The absence of sperm from the ejaculate (azoospermia) is found in 15% of infertile men and obstruction of the ductal system is responsible for approximately 40% of cases. Obstructive azoospermia may result from epididymal, vasal, or ejaculatory duct pathology. Vasectomy is the most common cause of vasal obstruction. Severe genitourinary infections, injury during scrotal or inguinal surgery such as hernia repairs are other common causes of obstructive azoospermia. Microsurgical reconstruction of the reproductive tract is preferable to sperm retrieval with in vitro fertilization/intracytoplasmic sperm injection in men with prior vasectomy if the obstructive interval is less than 15 years and no female fertility risk factors are present. If epididymal obstruction is present, the decision to use either microsurgical reconstruction or sperm retrieval with in vitro fertilization/ intracytoplasmic sperm injection should be individualized. Vasoepididymostomy should be performed by an expert in reproductive microsurgery.
Sperm retrieval/ICSI is preferred to surgical treatment when:
- advanced female age is present
- female factors requiring IVF are present
- the chance for success with sperm retrieval/ICSI exceeds the chance for success with surgical treatment
- sperm retrieval/ICSI is preferred by the couple for financial reasons.
A general anesthetic and local cord block with 1% plain lidocaine are used. A 2-3 cm incision is made on both sides of the scrotum over the vas deferens at the area of prior ligation. The old scar and/or clips are removed and the fluid at the ends of the sperm tubes are examined for signs of sperm. An operating microscope is is to connect the two tubes in 2 layers with tiny suture the size of human hair. if there is concern that the blockage is at the epididymus then a bypass procedure is performed.
There may be some mild swelling and discomfort in the scrotum afterwards. Ice will help with scrotal swelling. A pain pill is prescribed to take if needed. Patients should wear a scrotal support or compression shorts for the first week to minimize swelling and discomfort. It is ok to shower but no tub soaking or swimming for 2 weeks. Patients may resume regular physical activity after 2 weeks and sexual activity at 4 weeks.