Sperm analysis of the vas deferens fluid after a long interval of unilateral percutaneous epididymal sperm aspiration in vasectomized patients

Abstract

Objectives

Evaluation of the presence of spermatozoa in vas deferens fluid after a long interval of unilateral and homolateral percutaneous epididymal sperm aspiration (PESA) in vasectomized men. When found, the spermatozoa were evaluated including concentration and motility, in order to verify the patency of the epididymal tubules.

Materials and Methods

Four patients, numbered in a progressive order, from one to four, with 38, 40, 48 and 51 years old and vasectomy interval of 10, 10, 25 and 11 years, respectively, whose wives did not get pregnant using intracytoplasmic sperm injection of sperm obtained by unilateral PESA and decided to try only natural conception, were submitted to intrasurgical sperm analysis of the vas deferens fluid (ISAVDF) during microsurgery for reconstruction of the seminal tract.

Results

Time interval between PESA and ISAVDF was 13.75 ± 11.12 months (x ± s) varying from 3 to 29 months. Homolateral ISAVDF and PESA showed the presence of spermatozoa. Patients 1, 2 and 4 had a high concentration of 10 x 106, 64 x 106 and 45 x 106 spermatozoa/ mL; the first two had motile sperms and patient 3 had no sperms.

Conclusions

Three of four patients showed spermatozoa in the vas deferens fluid after a long interval of unilateral and homolateral PESA with high concentration, including motile forms. These findings support the concept that PESA may not result in late epipidymal tubule obstruction in vasectomized patients.

PESA; Epididymis; Vasovasostomy; Spermatozoa; Vas Deferens


INTRODUCTION

Although most men at the time of vasectomy are sure of the choice of surgical contraception, around 4 to 6% will desire posteriorly to father children using their own spermatozoa (11. Belker AM, Thomas AJ Jr, Fuchs EF, Konnak JW, Sharlip ID: Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol. 1991; 145: 505-11.). In those cases the treatment options include microsurgical reconstruction of seminal tract and intracytoplasmic sperm injection (ICSI).

In order to obtain spermatozoa to ICSI some surgical techniques are employed, as percutaneous epididymal sperm aspiration (PESA), testicular sperm aspiration (TESA), testicular sperm extraction (TESE) and microsurgical dissection of seminiferous tubules (microTESE) (22. Glina S, Fragoso JB, Martins FG, Soares JB, Galuppo AG, Wonchockier R: Percutaneous epididymal sperm aspiration (PESA) in men with obstructive azoospermia. Int Braz J Urol. 2003; 29: 141-5; discussion 145-6.

3. Esteves SC, Miyaoka R, Agarwal A: Sperm retrieval techniques for assisted reproduction. Int Braz J Urol. 2011; 37: 570-83.
-44. Schlegel PN: Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Hum Reprod. 1999; 14: 131-5.). It is still possible to use microsurgical epididymal sperm aspiration (MESA) (55. Temple-Smith PD, Southwick GJ, Yates CA, Trounson AO, de Kretser DM: Human pregnancy by in vitro fertilization (IVF) using sperm aspirated from the epididymis. J In Vitro Fert Embryo Transf. 1985; 2: 119-22.

6. Silber SJ, Ord T, Balmaceda J, Patrizio P, Asch RH: Congenital absence of the vas deferens. The fertilizing capacity of human epididymal sperm. N Engl J Med. 1990; 323: 1788-92.
-77. Palermo G, Joris H, Devroey P, Van Steirteghem AC: Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. Lancet. 1992; 340: 17-8.), during which it is performed a microsurgical repair of the epididymal tubule in order to avoid posterior obstructive scarring of the tubules keeping them patent.

Classically, PESA is considered a recovery technique that causes obstruction of epididymal tubules (33. Esteves SC, Miyaoka R, Agarwal A: Sperm retrieval techniques for assisted reproduction. Int Braz J Urol. 2011; 37: 570-83.,88. Chan PT, Libman J: Feasibility of microsurgical reconstruction of the male reproductive tract after percutaneous epididymal sperm aspiration(PESA). Can J Urol. 2003; 10: 2070-3.). The mechanism of obstruction is related to scarring after the use of the aspiration needle and leakage of spermatozoa.

