Microsurgical vasoepididymostomy with sperm cryopreservation for future assisted reproduction

The pregnancy outcomes in patients with epididymal obstructive azoospermia after microsurgical vasoepididymostomy: a systematic review and meta-analysis

Purpose

Pregnancy outcomes (overall patency rate, overall pregnancy rate, natural pregnancy rate, and the ratio of patients with pregnancy by assisted reproductive technology) after microsurgical vasoepididymostomy (MVE) in patients with epididymal obstructive azoospermia (EOA) were assessed through meta-analysis.

Method

We searched PubMed, Embase, Web of Science, and the Cochrane Library databases up to 28 September 2022 for published literature related to retrospective or prospective clinical studies of obstructive azoospermia after apparent microsurgical vasoepididymostomy. Our search terms included obstructive azoospermia, epididymis obstruction, epididymal obstruction and vasoepididymostomy, and epididymovasostomy. Two researchers independently performed the literature search and assessed the eligibility of selected studies according to established inclusion criteria. The meta-analysis was performed using RevMan 5.4 software.

Result

A total of 504 patients with EOA were included in 10 studies (including 2 prospective clinical studies and 8 retrospective clinical studies). The mean patency rate after MVE was 72% (95% CI 68-76%). The overall pregnancy rate was 34% (95% CI 30-38%). The natural pregnancy rate is 21% (95% CI 17-24%). The ratio of patients with pregnancy by assisted reproductive technology (ART) was 34.9%. For the factors affecting pregnancy outcomes after MVE, the overall pregnancy rates in patients receiving bilateral MVE were significantly higher than those receiving unilateral MVE (75.4 vs. 24.6%). The mean best sperm count and sperm motility in patients with overall pregnancy were significantly higher than those with failing pregnancies. For the subgroup meta-analysis of microsurgical vasoepididymostomy, there were no statistically significant differences in the overall patency rate (68 vs. 70%), the overall pregnancy rate (33 vs. 37%), the natural pregnancy rate (20 vs. 23%), the ratio of ART (30 vs. 28%) in end-to-side or end-to-end anastomosis, and longitudinal or triangular intussusception MVE.

Conclusion

Vasectomy patency rates are higher, but natural pregnancy rates are lower in EOA male infertility patients after MVE. Altering the MVE procedures alone does not significantly improve pregnancy outcomes, but ART after MVE could improve the chance of pregnancy regardless of sperm parameters. We recommended that human sperms from EOA male infertility patients should be cryopreserved during intraoperative MVE for application in the subsequent ICSI treatment procedure.

Microsurgical seminal reconstruction; our experiences in a single institute

We assessed the contribution of microsurgical seminal reconstruction to achieving natural conception in conjunction with advanced assisted reproductive technologies. Ninety obstructive azoospermic subjects who underwent microsurgical seminal reconstruction were evaluated. Vasovasostomy (VV) was undertaken in 45 subjects whereas vasoepididymostomy (VE) in 45, respectively. VV was performed by employing a two microlayer anastomotic technique, whilst VE was undertaken using double needle longitudinal vaspepididymostomy (LIVE). Patency was achieved in 41 VV (91.1%), and 25 VE (55.6%) cases. In cases where patency was achieved, pregnancy and healthy delivery were recorded following natural intercourse in 7/41 (17.0%) VV, and in 7/25 (28.0%) VE cases. Where patency was not achieved, the use of cryopreserved sperm for intracytoplasmic sperm injection (ICSI), resulted in a healthy delivery in 4/4 (100%) VV and 14/21 (66.6%) in VE subjects. Although natural pregnancy was achieved only in a limited number of subjects treated (14/90; 15.6%), sperm harvested during surgery and cryopreserved for future ICSI use proved valuable, doubling the overall delivery rate (32/90; 36.6%). Surgical intervention is considered to be a useful technique in order to allow the possibility of a natural conception and by harvesting sperm at the same time contributes to the cost-effectiveness.

