|Year : 2005 | Volume
| Issue : 2 | Page : 112-115
Predictors of patency after two-stitch invagination vaso-epididymal anastomosis for idiopathic obstructive azoospermia
G Gautam, R Kumar, NP Gupta
Department of Urology, All India Institute of Medical Sciences, New Delhi, India
Assistant Professor, Department of Urology, All India Institute of Medical Sciences,New Delhi - 110029
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: Anastomotic patency with return of sperm in the ejaculate following microsurgical vasoepididymostomy (VEA) is not universal and may be delayed. The ability to predict the result of VEA based on preoperative or intra-operative parameters would enable the surgeon to offer the best treatment to the infertile couple. We used the two-stitch invagination technique of VEA in patients of idiopathic obstructive azoospermia and prospectively analyzed factors that could predict a patent anastomosis. While such studies have previously been done for patients undergoing VEA for secondary infertility following a vasectomy, to the best of our knowledge this is the first study analyzing these parameters for patients with primary infertility and idiopathic obstruction. Methods and materials: Over a 2-year period, 29 men underwent the 2-suture invagination VEA for idiopathic obstructive azoospermia. Twenty-four patients provided at least one postoperative semen sample. Preoperative and intra-operative parameters were compared between patients with a patent anastomosis with sperm in ejaculate (n = 12) and those with no sperm in the ejaculate (n = 12) using the t-test, Fisher's exact test or chi-square test, as appropriate and a multivariate statistical analysis to determine any significant difference. Results: The mean follow up of the 24 patients was 7.6 months (2-30 months). A significantly greater number of patients with patent anastomosis had motile epididymal sperms (P = 0.034) and higher surgeon's technical satisfaction with the procedure (P = 0.034). However, this difference was seen only on a univariate analysis and did not persist when a multivariate analysis was used. Conclusions: The presence of motile sperms in the epididymal fluid and a high level of technical satisfaction with the anastomosis may indicate a higher likelihood of success following a vaso-epididymal anastomosis for idiopathic obstruction. However, these parameters are not enough to prognosticate the outcome of surgery and advise early in vitro fertilization.
Keywords: Azoospermia; Infertility; Obstructive Azoospermia; Vaso-epididymal anastomosis; Vasoepididymostomy
|How to cite this article:|
Gautam G, Kumar R, Gupta N P. Predictors of patency after two-stitch invagination vaso-epididymal anastomosis for idiopathic obstructive azoospermia. Indian J Urol 2005;21:112-5
|How to cite this URL:|
Gautam G, Kumar R, Gupta N P. Predictors of patency after two-stitch invagination vaso-epididymal anastomosis for idiopathic obstructive azoospermia. Indian J Urol [serial online] 2005 [cited 2020 May 30];21:112-5. Available from: http://www.indianjurol.com/text.asp?2005/21/2/112/19633
There has been a rapid increase in the treatment options available to infertile couples with male factor infertility. In vitro fertilization particularly using intracytoplasmic sperm injection (ICSI) offers a viable alternative to surgical correction in men with obstructive azoospermia. Microsurgical vaso-epididymostomy (VEA) is a technically difficult surgery and is not universally available. It is also associated with a failure rate of up to 50% and even in successful cases, viable sperms in the postoperative semen sample may not be present up to 12 months after surgery resulting in delay in further treatment., The ability to predict the result of surgery preoperatively would enable proper counseling of the couple and enable the surgeon to offer the treatment protocol having the maximum chances of success resulting in significant time and financial savings.
