Reconstructive Management of Obstructive Azoospermia

Marcelo Mass Lindenbaum MD, Scott Lundy MD PhD, Brittany Berk MD, Aaron Smith MD, Sarah Vij MD, Raevti Bole MD

Bartholin cyst, Bartholin duct, marsupialization, Word catheter

Approximately 40% of all cases of azoospermia are due to an obstructive etiology. Etiologies range from iatrogenic, to infection, to vasal agenesis. Diagnosis is made on the basis of semen analysis, testosterone and FSH level and physical exam. Treatment can involve sperm retrieval for use with assisted reproduction, scrotal exploration with microsurgical reconstruction for those who wish to pursue natural conception, or a combination of both. Scrotal exploration for idiopathic OA results in the majority undergoing reconstruction with reported 6 month patency rates of approximately 80%. We present the case of a healthy 31 year-old male patient, with a history of a previous hydrocelectomy as a teenager and primary infertility for 2 years. He had a normal physical exam and hormonal profile, with a semen analysis showing azoospermia; thus an obstructive etiology was favored. The patient desired restoration of fertility for natural conception as he was not amenable to assisted reproduction. The video outlines the surgical exploration, vasogram and vaso-vasostomy that ultimately was successful in restoring patency and antegrade ejaculation of sperm. Iatrogenic injury to the vas deferens is most commonly associated with hernia repair, but can also occur during scrotal procedures like spermatocelectomy or hydrocelectomy. These injuries are often associated with poor blood flow and epididymal obstruction, jeopardizing future reconstruction attempts. Surgeons should be prepared to perform vaso-vasostomy, vaso-epididymostomy, or crossed vasovasostomy as needed. Pre-operative counseling regarding sperm cryopreservation is crucial in case reconstruction fails. 

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The authors have nothing to disclose

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