Surgical outcomes in male reconstructive urology: The Qatar experience

Abstract

Background: Obstructive azoospermia (OA) is a prevalent cause of male infertility in Qatar and globally, with vasectomy reversal (VV) and vasoepididymostomy (VE) being the primary surgical treatments. While microsurgical techniques have advanced, data from the Middle East remain limited, influenced by the region's distinct demographic and cultural factors. This study aimed to evaluate the outcomes of microsurgical VV and VE performed for OA in a tertiary center in the Middle East, with a focus on success rates, influencing factors, and the unique regional characteristics of OA.

Methods: A retrospective cohort study analyzed 105 patients with OA undergoing VV or VE over a period of 10 years. Data on demographics, clinical variables, surgical findings, and postoperative outcomes were assessed. Success was defined as sperm presence in semen within 3–6 months post-surgery.

Results: The overall success rate for VV was 85.7%, with similar rates across bilateral and unilateral procedures. VE success was 50%, with bilateral intussusception technique yielding superior outcomes (71.9%). Factors predicting success included shorter obstructive interval for VV and bilateral reconstruction for VE.

Conclusion: Microsurgical VV remains a reliable first-line treatment for OA, achieving high success rates consistent with international benchmarks. VE presents greater variability in outcomes, highlighting the complexity of managing epididymal obstruction and the importance of advanced surgical techniques like intussusception. The distinct etiological patterns observed in the Middle East emphasize the need for tailored approaches to diagnosis, surgical planning, and patient counseling.

Graphical abstract

Keywords

obstructive azoospermia / predictors of success / vasoepididymostomy / vasovasostomy

1 INTRODUCTION

Infertility is a growing global health concern, affecting approximately 15% of couples worldwide. Male factors contribute to infertility in 20%–50% of cases[1]. In Qatar, the prevalence of primary and secondary infertility among men aged 20–60 years is 10.2% and 19.6%, respectively[2]. Approximately 63% of infertile men seeking fertility treatment exhibit abnormal semen parameters, including azoospermia[3], which is defined by the complete absence of sperm in the ejaculate.

Azoospermia is diagnosed in 10%–15% of infertile men[4,5] and is classified into obstructive azoospermia (OA) and non-obstructive azoospermia (NOA). NOA results from testicular dysfunction caused by hormonal or genetic disorders, as well as exposure to gonado-toxins. Whereas OA results from blockages in the semen ductal system, which can occur at various points within the male reproductive tract, including the epididymis, vas deferens, and ejaculatory ducts[6]. Approximately 40% of individuals with azoospermia have an obstructive cause[5,7].

Besides vasectomy-related vasal obstruction, epididymal obstruction is a frequent cause of OA. This can result from infections, iatrogenic injury, trauma-related, or idiopathic reasons. Obstruction of the ejaculatory duct is a less common cause of OA[8,9]. Table 1 summarizes the causes of OA.

Treatment options for infertile patients with OA include sperm retrieval for assisted reproductive technology (ART) or microsurgical reconstruction. Several factors influence the decision-making process, such as the urologist's surgical experience, the desired number of children, the female partner's age, the preference for natural conception, and the availability of necessary instruments.

The two primary microsurgical reconstruction procedures are microsurgical vasovasostomy (VV) and microsurgical vasoepididymostomy (VE). VV is primarily performed for patients seeking vasectomy reversal. Various techniques and advancements have been described for VV, including the use of surgical microscopes and robotic systems, as well as modifications to the number of anastomosis layers[10].

On the other hand, microsurgical VE is used for patients with epididymal obstruction[11]. Microsurgical VE has undergone significant advancements since its inception in 1902[12]. Techniques have evolved from early fistulous communications between the multiply incised epididymal tubules and the transected vasal lumen[13] to precise epididymal tubule anastomosis facilitated by surgical microscopes[14,15]. Various surgical approaches, including end-to-side[16,17], triangulation[18,19], and longitudinal intussusception, have then been developed with the intent to improve patency rates. The microsurgical longitudinal intussusception VE (LIVE) technique reported by Chan et al. has gained popularity due to a potentially superior patency rate compared to other techniques[20–22].