The two-stitch invagination VEA in the human model was first described by Marmar in 2000, who achieved patency rates of 77.7% in patients undergoing bilateral VEA for vasectomy reversals. We used this technique in patients of primary infertility with idiopathic obstruction and analyzed our results with reference to preoperative and intra-operative parameters to determine predictive factors for a successful outcome. Idiopathic obstruction may be present in up to 50% patients with obstructive azoospermia and while earlier studies have analyzed predictors of patency following VEA for vasectomy reversal in patients with previously documented normal fertility, ,,,, to the best of our knowledge, no study has analyzed these factors in cases where the etiology of obstruction is unknown.
| Patients and methods|| |
All patients presenting with primary infertility to our Urology clinic between December 2002 and November 2004 were evaluated with a detailed history and physical examination for the size of testis, fullness of epididymis, presence of vas, and varicocele. Obstructive azoospermia suitable for VEA was diagnosed when, in men with at least one palpable vas deferens, at least two semen samples were more than 2 ml each, had normal fructose levels with absence of sperms in the pellet after centrifugation along with normal spermatogenesis on fine needle aspiration cytology of the testis. Obstruction was considered idiopathic when patients had no history of previous vasectomy, inguinal, or scrotal surgery/trauma, or scrotal inflammation/infection.
Surgery was performed unilaterally on the testis with larger volume with confirmed spermatogenesis. The two-stitch invagination technique of single tubule microsurgical vaso-epididymal anastomosis using two double-armed 10-0 nylon sutures (Ethilon®, Ethicon, Aurangabad, India) was performed in all patients. Minor modifications were made to the originally described technique. We incise the tubule while both the needles are still in place. In some patients, the needles were placed longitudinally in the tubule rather than transversly. The epididymal fluid color, sperm motility, site, and technique (whether transverse or longitudinal) were recorded. In case, the tubules were collapsed with no fluid on incision or if sperms were not visualized on microscopy of the epididymal fluid, a more proximal site was chosen for anastomosis. If still no sperms were found, the procedure was abandoned. Only patients who had sperms in the epididymal fluid during surgical exploration and underwent a VEA were included in the study. At the culmination of the procedure the operating surgeon's satisfaction with the technical aspect of the surgery was recorded in a scale of 1-3, with 3 being a technically perfect procedure and 1 representing poor technical satisfaction.
Postoperative abstinence was advised for 6 weeks. Semen samples were collected at 6 weeks and three monthly thereafter till pregnancy was achieved. Complications were noted at each follow up visit.
For evaluation of predictive parameters, patients were divided into two groups; group I, consisting of men with a patent anastomosis and group II who are negative for sperms till the last available follow-up. The two groups were compared for factors that may have influenced the appearance of sperms in the ejaculate after surgery. Preoperative factors considered were age, duration of infertility, testicular volume, clinical distension of epididymis and serum Follicle stimulating hormone (FSH), and Leutenizing hormone (LH). Other data included were epididymal fluid color, motility of epididymal sperms, site of anastomosis on the epididymis, technique of anastomosis and technical satisfaction, and postoperative follow-up duration. Statistical evaluation was done using t -test, Fisher's exact test or chi-square test as appropriate and a multivariate statistical analysis.
| Results|| |
Twenty-nine patients underwent the two-stitch invagination VEA during the study period [Table - 1]. Mean operating time was 55 min. There were no intraoperative complications. Five patients have not returned for any follow up visit. The mean follow up of the 24 patients who provided at least one postoperative semen sample was 7.6 months (1.5-30 months). In 12 of these men (50%: group I), patency was demonstrated by the presence of sperms in postoperative semen sample at a mean of 3.2 (1.5-7) months after surgery. The 12 men who continued to be azoospermic postoperatively (group II) had a mean follow up of 6.9 (2-30) months.
The two groups were similar in age, duration of infertility, testicular size, distension of epididymis, serum FSH, and serum LH [Table - 2]. The two groups were also similar with regards to epididymal fluid color, site of anastomosis on the epididymis, technique of anastomosis (longitudinal or transverse), and duration of postoperative follow up [Table - 3]. However, in group I, sperms from the epididymal fluid at the time of VEA were motile in significantly greater number of patients as compared to group II (50 vs 8.3%, P = 0.034). The level of the surgeon's technical satisfaction at the culmination of the procedure was also significantly different between the two groups ( P = 0.034). While the mean satisfaction score in the patients with a patent anastomosis was 2.92, it was 2.50 in patients with an unsuccessful outcome. None of the patients in either group had a technically poor rating of 1/3.
