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Wang Z, Wang X, Song C, Lu F, Zhai J, Li N, Jiang B, Tan S, Xuan X. The pregnancy outcomes in patients with epididymal obstructive azoospermia after microsurgical vasoepididymostomy: a systematic review and meta-analysis. Front Med (Lausanne) 2023; 10:1186729. [PMID: 37275372 PMCID: PMC10233013 DOI: 10.3389/fmed.2023.1186729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/24/2023] [Indexed: 06/07/2023] Open
Abstract
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.
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Affiliation(s)
- Zilong Wang
- Department of Andrology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Xinkun Wang
- Department of Andrology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Changze Song
- Department of Andrology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Fuding Lu
- Department of Andrology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Jiawen Zhai
- Department of Andrology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Naifa Li
- Department of Andrology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Baohong Jiang
- Department of Andrology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Senbao Tan
- Department of Andrology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Xujun Xuan
- Department of Andrology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Cheeloo College of Medicine, Shandong University, Jinan, China
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The management of obstructive azoospermia: a committee opinion. Fertil Steril 2019; 111:873-880. [PMID: 31029241 DOI: 10.1016/j.fertnstert.2019.02.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/12/2019] [Indexed: 01/29/2023]
Abstract
Infertility due to obstructive azoospermia may be treated effectively by surgical reconstruction or by retrieval of sperm from the epididymis or testis, followed by in vitro fertilization with intracytoplasmic sperm injection. This replaces the ASRM documents titled "Sperm retrieval for obstructive azoospermia" and "The management of infertility due to obstructive azoospermia," last published in 2008.
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Affiliation(s)
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- American Society for Reproductive Medicine, Birmingham, Alabama
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Yoon YE, Lee HH, Park SY, Moon HS, Kim DS, Song SH, Kim DK. The role of vasoepididymostomy for treatment of obstructive azoospermia in the era of in vitro fertilization: a systematic review and meta-analysis. Asian J Androl 2018; 21:238926. [PMID: 30106012 PMCID: PMC6337956 DOI: 10.4103/aja.aja_59_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 06/12/2018] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Young Eun Yoon
- Department of Urology, Hanyang University College of Medicine, Seoul 04763, Korea
| | - Hyung Ho Lee
- Department of Urology, National Health Insurance Corporation Ilsan Hospital, Gyeonggi-do 10444, Korea
| | - Sung Yul Park
- Department of Urology, Hanyang University College of Medicine, Seoul 04763, Korea
| | - Hong Sang Moon
- Department of Urology, Hanyang University College of Medicine, Seoul 04763, Korea
| | - Dong Suk Kim
- Department of Urology, Fertility Center of CHA Gangnam Medical Center, CHA University, Seoul 06135, Korea
| | - Seung-Hun Song
- Department of Urology, Fertility Center of CHA Gangnam Medical Center, CHA University, Seoul 06135, Korea
| | - Dae Keun Kim
- Department of Urology, CHA Seoul Station Fertility Center, CHA University, Seoul 04637, Korea
- Department of Urology, School of Medicine, Graduate School, Hanyang University, Seoul 04763, Korea
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Chen XF, Wang HX, Liu YD, Sun K, Zhou LX, Huang YR, Li Z, Ping P. Clinical features and therapeutic strategies of obstructive azoospermia in patients treated by bilateral inguinal hernia repair in childhood. Asian J Androl 2015; 16:745-8. [PMID: 24994783 PMCID: PMC4215684 DOI: 10.4103/1008-682x.131710] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Childhood inguinal herniorrhaphy is one common cause of seminal tract obstruction. Vasovasostomy (VV) can reconstruct seminal deferens and result in appearance of sperm and natural pregnancy in some patients. Secondary epididymal obstruction caused by a relatively long-term vasal obstruction is a common cause of lower patency compared with VV due to vasectomy in adults. From July 2007 to June 2012, a total of 62 patients, with history of childhood inguinal herniorrhaphy and diagnosed as obstructive azoospermia were treated in our center. The overall patency rate and natural pregnancy rate were 56.5% (35/62) and 25.8% (16/62), respectively. 48.4% (30/62) of the patients underwent bilateral VV in the inguinal region, with a patency rate of 76.7% (23/30) and a natural pregnancy rate of 36.7% (11/30), respectively. 30.6% (19/62) of the patients underwent bilateral VV and unilateral or bilateral vasoepididymostomies due to ipsilateral epididymal obstruction with the patency and natural pregnancy rate decreasing to 63.2% (12/19) and 26.3% (5/19). 21.0% (13/62) of the patients merely underwent vasal exploration without reconstruction due to failure to find distal vasal stump, etc. Our study indicate that microsurgical reanastomosis is an effective treatment for some patients with seminal tract obstruction caused by childhood inguinal herniorrhaphy.
