA were transferred the remaining oocyte were fertilized by ICSI and cryopreserved. Clinical pregnancy rate for the above series was 46% (1840/4000) the average age of female patients was 35.4% and multiple pregnancy rate was 22.2%.Conclusions: Success of tubal transfer for post ICSI ova is related to maternal age (ova number and quality) and the programs’ rate of fertilization and embryo development and in the hand of well-trained personnel can afford the severe Male Factor patients high chance of success.Supported By: Grant in the memorial of Navid Sahebkashaf by Navid’s institute of infertility. Objective: Gamete Intrafallopian Transfer (GIFT) is a well-established technique of assisted conception and as the technique of choice for infertile couple with patent fallopian tubes although Gift lost popularity because of its requirement of a fully equipped operating room and improving in-vitro embryo culture system. But it still offers a high pregnancy rate in the hands of well trained personnel probably because of more physiologic environment of the tubal epithelium. We presented probably for the first time the treatment of 100 couples with severe Male Factor infertility in 16th world congress and 54th annual meeting of ASRM 1998. We endeavor to show that Gamete Intrafallopian Transfer of ova immediately after intracytoplasmic sperm injection (RAPID ICSI ZIFT) is a treatment for severe Male Factor Infertility. Design: A retrospective study of 4000 consecutive RAPID ICSI ZIFT cases conducted in a private and university ART centers during a 54 month period from July 1996 to December 2000. Materials/Methods: 4000 couples were selected in whom severe Male Factor was the primary infertility diagnosis. Semen was collected after masturbation (N#2300), microscopic epididymal sperm aspiration (MESA) (N#460), percutaneous sperm aspiration from the epididymis (PESA) (N#830) or testical (TESA) (N#215) and vibratone assisted ejaculation (N#195). 2480 semen samples collected, exhibited two or more suboptimal sperm parameters. 2200 samples contained sperm concentration which were < 3 mil, 2000 samples with 15% forward progressive sperm and suboptimal morphology in 2440 samples. Females 25 to 45 years of age exhibited tubal patency as determined by hystrosalpingogram and laparascopy. All patients had been stimulated with LH/RH agonist Buserlin (Suprefact) HMG combinations in the form of a long protocol and transvaginal ultrasound guided oocyte retrieval, ICSI and laparascopic tubal transfer. Results: In average 10 oocyte per collection was retrieved and a mean of 5.5 post ICSI-OVA were transferred the remaining oocyte were fertilized by ICSI and cryopreserved. Clinical pregnancy rate for the above series was 46% (1840/4000) the average age of female patients was 35.4% and multiple pregnancy rate was 22.2%. Conclusions: Success of tubal transfer for post ICSI ova is related to maternal age (ova number and quality) and the programs’ rate of fertilization and embryo development and in the hand of well-trained personnel can afford the severe Male Factor patients high chance of success. Supported By: Grant in the memorial of Navid Sahebkashaf by Navid’s institute of infertility.

Impaired spermatogenesis in men with congenital absence of the vas deferens

It is generally assumed that men with congenital bilateral absence of the vas deferens (CBAVD) have azoospermia because of obstruction and that sperm production is normal. This study examines spermatogenesis in men with CBAVD to assess the validity of this assumption. We identified all men with CBAVD who had undergone either a diagnostic or therapeutic fertility procedure. Procedures included diagnostic biopsy, testis fine needle aspiration (FNA) mapping, microscopic epididymal sperm aspiration (MESA), and testis sperm extraction (TESE). Among 33 CBAVD men, 18 underwent testis biopsy, 27 had MESA/TESE, and 10 had FNA mapping. On evaluation of these procedures, normal spermatogenesis was present in 29 men. Four men (12%) demonstrated impaired spermatogenesis. One patient had FNA testis cytology consistent with late maturation arrest, another demonstrated hypospermatogenesis on biopsy and low sperm yield by MESA, and two patients had pure Sertoli cell only histology on biopsy. Aetiologies for impaired spermatogenesis included varicocele and underlying genetic abnormalities. Although patients with CBAVD are assumed to have normal spermatogenesis and infertility due simply to obstruction, the potential for concomitant defects in sperm production exists. A clinical suspicion of testis failure should prompt further diagnostic evaluation of spermatogenesis prior to sperm retrieval. In addition, genetic counselling should be offered and testing for genetic lesions, including cystic fibrosis gene mutations and/or variants, Y chromosome microdeletions, and karyotype abnormalities, should be considered.

Vasectomy reversal.

Vasectomy reversal.

Ejaculatory duct obstruction in infertile men.

