Vasectomy Reversal and Treatment of Obstructive Azoospermia Vasectomy can be reversed effectively using microsurgical vasovasostomy or vasoepididymostomy. These techniques can be used for epidymal obstructions (93). Patency and subsequent pregnancy rates approach 100% and 80%, respectively. Pregnancy typically occurs within 24 months of reversal (94). Rates of patency and pregnancy vary inversely with the length of time from vasectomy, particularly for reversal procedure performed after 15 years or more (93,94). Although 60% of reversal patients develop antisperm antibodies, these do not appear to affect fecundability. Following surgery, periodic semen analyses can identify reobstruction, which can range from 3% to 21% depending on which segments were anastamosed. For those patients with azoospermia 6 months after reversal, the procedure is considered a failure and testicular sperm aspiration with ICSI could be considered. However, repeat vasovasostomy is associated with patency rates of 75% and pregnancy rates of 43% (94).
Surgical Sperm Recovery for Intracytoplasmic Sperm Injection Among the many surgical methods for sperm recovery, the most widely described are microsurgical epididymal sperm aspiration (MESA), percutaneous epididymal sperm aspiration (PESA), testicular sperm extraction (TESE), and percutaneous testicular sperm fine-needle aspiration (TESA, also called fine-needle aspiration, or FNA). Both MESA and TESE are open surgical procedures performed with an operating microscope and general or regional anesthesia, whereas the percutaneous procedures need only local anesthesia. The optimal choice for surgical sperm recovery method has not been determined and certainly varies based on patient history. Hematoma risk appears to be low regardless of method. Testicular atrophy is a rare complication of TESE and TESA even when biopsies are obtained from multiple testicular sites (92).
With obstructive azoospermia, pregnancy rates using sperm retrieval and ICSI are 24% and 64%, respectively, and outcomes using either frozen-thawed or fresh sperm are comparable. Because MESA allows for diagnosis and possible reconstruction of ductal pathology and because it usually yields very large numbers of sperm, sperm cryopreservation and avoidance of repeat surgery may be possible (92). If repeat sperm retrievals are needed, the minimum interval between procedures is 3 to 6 months to allow for adequate healing (93).
For nonobstructive (testicular) azoospermia, epididymal aspiration is not an option. Although pregnancies have been reported following testicular sperm retrieval with nonobstructive azoospermia, the likelihood of retrieving sperm is low as are subsequent pregnancy rates (92,95). Patients with obstructive azoospermia must be counseled regarding the risk of transmitting genetic disorders to their offspring (47,86).
Donor Insemination For men with azoospermia, couples with significant male factor infertility who do not desire ART, or women without a male partner who are seeking pregnancy, therapeutic donor insemination offers an effective option (96). In several prospective randomized or crossover trials, IUI was shown to be superior to intracervical insemination for donor insemination (68). In patients younger than 30 years of age who have no other infertility factors, delivery rates approach 90% after 12 cycles of IUI treatment with frozen sperm, so patients who do not conceive within 6 to 12 months should be assessed for female factors and encouraged to terminate treatment or proceed with alternative forms of therapy. The concomitant use of clomiphene citrate or gonadotropin (hMG) for controlled ovarian hyperstimulation (COH) did not result in higher fecundity rates in these patients (97). Psychological counseling should be offered because of the potential repercussions of using donor gametes (96).