Ejaculatory Duct Obstruction Research Articles

PATHOLOGICAL EPIDIDYMAL OBSTRUCTION UNRELATED TO VASECTOMY: RESULTS WITH MICROSURGICAL RECONSTRUCTION

Purpose We determine the success of end-to-side epididymovasostomy in patients presenting with obstructive azoospermia from primary epididymal obstruction and identify prognostic factors that could predict a successful outcome. Materials and Methods Of 256 consecutive patients undergoing end-to-side epididymovasostomy 49 had primary epididymal obstruction unrelated to prior vasectomy. Patients were excluded from study if they had a history of vasectomy, microsurgical reconstruction or ejaculatory duct obstruction. Results Followup was available in 43 of the 49 patients (88%). Patency rates were 87% in the bilateral epididymovasostomy group, 69% in the unilateral group and 81% overall. Pregnancy rates were 43% in the bilateral and 23% in the unilateral group. While higher patency rates were observed for proximal anastomoses, higher pregnancy rates were observed for distal anastomoses. Intraoperative epididymal fluid quality correlated with patency, that is motile sperm in the epididymal aspirate correlated with postoperative patency (p <0.05). There was no correlation between fluid quality and pregnancy rates. Postoperative semen analyses demonstrated higher sperm density and higher motility in the pregnant versus nonpregnant groups. Conclusions Epididymovasostomy may be performed in patients with obstructive azoospermia unrelated to vasectomy with high patency and good pregnancy rates. Intraoperative epididymal fluid quality can be predictive of patency. There was a trend towards higher pregnancy rates for distal anastomosis. There were no pregnancies when anastomosis was at the caput epididymis on both sides.

Endoscopic management of ejaculatory duct obstruction.

A total of 191 patients were evaluated at our department for azoospermia, and 11 were found to have azoospermia due to ejaculatory duct obstruction as proved by normal serum hormones, normal testicular biopsy, low ejaculate volume and absence of fructose in semen. Also transrectal ultrasound was performed, revealing distended seminal vesicles and dilated ejaculatory ducts. All these criteria together suggested ejaculatory duct obstruction as a cause of azoospermia. All patients underwent endoscopic management for treatment of their ejaculatory duct obstruction in the form of resection and/or incision of the ejaculatory duct ostium inside the urethra and patency was checked intraoperatively by injection of sterile methylene blue in the vas and visualizing the efflux of the blue dye endoscopically. Intraoperative patency was documented in 10 patients and postoperative patency by follow-up semen analysis in 7 patients (70% patency rate) of which 2 (20% pregnancy rate) were able to conceive within 2 years of endoscopic treatment. Postoperative complications included acute urinary retention in 1 patient, haematuria in 5 and recurrent epididymitis in 2 patients.

Ejaculatory Duct Obstruction: TRUS-Guided Opacification of Seminal Tracts

Objective: To assess the usefulness of TRUS-guided aspiration and opacification of seminal tracts in the evaluation and management of patients with ejaculatory duct obstruction (EDO). Methods: In 21 men who had dilated seminal vesicles and/or midline cysts on TRUS, a mixture of contrast media and indigocarmine was injected and then pelvic radiographs were taken. Results: The diagnoses based on the findings of TRUS-guided opacification were bilateral EDO in 9 patients, unilateral EDO in 1, and midline cyst with EDO in 11. Midline cysts had communication with seminal tracts in 7. Transurethral unroofing was performed in 12, in all of whom blue color of the injected indigocarmine facilitated the surgical procedure. Conclusion: TRUS-guided opacification of the seminal tracts with a mixture of contrast media and indigocarmine may be valuable in the evaluation and management of the patients with EDO.

TRANSURETHRAL RESECTION OF PARTIALLY OBSTRUCTED EJACULATORY DUCTS: SEMINAL PARAMETERS AND PREGNANCY OUTCOMES ACCORDING TO THE ETIOLOGY OF OBSTRUCTION

