Occlusion of the male reproductive duct system is noted in 7% of infertile men. It is an important cause because it is
potentially reversible. Causes include ductal obstruction from congenital absence or narrowing of the ductal system, stricture which maybe due to infection, and vasectomy. The hallmarks of men with obstruction of the reproductive ducts include azoospermia (no sperm in ejaculation), normal testicular size, and normal hormone levels (FSH, LH). The diagnosis
of epididymal obstruction can almost certainly be made in addition to the above characteristics, the ejaculation is normal and alkaline (pH is base).
The epididymis is a structure on the back of the testicle which contains a very fine set of tubes which are part of the male reproductive duct system. The epididymis is involved in sperm maturation and is prone to injury due to infection, trauma,or from a vasectomy. The operative procedure to correct epididymal obstruction is called a vasoepididymostomy. In this
procedure, the vas deferens is attached to a tiny epididymal tubule in order to bypass an obstruction.
The intraoperative finding of sperm within the epididymal tubule is the best predictor of success. In fact, if sperm are not noted in the epididymal tubular fluid, a testicular biopsy will be done and if sperm are present in the testicular tissue, a portion can be saved to process and collect the sperm. This sperm can then be frozen for future advanced techniques such
as intracytoplasmic sperm injection ICSI). This entails the injection of single sperm into an egg. If sperm are noted in the epididymal tubule at the time of operation, it is recommended sperm be obtained and frozen. This is done as insurance in case the procedure is unsuccessful.
The overall success rate is 60 to 80% positive sperm in the ejaculation after a vasoepididymostomy. This is in contrast to a 35 to 50% pregnancy rate, meaning some patients will have sperm and be unable to conceive. Many patients will not have sperm present in the first postoperative semen analysis. 40 % of patients in whom sperm was not seen on initial postoperative semen analysis will have sperm on subsequent examinations. It may take up to 18 months for sperm to be present in the
ejaculate. Pregnancy may take 1 to 2 years to achieve. There is a 10% chance that obstruction will develop after sperm was initially noted. It is sometimes recommended, therefore, that frozen sperm be obtained in patients who have undergone vasoepididymostomy once sperm is present in the ejaculation.
The procedure is done on an outpatient basis (no overnight hospitalization) via a 2 inch scrotal incision. The procedure takes approximately 4 to 5 hours and uses an operating microscope to visualize the structures and allow the use of sutures which are finer than a human hair. Anesthesia is typically general anesthesia (sleep) or sometimes epidural (lower 1/2 of body without feeling). Oral pain medication will be provided and is -generally required for 24 to 48 hours. An ice pack should be placed on the scrotum for the first 12 to 24 hours. No heavy lifting, sports or sexual activity should be performed for four weeks. Work may be resumed in five days unless the job is physically demanding, then at least ten to
fourteen days will be required. One week after the operation, a postoperative check should be performed and a semen analysis obtained four to eight weeks after the operation. As stated above, many patients will not demonstrate sperm at this time and repeat semen analysis should be performed every three months until sperm is noted.
Bleeding and infection are potential complications of all types of surgery. A scrotal hematoma (bleeding in the scrotum)occurs in approximately 1 to 2 % of patients. Infection occurs less than 1 % of the time. Scarring and persistent pain at the operative site rarely occur.
