Genital Tract Obstruction

2.0 GENITAL TRACT OBSTRUCTION

Clinical Characteristics

Most men with genital tract obstruction have azoospermia, normal testicular size, normal virilization, and normal serum FSH levels.
However, some have combined obstruction and spermatogenic disorders, or partial obstructions and severe oligospermia. There may be a history of an event that caused the obstruction, such as epididymitis with gonorrhea or associated respiratory disease.
Because a few men with normal spermatogenesis have elevated FSH levels and some spermatogenesis may occur in association with a severe spermatogenic disorder, all patients should be offered further investigation.
In men with congenital absence of the vas or ejaculatory duct obstruction, semen volume, pH and fructose levels are low.
The semen also does not have its characteristic smell and does not form a gel after ejaculation because it contains only prostatic and urethral fluid.
The semen characteristics of complete ejaculatory duct obstruction are the same as for BCAV but the vasa are palpable.
Rectal ultrasound may show the cause of the obstruction such as a cyst of the prostatic utricle.
Some men may have partial or intermittent ejaculatory duct obstruction and may notice the low ejaculate volume.
Testicular biopsy is normal or there may be some reduction in spermatogenesis either as a coincidence or as a result of the obstruction particularly after vasectomy.

Pathophysiology

Degeneration or failure of development of the Wolffian duct structures with cystic fibrosis gene mutations or other factors is covered above.
Some men with Young syndrome had children and must have developed the block in adulthood.
The pathology shows inspissated material in the head of the epididymis, and there are lipid inclusions in the epithelial cells. Young syndrome is not related to cystic fibrosis gene mutations.
Postinflammatory obstructions after gonorrhea typically occur in the tail of the epididymis, whereas nonspecific bacterial inflammation produces more widespread destruction, and tuberculosis usually causes multiple obstructions in the epididymides and vasa. Back pressure blowout obstructions in the epididymis are frequent after vasectomy. Iatrogenic causes of genital tract obstruction include inadvertent epididymectomy during testicular biopsy, vasal damage during hernia repair or pelvic or lower abdominal surgery such as renal transplantation, and ejaculatory duct obstruction from prostatectomy or complicated bladder catheterization.

Differential Diagnosis

Men with persistent azoospermia, normal testicular size, normal virilization, and normal FSH levels can be assumed to have obstruction until proved otherwise. Up to one third of men with this clinical picture are found to have a serious spermatogenic disorder on testicular biopsy despite the normal serum FSH level. There are rare instances of normal men who show azoospermia on single occasions or over a short period.

This "spurious azoospermia" must be excluded before surgery is contemplated. Once diagnosis of obstruction is confirmed, it is necessary to determine the feasibility of surgery. Intratesticular and caput-epididymal obstructions have a poor prognosis but cauda-epididymal and vasal obstructions can often be treated successfully with surgery and after treatments with Ayurvedic.

Distal obstructions are important to diagnose because they may be reversed at transurethral endoscopy. Ayurvedic is also used when reconstructive surgery is not possible, or after surgery, the female partner has an infertility problem or the couple can not wait six to twelve months to have a reasonable attempt at conceiving naturally after surgery, and treatments.

General Management

Genetic abnormalities associated with the cystic fibrosis gene need to be considered if a pregnancy are to be attempted using the man's sperm. The woman should be screened for cystic fibrosis gene abnormalities and the couple counseled accordingly. Preimplantation or prenatal genetic diagnosis may be performed if mutations are found in both partners. The woman should be investigated in detail to ensure her potential fertility before surgery is contemplated in the man.

The prognosis of the procedure and the availability of other forms of treatment should be discussed realistically with the couple. After doing Ayurvedic treatments sperm may be obtained by testicular biopsy or percutaneous sperm aspiration from the epididymis under local anesthesia. If a natural spermatocele is present, usable sperm may be obtained by direct puncture through the scrotal skin. It may be possible to combine vasoepididymostomy with sperm aspiration for I.U.I.

Epididymal and Vasal Surgery

Specialist micro surgeons, and Ayurvedic physicians’ best undertake treatment of male genital tract obstructions.
The testis is exposed and the most proximal (to the testis) level of obstruction determined.
A testicular biopsy is obtained and the patency of the vas is determined by syringing with saline or by vasography.
The vas or epididymal tubule is opened proximal to the obstruction, and if possible, the presence of motile sperm is demonstrated by microscopy.
Then microsurgical anastomosis between the ends of the vas or between the vas and the epididymal tubule is undertaken.

RESULTS

Vasovasostomy and vasoepididymostomy for caudal blocks produce relatively good results - 50 to 80 per cent of patients having sperm present in the semen; however, less than half of these produce a pregnancy within the first year.
The poor results may be related to continuing obstruction, sperm autoimmunity, or coexisting spermatogenic disorders.
The results of vasoepididymostomy for proximal blocks are poor.
Although sperm may appear in the semen, pregnancies are extremely uncommon following vasoepididymostomy for caput epididymal blocks.
The results of ICSI with testicular or epididymal sperm, fresh or after cryopreservation, are similar to those obtained with sperm from semen.