In the vasectomized patient, the spermatozoa flow freely inside the epididymal tubules until the place of the vasectomy with natural processes of production, death and absorption of sperm. On the other hand, it was believed that in the vasectomized patients submitted to PESA, there would be an air-tight space between the place of PESA and the site of vasectomy where spermatozoa would only suffer death and absorption, and after a period of time, this site would not present sperms.

The presence of high concentration of sperms including motile forms during intrasurgical analysis of vas deferens fluid (ISAVDF) after a long interval of time of PESA, homolateral to ISAVDF, would definitely demonstrate that PESA do not cause epididymal tubule obstruction. From a practical point of view, these ISAVDF findings would allow homolateral vasovasoanatomosis (VV) to PESA instead of vasoepididymal anastomosis (VE), that is more troublesome and more complex, with the need of great microsurgical ability and results of pregnancy and patency inferior to VV.

The objetive of the present study was to determine the presence of spermatozoa in the vas deferens fluid after a long period of the unilateral and homolateral PESA in vasectomized patientes, and, if affirmative, to determine their concentration and motility in order to infer epididymal tubule patency.

MATERIALS AND METHODS

The study was performed in four patients with azoospermia due to bilateral vasectomy who were submitted to unilateral PESA and ICSI, whose wives did not get pregnant. These patients further decided to father children spontaneously and decided to be submitted to ISAVDF during bilateral microsurgical reconstruction of seminal tract. It was proposed vasoepididymal anastomosis in the homolateral side submitted to PESA and VV or VE on the contralateral side of unilateral PESA, according to the results of ISAVDF.

VE was proposed using termino-lateral microsurgical anastomosis with single stitches of mononylon 10-0 and VV termino-terminal anastomosis with single stitches of mononylon 9-0, single plan under surgical microscope. The fluid from the proximal vas deferens stumps in relation to the epididymus was aspirated in natura with a 26G needle attached to a 1 mL syringe that was send to the clinical laboratory. After surgery, patients were evaluated every three months. Table-1 shows the patients age as well as their wives age, time since vasectomy, side, place and number of aspirative punctures with 26G needles during unilateral PESA and the time between unilateral PESA and the microsurgical reconstructive procedure.

Table 1-
Distribution of patients, time since vasectomy and unilateral PESA data.

RESULTS

The median age of the patients was 44.25 ± 6.24 years (medium ± standard deviation) and of the wives 33.00 ± 1.63 years. The median time of interval between vasectomy and microsurgical reconstruction was 14.00 ± 7.35 years and between unilateral PESA and microsurgical reconstruction was 13.75 ± 11.12 months, varying from 3 to 29 months.

In all patients, the fluid from the vas deferens stump during ISAVDF homolateral and contralateral to unilateral PESA was whitish or transparent serous.

ISAVDF homolateral to unilateral PESA showed the presence of a high number of spermatozoa: 10 x 106, 64 x 106 and 45 x 106 sperms/mL, with motility of 30%, 1% and 0% in patients 1, 2 and 4, respectively. Patient 3 showed no sperms.

Contralateral ISAVDF in relation to unilateral PESA showed the presence of high number of spermatozoa, of 8 x 106 and 54 x 106 sperms/mL and motility of 0% and 32% in patients 1 and 2, respectively; patients 3 and 4 had no sperms.

Tables 2 and 3 show the results of homolateral and contralateral ISAVDF in relation to PESA, respectively. All patients were submitted to VV. The follow-ups every three months of patients are described in Table-4.

Table 2-
Results of intrasurgical analysis of vas deferens fluid homolateral to unilateral PESA.

Table 3-
Results of intrasurgical analysis of the vas deferens fluid contralateral to unilateral PESA.

Table 4-
Post-surgical results of microscopic reconstruction of seminal tract (bilateral microsurgical vasovasoanastomosis).

