Vol. 58, No.3, September 1992
FERTILITY AND STERILITY
Printed on acid-free paper in U.S.A.
Copyright If) 1992 The American Fertility Society
Unilateral obstruction of the vas deferens caused by childhood inguinal herniorrhaphy in male infertility patients
Tadashi Matsuda, M.D. Yasuki Horii, M.D. Osamu Yoshida, M.D.* Department of Urology, Kyoto University Hospital, Kyoto, Japan
Objective: To study the incidence, diagnosis, and treatment of unilateral obstruction of the vas deferens caused by inguinal herniorrhaphy (IH) during childhood. Design: Retrospective. Setting: Kyoto University Hospital. Patients: Unilateral obstruction of the vas deferens after IH was diagnosed and treated in 10 of 724 sub fertile patients. Interventions: Reanastomosis of the vas deferens using a microsurgical two-layer technique. Main Outcome Measures: Follow-up seminal analysis of the patients and the occurrence of pregnancy in their wives. 'Results: The incidence of unilateral vas deferens obstruction caused by IH was 26.7% for subfertile patients with a history of IH during childhood. Unilateral vas deferens obstruction was detected through palpation of the scrotal vas deferens in 7 of the 10 patients. After vasovasostomy, the semen quality improved in 5 patients, and pregnancy was achieved by 2 patients. Conclusions: The incidence of vas deferens obstruction was unexpectedly high in subfertile patients with a history of IH during childhood. Careful palpation of the scrotal contents was a useful and noninvasive method to diagnose unilateral vas deferens obstruction, and microsurgical vasovasostomy was treatment of choice. Fertil Steril 1992;58:609-13 . Key Words: Male infertility, vas deferens obstruction, inguinal herniorrhaphy, vasovasostomy
The majority of cases with seminal tract obstruction are bilateral and are usually found among azoospermic patients. However, some etiologies of seminal tract obstruction can cause unilateral seminal tract obstructions rather than bilateral obstructions. In particular, there should be many cases of unilateral vasal obstruction after inguinal herniorrhaphy (IH) during infancy (1); however, there are no studies on the incidence of vas deferens obstruction after IH. The detection of unilateral seminal tract obstruction, however, is not easy because these cases are usually nonazoospermic. We report 10 cases of unilateral vas deferens obstruction after IH treated by microsurgical vasoReceived February 4,1992; revised and accepted May 27, 1992. * Reprint requests: Osamu Yoshida, M.D., Department of Urology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606, Japan. Vol. 58, No.3, September 1992
vasostomy. The obstruction was detected by palpation of the dilated vas deferens. The incidence of vas deferens obstruction was investigated in sub fertile male patients with a history of childhood herniorrhaphy, resulting in an unexpectedly high incidence. MATERIALS AND METHODS Patients
Unilateral obstruction of the vas deferens caused by IH was identified in 10 of 724 subfertile patients at the male infertility clinic in Kyoto University Hospital between January 1987 and December 1990. The medical records of these 724 sub fertile patients were reviewed to uncover childhood IH, and the incidence of vas deferens obstruction after IH was calMatsuda et al.