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Affiliation(s)
| | | | | | | | | | | | | | - Ping Ping
- Department of Urology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Andrology, Shanghai, China
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Harza M, Voinea S, Ismail G, Gagiu C, Baston C, Preda A, Manea I, Priporeanu T, Sinescu I. Predictive factors for natural pregnancy after microsurgical reconstruction in patients with primary epididymal obstructive azoospermia. Int J Endocrinol 2014; 2014:873527. [PMID: 24987417 PMCID: PMC4058594 DOI: 10.1155/2014/873527] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 05/18/2014] [Accepted: 05/19/2014] [Indexed: 11/18/2022] Open
Abstract
Primary epididymal obstructive azoospermia (OA) is the most prevalent form of OA in nonvasectomized patients and has been less studied. We aim to assess the results with microsurgical vasoepididymostomy used in the treatment of men diagnosed with primary epididymal obstructive azoospermia and to identify the factors associated with natural pregnancy occurring after microsurgical reconstruction. This prospective study included consecutive patients with epididymal OA who underwent microsurgical reconstruction in our center. Clinical and biological data were obtained every three months during follow-up. Occurrence of natural pregnancy was the primary study outcome. In total, 36 patients underwent microsurgical reconstruction. The mean age was 34 ± 4.5 years (range 24-46 years). Median follow-up time was 15 [IQR 12-21] months. The total patency rate was 77.7% (n = 28). During follow-up, 8 (22.2%) natural pregnancies occurred. The overall live birth rate was 100%. Low FSH levels (HR: 0.22; 95% CI: 0.052-0.88; P = 0.032) and higher total motile sperm count (TMSC) (HR: 1.001; 95% CI 1-1.001; P = 0.012) were associated with a higher rate of natural pregnancy. Our data suggest that microsurgical vasoepididymostomy is an effective therapy of primary epididymal OA. Baseline lower FSH and higher TMSC were independent predictors for natural pregnancy occurrence.
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Affiliation(s)
- Mihai Harza
- Center for Uronephrology and Renal Transplantation, Fundeni Clinical Institute, 258 Fundeni Street, District 2, 022328 Bucharest, Romania
| | - Sebastian Voinea
- Center for Uronephrology and Renal Transplantation, Fundeni Clinical Institute, 258 Fundeni Street, District 2, 022328 Bucharest, Romania
| | - Gener Ismail
- Center of Internal Medicine-Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Cristian Gagiu
- Center for Uronephrology and Renal Transplantation, Fundeni Clinical Institute, 258 Fundeni Street, District 2, 022328 Bucharest, Romania
| | - Catalin Baston
- Center for Uronephrology and Renal Transplantation, Fundeni Clinical Institute, 258 Fundeni Street, District 2, 022328 Bucharest, Romania
| | - Adrian Preda
- Center for Uronephrology and Renal Transplantation, Fundeni Clinical Institute, 258 Fundeni Street, District 2, 022328 Bucharest, Romania
| | - Ioan Manea
- Center for Uronephrology and Renal Transplantation, Fundeni Clinical Institute, 258 Fundeni Street, District 2, 022328 Bucharest, Romania
| | - Tiberiu Priporeanu
- Center for Uronephrology and Renal Transplantation, Fundeni Clinical Institute, 258 Fundeni Street, District 2, 022328 Bucharest, Romania
| | - Ioanel Sinescu
- Center for Uronephrology and Renal Transplantation, Fundeni Clinical Institute, 258 Fundeni Street, District 2, 022328 Bucharest, Romania
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Abstract
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.