In the Middle East, vasectomy is less prevalent due to cultural and religious factors. Consequently, VE indications differ from those in Western countries. While long-standing vasectomy is the primary cause of secondary epididymal obstruction and the main reason for VE in Western countries[8], in contrast, in the Middle East, the procedure is more commonly performed to address obstructions resulting from infectious, inflammatory, or idiopathic causes.

Due to the unique characteristics of the Middle Eastern patient population, the conclusions of international publications on microsurgical VE may not be directly applicable. This highlights the need for further research to investigate the outcomes of microsurgical reconstruction in this population.

This study aims to investigate the microsurgical reconstruction procedures performed at our tertiary referral center for male infertility in Qatar, reflecting Middle Eastern practices. Given that Qatar is a cosmopolitan country in the Arabian Gulf with expatriates constituting about 75% of its population, including many from various Middle Eastern nations, it serves as a pertinent setting for this research. We analyzed patient characteristics undergoing microsurgical VV and VE, and evaluated the outcomes of these surgeries. The study also identified predictors of successful and favorable outcomes from these procedures.

2 MATERIAL AND METHODS

2.1 Study design and participants

This retrospective cohort study was carried out in the Ambulatory Care Center at Hamad Medical Corporation, Doha, Qatar. The study duration was over the last 10-year period.

The charts of all patients who underwent reconstructive surgery at the Male Infertility Unit were screened for inclusion in the study. Inclusion criteria were patients following in the male infertility clinic, complaining of infertility, diagnosed as OA after two semen samples, having normal hormonal profiles, and performed reconstructive surgery (VV or VE). Exclusion criteria were cases of congenital bilateral absence of the vas deferens, ejaculatory duct obstruction, NOA, those with previous repair attempt, OA cases who didn't undergo reconstructive surgery (due to intraoperative intratesticular obstruction or proximal vas obstruction), male genetic abnormalities, history of mumps orchitis, history of receiving chemotherapy or radiotherapy, and history of testicular tumor.

Two investigators reviewed the electronic medical records of male patients to extract data, including the patient's age, related past medical history (e.g., type of infertility, history of sexually transmitted infections, testicular trauma, epididymo-orchitis, prostatitis), history of surgical procedures relevant to the male genital tract, microscopic reconstructive operative details, histopathology results, and postoperative outcomes. Clinical examination data involving general and local genital examination, laboratory data including pre- and post-operative semen analysis, and hormonal profiles were also extracted. All the male reconstructive procedures were performed by fellowship-certified surgeons in male reproductive medicine with extensive microsurgical experience.

2.2 Diagnosis of OA

The diagnosis of OA was principally based on clinical suspicion in patients with absence of sperm from the ejaculate after two centrifuged semen samples[23]; normal testes volume (≥ 14cc)[4]; engorged epididymis[24]; and normal reproductive hormones including follicular stimulating hormone (FSH), Luteinizing hormone (LH) and Testosterone (T)[19]. In equivocal cases in which the diagnosis was not established based on the clinical presentation, a diagnostic testis biopsy was performed either separately or at the time of reconstructive surgery.

2.3 Study procedures

2.3.1 Semen analysis

Semen tests were conducted on samples obtained via masturbation after 2–7 days of abstinence and analyzed according to the WHO criteria (5th edition) in the andrology laboratory of the center[4,23].

2.3.2 Male endocrine profile

Analyses of reproductive hormones were performed at the same certified laboratory using third-generation chemiluminescence immune assay on blood samples collected between 7 a.m. and 10 a.m. using the immunoassay chemiluminescence method, Architect i1000SR® (Abbott Systems). Serum hormone levels, including testosterone (reference values 10.4–35 nmol/L), luteinizing hormone (LH, reference values 1–9 IU/L), follicular stimulating hormone (FSH, reference values 1–19 IU/L) and estradiol (reference values 73–275 pmol/L) were collected.

2.4 Microsurgical operative details

In cases where no diagnostic biopsy was performed prior to surgery, the procedure initially commenced with obtaining a small piece of testicular tissue using needle aspiration biopsy, which was then placed on a slide with sperm washing medium, minced, and then pressed under a glass coverslip. Specimen examination for sperm using a high-power (×40) lens was performed. If active spermatogenesis was detected (presence of around 20–30 mature sperm per high power field), reconstruction could proceed immediately. Additionally, sperm could be sent for cryopreservation during the biopsy for potential use in in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). This was a standard procedure applied to all cases where sperm were identified during the biopsy to provide an option for ARTs in case of future fertility challenges. In instances where intratesticular obstruction or proximal vas obstruction was identified during scrotal exploration, the reconstruction procedure was discontinued. The surgical microscope used was the Pantero 900 (Carl Ziess).