Purpose We determine how transurethral resection of the ejaculatory ducts performed for infertility affects seminal parameters and pregnancy outcomes in patients with partial ejaculatory duct obstruction due to a congenital or acquired etiological factor. Materials and Methods Based on history and physical examination, hormonal profiles, semen analyses, transrectal ultrasonography and vasography findings partial ejaculatory duct obstruction was diagnosed in 14 men a mean of 30 years old who presented for infertility evaluation. Patients were grouped according to congenital or acquired cause of obstruction. Transurethral resection of the ejaculatory ducts was performed using the standard resectoscope loop technique. Clinical outcome was assessed by postoperative analyses of seminal parameters and pregnancy reports. Results Transurethral resection of the ejaculatory ducts significantly improved semen quality (ejaculate volume and percentage of sperm motility) in all patients in the congenital group, while all but 1 (83%) had an improved sperm count. Pregnancy was achieved via sexual intercourse by 66% of the patients an average of 5.7 months postoperatively. Of the acquired etiological factor group 37.5% had improved semen quality after transurethral resection of ejaculatory duct and 12.5% achieved pregnancy via sexual intercourse. Postoperative complications occurred at a similar rate in each group (33%). However, complications in the congenital etiology group were minor, while 25% of the men in the acquired group had significant impairment of seminal parameters after transurethral resection of the ejaculatory ducts. Conclusions Semen quality improvement and pregnancy outcome after transurethral resection of the ejaculatory ducts for partial ejaculatory duct obstruction differ significantly according to the main etiological cause of obstruction. An equivocal diagnosis of partial obstruction and technical problems during transurethral resection of the ejaculatory ducts may contribute to failure. However, in some cases the reason for failure remains unclear.

Genetic diseases of the seminal ducts

Azoospermia due to an obstruction of the genital tract is one of numerous possible pathophysiologic mechanisms underlying male infertility. The blockage of the seminal ducts may be acquired or congenital. Only recently has the strong association between mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene and various subtypes of obstructive azoospermia been elucidated. Most patients with congenital bilateral absence of the vas deferens or bilateral ejaculatory duct obstruction are carriers of such mutations. The relationship between abnormal CFTR alleles and unilateral absence of the vas deferens, isolated seminal vesicle anomalies, and Young syndrome is less well characterized and awaits further investigation.

SPERM PELLET ANALYSIS: A TECHNIQUE TO DETECT THE PRESENCE OF SPERM IN MEN CONSIDERED TO HAVE AZOOSPERMIA BY ROUTINE SEMEN ANALYSIS

Purpose In men considered to have azoospermia by routine semen analyses sperm may be identified after centrifuging the semen. Because these sperm may be used for intracytoplasmic sperm injection, we describe our technique and findings of sperm pelleting. Materials and Methods Semen centrifugation for sperm pellet analysis was performed in 140 consecutive men in whom no sperm was identified on routine semen analysis and who were categorized as having obstructive or nonobstructive azoospermia. Obstructive azoospermia was defined as failed vasectomy reversal, failed reconstruction for congenital vasal or epididymal occlusion, or an acquired obstruction unrelated to ejaculatory duct obstruction. Patients with congenital absence of the vas deferens or who had undergone vasectomy were not included in the study. Nonobstructive azoospermia was defined as moderate to severe testicular atrophy with markedly elevated serum follicle-stimulating hormone (greater than 3 times normal), or a testicular biopsy that revealed maturational arrest, severe hypospermatogenesis or the Sertoli-cell-only pattern. Obstructive and nonobstructive azoospermia were present in 70 men who provided 109 samples and 70 who provided 103, respectively. Results Motile and nonmotile sperm was identified in 13 of the 70 patients (18.6%) with obstructive and in 16 of the 70 (22.8%) with nonobstructive azoospermia. Pellet variability, that is the absence of sperm in 1 specimen and its presence in another from the same patient, was noted in 7 of the 17 men (41.2%) with obstructive and 2 of the 17 (11.8%) with nonobstructive azoospermia (not statistically significant). Motile sperm was present in the pellets of 6 of the 70 men (8.6%) with obstructive and 15 of the 70 (21.4%) with nonobstructive azoospermia. The median number of motile sperm was lower in the obstructive than in the nonobstructive group (0 sperm in 17 samples versus 5 sperm in 41 samples, p <0.001). The median value of 0 in the obstructive azoospermia group reflects the finding that 9 of the 17 samples did not contain motile sperm. Similarly the median number of nonmotile sperm was lower in the obstructive than in the nonobstructive group (5 versus 8 sperm). Conclusions We demonstrated the presence of motile and nonmotile sperm in a significant number of men considered to have azoospermia by routine semen analysis. Semen centrifugation (sperm pelleting) should be performed in all men considered to have this condition by routine semen analysis, especially those with testicular failure and those in whom intracytoplasmic sperm injection is possible.

Partial Ejaculatory Duct Obstruction Causing Early Demise of Sperm

We report a case of partial ejaculatory duct obstruction secondary to a müllerian duct cyst presenting with failure to fertilize and early demise of sperm during in vitro fertilization.