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Schwarzer JU. Vasectomy reversal using a microsurgical three-layer technique: one surgeon’s experience over 18 years with 1300 patients. ACTA ACUST UNITED AC 2012; 35:706-13. [DOI: 10.1111/j.1365-2605.2012.01270.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Epididymovasostomy as the first-line treatment of obstructive azoospermia in young couples with normal spermatogenesis. Reprod Biomed Online 2010; 20:594-601. [PMID: 20219429 DOI: 10.1016/j.rbmo.2010.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Revised: 06/19/2009] [Accepted: 12/14/2009] [Indexed: 11/22/2022]
Abstract
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.
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11
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Silber SJ, Grotjan HE. Microscopic vasectomy reversal 30 years later: a summary of 4010 cases by the same surgeon. ACTA ACUST UNITED AC 2005; 25:845-59. [PMID: 15477352 DOI: 10.1002/j.1939-4640.2004.tb03150.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Sherman J Silber
- Infertility Center of St Louis, St Luke's Hospital, 224 South Woods Mill Rd, Suite 730, Chesterfield, MO 63017, USA.
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Abstract
PURPOSE We analyzed our experience with repeat microsurgical vasovasostomy after failed vasovasostomy and elucidate the possible predictors of surgical outcome. MATERIALS AND METHODS We evaluated 62 repeat vasectomy reversal cases with followup data available. Regardless of the intraoperative observation of sperm in the vasal fluid bilateral microsurgical 2-layer vasovasostomy was performed when surgically possible. Of these 62 patients 60 (97%) underwent bilateral (58) or unilateral (2) vasovasostomy and 2 (3%) underwent unilateral vasovasostomy with contralateral epididymovasostomy. RESULTS Patency and pregnancy followup data were available on 62 and 42 patients, respectively. The overall patency and pregnancy rates achieved were 92% and 57%, respectively, and the natural birth rate was 52%. Increased age of the wife proved a negative prognostic factor for pregnancy (p = 0.018). The intraoperative detection of sperm and other factors, including obstructive interval, reconstruction type, anastomotic site, patient age and postoperative semen parameters, did not influence the surgical outcome. CONCLUSIONS Regardless of the detection of sperm in the intravasal fluid during the operation repeat microsurgical vasovasostomy resulted in a better outcome than in other studies, in which adopted epididymovasostomy was done when sperm was absent from the vas fluid. Our study suggests that compromised anastomosis after previous surgery is the most common cause of failed vasovasostomy. We recommend that microsurgical vasovasostomy should be performed preferentially in failed vasovasostomy cases.
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Affiliation(s)
- Jae-Seung Paick
- Department of Urology, Seoul National University College of Medicine and Seoul Boramae Hospital, Korea
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Abstract
The advent of intracytoplasmic sperm injection (ICSI) has offered new solutions for the management of patients with azoospermia. Surgical sperm recovery combined with ICSI has allowed many men with azoospermia to father their own biological children. Azoospermia can be classified as obstructive and non-obstructive, with investigations, management and success rates varying markedly between the two forms. In certain cases of obstructive azoospermia surgical reconstruction remains a viable option, whereas cases with congenital obstruction need to be screened for mutations of the cystic fibrosis gene. In most cases of obstruction sperm can be retrieved from the epididymis using percutaneous epididymal sperm aspiration (PESA). If PESA is unsuccessful, testicular sperm extraction (TESE) is successful in all cases. With non-obstructive azoospermia, the genetic basis has been investigated intensely. Screening for karyotypic abnormalities as well as Y microdeletions is recommended. Irrespective of the histological diagnosis, focal spermatogenesis can be observed in 40-50% of cases using multiple testicular biopsies.
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Affiliation(s)
- Uma Deve Gordon
- Centre for Reproductive Medicine, 4 Priory Road, Clifton, Bristol BS8 1TY, UK
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