2.4.1 VE

Our institution adopted the end-to-side intussusception method in our reconstructive cases. The essential principle of end-to-side intussusception technique was invaginating an open epididymal tubule into the vasal lumen. The vas was isolated about 3 cm proximal to the convoluted epididymis, cut sharply, and lumen dilatation using 22- and 24-gauge angiocatheter was performed. Proximal patency was checked by saline injection to confirm the absence of obstruction. Moving on to the epididymis, microscopic screening of the epididymal tubules was done to detect dilated tubules starting from the lower tail and moving upwards toward the epididymal body and head. When a dilated tubule was identified, two double-armed 10-0 nylon sutures (nylon monofilament; Ethilon, Ethicon Inc., Johnson & Johnson) were inserted into an epididymal tubule simultaneously and in parallel, preventing immediate decompression. The tubule was then incised between the sutures, and the resulting fluid was examined microscopically to ensure the presence of sperm. If sperm were absent, a more proximal location is chosen for the anastomosis till sperm was identified. If sperm were present, the tubule was intussuscepted into the vasal lumen by placing all four needles inside-out in the vasal lumen. The sutures were then tied to themselves as the tubule retracts into the vas. Using 8.0 Prolene (polypropylene suture, Ethicon Inc., Johnson & Johnson), the remainder of the muscularis of the vas was circumferentially secured to the tunica of the epididymis, thereby completing the anastomosis[19,24–26].

In cases where intussusception was technically not possible due to the small size of the tubule, usually at the head of the epididymis, a fistula technique was attempted to establish a connection between the vas deferens and the epididymis. The concept of the fistula technique depends on the circumferential placement of 10-0 nylon sutures (nylon monofilament, Ethilon, Ethicon Inc., Johnson & Johnson) that penetrates the vasal sheath and the tubular wall of the epididymis without fully traversing its entire thickness, to avoid damaging the opposite wall and causing additional obstruction, to ensure that the lumen of the vas deferens and the epididymal tubule are aligned and held open to facilitate the passage of sperm[27]. Our average procedure duration for VE was between 130 min and 260 min.

2.4.2 VV

Our institution adopted the modified one-layer method for VV. The vasal ends were aligned in a tension-free manner, which could be accomplished using either an adventitial stay suture or a microspike approximating clamp[28]. Using the operative microscope, the site of the previous vasectomy was identified. The vas deferens edges were sharply cut till a fresh edge with a patent lumen was identified. The proximal end was milked, and fluid exuded aspirated and examined under ×400 microscopy for sperm or sperm particles. The transected vasal segment was excised with the cautery and removed from the field. The distal end of the vas was dilated with the vasal dilator. Then, a 24 gauge angiocatheter was placed in the distal vas lumen, and saline was easily irrigated toward the bladder, indicating distal patency. The modified single-layer anastomosis involved using four full-thickness 8.0 sutures under microscopic guidance to carefully re-approximate the muscular and mucosal layers of the vas deferens. The direction of suturing was Out-to-In and then In-to-Out. This was followed by placing six to eight interrupted 8.0 nylon sutures to secure the intervening seromuscular layer. The surgeon ensured tension-free and watertight anastomosis, and, if needed, additional sutures were placed to accomplish these goals[29–31]. Our average procedure duration for VV was between 95 min and 205 min. Follow up examination with semen analysis was done 3 months and 6 months after the operation. A successful procedure outcome was defined as the presence of sperm in semen samples collected within 3 months or 6 months following microsurgical reconstructive procedures (VV and VE).

2.5 Statistical analysis

Statistical analyses were performed using IBM Statistical Package for the Social Sciences (SPSS, version 25). Continuous variables were expressed by mean and standard deviation. Frequencies and percentages expressed categorical variables. The normal distribution of variables was tested using a histogram and the Shapiro–Wilk test. Student's t-test compared the clinical and laboratory variables between the study groups. Paired-t-test assessed changes in laboratory variables at different time points. Multivariate binary logistic regression analysis using the forward method explored the predictors for successful outcomes for VV and VE. p-values < 0.05 were considered statistically significant with an acceptable margin of error of 5%.

