Study question: Can microsurgical vasoepididymostomy (MVE) be used to treat azoospermia in men with epididymal obstruction who have had a prior attempt at sperm retrieval with ICSI and failed to achieve a pregnancy?
Summary answer: MVE is an effective treatment for epididymal obstruction.
What is known already: MVE is an effective treatment for non-vasectomized patients with epididymal obstruction. However, ICSI is the preferred treatment for patients with obstructive azoospermia in some reproductive centers. The clinical pregnancy rate in per ICSI cycle is <40% and more than half of couples need repeated ICSI. Some couples cannot bear the high medical costs or the pain associated with repeated IVF/ICSI. Therefore, MVE may be an alternative treatment for such patients.
Study design, size and duration: This retrospective study investigated whether MVE could be used to treat patients with epididymal obstruction and a previous failed ICSI attempt. From January 2009 to July 2012, 268 patients underwent MVE for epididymal obstruction in our center; we included 68 who had experienced failure of at least one cycle of ICSI in this study.
Materials, setting, methods: We studied 68 patients with obstructive azoospermia who were treated by MVE and had previously undergone surgical sperm recovery and ICSI. The patients were divided into two groups according to the sperm retrieval method used in their ICSI attempt: percutaneous epididymal sperm aspiration (PESA) (41.2%, 28/68) and testicular sperm extraction (TESE) (58.8%, 40/68). We evaluated the obstructive causes, patency, pregnancy and live birth rates and the effect of sperm retrieval methods on the outcome of MVE.
Main results and the role of chance: In total, 62 patients (91.2%) showed epididymal obstruction, 2 (2.9%) intratesticular obstruction and 4 (5.9%) vasal obstruction. The mean age was 30.4±5.3 years (range: 22-48 years). We followed up 53 (85.5%) at a mean follow-up of 19.8±9.1 months (range: 6-43 months). The total patency and natural pregnancy rates were 79.2% (n=42) and 35.8% (n=19), respectively. The overall live birth rate was 28.3%. The results of MVE did not differ between the two groups: PESA and TESE.
Limitations, reasons for caution: A randomized controlled trial comparing pregnancy rates, live birth rates, risks and medical costs of MVE and IVF/ICSI is needed. The size of our sample was limited, so we did not reveal significantly different patency, pregnancy and live birth rates between PESA and TESE. A larger sample size is needed to evaluate the effect of sperm retrieval on patency, pregnancy and live birth rates.
Wider implications of the findings: Epididymal obstruction is the most common obstructive cause in non-vasectomized patients. Data from this study have shown that MVE is an effective therapy for such azoospermic patients with epididymal obstruction and prior failed ICSI for pregnancy. Obstructive causes should be differentiated to select optimal therapy for patients with obstructive azoospermia in reproductive centers.
