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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 4  |  Page : 583-586
Male Fertility after Spermatocele Formation from Tunica Vaginalis in Patients with Bilateral Vas Agenesis


1 Urology section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
2 Biostatistics section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
3 Urology section, Hamadan University, Hamadan, Iran

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   Abstract 

To form spermatocele from vaginal layers as a sperm reservoir and intra-uterine insemination (IUI) in infertile men with bilateral vas agenesis (BVA), we studied 19 patients with azoospermia due to BVA referred to our infertility clinic from March 1992 until May 2003. The ages of the patients ranged from 20-41 (mean 29.6 ± 5.8) years. After physical examination, hormone assay, testis biopsy, and confirming normal spermatogenesis, we have performed 23 alloplastic spermatoceles from the tunica vaginal layers in 11 patients. We retrieved sperms and performed IUI in 6 patients' wives 3 months post-operation when scrotal sonography revealed spermatocele with a good volume of seminal liquid. Among 6 patients' wives, 2 successful preg­nancies occurred, and 2 normal babies (one boy with normal bilateral vas and one girl) were delivered successfully by cesarean section. We conclude that although the method of choice for fer­tility in BVA in artificial reproductive therapy era is percutaneous epididymal sperm aspiration (PESA) and intracytoplasmic sperm injection (ICSI), but when the sophisticated facilities are not available or cost-effectiveness is matter of concern, alloplastic spermatocele from tunica vaginalis and IUI may be a viable option.

Keywords: Spermatocele, Bilateral vas agenesis, Azoospermia, Tunica Vaginalis, Infertility

How to cite this article:
Shamsa A, Shakeri M T, Amirzarghar MA, Yavanghi M, Abolbashari M. Male Fertility after Spermatocele Formation from Tunica Vaginalis in Patients with Bilateral Vas Agenesis. Saudi J Kidney Dis Transpl 2008;19:583-6

How to cite this URL:
Shamsa A, Shakeri M T, Amirzarghar MA, Yavanghi M, Abolbashari M. Male Fertility after Spermatocele Formation from Tunica Vaginalis in Patients with Bilateral Vas Agenesis. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Nov 22];19:583-6. Available from: http://www.sjkdt.org/text.asp?2008/19/4/583/41318

   Introduction Top


Bilateral vas agenesis is a rare anomaly,with incidence of 1.4% among infertile male patients. [1] Cystic fibrosis gene is common in BVA with incidence from 65%-95%. [2]

In the centers where artificial reproduc­tive therapy (ART) facillities are available, the routine procedures for infertility treat­ment are percutaneous epididymal sperm as­piration (PESA) and intracytoplasmic sperm injection (ICSI). [3] Before ART techniques were available, the routine procedure was alloplastic spermatocele (AS) formation from various material such as vein, silicon, etc, followed by sperm retrieval for intrauterine insemination (IUI).

Besides the above mentioned facts, we are facing many infertile men with BVA who are willing to be fertile and unable to afford the cost of PESA+ ICSI. Such patients may benefit from this alternative procedure that results in ferility in patients with BVA.

Here, we will present our experience in performing spermatocele from patients' tunica vaginalis (TV) layers and its results.


   Methods and Materials Top


We studied 19 cases of BVA referred because of male infertility to urology section at Ghaem Hospital, Mashhad University, Mashhad; and Ekbatan Hospital, Hamadan University, Hamadan, Iran, from March 1992 to September 2003. Their ages ranged from 20-41 (mean 29.6 + 5.8) years.

The study patients underwent routine blood tests, sperm analysis including fructose mea­surement, hormone assays, and testicular measurement.

All except one case had normal testis size, normal serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), and tes­tosterone levels. The excluded patient from the study revealed bilateral testicular atro­phy, increased serum FSH, LH and low serum testosterone. Accordingly, we per­formed testicular biopsy on the remaining 18 cases. The histopathologic finding dis­closed normal spermatogenesis. Six patients refused the operation. Therefore, we per­formed only 23 spermatoceles on 12 pa­tients (eleven cases bilaterally, and one case unilaterally). There was no history of cys­tic fibrosis in any of the study patients.

Surgical Procedure

Under general anesthesia scrotal incision was performed. Then, TV layers and testis were exposed. A pendenculated graft from parietal layers was formed, followed by a longitudinal incision 2-3 cm on globus major of epididymis. We resected about 5 mm of the convulated tubules to facilitate the accu­mulation of sperms from them via the epi­didymis into the AS. The edges of peden­culated graft were then sutured to the epi­didymal edges with continuous 4-0 chromic catgut or 5-0 prolene sutures. Accordingly, AS was formed from parietal vaginal layer. At the end of the operation, the volume of AS was measured and its capacity was between 5-15 ml. Finally, AS was fixed under the upper and lateral part of hemi­scrotum for future aspiration. We present the details of the surgical procedure in the [Figure 1],[Figure 2],[Figure 3]. All patients were discharged two days post operatively.

Postoperatively, we administered human chorionic gonadotropin (HCG), 5000 IU, once weekly for 4 weeks in each patient. Sperm aspiration was attempted from AS and I.U.I performed only on six patients' wives.


   Results Top


Scrotal sonography was performed 3 months after surgery. The volume of AS on sono­graphy varied from 2-5 ml.