Seminal plasma neutral alpha-glucosidase activity as an early predictor of patency and natural pregnancy after microsurgical vasoepididymostomy

Microsurgical vasoepididymostomy (MVE) is recommended as a first-line option for treatment of epididymal obstructive azoospermia (EOA). However, early indicators for predicting patency and natural pregnancy are unclear. Our aim was to explore the early predictive value of seminal plasma neutral alpha-glucosidase (NAG) activity for patency and natural pregnancy after MVE. Eighty-four patients with EOA who underwent MVE were enrolled in this study. The post-operative patency and natural pregnancy rates were 60.71% and 33.33% respectively. The presence of motile epididymal spermatozoa at the anastomosis site and NAG activity measured at the first month after MVE were early and independent predictors of patency and natural pregnancy. The areas under the receiver operating characteristic curves (AUCs) of NAG activity for prediction of patency and natural pregnancy were 0.78 (95% confidence interval [CI]: 0.68-0.88) and 0.82 (95% CI: 0.73-0.92). The best cut-off values of NAG activity for predicting patency and pregnancy were 15.9 and 17.0 m IU/ejaculate respectively. In conclusion， NAG activity measured at the first month after MVE is an early and independent predictor of patency and natural pregnancy.

The role of vasoepididymostomy for treatment of obstructive azoospermia in the era of in vitro fertilization: a systematic review and meta-analysis

This study comprises a systematic review and meta-analysis of microsurgical vasoepididymostomy outcomes in epididymal obstructive azoospermia. A comprehensive literature search was performed using Medline, Embase, and the Cochrane library that included all studies related to microsurgical vasoepididymostomy. Keywords included "vasoepididymostomy," "epididymovasostomy," "epididymal obstruction," and "epididymis obstruction." Event rate and risk ratio (RR) were estimated. Patency rate and pregnancy rate were investigated. The analysis comprised 1422 articles, including 42 observational studies with 2298 enrolled patients performed from November 1978 to January 2017. The overall mean patency rate was 64.1% (95% confidence interval [CI]: 58.5%-69.3%; I2=83.0%), and the overall mean pregnancy rate was 31.1% (95% CI: 26.9%-35.7%; I2=73.0%). We performed a meta-analysis comparing the patency rate of bilateral microsurgical vasoepididymostomy and unilateral microsurgical vasoepididymostomy and found an RR of 1.38% (95% CI: 1.21%-1.57%; P < 0.00001). A comparison of the site of microsurgical vasoepididymostomy showed that caudal or corpus area was favorable for patency rate (RR = 1.17%; 95% CI: 1.01%-1.35%; P = 0.04). Patients with motile sperm in epididymal fluid exhibited an RR of 1.53% (95% CI: 1.11%-2.13%; P = 0.01) with respect to patency rate. Microsurgical vasoepididymostomy is an effective treatment for epididymal obstructive azoospermia that can improve male fertility. We find that performing microsurgical vasoepididymostomy bilaterally, anastomosing a larger caudal area, and containing motile sperm in epididymis fluid can potentially achieve a superior patency rate.

The evolution and refinement of vasoepididymostomy techniques

Obstructive azoospermia secondary to epididymal obstruction can be corrected by microsurgical reconstruction with vasoepididymostomy (VE). Although alternative management such as epididymal or testicular sperm aspiration in conjunction with intracytoplasmic sperm injection is feasible, various studies have established the superior cost-effectiveness of VE as a treatment of choice. Microsurgical VE is considered one of the most technically challenging microsurgeries. Its success rate is highly dependent on the skills and experience of the surgeons. Various techniques have been described in the literature for VE. We have pioneered a technique known as longitudinal intussusception VE (LIVE) in which the epididymal tubule is opened longitudinally to obtain a larger opening to allow its tubular content to pass through the anastomosis. Our preliminary data demonstrated a patency rate of over 90%. This technique has been widely referenced in the recent literature including robotic-assisted microsurgery. The history of the development of different VE approaches, the preoperative evaluation along with the techniques of various VE will be described in this article.

