Semen anomalies due to voiding defects of the ampullo-vesicular tract. Infertility due to ampullo-vesicular voiding defects

A novel surgical management for male infertility secondary to midline prostatic cyst

Background

To summary the procedure and experience of a novel surgical management for male infertility secondary to midline prostatic cyst (MPC).

Methods

From February 2012 to February 2014, 12 patients were diagnosed with PMC by semen analysis, seminal plasma biochemical analysis, transrectal ultrasonography (TRUS), and pelvic magnetic resonance imaging (MRI). All patients underwent the transurethral unroofing of MPC using resectoscope, the dilation of ejaculatory duct, and the irrigation of seminal vesicle using seminal vesiculoscope. All patients were followed up at least 3 months after operation.

Results

Preoperative semen analyses of 12 patients showed oligoasthenozoospermia (5/12) or azoospermia (7/12), low semen volume (0–1.9 mL), and low pH level (5.5-7.0). Preoperative seminal plasma biochemical analyses showed reduced semen fructose. TURS and MRI revealed a cyst lesion located in the midline of prostatic. After 3 months follow up, the semen quality of 80% patients (4/5) with oligoasthenozoospermia improved obviously. The spermatozoa were present in the semen in 5 of 7 cases with azoospermia. In one patient, the spermatozoa occurred in the urine after ejaculation.

Conclusions

Surgical management using transurethral resectoscopy and seminal vesiculoscopy is effective, minimally invasive, and safe for male infertility secondary to MPC.

[Surgery of male infertility: an update]

Surgery for male infertility includes three main areas: varicocele surgery, recanalization of seminal tract, sperm retrieval.Varicocele treatment in infertily is still controversial. Recent scientific evidence appears to demonstrate that in selected cases varicocele treatment is beneficial in improving semen parameters and pregnancy rate. The key for the success of treatment seems to be a correct indication. It is our opinion that varicocele should be treated in presence of abnormal semen parameters, when clinically significant, and in adolescents with atrophy of the affected testis. So far, no specific technique, either surgical, microsurgical or sclerotherapic, can be considered the gold standard. Good results in our hands have been obtained with the microsurgical lymphatic sparing high ligation of internal spermatic vein.Innovations in surgery for seminal tract obstructions include the new tubular invagination techniques for epididimovasostomy, which showed excellent results with a simplified and time-saving microsurgical approach. In distal obstructions, a new transperineal ultrasound-guided approach has been proposed for the diagnostic work-up and treatment. Advantages of this technique and of the TURED must be balanced with those of immediate sperm retrieval for ART.In sperm retrieval, microTESE represents the most important surgical evolution in non-obstructive azoospermia. We have recently proposed a new stepwise approach starting with a minimal equatorial incision for conventional testicular biopsy which is extended to perform microTESE only when no sperm is retrieved. In this way microTESE is offered only to patients who really need it. Another field of innovation is sperm retrieval for ICSI in patients with Klinefelter Syndrome.

ICSI outcome is significantly better with testicular spermatozoa in patients with necrozoospermia: a retrospective study

OBJECTIVE

To determine whether intracytoplasmic sperm injection (ICSI) outcome with testicular sperm is superior to that of ejaculated sperm in men with incomplete necrozoospermia, defined as sperm viability ≥5 to ≤45%.

STUDY DESIGN

Retrospective study at a Reproductive Medicine Center of a tertiary referral hospital. A total of 231 couples with male infertility due to incomplete necrozoospermia underwent 342 ICSI cycles with freshly ejaculated sperm (ICSI-ejaculated) and 182 cycles with testicular sperm (ICSI-TESE).

RESULTS

Overall 1624 MII oocytes were injected in the ICSI-ejaculated group with a fertilisation rate of 60.8%, while in ICSI- TESE cycles the fertilisation rate was 59.6% in 874 MII oocytes. The cleavage rate was higher in ICSI-ejaculated cycles than in ICSI-TESE cycles (96.3% versus 92.9%; p = 0.004). However, the pregnancy and implantation rates per cycle were significantly higher in the ICSI-TESE group (67/182, 36.8% versus 68/342, 19.9% (p = 0.0001); and 23.7% versus 12.7% (p = 0.0001), respectively). The miscarriage rate was similar (ICSI-ejaculated 26.5% versus ICSI-TESE 17.9%, p = 0.301). Live birth rate per cycle in the ICSI-ejaculated group was significantly lower than in the ICSI-TESE (13.7% versus 28.6%, p = 0.0001).

CONCLUSIONS

In cases of persistent necrozoospermia, testicular sperm should be favoured over ejaculated sperm. These data call for more research to understand the pathophysiology of refractory necrozoospermia.

Novel methods for the diagnosis and treatment of ejaculatory duct obstruction

OBJECTIVES

• To investigate a new method of vas deferens radiography for ejaculatory duct obstruction (EDO). • To evaluate the effect of a procedure involving dilation of the ejaculatory duct by F9 seminal vesicoscopy.

PATIENTS AND METHODS

• Twenty-two patients with EDO were diagnosed using semen analysis, semen fructose measurement, transrectal ultrasonography (TRUS) and vas deferens radiography. • Of these, 18 patients were successfully treated by dilation of ejaculatory duct using F9 seminal vesicoscopy and four patients, whose treatment was unsuccessful, were treated by transurethral resection of the ejaculatory ducts (TURED). • All patients were followed up for at least 3 months after treatment.

RESULTS

• Semen analyses in all 22 patients showed oligoasthenozoospermia or azoospermia, low semen volume (0-1.9 mL), low pH level (5.6-7.0) and absent or low semen fructose. TRUS and radiography showed pure dilated seminal vesicles on both sides in three patients, partial dilated seminal vesicles in one patient, dilation of both the ejaculatory duct and seminal vesicles in ten patients, dilated seminal vesicles and a prostatic cyst in four patients, and dilated ejaculatory duct or cystic lesions without dilated seminal vesicles in the remaining four patients. • At >3-month follow-up after dilation or TURED, the semen characteristics of 18 patients were improved and sperm were present in the semen in 13 cases. Normal semen analyses were found in 7 patients and 6 patients had conceived. • Voiding urethral radiography showed that no patients who had undergone dilation by seminal vesicoscopy had urine reflux into the ejaculatory duct. Only one patient showed urine reflux into the seminal vesicle after TURED. • All patients felt that their symptoms had improved after treatment.

CONCLUSIONS

• The approach to vas deferens radiography using vas deferens aspiration has proved to be an effective and safe method for EDO diagnosis. • The procedure involving the dilation of the ejaculatory duct using F9 seminal vesicoscopy is equally effective but has fewer postoperative complications than TURED.

Percutaneous vesiculodeferentography in the diagnosis of male infertility: A review of our results and the data reported in the literature

Vesiculodeferentography was used in the past to evaluate suspected cases of obstruction of the seminal ducts. Over the years, numerous attempts have been made to improve the technique used to perform this examination and to render it less invasive. Its use is currently indicated in selected cases, where it is combined with functional studies like seminal tract washout and followed by immediate interventions to correct the alterations revealed. Vesiculodeferentography includes collection of the contents of the seminal vesicles, which can later be used in vitro assisted fertilization procedures.

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.