3 RESULTS

3.1 Characteristics of the studied population

A total of 105 patients fitted the selection criteria and were included in the study, comprising 25 VV cases and 80 VE cases. Table 2 reports the characteristics of the study population overall, as well as in those who underwent VV and VE. The mean age of the study population was 39.5 ± 9.4 years, and VV was performed on patients who were relatively older (47.5 ± 8.5 years) than those who underwent VE (36.9 ± 8.2 years). Conditions such as sexually transmitted infections, epididymo-orchitis, and prostatitis were solely reported in patients who underwent VE. Engorgement of the right and left epididymis was observed in more than half of patients undergoing VV and in almost two-thirds of patients undergoing VE. Normal hormone results were reported in both groups of the studied population.

3.2 VV outcomes

Among the 25 vasectomy reversal cases that were scheduled based on the patient's vasectomy history, 14 cases underwent bilateral VV, 7 cases had VV on one side and contralateral VE (intussusception) on the other, and the remaining 4 cases, identified with secondary epididymal obstruction, underwent bilateral VE, and were further shifted and analyzed under the VE group.

For the 11 cases where bilateral VV was not feasible, right epididymal and proximal vasal obstruction was observed in 41.7% and 58.3% of cases, respectively. While left epididymal obstruction was identified in 44.4% and left proximal vasal obstruction in 55.6% of cases.

A success rate of 85.7% was observed in both patients who underwent bilateral (12/14 patients) or unilateral (6/7 patients) VV. The mean number of years since vasectomy was 11.68 ± 8.36 years. The patients’ postoperative semen analysis results showed a median semen volume of 2.75 mL (IQR: 1.62–3.5 mL), a median sperm count of 4.05 million/mL (IQR: 0.075–31.25 million/mL), a median total motility of 12% (IQR: 1%–40%), a median progressive motility of 0% (IQR: 0%–10%) and a median morphology (normal forms) of 2% (IQR: 1%–7.5%).

Table 3 compares various characteristics of patients with positive or negative outcomes following VV. Despite a non-statistically significant result, patients with a negative VV outcome had a higher mean number of years since vasectomy (19 ± 10.6 years) compared with those having a positive VV outcome (11.9 ± 6.1 years). No other significant differences were observed in the clinical or laboratory variables or intraoperative details between those having a positive or negative VV outcome.

3.3 VE outcomes

Out of the 80 patients who were initially scheduled for microsurgical VE, 20 cases were aborted due to intratesticular obstruction or proximal vas obstruction. Therefore, the analysis was performed on 64 VE cases (including the 4 cases shifted from the VV group). The type of anastomosis performed intraoperatively was unilateral intussusception in 11% (7/64) of patients, bilateral intussusception in 65.6% (42/64), intussusception combined with fistula in 20.3% (13/64), and bilateral fistula in 3.1% (2/64) of cases. The site of reconstruction differed between the right and left epididymal units; on the right, most connections were made at the epididymal head followed by the tail and body. While on the left, most connections were made with the epididymal tail followed by the head and body (Figure 1).

Overall, 50% of the patients who underwent VE had a successful outcome. Their median semen analysis result post-VE showed a volume of 3 mL (IQR: 2.5–4 mL), median sperm count was 0 million/mL (IQR: 0–15 million/mL), median total motility was 2.5% (IQR: 0%–41.25%), median progressive motility was 2% (IQR: 0%–15%) and the median morphology (normal forms) was 6% (IQR: 1%–10.5%).

Table 4 compares patients’ characteristics between those who had or did not have a successful outcome. No significant differences were observed in the demographic, clinical or laboratory characteristics of patients having a positive or negative VE outcome. Sub-analysis of the outcome among the different VE techniques revealed that the majority of patients with a successful outcome had undergone bilateral intussusception (71.9%; 23/32) with no statistically significant differences between the different methods. In our cohort, only two cases of self-limiting hematoma occurred and were managed conservatively—one following VE and the other post-VV.