Unilateral vas deferens obstruction
609
Table 1
Clinical Features of 10 Patients With Unilateral Vas Deferens Obstruction
Patient
Age
1 2 3 4 5 6 7 8 9 10
34 26 25 35 36 31 30 37 24 38
Side of obstruction
Duration of obstruction
Right Right Right Left Right Right Right Left Right Right
30 25 21 29 31 26 25 32 20 32
y
Basis of diagnosis
Comments
y
culated. During the same period, a total of 34 patients with bilateral or unilateral obstruction of their seminal tracts were treated in our hospital. All 10 of the patients consulted the clinic because of primary infertility lasting from 20 months to 8.5 years. The patients' ages ranged from 24 to 38 years, with an average age of 31.6 years. The side, duration of vas deferens obstruction, diagnosis, and other clinical features of these patients are shown in Table 1. Inguinal herniorrhaphy, which caused the obstruction of the vas deferens, had been performed > 20 years previously in all patients at 2 to 6 years of age. Herniorrhaphy was performed unilaterally in all cases except for cases 3 and 4. Case 3 underwent bilateral IH at age 4, resulting in an obstruction of the right vas deferens. In case 4, left herniorrhaphy at 6 years of age caused an obstruction of the vas
Biopsy Biopsy Biopsy Palpation Palpation Palpation Palpation Palpation Palpation Palpation
Left mumps orchitis Left varicocele testis (grade 1) After left IH Cystic dilatation of right seminal vesicle Left varicocele testis (grade 2) Left varicocele testis (grade 3)
Left varicocele testis (grade 2)
deferens, whereas right herniorrhaphy performed at age 20 did not cause any obstruction. Vas deferens obstruction was detected by noting that the obstructed vas in the scrotum was thicker than the patent, contralateral vas by palpation in 6 patients, whereas the proximal end of the obstructed vas deferens was palpable in the scrotum of 1 patient. In the other 3 patients, vas deferens obstruction was suspected from discrepancies in testicular histology and semen quality. Left varicocele testis was found in 4 patients by means of palpation and Doppler sonography. Vasography revealed a cystic dilatation of the seminal vesicle on the patent side in case 4. The results from testicular volume assessment, testicular biopsy, hormone analysis, antisperm antibody tests, operative findings, and before and after semen analyses are shown in Table 2. The testicular
Table 2 Results of Preoperative and Postoperative Examinations, Operative Findings, and Follow-up Results of 10 Patients With Unilateral Vas Deferens Obstruction Antisperm antibody Patient
Testicular volume
1 2 3 4 5 6 7 8 9 10
§22/14 §16/14 §20/7 20/20§ §16/16 §22/18 §22/12 18/20§ §16/12 §14/13
Testicular histology*
Serum FSH
§8.4/2.3 §8.9/5.0 §9.2/6.9 8.7/8.3§ §8.6/8.6 §9.2/9.1 §8.4/8.6 8.5/8.9§ §8.7/8.8 §8.5/8.3
12.3 10.8 16.9 5.7 8.3 9.6 19.811 13.111 6.811 34.111
mL
SITt
IBT:j:
lUlL
+
+ +
+
+
NEil
NEil
+ NEil
* Assessed using Johnsen's mean score method (3). t Sperm immobilization test. :j: Indirect immunobead test. § Obstructed side (right/left). 610
Matsuda et al.
Before operation Sperm at proximal vas end
Unilateral vas deferens obstruction
+ + + + + + +
After operation
Sperm density
Motility
Sperm density
Motility
XlO'ImL
%
XlO'ImL
%
0.03 0.02 0.04 2.7 15.5 73.3 0 3.3 0.4 0.4
0 15 30 0 18 53
110.2 3.6 35.0 4.4 51.0 142.0 0 6.2 41.0 1.9
4 22 27 0 43 55
5 0 65
Conception
+ +
26 25 67
II NE, not evaluated. 11 Measured using radioimmunometric assay (normal range: 1.6 tp 14.9 lUlL). Double-antibody RIA was used for the other cases (normal range: 3.0 to 17.6 lUlL). Fertility and Sterility
volume was measured using a punched-out orchidometer (2). The testicular volume of the contralateral side was apparently smaller than that of the obstructed side in four cases (cases 1, 3, 7, and 9). Testicular biopsy was performed preoperatively under local anesthesia through a stab scrotal wound. Testicular histology, which was assessed using Johnsen's mean score method (3), demonstrated that the obstructed side was superior to the opposite side in three cases (cases 1, 2, and 3). Serum gonadotropin levels were measured by double-antibody radioimmunoassay (RIA) or radioimmunometric assay with normal values of 4.8 to 25.2 IU jL (RIA) and 1.1 to 9.8 IUjL (radioimmunometric) for