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10.6.1.2 Diagnostic evaluation
10.6.1.2.1 Clinical history
Clinical history-taking should follow the investigation and diagnostic evaluation of infertile men (See Section
10.3). Risk factors for obstruction include prior surgery, iatrogenic injury during inguinal herniorrhaphy,
orchidopexy or hydrocelectomy.

10.6.1.2.2 Clinical examination
Clinical examination should follow the guidelines for the diagnostic evaluation of infertile men. Obstructive
azoospermia is indicated by at least one testis with a volume > 15 mL, although a smaller volume may be
found in some patients with:
• obstructive azoospermia and concomitant partial testicular failure;
• enlarged and dilated epididymis;
• nodules in the epididymis or vas deferens;
• absence or partial atresia of the vas deferens.

10.6.1.2.3 Semen analysis
Azoospermia means the inability to detect spermatozoa after centrifugation at ×400 magnification. At least
two semen analyses must be carried out [1828, 1852] (see Section 10.3). When semen volume is low, a search
must be made for spermatozoa in urine after ejaculation. Absence of spermatozoa and immature germ cells in
the semen pellet suggest complete seminal duct obstruction.

10.6.1.2.4 Hormone levels
Hormones including FSH and inhibin-B should be normal, but do not exclude other causes of testicular
azoospermia (e.g., NOA). Although inhibin-B concentration is a good index of Sertoli cell integrity reflecting
closely the state of spermatogenesis, its diagnostic value is no better than that of FSH and its use in clinical
practice has not been widely advocated [1853].

10.6.1.2.5 Genetic Testing
Inability to palpate one or both sides of the vas deferens should raise concern for a CFTR mutation. Any patient
with unilateral or bilateral absence of the vas deferens or seminal vesicle agenesis should be offered CFTR
testing [1854].

10.6.1.2.6 Testicular biopsy
Testicular biopsy must be combined with TESE for cryopreservation. Although studies suggest that a
diagnostic or isolated testicular biopsy [1855] is the most important prognostic predictor of spermatogenesis
and sperm retrieval, the Panel recommends not to perform testis biopsies (including fine needle aspiration
[FNA]) without performing simultaneously a therapeutic sperm retrieval, as this will require a further invasive
procedure after biopsy. Furthermore, even patients with extremes of spermatogenic failure (e.g., Sertoli Cell
Only syndrome [SCOS]) may harbour focal areas of spermatogenesis [1856, 1857].

10.6.1.3 Disease management
Sperm retrieval
10.6.1.3.1 Intratesticular obstruction
Only TESE allows sperm retrieval in these patients and is therefore recommended.

10.6.1.3.2 Epididymal obstruction
Microsurgical epididymal sperm aspiration (MESA) or percutaneous epididymal sperm aspiration (PESA) [1858]
is indicated in men with CBAVD. Testicular sperm extraction and percutaneous techniques, such as testicular
sperm aspiration (TESA), are also options [1859]. The source of sperm used for ICSI in cases of OA and the
aetiology of the obstruction do not affect the outcome in terms of fertilisation, pregnancy, or miscarriage
rates [1860]. Usually, one MESA procedure provides sufficient material for several ICSI cycles [1861] and
it produces high pregnancy and fertilisation rates [1862]. In patients with OA due to acquired epididymal
obstruction and with a female partner with good ovarian reserve, microsurgical epididymovasostomy (EV) is
recommended [1863]. Epididymovasostomy can be performed with different techniques such as end-to-site
and intussusception [1864].

Anatomical recanalisation following surgery may require 3-18 months. A recent systematic review indicated
that the time to patency in EV varies between 2.8 to 6.6 months. Reports of late failure are heterogeneous and
vary between 1 and 50% [1865]. Before microsurgery, and in all cases in which recanalisation is impossible,
epididymal spermatozoa should be aspirated intra-operatively by MESA and cryopreserved to be used for

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