Microsurgery for Obstructive Azoospermia in a developing country
Obstruction is responsible for approximately 40% of cases of azoospermia and may result from epididymal, vasal, or ejaculatory duct pathology. Vasectomy is the most common cause of vasal obstruction. In addition, most vasectomized men will also develop more proximal (epididymal) obstruction within a few years after vasectomy due to epididymal "blow out". Worldwide between 3% and 6% of vasectomized men will desire to have their fertility restored in order to be able to father children again. The objectives of this study were to review the learning curve, complications and outcomes of the first 80 cases of microsurgical vasectomy reversal performed in a developing country (South Africa).
The first dedicated service in male infertility microsurgery in South Africa was established in 2012. Between January 2012 and August 2017, 80 patients underwent microsurgical vasectomy reversal by a single surgeon. Mean patient age was 45 years (range 29 to 66), mean age at vasectomy 33 years (range 19 to 56), mean number of children for the male partner 2,4 and mean age of the female partner 33 years (range 20 to 45). The mean time interval between vasectomy and vasectomy reversal was 11,3 years (range 0,5 to 29,5). Five patients had previous failed vasectomy reversals and in 3 patients the indication for reversal was post-vasectomy pain syndrome. A total of 26% of patients travelled from other countries for their surgery.
Mean surgical time per testicular unit was 80,2 minutes (range 37 to 115) and total operative time 157 minutes (range 95 to 200). Sperm motility (intra-operative light microscopy) was good in 23,5%, average in 8,4% and poor in 68,1%. Vasovasostomy was required in 45,8% of testicular units and vaso-epididymostomy in 42,2%. In 6 patients sperm was harvested at the time of reversal for cryopreservation. Complications occurred in 21% of patients and were managed conservatively in all but 3, who required an additional surgical procedure. For patients with adequate follow up the overall surgical success rate was 81%. Mean post-operative sperm count was 73,3 million. Eighteen pregnancies have been recorded during the limited follow up. Comparing the first 40 cases with the last 40 cases revealed no significant differences in surgical time, complications or patency rates. The mean post-operative sperm count was 10% higher for the last 40 cases.
Although microsurgical vasectomy reversal is technically demanding and requires specialized equipment and instruments, it can be successfully implemented in a developing country