luteinizing hormone (LH) and 3.0 to 17.6 IUjL (RIA) and 1.6 to 14.9 IUjL (radioimmunometric) for follicle-stimulating hormone (FSH). The serum FSH levels were elevated in two cases (cases 7 and 10). Serum LH and testosterone levels were normal in all cases. Serum antisperm antibodies were evaluated using a sperm immobilization test (4) and an indirect immunobead test (5). The sperm immobilization test was positive in two cases, whereas the immunobead test was positive in four cases. The sperm immobilization value (4) was 00 in the two positive cases. Sperm density was measured using a hemocytometer, and motility was assessed visually. Semen analysis was performed twice preoperatively, and the mean of the two values is listed. Only one patient was totally azoospermic, and seven patients showed severe oligozoospermia < 5 X 106 jmL. Treatment Microsurgical two-layer vasovasostomy was performed in all cases, basically according to the methods proposed by Silber (6). In case 1, transseptalcrossed vasovasostomy (7) was performed because the histology of the contralateral testis with a patent vas deferens showed that it was almost completely composed of Sertoli's cells. In the other cases, vasovasostomy was carried out ipsilaterally in the inguinal region. High ligation of the left internal spermatic veins was also performed in four cases with varicocele testis. RESULTS Fifty-five of the 724 subfertile patients underwent childhood IH (at 10 X 106 jmL before the operation, sperm density was apparently improved after the operation (cases 5 and 6). Vasography was performed in 2 cases after the operation, revealing that the anastomosis failed in case 7 and that there was a stenosis at the anastomosis Matsuda et al.
Unilateral vas deferens obstruction
611
site in case 2. Sperm density fluctuated between 0.1 X 106 and 20 X 106/mL postoperatively in case 2. A high titer of antisperm antibody persisted in cases 1 and 5 as determined by the sperm immobilization test. Case 1 was treated with prednisolone because of severe asthenozoospermia postoperatively. However, this treatment did not affect the antibody titer or the sperm motility. Pregnancy was achieved in 2 cases. DISCUSSION
The true incidence of vasal disruption caused by IH during infancy is unknown because a unilateral vasal obstruction affects neither the health nor the fertility if the contralateral testicular function is normal. When we estimated the incidence of vas deferens obstruction in subfertile patients with a history of unilateral herniorrhaphy, excluding an ascertainment bias, the obstruction rate was 26.7% (12 of 45 patients). Although we could not estimate the true incidence of vas deferens disruption caused by herniorrhaphy in infancy, we can conclude that the incidence of vas deferens obstruction was extremely high among subfertile patients with a history of IH. Clinical findings such as testicular histology, testicular volume, and operative outcomes indicate that half of the patients described in this paper had unilateral vas deferens obstruction with dysfunction of the contralateral testis, a rare coincidence. It is reasonable to assume that many patients with normal or slightly reduced sperm density may have unilateral vasal obstruction after IH. The diagnosis of unilateral vasal obstructions may have been overlooked in these cases. Detection of unilateral obstructions of the seminal tract is difficult, mainly because they do not cause azoospermia. In more than half of our cases, the diagnostic clue to the vas obstruction was careful palpation of the scrotal contents. Palpation of the vas deferens, which was obstructed in the inguinal region, revealed that it was apparently thicker than the contralateral patent vas. During vasovasostomy, the vas deferens proximal to the obstruction was found to be dilated without exception. The thickness of the vas, as determined by palpation, is a highly specific indicator of unilateral vas obstruction in patients with a history of IH. Vasography revealed a patent vas deferens in only one other patient whose vas deferens was suspected to be obstructed by palpation. Silber (8) demonstrated that sperm granulomas formed at the end of the vas prevented dilatation of the vas deferens in vasectomy cases. We 612
Matsuda et al.
