Evaluation and treatment of ejaculatory duct obstruction in the infertile male

FERTILITY AND STERILITY Copyright 99 The American Fertility Society Vol. 59, No,, February 99 Printed on acid4ree paper in U.S.A. Evaluation and treatment of ejaculatory duct obstruction in the infertile male Randall B. Meacham, M.D.* Daniel K. Hellerstein, M.D.t Larry I. Lipshultz, M.D.:\: Scott Department of Urology, Baylor College of Medicine, Houston, Texas Objective: To evaluate the role of ejaculatory duct obstruction as a cause for male factor infertility and review the treatment of this condition. Design: A retrospective study was carried out involving male patients diagnosed as having ejaculatory duct obstruction as a contributing cause for their subfertility. Setting: Patients were evaluated and treated through a university-based male infertility clinic. Patients, Participants: Patients were evaluated for the presence of ejaculatory duct obstruction if they suffered from decreased ejaculate volume, sperm density, and sperm motility but had normal physical examinations and otherwise normal laboratory evaluations. Interventions: Patients were treated by transurethral resection of the ejaculatory ducts. Main Outcome Measures: Results of semen analysis and pregnancy rates. Results: An alteration in semen quality was achieved in 79% of patients after transurethral resection. An increase in sperm density or motility was achieved in 5%, whereas 9% showed an increase in ejaculate volume only. Pregnancy rate postoperatively was 9%. Conclusions: Ejaculatory duct obstruction as a cause of male infertility is more common than was previously recognized, especially among nonazoospermic patients. In properly selected patients, transurethral resection of the ejaculatory ducts can result in marked improvement in semen quality with subsequent pregnancy. Fertil Steril 99;59:9-7 Key Words: Male infertility, transrectal ultrasound, transurethral resection, seminal vesicles, ejaculatory ducts Received June, 99; revised and accepted October, 99. * Present address: Division of Urology, University of Colorado Health Sciences Center, Denver, Colorado. t Present address: Department of Urology, Mayo Clinic, Jacksonville, Florida. :j: Reprint requests: Larry. Lipshultz, M.D., Scott Department of Urology, Baylor College of Medicine, 656 Fannin, Suite, Houston; Texas 77. Ejaculatory duct obstruction as a cause of male subfertility has in the past received relatively little attention. Although several authors have described the diagnosis and treatment ofthis lesion, the number of cases reported has been limited. Table (- ) summarizes the results of previously reported experiences in the treatment of ejaculatory duct obstruction in infertile males. In all cases described to date, obstruction was documented by intraoperative vasography. A variety of transurethral procedures were used to open the obstructed ejaculatory ducts. These procedures generally involved either Collings knife incision, loop resection lateral to the verumontanum, or loop resection of the veru itself. To investigate the prevalence of ejaculatory duct obstruction in the subfertile male population, we utilized trans rectal ultrasonography to evaluate a group of patients with characteristic semen parameters. Our results indicate that ejaculatory duct obstruction has been underdiagnosed in the past and that proper diagnosis and treatment can lead to gratifying results in a group of patients with profoundly impaired fertility. Vol. 59, No., February 99 Meacham et al. Ejaculatory duct obstruction 9

