Can an Epididymal Obstruction or Blockage be treated?
What is the epididymis?
The epididymis is a thin-walled, tightly coiled duct within the scrotum that collects and stores sperm from the sperm producing (seminiferous) tubules of the testes, where sperm are manufactured. It is crescent (moon) shaped and runs longitudinally along the back of the testis. Its walls become thicker and straighter as it becomes the vas deferens, which is the thicker tube that carries the sperm all the way to prostate and seminal vesicles. Believe it or not, when uncoiled, it is over 20 feet in length.
While sperm are passing through the epididymis, they mature and gain movement.
In some men, the epididymis becomes blocked, preventing sperm from entering the vas deferens and getting into the ejaculate. A blockage can occur on one side or on both sides.
If a man has an epididymal obstruction on one side, he may suffer a lowered sperm count. If a man has epididymal obstructions on both sides, this will lead to azoospermia (a zero sperm count).
What causes a blockage?
There are several causes for blockage of the epididymis:
- Infection: The epididymis is the most prone of all of the structures in the scrotum to become infected. This can be from sexually transmitted infections or (particularly in older men) bacteria. An infection can cause the epididymis to become permanently scarred down and blocked. (This is one of the reasons it is very important to treat any infection of the epididymis as soon as possible.)
- Surgery: Surgery in the scrotum can cause the epididymis to be blocked.
These surgeries may include:
Hydrocele Repair: A hydrocele is a buildup of fluid around the testicle.
Spermatocele Repair: A spermatocele is an outpouching of the tube of the epididymis, almost like a weakness in the wall of a tire. It then fills with fluid, and feels like a cyst. It is important to know that this collection of fluid rarely blocks the flow of sperm. However, the repair of a spermatocele has a high chance of blocking the travel of sperm through the epididymis. It is very, very, very rare for a cystic structure in the epididymis to represent cancer. Thus if one is discovered, it should be evaluated by ultrasound, and if found to be a simple cystic structure, be monitored but not operated on.
Surgery for Trauma: The epididymis can be damaged when the scrotum is explored for trauma, either in childhood or adulthood.
Treatment of a Testicular Torsion: If the testis twists on itself, this can cut off its blood supply, and permanently destroy the testis; thus this occurrence must be treated as a surgical emergency. In this situation, if found in time, the twisted testis and the one on the other side, are sewn down to the wall of the scrotum, to prevent them from twisting (orchidopexy.) Rarely, this can cause blockage of the epididymis on one or both sides.
Vasectomy: When the vas deferens is cut to prevent the sperm from passing through, the side coming from the testicle was traditionally closed, though the standard of care now is an open ended vasectomy (see section on open ended vasectomy). This leads to build up of pressure in the thin walled epididymis which can then blow out and subsequently scar down. This is relevant for men who are seeking to have children after having a vasectomy, and are considering a vasectomy reversal.
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Your doctor can actually feel an epididymal obstruction when he performs a physical exam. During examination of the ductal structures, the epididymis may feel as though it is dilated and hardened. Generally, it is flat in the middle and cannot be felt. If you have a dilated and hardened epididymis it may indicate a blockage.
If an epididymal obstruction is suspected in a man with no sperm in the ejaculate, you might have to undergo other tests to try and correct the problem. (Please refer to the section on azoospermia.)
If, after all the testing, your doctor tells you that he suspects an epididymal obstruction, the next step would be a testicular biopsy, depending on your medical history. A piece of the testis is taken either through an incision in the scrotum and testicle or with a needle. If good sperm production is found, then it is clear that production of sperm is not the issue, but the delivery of it into the ejaculate is. If other blockages are ruled out, a bypass of the blockage can be performed. This is called a vasoepididymostomy (because the vas deferens is reconnected to the epididymis.) As we've discussed in other sections, it's important that a skilled specialist, experienced with this type of surgery, perform this operation.
If the obstruction cannot be repaired, there are still options available. Sperm may be retrieved from the scrotum. This can be done in a number of ways. It can be done with a needle into the testis, or an incision in the testis. Most commonly a Microscopic Epididymal Sperm Aspiration (MESA) is done to get sperm from the epididymis. There are two advantages to this procedure over retrieval of sperm from the testis. The first is that the sperm are more mature, and thus usually have better motility (movement). The second is that there are significantly more sperm in the epididymis than the testis. This is because the ducts within the testis have collected the sperm already and delivered them into the epididymis. Often, the sperm retrieved through MESA can be frozen and used in multiple IVF cycles.
Sperm retrieved from the testis or epididymis may be used to attempt conception for couples using in-vitro fertilization (IVF) combined with intracytoplasmic sperm insertion (ICSI). IVF means that the eggs are retrieved from the woman. ICSI means that the sperm are injected directly in an egg.
Fortunately, an epididymal obstruction does not mean you have untreatable infertility. There are a number of options available to patients suffering from the blockage. A male infertility specialist will be able to review treatment options with the patient and provide the greatest likelihood of success.
An epididymal obstruction is treatable and we can help. Contact us today for more information or to schedule a consultation or appointment.