Unilateral vas deferens obstruction
found no sperm granuloma formation at the vas end in any of our cases. It is unlikely that a sperm granuloma would be formed in cases where the seminal tract was obstructed before the beginning of sperm output from the testis. Hendry (1) postulated that serum antisperm antibody is a useful indicator of seminal tract obstructions and showed a 76% positive rate using the tray agglutination test. We found positive antisperm antibodies in 50% of the patients' sera using an indirect immunobead test. We agree that patients with a history of IH in infancy should be tested for antisperm antibodies, and antibody-positive patients should be carefully evaluated for possible unilateral vas obstruction. Although we performed vasovasostomies in all cases without any apparent dysfunction of the ipsilateral testis, the indication for reanastomosis of the seminal tract in cases with unilateral obstructions should be discussed. Patients with normal semen quality, such as case 6, or patients with severe oligozoospermia showing a pathological elevation of their serum FSH, such as case 10, should not be candidates for vasovasostomy. Nevertheless, our patients underwent the operation according to their wishes. Patients with dysfunction of the opposite testis or with slight oligozoospermia, such as case 5, are the best candidates for this operation. The outcomes of vasovasostomies were not satisfactory in the present study, showing an improvement in sperm density in only 50% of the patients. There may have been technical failure of the anastomosis in some cases, including cases 2 and 7. The technical difficulties encountered are mainly because of severe adhesion at the inguinal region, and the loss of a long segment of the vas deferens in some cases caused by previous herniorrhaphy. Transseptal-crossed vasovasostomy (7) is an attractive alternative to ipsilateral vasovasostomy at the inguinal region when the contralateral testis is severely damaged, as in case l. Another problem in postherniorrhaphy vas deferens obstruction is the long period of obstruction. Silber (9) reported that the prognosis for vas ovasostomy performed> 10 years after vasectomy was poor mainly because of the absence of sperm in the proximal vas fluid. Long periods of obstruction without sperm granuloma can cause a blowout of the epididymal tubule, resulting in secondary epididymal obstruction (10). In our patients, however, vas fluid at the obstructed site contained sperm in 7 of 10 patients, despite an obstruction period of >20 years and the absence of granuloma. In the other Fertility and Sterility
3 patients, especially case 8, it is possible that secondary epididymal obstruction was responsible for the failure to improve the sperm concentration after vasovasostomy. It is also possible that deterioration of spermatogenesis derived from long periods of vasal obstruction may affect patients' fertility after the operation. Jarow et al. (11) reported significant adverse changes in the human testis after vasectomy and a significant correlation between interstitial fibrosis and infertility after vasovasostomy. However, they did not observe any correlation between the obstructive interval and histologic changes. In every patient who participated in the present study, the apparent histology of the obstructed testis was not worse than the histology of the patent testis according to Johnsen's mean score method. Postoperative sperm density revealed normal sperm output in 6 of 10 patients, including case 2 with a fluctuating sperm density. However, testicular damage may playa role in the other patients whose semen quality did not improve after the operation. In conclusion, we demonstrated that the incidence of vas deferens obstruction was unexpectedly high in subfertile patients with a history of childhood inguinal herniorrhaphy. Careful palpation of the scrotal contents, especially the thickness of the vas deferens, was a useful and noninvasive method of detecting possible unilateral vas obstructions.
Vol. 58, No.3, September 1992
REFERENCES 1. Hendry WF. Unilateral testicular obstruction in subfertile males. In: Negro-Vilar A, Isidori A, Paulson J, Abdelmassih R, de Castro MPP, editors. Andrology and human reproduction. New York: Raven Press, 1988:311-6. 2. Takihara H, Sakatoku J, Fujii M, Nasu T, Cosentino MJ, Cockett ATK. Significance of testicular size measurement in andrology. I. A new orchiometer and its clinical application. Fertil Steril 1983;39:836-40. 3. Johnsen SG. Testicular biopsy score count-a method for registration of spermatogenesis in human testes: normal values and results in 335 hypogonadal males. Hormones 1970;1: 2-25. 4. Isojima S, Li TS, Ashitaka Y. Immunologic analysis of spermimmobilizing factor found in sera of women with unexplained sterility. Am J Obstet Gynecol 1968;101:677-83. 5. Clarke GN, Stojanoff A, Cauchi MN, Johnston WIH. The immunoglobulin class of antispermatozoal antibodies in serum. Am J Reprod Immunol MicrobioI1985;7:143-7. 6. Silber SJ. Microscopic technique for reversal of vasectomy. Surg Gynecol Obstet 1976;143:630-1. 7. Lizza EF, Marmar JL, Schmidt SS, Lanasa JA Jr, Sharlip ID, Thomas AJ, et al. Transseptal crossed vasovasostomy. J UroI1985;134:1131-2. 8. Silber SJ. Sperm granuloma and reversibility of vasectomy. Lancet 1977;2:588-9. 9. Silber SJ. Vasectomy and vasectomy reversal. Fertil Steril 1978;29:125-40. 10. Silber SJ. Epididymal extravasation following vasectomy as a cause for failure of vasectomy reversal. Fertil SterilI979;31: 309-15. 11. Jarow JP, Budin RE, Dym M, Zirkin BR, Noren S, Marshall FF. Quantitative pathologic changes in the human testis after vasectomy. A controlled study. New Engl J Med 1985;313: 1252-6.