Table Collected Results of Treatment of Ejaculatory Duct Obstruction in Infertile Males No. of Date Author patients 978 Hassler and Weber () 978 Porch () 98 Weintraub () 4 98 Silber (4) 4 98 Amelar and Dobin (5) 6 98 Vicente et al. (6) 9 984 Sharlip (7) 984 Carson (8) 4 985 Goldwasser et al. (9) 986 Dunetz and Krane () Total No. of patients with postoperative improvement in semen quality 6 (5%) No. of pregnancies o (%) MATERIALS AND METHODS Twenty-four subfertile men were diagnosed over a 9-month period as having ejaculatory duct obstruction contributing to male factor infertility. Patients were evaluated in a university-based male infertility clinic. Mean patient age was years. Twenty-one patients reported primary infertility, whereas suffered from secondary infertility. All patients underwent a complete history and physical examination and evaluation of serum follicle-stimulating hormone (FSH). All but patients were found to have serum FSH within the normal range and all had normal testicular size and consistency. At least two semen analyses were obtained and were assessed for ejaculate volume, sperm density, sperm motility, and forward progression. Patients with low ejaculate volumes «.5 ml), reduced sperm density, and/or motility and serum FSH levels that were not greater than three times normal were evaluated by transrectal ultrasonography for evaluation of possible ejaculatory duct obstruction. A Bruel and Kjar (Marlborough, MA) ultrasound (US) unit with a 7-MHz probe was used. Scanning was performed in both the transverse and longitudinal planes. Ultrasound was considered positive if a posterior midline cyst (ejaculatory duct cyst) was seen in the region of the verumontanum or if gross dilation of the seminal vesicles or vasal ampullae was identified. As we have previously described, seminal vesicle dilation was defined as one or both seminal vesicle measuring>.5 cm in transverse dimension (). Corroborative findings included cystic appearance of the seminal vesicle with the presence of internal fluid levels. Characteristic US images are shown in Figure. Fourteen of 4 patients in this series underwent testis biopsy before or at the time of surgery. In azo- ospermic patients, testis biopsy confirms that spermatogenesis is intact, indicating an obstructive etiology. Biopsy can be performed at the time of surgery using touch imprint cytology analysis (). In this technique, the fresh biopsy specimen is gently touched repeatedly against a microscope slide, immediately sprayed with cytofixative, and stained with the hematoxylin and eosin technique. The imprint slide is then inspected for the presence of mature sperm. All patients were treated by transurethral resection of the ejaculatory ducts. Two patients underwent procedures for a total of 6 resections. Fourteen procedures were performed in azoospermic patients and procedures were performed in patients who had impaired semen quality but were not azoospermic. The technique used for endoscopic resection is illustrated in Figure. Resection was carried out at the level of the verumontanum. The veru itself was deeply resected taking care not to damage the rectum. If an ejaculatory duct cyst was unroofed, it was entered just deep to the veru. If a cyst was not unroofed using the above technique, a Collings knife was used to make bilateral longitudinal incisions just lateral to the base of the resected veru. This was done in an effort to open obstructed ejaculatory ducts that might have been missed in the initial midline resection. In all cases, electrocoagulation was used sparingly if at all to avoid occlusion of the newly opened ejaculatory ducts. A urethral catheter was left in place for at least 48 hours postoperatively and removed when hematuria had abated. Procedures were generally performed on an outpatient basis. Complications were rare. Two patients required recatheterization for delayed bleeding. No cases of rectal injury, postoperative changes in uri- 94 Meacham et ai. Ejaculatory duct obstruction Fertility and Sterility

Figure (A) Transrectal US image (transverse view) showing typical midline cyst posterior to the verumontanum. (B) Longitudinal view of the midprostate, again demonstrating ejaculatory duct cyst. +, distance from cyst to urethra. nary continence, or postoperative retrograde ejaculation were noted. RESULTS Results of transrectal ultrasonography are summarized in Table. The majority of patients were found to have either ejaculatory duct cysts or dilated seminal vesicles. In four cases, however, ejaculatory duct obstruction was not diagnosed preoperatively. In two of these cases, preoperative transrectal US was nondiagnostic, but on subsequent scrotal exploration and vasography, obstruction was found at the level of the ejaculatory ducts. On transurethral resection one patient was found to have an ejaculatory duct cyst. Two additional patients did not undergo preoperative ultrasonography but were found to have ejaculatory duct obstruction on intraoperative vasography. Patients were categorized into three groups based on response to treatment. Group is comprised of patients who postoperatively achieved an increase in sperm density, sperm motility, or both. Group consists of patients who showed a postoperative increase in ejaculate volume but no improvement in sperm count or motility. Patients who demonstrated no postoperative improvement in ejaculate volume or semen quality were placed in group. Overall results are presented in Table. Twelve procedures resulted in improvement in sperm density and/or motility (group ). Mean preoperative sperm density in this group was 7 X 6 /ml. Mean sperm density postoperatively was 6 X 6/mL. Mean sperm motility among these patients rose from % preoperatively to 6% after transurethral resection. Three of these patients were azoospermic before surgery. The remaining nine patients suffered from varying degrees of oligoasthenospermia preoperatively. An improvement in ejaculate volume only with no improvement in sperm density or motility was achieved after eight procedures (group ). Six of these patients were azoospermic preoperatively. Table Abnormalities Noted on Transrectal Ultrasonography Among Patients in Each Treatment Response Group Ejaculatory duct cyst Dilated seminal vesicles Dilated vasal ampullae or ejaculatory ducts Calcification of ejaculatory ducts Nondiagnostic ultrasound Figure Loop resection technique for endoscopic unroofing of obstructed ejaculatory ducts. If an ejaculatory duct cyst is present, it will usually lie just deep to the verumontanum. Vol. 59, No., February 99 Group * Group t Group :\: 4 4 * Postoperative improvement in sperm density and/or motility. t Improvement in ejaculate volume only. :\: No postoperative improvement in semen parameters. Two patients did not undergo preoperative ultrasonography. Meacham et al. Ejaculatory duct obstruction 95