DISCUSSION

After the report of the first ICSI (77. Palermo G, Joris H, Devroey P, Van Steirteghem AC: Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. Lancet. 1992; 340: 17-8.), PESA became progressively used to recover sperm in vasectomized patients, since it is a very simple technique, but with the inconvenience of contraindicating a future VV (33. Esteves SC, Miyaoka R, Agarwal A: Sperm retrieval techniques for assisted reproduction. Int Braz J Urol. 2011; 37: 570-83.,88. Chan PT, Libman J: Feasibility of microsurgical reconstruction of the male reproductive tract after percutaneous epididymal sperm aspiration(PESA). Can J Urol. 2003; 10: 2070-3.).

Marmar et al. (99. Marmar JL, Sharlip I, Goldstein M: Results of vasovasostomy or vasoepididymostomy after failed percutaneous epididymal sperm aspirations. J Urol. 2008; 179: 1506-9.) described the first VV after bilateral PESA in eight vasectomized patients, and during the intrasurgical microsurgical procedure they evaluated the presence of spermatozoa in the vas deferens fluid proximal stump in relation to epididymis. They reported that these patients had been submitted to one to four bilateral PESA; seven patients showed spermatozoa at least in one of the stumps intrasurgically and among three patients submitted to bilateral VV two of their wives got pregnant naturally.

Posteriorly Van Roijen (1010. van Roijen JH: Two cases of delayed patency following “failed” epididymovasostomy and subsequent percutaneous epididymal spermaspiration. Can J Urol. 2010; 17: 5022-5; discussion 5025.) described two vasectomized patients submitted to bilateral VE that presented post-surgical azoospermia and that were next submitted to bilateral PESA. Three years after the bilateral PESA in one patient and one year after the other, patients presented spermatozoa in the semen, and they concluded that VE could in a late period result in epididymal tubule patency even after PESA.

This study presents four vasectomized patients submitted to unilateral PESA that posteriorly were submitted to microsurgical reconstruction of the seminal tract. In three patients it was observed the presence of spermatozoa with high concentration at the vas deferens stumps homolateral to unilateral PESA, with motility in two patients. Since the interval time between PESA and ISAVDF of all patients was equal or superior to three months, enough time for death and tubular absorption of remaining sperms between the PESA and vasectomy sites, based on the results of ISAVDF, PESA did not cause late obstruction of the epididymal tubules. Macroscopic evaluations of the fluids collected during ISAVDF at the time of the microscopic reconstruction was coincident with the sperm analysis, since the fluids were serous, whitish or transparent, as shown in Tables 2 and 3.

Some additional observations must be made. First, in this study, there were a very limited number of patients, due to the rarity of vasectomized patients described in the literature that were submitted to microscopic reconstruction after PESA and with ISAVDF results showing spermatozoa (99. Marmar JL, Sharlip I, Goldstein M: Results of vasovasostomy or vasoepididymostomy after failed percutaneous epididymal sperm aspirations. J Urol. 2008; 179: 1506-9.). Second, patient 3 did not have spermatozoa in both sides during ISAVDF. However, due to the bilateral macroscopic characteristics of the fluids in the vas deferens stumps (Tables 2 and 3), and although with a long interval time between vasectomy and reconstruction, it was performed bilateral VV. Table-4 shows that this patient presented rare spermatozoa in the post-operatory period, that evolved to azoospermia, meaning that at least in one side there was epididymal patency. This patient was maintained in the study since he matched the inclusion methodological criteria. Third, patient 4 had spermatozoa present during ISAVDF at the homolateral side of PESA and no sperms on the contralateral side. This aspect could be explained by the characteristics of the vas deferens fluid at the contralateral side of PESA. Maybe it did not represent all tubular fluid of the vas deferens stump and the epididymis, being only the most proximal fluid at the site of vasectomy where possibly there were no sperms. At the homolateral side in relation to PESA, all fluid or most of it was present. Fourth, although the results of sperm analysis and pregnancies at Table-4 could not be related exclusively to microsurgical reconstruction homo or contralateral to PESA, these data were presented since they were part of the post-operatory follow-up of patients.