Matsuda et al.
Unilateral vas deferens obstruction
613
FERTILITY AND STERILITY
Printed on acid-free paper in U.S.A.
Copyright If) 1992 The American Fertility Society
Unilateral obstruction of the vas deferens caused by childhood inguinal herniorrhaphy in male infertility patients
Tadashi Matsuda, M.D. Yasuki Horii, M.D. Osamu Yoshida, M.D.* Department of Urology, Kyoto University Hospital, Kyoto, Japan
Objective: To study the incidence, diagnosis, and treatment of unilateral obstruction of the vas deferens caused by inguinal herniorrhaphy (IH) during childhood. Design: Retrospective. Setting: Kyoto University Hospital. Patients: Unilateral obstruction of the vas deferens after IH was diagnosed and treated in 10 of 724 sub fertile patients. Interventions: Reanastomosis of the vas deferens using a microsurgical two-layer technique. Main Outcome Measures: Follow-up seminal analysis of the patients and the occurrence of pregnancy in their wives. 'Results: The incidence of unilateral vas deferens obstruction caused by IH was 26.7% for subfertile patients with a history of IH during childhood. Unilateral vas deferens obstruction was detected through palpation of the scrotal vas deferens in 7 of the 10 patients. After vasovasostomy, the semen quality improved in 5 patients, and pregnancy was achieved by 2 patients. Conclusions: The incidence of vas deferens obstruction was unexpectedly high in subfertile patients with a history of IH during childhood. Careful palpation of the scrotal contents was a useful and noninvasive method to diagnose unilateral vas deferens obstruction, and microsurgical vasovasostomy was treatment of choice. Fertil Steril 1992;58:609-13 . Key Words: Male infertility, vas deferens obstruction, inguinal herniorrhaphy, vasovasostomy
The majority of cases with seminal tract obstruction are bilateral and are usually found among azoospermic patients. However, some etiologies of seminal tract obstruction can cause unilateral seminal tract obstructions rather than bilateral obstructions. In particular, there should be many cases of unilateral vasal obstruction after inguinal herniorrhaphy (IH) during infancy (1); however, there are no studies on the incidence of vas deferens obstruction after IH. The detection of unilateral seminal tract obstruction, however, is not easy because these cases are usually nonazoospermic. We report 10 cases of unilateral vas deferens obstruction after IH treated by microsurgical vasoReceived February 4,1992; revised and accepted May 27, 1992. * Reprint requests: Osamu Yoshida, M.D., Department of Urology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606, Japan. Vol. 58, No.3, September 1992
vasostomy. The obstruction was detected by palpation of the dilated vas deferens. The incidence of vas deferens obstruction was investigated in sub fertile male patients with a history of childhood herniorrhaphy, resulting in an unexpectedly high incidence. MATERIALS AND METHODS Patients
Unilateral obstruction of the vas deferens caused by IH was identified in 10 of 724 subfertile patients at the male infertility clinic in Kyoto University Hospital between January 1987 and December 1990. The medical records of these 724 sub fertile patients were reviewed to uncover childhood IH, and the incidence of vas deferens obstruction after IH was calMatsuda et al.
