The role of microsurgical vasoepididymostomy in the ICSI era

Despite the recent success and diffusion of the techniques of sperm retrieval (MESA,TESE) for ICSI (IntraCytoplasmic Sperm Injection), microsurgical reconstruction of the seminal tract, when possible, should still be considered as the first choice treatment in epididymal obstructions, particularly m younger patients who wish to have more than one child Even in the case of the partial success of the procedure, i.e when only a few motile sperms appear in the ejaculate, it will be possible to use them for ICSI without a sperm retrieval operation. Vaso-epididimostomy can also be simultaneously associated with ICSI, employing fresh sperm aspirated from the tubule during the procedure or freezing the aspirated sperm for subsequent ICSI cycles. In the video-tape the technique of side to end double layer vaso-epididymostomy described by Thomas is illustrated. In our experience this technique is the most adequate and the easiest to accomplish for obstructions at any level of the epididymis (cauda, corpus, caput). After testing the patency of the distal part of the vas, a small opening is made on the albuginea of the epididymis A dilated tubule is incised and the fluid aspirated and examined under the microscope If motile sperm is found, a side to end anastomosis is performed. The inner layer between the mucosa of the vas and the epididymal tubule is sutured first, with five 10-0 nylon stitches. The outer layer between the muscularis of the vas and the albuginea of the epididymis is then sutured with eightten 9-0 nylon stitches. Two cases with obstruction respectively on the epididymal caput and cauda are shown in the video. In conclusion, although the success rate of ICSI in obstructive azoospermia is good, we still believe that an attempt at reconstruction for natural fertilization is to be recommended.