AZOOSPERMIA: SURGICAL TREATMENT

Male infertility affects the psychological well-being of men, resulting in emotional distress and challenging their sense of identity. Male infertility presents a significant challenge in the field of reproductive health today. As an area of treatment that remains largely unexplored, it requires further research and innovative approaches to fully understand its complexities. However, it is important to remember that with the right support and guidance, there are possibilities to help couples facing these difficulties.  Hope and perseverance often lead to successful outcomes, even in the face of adversity.

Treatment of Obstructive Azoospermia

Azoospermia is defined as the absence of sperm in the ejaculate after centrifugation due to an obstructive cause. It is a condition that affects about 30% of men with azoospermia.

Obstruction can occur at several levels:

– Intratesticular (15%)

– Epididymal (30-60%)

– Vas deferens

– Ejaculatory ducts

There are various surgical techniques for the treatment of obstructive azoospermia. The choice depends on the etiology and location of the obstruction.

Intratesticular Obstruction

For men with intratesticular obstruction, retrieving sperm can seem like an insurmountable challenge. However, the technique of Testicular Sperm Extraction (TESE) offers an effective solution. This procedure is recommended and allows for the retrieval of viable sperm, opening up possibilities for fatherhood.

Epididymal Obstruction

In men with epididymal obstructions, such as those with congenital absence of the vas deferens (CBAVD), several options are available. Microscopic Epididymal Sperm Aspiration (MESA) is a technique that often provides sufficient material for multiple cycles of Intracytoplasmic Sperm Injection (ICSI), increasing the chances of success. Other procedures such as TESE and Percutaneous Epididymal Sperm Aspiration (PESA) are also viable alternatives. For those with acquired obstructions, reconstructive microsurgery may be considered, with a waiting period ranging from three to eighteen months to see results. In the meantime, sperm can be collected and preserved, ready for use when needed.

Proximal Vas Deferens Obstruction

If the obstruction is in the proximal vas deferens, often due to a previous vasectomy, surgical reconnection may be a viable solution. Vasovasostomy is a procedure that can reopen the vas deferens, allowing sperm to pass through again. In some cases, if the surgery reveals that the obstruction also involves the epididymis, a micro-surgical tubulo-vasostomy may be performed.

Distal Vas Deferens Obstruction

When the obstruction is in the distal vas deferens, often due to previous surgeries such as hernia repair or orchidopexy, the situation can be complex. In such cases, direct surgical correction may not be feasible. However, techniques like Testicular Sperm Extraction (TESE), Microscopic Epididymal Sperm Aspiration (MESA), or sperm aspiration from the proximal vas deferens offer a chance to retrieve sperm. These can be cryopreserved for future use in Intracytoplasmic Sperm Injection (ICSI), keeping the hope of conception alive.

Ejaculatory Duct Obstruction

When facing an obstruction of the ejaculatory ducts, the treatment depends on the specific cause. One of the most common procedures is Transurethral Resection of the Ejaculatory Ducts (TURED). This can be particularly useful when the obstruction is due to past inflammation or when the ejaculatory ducts are blocked by an intraprostatic cyst. In these cases, resection helps to clear the passage, improving the situation.

If the obstruction is caused by a cyst, it will be necessary to open the cyst walls to allow sperm to pass freely. During this procedure, a transrectal prostate ultrasound can be used to ensure greater safety and accuracy. Additionally, using a blue dye can help verify that the ducts are indeed open.

It is important to note that while TURED can be effective, the chances of achieving spontaneous pregnancy after the procedure are limited. Therefore, other options, such as sperm aspiration and Intracytoplasmic Sperm Injection (ICSI), may need to be considered.

Complications of this type of intervention can include retrograde ejaculation, where sperm enters the bladder instead of exiting through the penis, and urine reflux into the ejaculatory ducts. If TURED is not suitable, other solutions include sperm aspiration from the vas deferens or seminal vesicles, guided by ultrasound, or directly from cysts.

Treatment of Non-Obstructive Azoospermia

Non-obstructive azoospermia is defined as the absence of sperm in the centrifuged seminal fluid, not due to an obstructive cause, but generally resulting from primary testicular dysfunction or dysfunction of the hypothalamic-pituitary-gonadal axis.

The surgical treatment aims to recover viable sperm directly from the testicles through cTESE or mTESE. Compared to conventional TESE, microtese uses an operating microscope with 25x magnification that allows for the identification of the tubules where sperm are most likely to be found. Typically, these tubules appear dilated and opaque. The rationale behind this technique is to increase the probability of recovering sperm with a smaller amount of sampled tissue and a lower risk of complications. Lower complication rates have been observed with mTESE compared to cTESE, both in terms of hematoma and fibrosis.

In conclusion, there are numerous surgical techniques that allow for the recovery of sperm. The choice of treatment depends on the etiology of the azoospermia and the preferences of the patient.

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