Unilateral vas deferens obstruction
609
Table 1
Clinical Features of 10 Patients With Unilateral Vas Deferens Obstruction
Patient
Age
1 2 3 4 5 6 7 8 9 10
34 26 25 35 36 31 30 37 24 38
Side of obstruction
Duration of obstruction
Right Right Right Left Right Right Right Left Right Right
30 25 21 29 31 26 25 32 20 32
y
Basis of diagnosis
Comments
y
culated. During the same period, a total of 34 patients with bilateral or unilateral obstruction of their seminal tracts were treated in our hospital. All 10 of the patients consulted the clinic because of primary infertility lasting from 20 months to 8.5 years. The patients' ages ranged from 24 to 38 years, with an average age of 31.6 years. The side, duration of vas deferens obstruction, diagnosis, and other clinical features of these patients are shown in Table 1. Inguinal herniorrhaphy, which caused the obstruction of the vas deferens, had been performed > 20 years previously in all patients at 2 to 6 years of age. Herniorrhaphy was performed unilaterally in all cases except for cases 3 and 4. Case 3 underwent bilateral IH at age 4, resulting in an obstruction of the right vas deferens. In case 4, left herniorrhaphy at 6 years of age caused an obstruction of the vas
Biopsy Biopsy Biopsy Palpation Palpation Palpation Palpation Palpation Palpation Palpation
Left mumps orchitis Left varicocele testis (grade 1) After left IH Cystic dilatation of right seminal vesicle Left varicocele testis (grade 2) Left varicocele testis (grade 3)
Left varicocele testis (grade 2)
deferens, whereas right herniorrhaphy performed at age 20 did not cause any obstruction. Vas deferens obstruction was detected by noting that the obstructed vas in the scrotum was thicker than the patent, contralateral vas by palpation in 6 patients, whereas the proximal end of the obstructed vas deferens was palpable in the scrotum of 1 patient. In the other 3 patients, vas deferens obstruction was suspected from discrepancies in testicular histology and semen quality. Left varicocele testis was found in 4 patients by means of palpation and Doppler sonography. Vasography revealed a cystic dilatation of the seminal vesicle on the patent side in case 4. The results from testicular volume assessment, testicular biopsy, hormone analysis, antisperm antibody tests, operative findings, and before and after semen analyses are shown in Table 2. The testicular
Table 2 Results of Preoperative and Postoperative Examinations, Operative Findings, and Follow-up Results of 10 Patients With Unilateral Vas Deferens Obstruction Antisperm antibody Patient
Testicular volume
1 2 3 4 5 6 7 8 9 10
§22/14 §16/14 §20/7 20/20§ §16/16 §22/18 §22/12 18/20§ §16/12 §14/13
Testicular histology*
Serum FSH
§8.4/2.3 §8.9/5.0 §9.2/6.9 8.7/8.3§ §8.6/8.6 §9.2/9.1 §8.4/8.6 8.5/8.9§ §8.7/8.8 §8.5/8.3
12.3 10.8 16.9 5.7 8.3 9.6 19.811 13.111 6.811 34.111
mL
SITt
IBT:j:
lUlL
+
+ +
+
+
NEil
NEil
+ NEil
* Assessed using Johnsen's mean score method (3). t Sperm immobilization test. :j: Indirect immunobead test. § Obstructed side (right/left). 610
Matsuda et al.
