Intravasal azoospermia: a surgical dilemma

Abstract

Objectives To determine the incidence of intravasal azoospermia (IVA) and evaluate which factors before and during surgery in¯uence outcome, by prospectively and intentionally performing bilateral vasovasostomies (VVs) only in men with intraoperative IVA. Patients and methods Using a multilayer technique, 472 men underwent microsurgical reconstructive procedures. Intravasal¯uid was examined for sperm by the surgeon and a pathologist. Strict enrolment criteria included total absence of sperm or sperm parts and bilateral VV as a treatment procedure. Patients were followed up by semen analysis and paternity assessed only by naturally conceived pregnancies. Results Of the 472 patients, 27 (5.7%) had bilateral IVA; 15 of these patients were available for a follow-up of 1±47 months. Eleven patients had identical gross appearance of intravasal¯uid bilaterally. Of these patients, ®ve had sperm in the ejaculate after surgery (three with clear intravasal¯uid and two with no¯u id). Bilaterally different vasal¯uid was found in four men. Unilateral clear¯uid was present in three patients, two of whom had sperm in semen analysed after VV. Overall, there was sperm in the ejaculate in seven of 15 patients with IVA; ®ve of these seven had clear¯uid in at least one vas deferens. One patient with unilaterally clear¯uid achieved paternity by a naturally conceived pregnancy. The difference between the mean (SEM) obstruction interval in men who had sperm in a semen sample after VV, at 16.7 (3.30) years, and in persistently azoospermic patients, at 15.5 (1.89) years, was not statistically signi®cant (P = 0.741). Conclusion The results of VV in patients with IVA are unsatisfactory; the patency rate is higher in men with copious clear¯uid in at least one vas. The obstructive interval in patients with IVA does not appear to in¯uence the outcome of VV.

Vasovasostomy

“…Instead when aspirates appeared creamy and pasty the patency and pregnancy rates dropped to an average of 26%. Similar observations have been made by other groups [27,28]. In this context it has to be considered that the patency rates of tubulovasostomies vary between 70 and 83%, and pregnancy rates range from 31 to 56% in larger series [25,[29][30][31].…”

“…However, in 5.7-27% of all cases spermatozoa cannot be detected in the aspirate [23,26,27]. In this group the patency and pregnancy rates also appear to be related to the physical appearance of the aspirate.…”

Association Between the Presence of Sperm in the Vasal Fluid During Vasectomy Reversal and Postoperative Patency: A Systematic Review and Meta-analysis

“…Four case series 6,13-15 and two retrospective cohort studies 3,16 of 1,293 eligible patients were identified (Figure 1). The studies were published between 1977 and 2014 and took place in Asia, Australia, and the United States (Table 1).…”

Vasectomy reversal

“…Although the results of vasovasostomy generally are good even when only sperm heads (grade 4) are observed in the testicular vasal fluid (1,18), some experienced microsurgeons prefer to perform vasoepididymostomy in such circumstances (19). When no sperm are observed in the vasal fluid, the time elapsed since vasectomy does not predict the likelihood of a return of sperm to the ejaculate after vasovasostomy (20,21), but the gross characteristics of the fluid can help to determine the best choice of procedure. The likelihood that sperm will return to the semen (patency) and the likelihood of pregnancy are greatest when the vasal fluid appears watery (clear, colorless, and transparent) and are lower when the fluid appears cloudy, and even lower when the fluid appears thick and creamy (1).…”