4 DISCUSSION

This study evaluated the outcomes of microsurgical reconstructive surgeries performed for OA in a tertiary center in the Middle East, providing a comprehensive analysis of success rates and predictive factors. We observed a success rate of 85.7% for VV and 50% for VE, with no significant predictors identified for success. Both procedures showed measurable improvements in semen parameters postoperatively, which may render IVF unnecessary or at least obviate the need for testicular sperm retrieval during subsequent IVFs. This approach presents several advantages for patients with OA, including greater cost-effectiveness compared to direct IVF[32]. It also minimizes risks associated with IVF, such as ovarian hyperstimulation and multiple gestations, as well as complications from sperm retrieval, such as hematoma and testicular dysfunction.

Our study holds particular significance in the Middle East due to the unique etiology of obstruction observed in this region. Unlike Western populations, where vasectomy reversal cases dominate, and iatrogenic factors are more prevalent[8,33], obstruction in the Middle East is often idiopathic or, when documented, secondary to infections including epididymo-orchitis, sexually transmitted infections, and prostatitis. Chan et al. reported that among their cohort of patients undergoing VE, 51.5% had obstructive etiologies related to previous vasectomy, iatrogenic factors, or trauma, while infectious conditions and idiopathic causes accounted for 22% and 27% of cases, respectively[33]. In contrast, in our cohort, only 4 patients undergoing VE had a history of vasectomy, whereas 33.5% presented with a history of infectious conditions, and 66.5% underwent VE for idiopathic causes. This difference in etiology necessitates a tailored approach to both diagnosis and management, highlighting the importance of evaluating surgical outcomes within this specific demographic group.

The outcomes observed in the VV cohort of our study are consistent with findings from international literature. A systematic review and meta-analysis analyzing 54 studies with a total of 11,487 subjects reported patency rates for microsurgical VV ranging from 60.5% to 99.5%[10]. The authors also identified factors associated with improved patency rates, including shorter intervals between vasectomy and VV, bilateral detection of spermatozoa intraoperatively, the presence of sperm granuloma, and performing the procedure bilaterally. Conversely, advanced age, smoking, prior inguinal surgeries, repeated reversals, and complications post-surgery were associated with higher failure rates[10]. We reported a success rate of 85.7%, which aligns with the range observed in the systemic review. The mean obstructive interval in our cohort was 11.68 ± 8.36 years. The influence of the time interval since vasectomy on VV outcomes, though not statistically significant in this study, has been well-documented in the literature. A longer interval is often associated with epididymal blockage and changes in vasal fluid quality, both of which contribute to reduced success rates. The VV study group reported an inverse relationship between patency rates and obstructive interval with patency rates of 97%, 88%, 79%, and 71% observed in obstructive intervals of < 3 years, 3–8 years, 9–14 years, and >15 years, respectively[30]. The absence of statistical significance of obstruction interval noticed in our study could be attributed to the relatively small sample size. Other factors including age, smoking status, clinical, and laboratory data were not found in this cohort to significantly impact the outcome.

For VE, the 50% success rate observed in this study is slightly lower than what is reported in Western literature. A recent systemic review and meta-analysis by Wang et al. observed a mean patency rate of 69.3% among 25 observational studies, with a total of 1400 subjects[34]. This discrepancy may be attributed to the fact that most studies included in the systematic review focused on VE cases performed on patients with a history of vasectomy and relatively shorter obstructive intervals. For instance, a multi-institutional study by Ory et al.[35]. reported a patency rate of 50% in patients undergoing VE with a median obstructive interval of 15 years, and Kumar et al. reported a patency rate of 48% in patients with idiopathic obstruction undergoing VE[36]. Our findings align closely with these results. Additionally, the shorter follow-up period in our study could have influenced the results, as delayed sperm appearance in the ejaculate following VE has been documented in previous studies[37]. While no significant predictors of VE success were identified in our cohort, prior studies suggest that factors such as the site of epididymal anastomosis and the degree of obstruction may influence outcomes[35,38]. One study reported anastomoses on the head (24.5%), body (62.3%), and tail (13.2%) of the epididymis with patency rates of 38.5%, 78.5%, and 100%, respectively[39]. This could be explained by the smaller tubule diameter at the head compared to the body and tail, which will make the procedure more challenging. In our cohort, approximately one-third of the cases had anastomosis at the caput. However, there was no difference in patency rate between the groups. The lack of significant predictors in our analysis highlights the complexity of VE and underscores the need for individualized surgical planning.