Before operation Sperm at proximal vas end
Unilateral vas deferens obstruction
+ + + + + + +
After operation
Sperm density
Motility
Sperm density
Motility
XlO'ImL
%
XlO'ImL
%
0.03 0.02 0.04 2.7 15.5 73.3 0 3.3 0.4 0.4
0 15 30 0 18 53
110.2 3.6 35.0 4.4 51.0 142.0 0 6.2 41.0 1.9
4 22 27 0 43 55
5 0 65
Conception
+ +
26 25 67
II NE, not evaluated. 11 Measured using radioimmunometric assay (normal range: 1.6 tp 14.9 lUlL). Double-antibody RIA was used for the other cases (normal range: 3.0 to 17.6 lUlL). Fertility and Sterility
volume was measured using a punched-out orchidometer (2). The testicular volume of the contralateral side was apparently smaller than that of the obstructed side in four cases (cases 1, 3, 7, and 9). Testicular biopsy was performed preoperatively under local anesthesia through a stab scrotal wound. Testicular histology, which was assessed using Johnsen's mean score method (3), demonstrated that the obstructed side was superior to the opposite side in three cases (cases 1, 2, and 3). Serum gonadotropin levels were measured by double-antibody radioimmunoassay (RIA) or radioimmunometric assay with normal values of 4.8 to 25.2 IU jL (RIA) and 1.1 to 9.8 IUjL (radioimmunometric) for luteinizing hormone (LH) and 3.0 to 17.6 IUjL (RIA) and 1.6 to 14.9 IUjL (radioimmunometric) for follicle-stimulating hormone (FSH). The serum FSH levels were elevated in two cases (cases 7 and 10). Serum LH and testosterone levels were normal in all cases. Serum antisperm antibodies were evaluated using a sperm immobilization test (4) and an indirect immunobead test (5). The sperm immobilization test was positive in two cases, whereas the immunobead test was positive in four cases. The sperm immobilization value (4) was 00 in the two positive cases. Sperm density was measured using a hemocytometer, and motility was assessed visually. Semen analysis was performed twice preoperatively, and the mean of the two values is listed. Only one patient was totally azoospermic, and seven patients showed severe oligozoospermia < 5 X 106 jmL. Treatment Microsurgical two-layer vasovasostomy was performed in all cases, basically according to the methods proposed by Silber (6). In case 1, transseptalcrossed vasovasostomy (7) was performed because the histology of the contralateral testis with a patent vas deferens showed that it was almost completely composed of Sertoli's cells. In the other cases, vasovasostomy was carried out ipsilaterally in the inguinal region. High ligation of the left internal spermatic veins was also performed in four cases with varicocele testis. RESULTS Fifty-five of the 724 subfertile patients underwent childhood IH (at 10 X 106 jmL before the operation, sperm density was apparently improved after the operation (cases 5 and 6). Vasography was performed in 2 cases after the operation, revealing that the anastomosis failed in case 7 and that there was a stenosis at the anastomosis Matsuda et al.
Unilateral vas deferens obstruction
611
site in case 2. Sperm density fluctuated between 0.1 X 106 and 20 X 106/mL postoperatively in case 2. A high titer of antisperm antibody persisted in cases 1 and 5 as determined by the sperm immobilization test. Case 1 was treated with prednisolone because of severe asthenozoospermia postoperatively. However, this treatment did not affect the antibody titer or the sperm motility. Pregnancy was achieved in 2 cases. DISCUSSION
The true incidence of vasal disruption caused by IH during infancy is unknown because a unilateral vasal obstruction affects neither the health nor the fertility if the contralateral testicular function is normal. When we estimated the incidence of vas deferens obstruction in subfertile patients with a history of unilateral herniorrhaphy, excluding an ascertainment bias, the obstruction rate was 26.7% (12 of 45 patients). Although we could not estimate the true incidence of vas deferens disruption caused by herniorrhaphy in infancy, we can conclude that the incidence of vas deferens obstruction was extremely high among subfertile patients with a history of IH. Clinical findings such as testicular histology, testicular volume, and operative outcomes indicate that half of the patients described in this paper had unilateral vas deferens obstruction with dysfunction of the contralateral testis, a rare coincidence. It is reasonable to assume that many patients with normal or slightly reduced sperm density may have unilateral vasal obstruction after IH. The diagnosis of unilateral vasal obstructions may have been overlooked in these cases. Detection of unilateral obstructions of the seminal tract is difficult, mainly because they do not cause azoospermia. In more than half of our cases, the diagnostic clue to the vas obstruction was careful palpation of the scrotal contents. Palpation of the vas deferens, which was obstructed in the inguinal region, revealed that it was apparently thicker than the contralateral patent vas. During vasovasostomy, the vas deferens proximal to the obstruction was found to be dilated without exception. The thickness of the vas, as determined by palpation, is a highly specific indicator of unilateral vas obstruction in patients with a history of IH. Vasography revealed a patent vas deferens in only one other patient whose vas deferens was suspected to be obstructed by palpation. Silber (8) demonstrated that sperm granulomas formed at the end of the vas prevented dilatation of the vas deferens in vasectomy cases. We 612
Matsuda et al.