While these differences were noted on a univariate analysis, no difference was found between the two groups on a multivariate analysis.
| Discussion|| |
For patients with obstructive azoospermia, surgical reconstruction is an acceptable management option. In comparison with assisted reproduction techniques (ART) such as ICSI, which tend to bypass the male factor etiology, surgical correction offers a long-term solution and aims at correcting the underlying pathology. It also obviates the need for repeated ART each time the individual wishes to contribute to a pregnancy.
Vasoepididymostomy via invagination of the epididymal tubule was originally described and evaluated in the rat model and resulted in improved patency rates as compared to other methods prevalent at that time., The two-stitch single tubule invagination technique was first applied to 19 azoospermic men by Marmar in 2000. He achieved excellent patency rates of 77.7% in men undergoing bilateral VEA and 85.7% in those undergoing unilateral VEA with vasovasostomy on the opposite side. We began using the two-stitch technique since early 2001 in all our patients, primarily because of its simplicity and have a patency rate of 50% in idiopathic azoospermia.
The etiology of azoospermia in our cohort is unclear. It is presumed to be obstructive based on the presence of normal spermatogenesis in the testis. However, compared to men with secondary infertility due to vasectomy who clearly have an obstructive cause, these men with primary infertility may have additional abnormalities that cannot be definitively evaluated. In view of the lower patency rates in our patients, it becomes even more important to evaluate the possible predictors of a successful surgery so as to judiciously counsel the patients.
The quality of intravasal fluid at the time of vasectomy reversal has been demonstrated to affect the likelihood of technically successful vasectomy reversals. Ninety-four percent of patients with clear fluid and motile intravasal sperm had a return of sperm to the ejaculate, compared with 60% of those with no sperm in the vasal fluid. Sigman, however, demonstrated that patency rates are not significantly associated with intravasal sperm quality and excellent patency rates of 95% could be achieved if any sperm parts could be identified in the vasal fluid. These reports relate to vasectomy reversals where obstruction is undoubtedly present and presence of any sperm parts rather than motile sperms probably signifies the absence of a more proximal obstruction. Postoperative patency rates in these men is unlikely to be affected by the motility of vasal sperms while pregnancy rates may be.
In our study, presence of motile sperms in the epididymal fluid during VEA was a significant univariate predictor of patency postoperatively. The principal function of the epididymis is related to sperm motility and the presence of motile sperms may suggest a normal epididymal function with truly obstructive etiology compared to men where the sperms, though present, were immotile. The men with immotile sperms in the epididymis may have additional abnormalities such as epididymal dysfunction contributing to the azoospermia rather than pure obstruction, thus a poorer result with the VEA.
Microsurgery for obstructive azoospermia is a technically demanding procedure and the surgical expertise of the surgeon plays a crucial role in determining the outcome of surgery. In a survey conducted by Nagler and Rotman, those surgeons who performed microscopic vasovasostomy without laboratory practice had a patency rate of 53% as compared to a patency rate of 89% for surgeons who practiced their microsurgical skills before employing them clinically. In our study, the level of the surgeon's technical satisfaction at the culmination of the procedure was also significantly different between the two groups ( P = 0.034) in the univariate analysis. Interestingly, 11 out of 12 (91.6%) patients with a patent anastomosis had a perfect rating of 3/3, while only six out of 12 (50%) in the unsuccessful group had this rating with the others having a score of 2/3.
Although our study is not able to demonstrate any significant predictors of success in a multivariate analysis, it does show significant trends towards the importance of epididymal sperm quality and technical expertise in the ultimate outcome of surgery. Further, adequately powered studies pertaining to this area may provide us a greater insight with regards to this aspect of surgery for azoospermia and overcome the dearth of literature on this subject.
| Conclusions|| |
Presence of motile sperms in the epididymal fluid and a high level of technical satisfaction with the anastomosis may indicate a higher likelihood of success following a vaso-epididymal anastomosis for idiopathic obstruction. However, these parameters are not enough to prognosticate the outcome of surgery and advise early in vitro fertilization.
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[Table - 1], [Table - 2], [Table - 3]
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