The choice of the surgical technique is a critical determinant of the outcome, particularly in VE. In this study, bilateral intussusception was the most commonly performed method for VE, with a trend toward higher success rates in this group (71.9%). Although the differences between techniques in our cohort were not statistically significant, international studies have provided insights into the relative efficacy of these methods. Intussusception techniques, particularly the two-suture or three-suture methods, are widely regarded as the gold standard in VE due to their ability to achieve a precise mucosa-to-mucosa anastomosis, ensuring better patency rates[34,40]. The 69.3% reported success rate in the meta-analysis by Wang et al. was for bilateral intussusception observed and coincides with the result observed in our study, further validating the utility of this approach in the Middle Eastern population.

Conversely, fistula techniques, are generally reserved for cases with challenging anatomy as seen during anastomosis with the very fine tubules in the head of the epididymis. Data pertaining to the success rate of fistula technique are sparse with one study reporting a patency rate of 26%[27]. This lower result is expected due to the higher likelihood of anastomotic failure and leakage. In our cohort, bilateral fistula VE accounted for a small fraction of cases, and as such, no sound comparisons could be made with cases who underwent intussusception.

The AUA (American Urological Association) and EAU (European Association of Urology) guidelines emphasize a comprehensive approach to managing OA, starting with a thorough diagnostic evaluation. This includes semen analysis, hormonal assessment, imaging, and genetic testing when indicated. Both organizations highlight the importance of identifying the underlying cause, particularly in cases of congenital bilateral absence of the vas deferens (CBAVD), where testing for cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations is essential[41,42].

For treatment, the guidelines recommend microsurgical reconstruction, such as VV or VE, as the preferred option when feasible. These procedures aim to restore natural fertility and are often more cost-effective than sperm retrieval combined with ART. When reconstruction is not viable, sperm retrieval techniques such as microsurgical epididymal sperm aspiration (MESA), testicular sperm extraction (TESE), percutaneous epididymal sperm aspiration (PESA), or testicular sperm aspiration (TESA) are commonly used in conjunction with ICSI[41,42].

Patient counseling is a critical component of care, particularly regarding genetic risks, partner evaluation, and long-term reproductive planning. The overall approach is individualized, ensuring that treatment decisions align with the best possible fertility outcomes for the couple.

Despite the valuable insights provided by this study, several limitations must be acknowledged. Firstly, the retrospective design may introduce selection and information bias. Data collection relied on existing medical records, which could result in incomplete or inconsistent documentation. Secondly, the sample size, particularly within subgroups (e.g., patients undergoing fistula-based VE), limits the statistical power to detect significant differences and draw definitive conclusions. Larger, multicenter studies would enhance the generalizability of these findings. Thirdly, the follow-up period focused primarily on short-term outcomes, such as semen parameters. While these are critical indicators of surgical success, long-term follow-up evaluating pregnancy rates and overall patient satisfaction would provide a more comprehensive assessment of the procedures’ efficacy. Lastly, as a single-center study, the results may not be fully generalizable to other populations or healthcare settings, particularly those with varying levels of surgical expertise or differing patient demographics. Future prospective studies incorporating larger cohorts, longer follow-up periods, and multicenter collaboration from centers within our region are warranted to validate these findings and address the limitations of this study.

5 CONCLUSION

The findings of this study offer valuable insights for the management of OA in the Middle East. With a high success rate observed for VV, the procedure proves to be a reliable first-line option, especially for patients with shorter intervals since vasectomy. These outcomes are consistent with international standards, showing that microsurgical VV can be successfully performed in regional settings where skilled expertise is available.

For VE, the results highlight the inherent challenges of addressing epididymal obstruction. Success rates were more variable, strongly influenced by the surgical technique used. The predominance of intussusception over fistula methods in achieving favorable outcomes emphasizes the importance of advanced microsurgical skills. These findings also point to the critical role of individualized patient counseling—helping patients understand the complexity of VE, the potential success rates, and the need for thorough preoperative assessments.

The study further underscores the importance of recognizing regional differences in the causes of OA. In the Middle East, idiopathic and infection-related causes are more common than in Western populations, where vasectomy-related cases dominate. These unique aetiologies require tailored diagnostic and surgical approaches supported by detailed preoperative evaluations.

