Surgical therapy in infertile men with ejaculatory duct obstruction: technique and outcome of a standardized surgical approach

In severe oligozoospermia or azoospermia, low ejaculate volume, low ejacula te pH and little or no fructose in seminal plasma suggest an obstruction of the seminal pathways at the level of the prostate gland, when vasal aplasi a and ejaculatory disorders are excluded. We report on our standardized sur gical approach in 16 consecutive patients with this condition after clinica l evaluation, semen analysis, endocrine assessment, testicular biopsy and t ransrectal ultrasonography. Pre-operatively, sperm analysis demonstrated ty pical low-volume ejaculates with azoospermia in 12 and severe oligozoosperm ia in four cases, Ultrasonography demonstrated seven central (Mullerian) an d five lateral cystic lesions. Four eases with central obstruction revealed no ultrasonographic pathology, After intraoperative vasopuncture and vasog raphy for definite localization of the level of obstruction, transurethral incision and/or resection of ejaculatory ducts (TURED) was performed. Paten cy was proven in 15 out of 16 cases by 'intra-operative chromotubation'. In nine out of 12 patients, spermatozoa could be harvested intra-operatively from the vas. During the follow-up of 12 months, postoperative ejaculates s howed persistent patency in six out of seven Mullerian cysts with concomita nt improvement of sperm quality, Only three of the other nine cases remaine d patent with the worst results in lateral cystic lesions. Only two of the patients with Mullerian cysts have fathered a child so far. The data provid e evidence for the effectiveness of surgical treatment of ejaculatory duct obstruction, especially in the case of central cystic lesions. The combinat ion of surgery, cryostoring of spermatozoa retrieved intraoperatively and t he possible storage of ejaculated spermatozoa post-operatively creates the possibility of subsequently using reproductive techniques if pregnancy is n ot achieved.