The turner biopsy needle facilitates seminal vesicle aspiration

Transrectal ultrasonography and seminal vesicle aspiration with or without vesiculography have become an integral part of the evaluation and management of the infertile male with ejaculatory duct obstruction. We have found that the Echo Tip Turner Biopsy Needle used in conjunction with ultrasound guidance greatly facilitates these transrectal procedures. UROLOGY 50: 277-278, 1997.

Imaging of obstructive azoospermia.

Obstructive azoospermia represents approximately 10 % of cases of male hypofertility. It is classified according to the volume of ejaculate. When the latter is normal a proximal obstruction is suspected. Scrotal sonography can help to detect dilation of the epididymal head when clinical findings are equivocal. Ejaculatory duct obstruction (EDO) is suspected when the volume of ejaculate is low. The use of transrectal ultrasonography (TRUS) plays a major role in the investigation of these patients, and endorectal MRI is a very useful adjunct in selected cases. The most common cause of EDO is congenital bilateral absence of vas deferens, which is now thought to be a genital form of cystic fibrosis in 80 % of cases. Consequently, a definitive diagnosis must be made before any attempt at in vitro fertilization. TRUS accurately visualizes abnormalities of the caudal junction of the vas deferens and seminal vesicles, yielding a definitive diagnosis without scrototomy. Other causes of EDO are congenital cysts compressing the distal part of the ejaculatory ducts and inflammatory distal stenosis. The former are accurately identified by TRUS, but the latter give more or less marked signs of obstruction which are only of value in azoospermic patients with a low-volume ejaculate. More invasive imaging is required to diagnose partial obstruction of the ED. Surgical vasography is still the reference, but puncture of the seminal vesicles under TRUS guidance is an attractive alternative, as it permits aspiration of seminal fluid (to seek motile sperm) and vasography without scrototomy. Lastly, endorectal MRI well assesses the relationships between the proximal prostatic urethra and the posterior wall of the ejaculatory ducts, which need to be precisely known when endoscopic resection of the ejaculatory ducts is planned.

Pregnancy After Relief of Ejaculatory Duct Obstruction by Aspiration Decompression of an Ectopic Ureter

A 29-year-old white man was referred for evaluation of a 7-year history of infertility. Physical examination demonstrated normal testes and vasa. Serum testosterone and follicle-stimulating hormone levels were within normal limits. Semen analysis revealed fructose-negative azoospermia and an ejaculate volume of only 1 ml. A right seminal vesicle cyst and marked dilatation of the left seminal vesicle were observed on transrectal ultrasonography. Abdominal ultrasonography showed a normal left kidney and absence of a kidney in the right flank. On endorectal magnetic resonance imaging (MRI) the seminal vesicle cyst proved to be a dilated ectopic ureter draining a small, probably dysplastic right kidney located anterior to the iliac vessels (fig. 1). The left ejaculatory duct was obstructed within the prostatic parenchyma by extrinsic compression by the dilated right ureter.

Pregnancy After Relief of Ejaculatory Duct Obstruction by Aspiration Decompression of an Ectopic Ureter

Pregnancy After Relief of Ejaculatory Duct Obstruction by Aspiration Decompression of an Ectopic Ureter

Role of ultrasound in the assessment of male infertility.

The use of ultrasonography has become an important component in the evaluation and treatment of male reproductive tract disorders. From the use of color flow Doppler ultrasonography for the assessment of varicoceles to transrectal ultrasonography combined with seminal vesiculography for the evaluation of ejaculatory duct obstruction, ultrasonography has practical clinical applications. In this article, the authors review the indications and use of ultrasonography in the assessment and treatment of the infertile male. The recent advances in diagnostic transrectal ultrasonography for ejaculatory duct obstruction, in particular, are emphasized.

Seminal Vesicle Aspiration of Fertile Men

Purpose Whether sperm normally reside in the seminal vesicles of fertile men without ejaculatory duct obstruction, and the effect of duration of sexual abstinence on results of seminal vesicle aspiration were determined. Materials and Methods Bilateral seminal vesicle aspiration was performed on 12 fertile volunteers under transrectal ultrasound guidance with randomization according to 0 and 5 days of abstinence. Seminal vesicle were examined microscopically for number and motility of sperm. A positive aspirate was defined as greater than 3 sperm per high power microscopic field. Results Duration of abstinence had a significant effect on outcome of seminal vesicle aspiration in fertile volunteers. No volunteer with 0 days of abstinence had a positive aspirate from either seminal vesicle, whereas a third of those with 5 days of abstinence had at least 1 positive seminal vesicle aspirate. Conclusions Significant numbers of sperm are not normally found in the seminal vesicles of fertile men immediately after ejaculation. Diagnostic seminal vesicle aspiration should be performed after 0 days of abstinence. Longer periods of sexual abstinence may be used in patients undergoing seminal vesicle harvesting of sperm for assisted reproduction.