While this study has limitations due to its retrospective design and focus on a single center, it adds to the growing understanding of microsurgical treatments for male infertility in understudied regions. Moving forward, larger, prospective studies with extended follow-up periods are essential to refine surgical techniques and improve outcomes for patients facing these challenges.

References

[1] Gnoth C, Godehardt E, Frank-Herrmann P, Friol K, Tigges J, Freundl G. Definition and prevalence of subfertility and infertility. Hum Reprod. 2005;20(5):1144–1147.

[2] Al-Ansari AA, Al-Said SS, Bener A, Yassin A. Patterns of primary and secondary infertility in Qatari male population. J Men's Health. 2009;6(3):264.

[3] Akhter A, Momen SHM, Fatema K, Nath SD. Prevalence of Abnormal Semen Parameters among the Infertile Couples Seeking Infertility Treatment. Mymensingh Med J. 2024;33(2):586–591.

[4] World Health, O. WHO laboratory manual for the examination and processing of human semen. 5th ed. Geneva: World Health Organization; 2010.

[5] Jarow JP, Espeland MA, Lipshultz LI. Evaluation of the azoospermic patient. J Urol. 1989;142(1):62–65.

[6] Jungwirth A, Giwercman A, Tournaye H, Diemer T, Kopa Z, Dohle G, et al. European Association of Urology guidelines on male infertility: the 2012 update. Eur Urol. 2012;62(2):324–332.

[7] Jarvi K, Lo K, Grober E, Mak V, Fischer A, Grantmyre J, et al. CUA Guideline: the workup and management of azoospermic males. Can Urol Assoc J. 2015;9(7–8):229–235.

[8] Kim ED, Winkel E, Orejuela F, Lipshultz LI. Pathological epididymal obstruction unrelated to vasectomy: results with microsurgical reconstruction. J Urol. 1998;160(6 Pt 1):2078–2080.

[9] Wosnitzer MS, Goldstein M. Obstructive azoospermia. Urol Clin North Am. 2014;41(1):83–95.

[10] Seth I, Gibson D, Bulloch G, Joseph K, Cevik J, Qin KR, et al. Vasovasostomy: a systematic review and meta-analysis comparing macroscopic, microsurgical, and robot-assisted microsurgical techniques. Andrology. 2024;12(4):740–767.

[11] Baker K, Sabanegh, Jr., E Obstructive azoospermia: reconstructive techniques and results. Clinics. 2013;68(Suppl 1):61–73.

[12] Pastuszak AW, Wenker EP, Lipshultz LI. The history of microsurgery in urology. Urology. 2015;85(5):971–975.

[13] Martin E, Carnett JB, Levi JV, Pennington ME. The surgical treatment of sterility due to obstruction at the epididymis; together with a study of the morphology of human spermatozoa. Univ Pa Med Bull. 1902;15(1):2–15.

[14] Lespinasse VD. Obstructive sterility in the male: treatment by direct vaso-epididymostomy. JAMA. 1918;70:448–450.

[15] Silber SJ. Microscopic vasoepididymostomy: specific microanastomosis to the epididymal tubule. Fertil Steril. 1978;30(5):565–571.

[16] Wagenknecht LV, Klosterhalfen H, Schirren C. Microsurgery in andrologic urology. I. Refertilization. Microsurgery. 1980;1(5):370–376.

[17] Thomas AJ. Vasoepididymostomy. Urol Clin North Am. 1987;14(3):527–538.

[18] Berger RE. Triangulation end-to-side vasoepididymostomy. J Urol. 1998;159(6):1951–1953.

[19] Marmar JL. Modified vasoepididymostomy with simultaneous double needle placement, tubulotomy and tubular invagination. J Urol. 2000;163(2):483–486.

[20] Chan PT. Vasoepididymostomy. In: Graham SD, Keane TE, Glenn JF, editors. Glenn's urologic surgery. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 379–386.

[21] Shiraishi K, Matsuyama H. Outcomes of partial intussusception and endo-to-side vasoepididymostomy in men with epididymal obstructive azoospermia. Int J Urol. 2020;27(12):1124–1129.

[22] Chan PT, Lee R, Li PS, Libman J, Goldstein M. Six years of experience with microsurgical longitudinal intussusception vasoepididymostomy (LIVE): a prospective analysis. J Urol. 2008;179(4S):591–592.

