EFFECT OF LEVEL OF ANASTOMOSIS AND QUALITY OF INTRAEPIDIDYMAL SPERM ON THE OUTCOME OF END-TO-SIDE EPIDIDYMOVASOSTOMY

Objectives. Epididymovasostomy is commonly performed at the most dista l site of the epididymis where whole sperm are present within the lume n, regardless of their motility status. Although more fresh and motile sperm can be found more proximally within the epididymis, it is belie ved that the outcome of epididymovasostomy is better more distally. Be cause the current results of epididymovasostomy are far from perfect, it would be ideal to be able to harvest motile sperm for cryopreservat ion at the time of surgery in case the patient remains azoospermic pos toperatively. The objective of this study was to determine the effect of the level of epididymal anastomosis and duality of sperm on the out come of surgery. Methods. An end-to-side epididymovasostomy was perfor med on 131 azoospermic men with a mean age of 39 years and a mean obst ructive interval of 18 years. The etiology of obstruction was vasectom y in 48%, infectious in 19%, congenital in 20%, and unknown in 13%. Th e average duration of follow-up was 32 months. The overall patency rat e was 67% and pregnancy rate was 27%. Subgroups of patients with an an astomosis to the same level of the epididymis on all functional sides were identified as follows: caput (56), corpus (28), and cauda (13). T hese groups were compared in regard to the presence of motile sperm wi thin the epididymal lumen at the time of surgery, patency rates, posto perative semen quality, and pregnancy rates. Results. Motile sperm wer e present more often in both the caput (54%) and corpus (61%)than in t he cauda epididymis (25%) (P < 0.05). The patency rates for the three subgroups were not significantly different. The postoperative total mo tile sperm count and pregnancy rate for the corpus epididymis (13 x 10 (6) and 45%) was significantly (P < 0.05) better than for the caput (4 .4 x 10(6) and 22%) but no different than that of the cauda (10 x 10(6 ) and 25%). The patency and pregnancy rates for anastomoses performed at levels demonstrating motile sperm were not significantly better tha n at sites with nonmotile sperm, but the postoperative total motile sp erm count was better (P < 0.05). Conclusions. The results of this stud y suggest that the outcomes of epididymovasostomy to the corpus and ca uda epididymis are roughly equivalent and superior to the caput. There fore, it may be reasonable to move more proximally from the cauda to c orpus in the search for motile sperm for cryopreservation during an en d-to-side epididymovasostomy. In contrast, moving from the corpus to t he caput epididymis has a significant adverse effect upon outcome; it is, therefore, not worthwhile to search for viable sperm for cryoprese rvation in this clinical setting. (C) 1997, Elsevier Science Inc.