In the present study it was also quoted the diameter of the needle and the number of aspirative punctures of epididymus during unilateral PESAs (Table-1). Accordingly, Saade et al. (1111. Saade RD, Neves PA, Glina S, D'Ancona CA, Dambros M, Lúcio MA: Quantitative (stereological) and qualitative study of rat epididymis after vasectomy and percutaneous epididymal spermaspiration. J Urol. 2008; 179: 381-4.) after histologic analysis of epididymal tissue, after one to five percutaneous aspirative punctures of sperm of epididymal rats, with a 25G needle, they concluded that there is a cumulative effect of the amount of lymphoplasmocitary infiltrate, local fibrosis and volumetric augmentation of the connective tissue, directly proportional to the number of punctures.

The hypothesis why PESA do not cause epididymal tubule obstruction after PESA had already been quoted by Marmar et at (99. Marmar JL, Sharlip I, Goldstein M: Results of vasovasostomy or vasoepididymostomy after failed percutaneous epididymal sperm aspirations. J Urol. 2008; 179: 1506-9.). They are based on the possibility of self-repair of epididymal tissue and that there are anatomically 10 to 15 efferent ducts that converge to a single epididymal tubule.

Finally, we suggest that multicentric and prospective studies with the same characteristics of the present must be realized, as well as studies in animals, in order to obtain a greater population analysis.

CONCLUSIONS

Three out of four patients showed sperm at the vas deferens fluid after a long period of the unilateral and homolateral PESA procedure, with high concentration and motile forms in two patients. It is possible to infer that PESA may not cause epididymal tubule obstruction in vasectomized patients.

REFERENCES

  • 1
    Belker AM, Thomas AJ Jr, Fuchs EF, Konnak JW, Sharlip ID: Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol. 1991; 145: 505-11.
  • 2
    Glina S, Fragoso JB, Martins FG, Soares JB, Galuppo AG, Wonchockier R: Percutaneous epididymal sperm aspiration (PESA) in men with obstructive azoospermia. Int Braz J Urol. 2003; 29: 141-5; discussion 145-6.
  • 3
    Esteves SC, Miyaoka R, Agarwal A: Sperm retrieval techniques for assisted reproduction. Int Braz J Urol. 2011; 37: 570-83.
  • 4
    Schlegel PN: Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Hum Reprod. 1999; 14: 131-5.
  • 5
    Temple-Smith PD, Southwick GJ, Yates CA, Trounson AO, de Kretser DM: Human pregnancy by in vitro fertilization (IVF) using sperm aspirated from the epididymis. J In Vitro Fert Embryo Transf. 1985; 2: 119-22.
  • 6
    Silber SJ, Ord T, Balmaceda J, Patrizio P, Asch RH: Congenital absence of the vas deferens. The fertilizing capacity of human epididymal sperm. N Engl J Med. 1990; 323: 1788-92.
  • 7
    Palermo G, Joris H, Devroey P, Van Steirteghem AC: Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. Lancet. 1992; 340: 17-8.
  • 8
    Chan PT, Libman J: Feasibility of microsurgical reconstruction of the male reproductive tract after percutaneous epididymal sperm aspiration(PESA). Can J Urol. 2003; 10: 2070-3.
  • 9
    Marmar JL, Sharlip I, Goldstein M: Results of vasovasostomy or vasoepididymostomy after failed percutaneous epididymal sperm aspirations. J Urol. 2008; 179: 1506-9.
  • 10
    van Roijen JH: Two cases of delayed patency following “failed” epididymovasostomy and subsequent percutaneous epididymal spermaspiration. Can J Urol. 2010; 17: 5022-5; discussion 5025.
  • 11
    Saade RD, Neves PA, Glina S, D'Ancona CA, Dambros M, Lúcio MA: Quantitative (stereological) and qualitative study of rat epididymis after vasectomy and percutaneous epididymal spermaspiration. J Urol. 2008; 179: 381-4.

Publication Dates

  • Publication in this collection
    Sep-Oct 2013

History

  • Received
    24 May 2013
  • Accepted
    13 Aug 2013
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