Unilateral vas deferens obstruction
found no sperm granuloma formation at the vas end in any of our cases. It is unlikely that a sperm granuloma would be formed in cases where the seminal tract was obstructed before the beginning of sperm output from the testis. Hendry (1) postulated that serum antisperm antibody is a useful indicator of seminal tract obstructions and showed a 76% positive rate using the tray agglutination test. We found positive antisperm antibodies in 50% of the patients' sera using an indirect immunobead test. We agree that patients with a history of IH in infancy should be tested for antisperm antibodies, and antibody-positive patients should be carefully evaluated for possible unilateral vas obstruction. Although we performed vasovasostomies in all cases without any apparent dysfunction of the ipsilateral testis, the indication for reanastomosis of the seminal tract in cases with unilateral obstructions should be discussed. Patients with normal semen quality, such as case 6, or patients with severe oligozoospermia showing a pathological elevation of their serum FSH, such as case 10, should not be candidates for vasovasostomy. Nevertheless, our patients underwent the operation according to their wishes. Patients with dysfunction of the opposite testis or with slight oligozoospermia, such as case 5, are the best candidates for this operation. The outcomes of vasovasostomies were not satisfactory in the present study, showing an improvement in sperm density in only 50% of the patients. There may have been technical failure of the anastomosis in some cases, including cases 2 and 7. The technical difficulties encountered are mainly because of severe adhesion at the inguinal region, and the loss of a long segment of the vas deferens in some cases caused by previous herniorrhaphy. Transseptal-crossed vasovasostomy (7) is an attractive alternative to ipsilateral vasovasostomy at the inguinal region when the contralateral testis is severely damaged, as in case l. Another problem in postherniorrhaphy vas deferens obstruction is the long period of obstruction. Silber (9) reported that the prognosis for vas ovasostomy performed> 10 years after vasectomy was poor mainly because of the absence of sperm in the proximal vas fluid. Long periods of obstruction without sperm granuloma can cause a blowout of the epididymal tubule, resulting in secondary epididymal obstruction (10). In our patients, however, vas fluid at the obstructed site contained sperm in 7 of 10 patients, despite an obstruction period of >20 years and the absence of granuloma. In the other Fertility and Sterility
3 patients, especially case 8, it is possible that secondary epididymal obstruction was responsible for the failure to improve the sperm concentration after vasovasostomy. It is also possible that deterioration of spermatogenesis derived from long periods of vasal obstruction may affect patients' fertility after the operation. Jarow et al. (11) reported significant adverse changes in the human testis after vasectomy and a significant correlation between interstitial fibrosis and infertility after vasovasostomy. However, they did not observe any correlation between the obstructive interval and histologic changes. In every patient who participated in the present study, the apparent histology of the obstructed testis was not worse than the histology of the patent testis according to Johnsen's mean score method. Postoperative sperm density revealed normal sperm output in 6 of 10 patients, including case 2 with a fluctuating sperm density. However, testicular damage may playa role in the other patients whose semen quality did not improve after the operation. In conclusion, we demonstrated that the incidence of vas deferens obstruction was unexpectedly high in subfertile patients with a history of childhood inguinal herniorrhaphy. Careful palpation of the scrotal contents, especially the thickness of the vas deferens, was a useful and noninvasive method of detecting possible unilateral vas obstructions.
Vol. 58, No.3, September 1992
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