The Use of Ultrasonograhy in the Evaluation and Management of Male Infertility

Although many causes of male infertility are not easily managed, in a significant number of cases a correctable factor is identified. This review article looks at the important role sonography plays in the evaluation and management of two such disorders—varicocele and obstruction of the ejaculatory ducts.

Normal Human Ejaculatory Duct Anatomy: A Study of Cadaveric and Surgical Specimens

Purpose We examined the anatomy of the ejaculatory ducts in normal men and correlated findings with theories of ejaculatory duct obstruction. Materials and Methods Gross and microscopic anatomical studies were performed on cadaveric and operative specimens derived from radical prostatectomy. Results Histologically, the ejaculatory ducts are a continuation of the seminal vesicles. However, the thick muscle wall of the seminal vesicle is not present within the ejaculatory duct. Normal ejaculatory duct luminal and wall dimensions are remarkably uniform among men. A luminal diameter of greater than 2.3 mm. defines a dilated system statistically. Conclusions The largely collagenous ejaculatory ducts may serve as simple semen conduits instead of muscular tubes with spasmodic, sphincteric or peristaltic properties. The anatomical findings presented suggest several possible mechanisms for the prevention of urinary reflux into the ejaculatory ducts.

Semen Parameters Before and After Transurethral Surgery for Ejaculatory Duct Obstruction

Purpose We examined how transurethral resection of the ejaculatory ducts, performed for infertility, affects semen quality in patients with azoospermia and oligo-asthenospermia. Materials and Methods A retrospective review was done of 46 cases of transurethral resection of the ejaculatory ducts for ejaculatory duct obstruction, confirmed by transrectal ultrasound. Clinical course and semen quality were assessed by semen parameter indications. Results In 65 percent of the patients transurethral resection of the ejaculatory ducts improved semen quality (greater than a 50 percent increase in total motile sperm count) and 20 percent initiated a pregnancy an average of 6.1 months postoperatively. Statistically significant increases in total motile sperm count were achieved in men with azoospermia and those treated for oligo-asthenospermic indications; the improvement also was shown to be sustainable. Complications occurred in 20 percent of the men. Conclusions Significant and durable semen quality improvement can be achieved after transurethral resection of the ejaculatory ducts for all surgical indications. In most unsuccessful cases the reason for failure is unclear.

Semen Parameters Before and After Transurethral Surgery for Ejaculatory Duct Obstruction

Semen Parameters Before and After Transurethral Surgery for Ejaculatory Duct Obstruction

Ejaculatory duct obstruction: diagnosis and treatment with transrectal sonography.

Ejaculatory duct obstruction is thought to be a relatively uncommon but readily treatable cause of male infertility. Obstruction is frequently caused by cysts originating from or impinging on the ejaculatory ducts. The use of transrectal sonography has facilitated identification of patients with ejaculatory duct obstruction and has led to the realization that this abnormality is more common than was previously recognized. Transrectal sonography now plays a critical role in both the diagnosis and the treatment of this condition. The purpose of this pictorial essay is to illustrate the use of transrectal sonography in the diagnosis and treatment of ejaculatory duct obstruction.

Refractory Epididymitis and Ejaculatory Duct Obstruction

Ejaculatory duct obstruction is a relatively uncommon entity that is occasionally found at evaluation for infertility. Often thought to be exceedingly rare, it has been discovered more frequently due to the availability of transrectal ultrasonography. I report on a patient who presented for evaluation of hematospermia in whom refractory epididymitis with ipsilateral ejaculatory duct obstruction was successfully treated by transurethral unroofing of the seminal vesicle. A review of the literature for the last 20 years failed to reveal similar cases of epididymitis treated by unroofing an obstructed ejaculatory duct.

Antegrade ejaculatory duct recanalization and dilation

Ejaculatory duct obstruction is a rare but correctable cause of male infertility. Standard therapy is transurethral resection of the ejaculatory ducts, which is frequently complicated by seminal vesicle urinary reflux and is contraindicated when the obstruction is located outside the prostate gland. Herein, we report a minimally invasive technique that successfully dilated the ejaculatory duct without complications in a patient with unilateral, complete ejaculatory duct obstruction located outside the prostate.