[23] Cooper TG, Noonan E, von Eckardstein S, Auger J, Baker HWG, Behre HM, et al. World Health Organization reference values for human semen characteristics. Hum Reprod Update. 2010;16(3):231–245.

[24] Chan PTK, Li PS, Goldstein M. Microsurgical vasoepididymostomy: a prospective randomized study of 3 intussusception techniques in rats. J Urol. 2003;169(5):1924–1929.

[25] Chan PT. The evolution and refinement of vasoepididymostomy techniques. Asian J Androl. 2013;15(1):49–55.

[26] Yoon Y, Lee H, Park S, Moon H, Kim D, Song SH, et al. The role of vasoepididymostomy for treatment of obstructive azoospermia in the era of in vitro fertilization: a systematic review and meta-analysis. Asian J Androl. 2019;21(1):67–73.

[27] Mansi MK. Scrotal exploration in 123 azoospermic patients: the results of surgery for obstructive azoospermia. Ann Saudi Med. 1995;15(6):609–613.

[28] Fantus RJ, Halpern JA. Vasovasostomy and vasoepididymostomy: indications, operative technique, and outcomes. Fertil Steril. 2021;115(6):1384–1392.

[29] Goldstein M. Microspike approximator for vasovasostomy. J Urol. 1985;134(1):74.

[30] Belker AM, Thomas, Jr., AJ, Fuchs EF, Konnak JW, Sharlip ID. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol. 1991;145(3):505–511.

[31] Nyame YA, Babbar P, Almassi N, Polackwich AS, Sabanegh E. Comparative cost-effectiveness analysis of modified 1-layer versus formal 2-layer vasovasostomy technique. J Urol. 2016;195(2):434–438.

[32] Dubin JM, White J, Ory J, Ramasamy R. Vasectomy reversal vs. sperm retrieval with in vitro fertilization: a contemporary, comparative analysis. Fertil Steril. 2021;115(6):1377–1383.

[33] Chan PTK, Brandell RA, Goldstein M. Prospective analysis of outcomes after microsurgical intussusception vasoepididymostomy. BJU Int. 2005;96(4):598–601.

[34] Wang S, Fang Y. Outcomes of microsurgical vasoepididymostomy using intussusception technique: a systematic review and meta‑analysis. Sci Rep. 2023;13(1):3340.

[35] Ory J, Nackeeran S, Blankstein U, White JT, Grober E, Marks SH, et al. Predictors of success after bilateral epididymovasostomy performed during vasectomy reversal: a multi-institutional analysis. Can Urol Assoc J. 2022;16(3):132.

[36] Kumar R, Mukherjee S, Gupta NP. Intussusception vasoepididymostomy with longitudinal suture placement for idiopathic obstructive azoospermia. J Urol. 2010;183(4):1489–1492.

[37] Jarow JP, Sigman M, Buch JP, Oates RD. Delayed appearance of sperm after end-to-side vasoepididymostomy. J Urol. 1995; 153(4):1156–1158.

[38] Namekawa T, Imamoto T, Kato M, Komiya A, Ichikawa T. Vasovasostomy and vasoepididymostomy: review of the procedures, outcomes, and predictors of patency and pregnancy over the last decade. Reprod Med Biol. 2018;17(4):343–355.

[39] Peng J, Yuan Y, Zhang Z, Gao B, Song W, Xin Z, et al. Patency rates of microsurgical vasoepididymostomy for patients with idiopathic obstructive azoospermia: a prospective analysis of factors associated with patency-single-center experience. Urology. 2012;79(1):119–122.

[40] Pathak US, Balasubramanian A, Beilan JA, Butaney M, Tatem AJ, Thirumavalavan N, et al. Vasoepididymostomy: an insight into current practice patterns. Transl Androl Urol. 2019;8(6):728–735.

[41] Brannigan RE, Hermanson L, Kaczmarek J, Kim SK, Kirkby E, Tanrikut C. Updates to Male Infertility: AUA/ASRM Guideline (2024). J Urol. 2024;212:789–799.

[42] Salonia A, Bettocchi C, Boeri L, Capogrosso P, Carvalho J, Cilesiz NC, et al. European Association of Urology guidelines on sexual and reproductive health-2021 Update: male sexual dysfunction. Eur Urol. 2021;80(3):333–357.

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