To analyse our experience of ejaculatory duct obstruction (EDO) in infertile men, evaluating the diagnostic steps and the outcome of management according to the aetiology. Over a 7-year period, 50 infertile men were diagnosed with EDO as a contributory factor to male infertility. Diagnostic criteria included a history, physical examination, semen analyses, semen fructose measurement, hormonal study, testicular biopsy, transrectal ultrasonography (TRUS) and/or vasography. Thirty-one patients with EDO were treated by transurethral resection (26) or forced lavage via a vasotomy (five). In 45 of the 50 men, semen analyses showed the typical characteristics of complete EDO. Seminal values were variable in five cases of partial EDO; the semen fructose levels were < 1.4 g/L in all five. The main cause of EDO was a midline cyst in 16, Wolffian malformation in four, tuberculosis in 17, previous genitourinary infection in five and idiopathic in eight men. In 17 patients the seminal vesicles appeared to be atrophied on TRUS; 15 of these patients had a history of pulmonary tuberculosis and subsequent vasography in five showed multiple bilateral vasal obstruction. TRUS findings correlated well with vasography except in one case. The overall rate of improved semen values and paternity was 61% and 26%, respectively. Of 16 patients with midline cysts, 14 had improved semen variables and achieved paternity, seven after transurethral resection. TRUS should be the first diagnostic procedure used when infertile men are suspected of having EDO, but vasography should still be considered for a more comprehensive diagnosis. In patients with atrophic seminal vesicles on TRUS and with a history of pulmonary tuberculosis, further study is unnecessary and microscopic epididymal sperm aspiration is recommended for in vitro fertilization. The measurement of semen fructose may be helpful in diagnosing partial EDO. Patients with midline cysts who are treated by transurethral resection are expected to have the best outcome.

P-199 Office-based microscopic epididymal sperm aspiration (MESA) versus operating room-based MESA: Cost and success analysis

P-199 Office-based microscopic epididymal sperm aspiration (MESA) versus operating room-based MESA: Cost and success analysis

Male infertility after surgery for imperforate anus

Congenital abnormalities of the genitourinary tract often coexist, and cryptorchidism is common in patients who have had imperforate anus. Twenty men who had pull-through procedures for imperforate anus in infancy have been aveluated for infertility. Seven had coexisting renal abnormalities, 4 had had recurrent epididymitis, 3 had had bilateral orchidopexies (at age 7 to 12), 2 had spina bifida, and 1 had a pituitary adenoma. Seven had no ejaculate (aspermia), 11 were azoospermic, 1 was severely oligozoospermic, and 1 had a normal sperm concentration in a small volume of ejaculate. Both vasa were blocked in 5 men, and this appeared to be a result of the original operative procedure. One vas was blocked in another 7 patients who had abnormalities on the contralateral side; three had epididymal blocks after epididymitis, and four had congenital malformations associated with an absent or ectopic kidney. After reconstruction (4), insertion of sperm reservoirs (4), microscopic epididymal sperm aspiration (2), or artificial insemination (1), sperm were retrieved from 9 men (ejaculated by 4) 2 pregnancies occurred. Male infertility after treatment of imperforate anus in infancy can be related to a wide variety of causes, some of which are amenable to treatment.

Andrology: Percutaneous epididymal sperm aspiration for obstructive azoospermia

We report the use of percutaneous epididymal sperm aspiration as a simpler and more acceptable alternative to microscopic epididymal sperm aspiration for patients with obstructive azoospermia in whom bypass surgery is not feasible or has not been successful. Some contamination of the aspirate with blood is inevitable, but with careful sperm preparation techniques this can be reduced substantially in the final aliquot used for assisted conception. Spermatozoa with active forward progression may be used for gamete intra-Fallopian transfer treatment, but when this capacity is absent intracytoplasmic sperm injection is recommended. Three pregnancies were obtained in seven couples and a set of twins has been delivered.

Tunica vaginalis sperm reservoir in a monkey model of vas deferens obstruction.

Repeat microscopic epididymal sperm aspiration (MESA) is used to treat congenital absence of the vas deferens (CAVD). Use of alloplastic implants as reservoirs results in poor sperm motility and pregnancy rates. An autoplastic tunica vaginalis reservoir for epididymal sperm has been used in four patients, with one resultant pregnancy. We studied this technique in a monkey model. Eight reservoirs were created in four monkeys (Cercopithecus aethiops). The vas deferens was ligated close to the epididymis. A transverse incision was made in the caput epididymis, and sperm were aspirated for analysis. Cut margins of the epididymal duct were sutured open to the visceral layer of the tunica vaginalis. The defect in the parietal layer of the tunica vaginalis was repaired, and sterile Tyrode's solution was instilled in the potential space between the parietal and visceral layers. Initial epididymal sperm obtained at the creation of the sperm reservoir demonstrated adequate mean motility (60.5%, grade 1.5), morphology (82.8% normal), and viability by Eosin-Y exclusion (69.9%). At 4 weeks, no reservoirs were palpable. Percutaneous aspiration (25-gauge angiocatheter) yielded no fluid. Surgical exposure of the reservoirs demonstrated significant adhesions and scar formation between the parietal and visceral layers of the tunica vaginalis, obliterating the potential space. No sperm were detected in irrigant fluids at this time. In conclusion, adhesion and scar formation may prevent use of the tunica vaginalis reservoir as an alternative to repeat MESA in treatment of CAVD.