For IUI, sperm aspiration from AS was performed with and without sonographic guidance. The procedure was with minimal pain and there was no need for any anes­thesia. The amount of seminal fluid retrieved from this procedure was 1-2 ml. The semi­nal fluid was centerifuged and examined under light microscopy, which revealed mo­tile sperms with excellent morphology. An example of analysis of retrieved sperms from AS from one patient is shown in [Table 1].

So far, we had two successful pregnan­cies and two normal babies (one boy and one girl) who were delivered by cesarean section. The boy had normal bilateral vas.


   Discussion Top


BVA is a rare cause of infertility. How­ever, nearly 12% of azoospermic patients, congenitally lack vas. Goldstein (1988) sta­ted that these patients manifest other ano­malies such as renal agenesis, hypoplasia or even agenesis of seminal vesicles in abdo­minal or pelvic CT and transrectal ultra­sonography (TRUS). [4] However, since these findings do not preclude us to perform AS or decrease the cost effectiveness, we did not perform abdominal or pelvic CT or TRUS. Moreover, 10% of patients have acquired destruction of vas deference, epididymis or ejaculatory duct. [5]

Silber et al were the first to document conception with PEAS and ICSI in patient with congenital BVA. [6] At present, this is a first choice for infertility treatment. How­ever, PESA procedure fails to reveal sperms in the epididymal fluid in 73% of the cases, and more than 70% of patients disclosed scars in their epididymal tubules. [7]

In 1968, Schoysman developed the first AS from saphenous vein in animals, but its lumen closed after a few weeks. Wagen­knecht et al (1973), Kelami et al (1977), and Jiminezy-Cruz (1980) developed AS from silicon or artificial vascular graft, with poor results. However, Turner (1988) reported 3 pregnancies among 200 cases of AS. [8] lker et al (1986) reported 7.7 percent pregnancy and 4.4 percent full term elivery in 130 AS implanted in 91 pa­tients. [9] Moreover, a graft from tunica vagi­nalis was also used as a sperm reservoir, but without any successful pregnancies. [5]

The most important marker of success in artificial spermatocele is its patency, be­cause after recurrent aspiration the device becomes traumatized and obliterated. How­ever, AS from vaginal layers has physio­logical secretion and remain patent all the time. In addition, the secretions are a source of nutrition and maturation of sperm.

When cost-effectiveness matters our me­thod is more cost effective than PESA & ICSI. For example the cost of AS from TV and IUI vs PESA+ ICSI in our university hospital is 25 US$, 59 US$ (IUI 19 US$; the drugs, 40 US$) vs 1,250 US$, respec­tively. To our knowledge these are the first successful pregnancies and deliveries after AS plus IUI, at least in Iran.


   Conclusion Top


We conclude that AS from TV in com­parison to PESA + ICSI is more cost effec­tive and should be considered as alternative line of fertility treatment in BVA, especially in centers where ART is not available, or the financial support is not sufficient.

 
   References Top

1.Meacham RB, Lipschltz LI, Howard SS. Male infertility. In: Gillenwater JY, ed. Adult and pediatric urology, 3 rd ed, Phila­delphia: W.B. Saunders Co; 1996. p. 1783.  Back to cited text no. 1    
2.Schneck FX, Bellinger MF. Abnormalities of the testes and scrotum and their surgical management. In: Wein AJ, ed. Campbell­Walsh Urology, 9th ed. Philadelphia: Saunders Elsevier; 2007. p. 3797.  Back to cited text no. 2    
3.Sigman M, Jarow JP. Male infertility. In: Walsh PC, ed. Campbell,s Urology, 8th ed, Philadelphia: W.B. Saunders Co; 2002. p. 1512.  Back to cited text no. 3    
4.Goldstein M, Schlossberg S. Men with congenital absence of the vas deferens often have seminal vesicles. J Urol 1988; 140(1):85.  Back to cited text no. 4    
5.Wagenknecht LV. Alloplastic spermatocele. In: Goldstein M, ed. Surgery of male infertility. Philadelphia: W.B. Saunders Co; 1995. p. 145.  Back to cited text no. 5    
6.Silber SJ, Balmaceda J, Borrero C, Ord T, Asch R. Pregnancy with sperm aspiration from the proximal head of the epididymis: A new treatment for congenital absence of the vas deferens. Fertil Steril 1988;50(3): 525-8.  Back to cited text no. 6    
7.Pasqualotto FF, Rossi-Ferragut LM, Rocha CC, Laconelli A Jr, Ortiz V, Borges E Jr. The efficacy of repeat percutaneous epididymal sperm aspiration procedures. J Urol 2003;169(5):1779-81.  Back to cited text no. 7    
8.Goldstein M. Surgery of male infertility and other scrotal disorders. In: Walsh PC, ed. Campbell,s Urology 6th ed, Phila­delphia: W.B. Saunders Co; 1992. p. 3136.  Back to cited text no. 8    
9.Belker AM, Jimenez-Cruz DJ, Kelami A, Wagenknecht LV. Alloplastic spermatocele. J Urol 1986;136(2):408-9.  Back to cited text no. 9    

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Correspondence Address:
Ali Shamsa
Professor of Urology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad
Iran
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PMID: 18580017

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