r Table Group It Group + Group Total Overall Response to Treatment No. of patients No. of pregnancies* 6 (5) 8 (.5) 6 6 7 (7) * Values in parentheses are percentages. t Postoperative improvement in sperm density and/or motility. + Improvement in ejaculate volume only. No postoperative improvement in semen parameters. A final group of six patients (group ) failed to achieve any improvement in semen characteristics after transurethral resection of the ejaculatory ducts. Five of these patients were azoospermic preoperatively. Eleven of the 4 patients (46%) included in this study had reduced semen parameters but were not azoospermic. Such patients appeared to have a partial obstruction of the ejaculatory ducts. In 8 such patients, an ejaculatory duct cyst was opened at the time of surgery. Nine partially obstructed patients achieved improvement in sperm density or motility postoperatively and 6 went on to achieve pregnancies. The spouses of 7 patients became pregnant postoperatively. One pregnancy occurred among the patients who had been azoospermic preoperatively. The remaining six pregnancies occurred among the 4 patients who were not azoospermic but had severe impairment of their semen quality before surgery. DISCUSSION Ejaculatory duct obstruction should be considered in patients with azoospermia or markedly decreased sperm count, decreased motility (in nonazoospermic patients), and an ejaculate volume <.5 ml. Serum gonadotropins and testosterone are generally within the normal range. Physical examination is characteristically unremarkable. The testicles are usually of normal size and consistency, although there may be induration of the epididymides secondary to obstruction. Rectal examination is often normal but rarely may reveal dilated seminal vesicles or a midline cystic structure in the area of the midprostate. Diagnosis of ejaculatory duct obstruction has been relatively uncommon in the past, due in large part to the technical difficulties involved in its identification. All patients reported in previous series were diagnosed by means of operative vasography. This is an expensive and time consuming procedure, however, and poses the risk of vasal scarring. Vasography has been limited therefore to a select group of patients. Although evaluation of semen fructose can provide presumptive evidence of ejaculatory duct obstruction or seminal vesicle atreasia, this test yields little information regarding individual patient anatomy. Ejaculatory duct obstruction and testicular pathology, such as incomplete maturation arrest or focal hypospermatogenesis, may coexist in the same patient. Interpretation ofthe results of testis biopsy in such cases may therefore be difficult, especially in patients who are not azoospermic. In general, however, a positive transrectal US in a patient with a typical presentation and a testis biopsy showing at least partially intact spermatogenesis should be suspected of having ejaculatory duct obstruction. Eleven patients in this study appeared to suffer from partial ejaculatory duct obstruction. These patients had decreased semen quality but were not azoospermic. Eight patients achieved a marked improvement in ejaculate volume but showed no increase in sperm density or motility. Such patients may have developed epididymal obstruction from prolonged distal blockage similar to that seen in some patients after vasectomy. A similar group of patients identified after transurethral resection of obstructed ejaculatory ducts has previously been described (4). Such patients may require subsequent epididymo-vasostomy to re-establish sperm transport from the epididymis. The advent of high-resolution transrectal ultrasonography has greatly facilitated the diagnosis of ejaculatory duct obstruction. Developed largely for the diagnosis of prostatic pathology, transrectal ultrasonography is a modality that is now familiar to most urologists. The diagnosis of ejaculatory duct obstruction is suggested by the presence of dilated seminal vesicles or a posterior midline cyst in the region of the prostatic urethra. Calcifications, suggesting previous inflammation may also be seen in the region of the ejaculatory ducts. Because transrectal US is much less invasive and more easily obtained than vasography, the indications for evaluating patients suspected of having ejaculatory duct obstruction may be broadened. More frequent evaluation for this condition will provide a more accurate determination of its prevalence. In our experience, we found that ejaculatory duct obstruction was more common than anticipated and was associated with a favorable prognosis in many of the affected patients. 96 Meacham et al. Ejaculatory duct obstruction Fertility and Sterility

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