Epididymovasostomy as the first-line treatment of obstructive azoospermia in young couples with normal spermatogenesis

In the management of obstructive azoospermia (OA), microsurgery is often replaced by testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI). Testicular biopsy and microsurgical side-to-side epididymovasostomy were performed in 34 azoospermic men with OA mostly due to inflammation. Ductal system patency was recovered in 21 (63.6%) men and natural pregnancy achieved in 13 (38.2%) of couples. Using multiple logistic regression analysis, it was found that ductal system patency and pregnancy were influenced by male and female age and testicular histology. The chance of obtaining patency was three times higher when male age was <38 years and two times higher when normal spermatogenesis alone was found to be present compared with mixed lesions. The chance of achieving a pregnancy was three times higher when the female partner's age was <29 years or normal spermatogenesis alone was present. The pregnancy rates obtained after surgery were not statistically different from those obtained by TESE-ICSI, but when also considering multiple pregnancies, miscarriages and side effects, the results obtained with surgery are better than those obtained with TESE-ICSI.

Prediction of candidates for seminal tract reconstructive surgery among patients with clinically suspected idiopathic or inflammatory obstructive azoospermia

Background and Aim:  We reviewed the findings of scrotal exploration, histological examination and clinical parameters in patients with clinically suspected idiopathic or inflammatory obstructive azoospermia without confirmation by isolated testis biopsy in advance. Methods:  The present study included 27 patients who underwent scrotal exploration for the purpose of vasoepididymostomy, with simultaneous testicular sperm extraction. Results:  Sperm in the epididymis was proven in 11 patients (40.7%). In two of these patients, the vas deferens was obstructed on the seminal vesicle side. Histologically, normal spermatogenesis was seen in all patients. The 16 (59.2%) patients with no sperm in the epididymis included two with normal spermatogenesis. Serum follicle stimulating hormone (FSH) levels were significantly higher in men with no sperm in the epididymis in contrast to those in men with sperm proven in the epididymis (P = 0.0057). By using a cut-off point of 6.02 mIU/mL, serum FSH can predict the existence of sperm in the epididymis, with a sensitivity of 81.8%, a specificity of 81.2% and a positive predictive value of 75.0%. Conclusion:  No more than a third of the patients in the present study who had clinically suspected obstructive azoospermia were actual candidates for vasoepidydimostomy. A serum FSH level cut-off point of 6.02 mIU/mL might be useful to determine its indication. (Reprod Med Biol 2006; 5: 211-214).

Clinical experience of vasoepididymostomy using a triangulation technique

Background: Although the number of patients receiving vasoepididymostomies is gradually increasing, these individuals are limited in the recent advanced assisted reproductive technology (ART) era. A novel technique involving vasoepididymostomy with epididymal tubular invagination has been reported. We attempted to define the results of this method and to compare them with the conventional end-to-side technique in patients with suspected epididymal obstruction and no previous history of vasectomy. Methods and Results: Eight eligible triangulation end-to-side vasoepididymostomy procedures performed on five azoospermic patients exhibiting either unilateral or bilateral epididymal obstruction are described. The overall patency rate following operation was 100% (five of five). Two pregnancies were achieved by natural intercourse and one was accomplished via artificial insemination. A single pregnancy was obtained with an intracytoplasmic sperm injection using frozen-thawed sperm collected during the operation. Conclusion: Vasoepididymostomy, using the triangulation technique for epididymal obstruction, resulted in an earlier patency in all patients. This method may afford advantages when compared with the conventional end-to-side approach; however, larger subject populations are required in order to assess further the efficacy of this procedure. In addition, long-term follow up is necessary. (Reprod Med Biol 2003; 2: 101-104).