Systems Biology in Reproductive Medicine

ISSN: 1939-6368 (Print) 1939-6376 (Online) Journal homepage: https://www.tandfonline.com/loi/iaan20

Obstructive azoospermia caused by low ligation of

varicocele: A case report

Jun Hagiuda, Hiromichi Ishikawa, Masayuki Hagiwara, Hidaka Kono, Ken

Nakagawa & Mototsugu Oya

To cite this article: Jun Hagiuda, Hiromichi Ishikawa, Masayuki Hagiwara, Hidaka Kono,
Ken Nakagawa & Mototsugu Oya (2017) Obstructive azoospermia caused by low ligation of
varicocele: A case report, Systems Biology in Reproductive Medicine, 63:5, 338-339, DOI:
10.1080/19396368.2017.1350769

To link to this article: https://doi.org/10.1080/19396368.2017.1350769

Published online: 03 Aug 2017.

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SYSTEMS BIOLOGY IN REPRODUCTIVE MEDICINE
2017, VOL. 63, NO. 5, 338–339
https://doi.org/10.1080/19396368.2017.1350769

CLINICAL CORNER: CASE REPORT

Obstructive azoospermia caused by low ligation of varicocele: A case report

Jun Hagiudaa, Hiromichi Ishikawaa, Masayuki Hagiwaraa, Hidaka Konoa, Ken Nakagawaa, and Mototsugu Oyab
a
Department of Urology, Ichikawa General Hospital, Tokyo Dental College, Chiba, Japan; bDepartment of Urology, School of Medicine, Keio
University, Tokyo, Japan

ABSTRACT ARTICLE HISTORY

Varicocele is commonly observed in male partners of infertile couples. The surgical ligation of Received 10 April 2017
varicoceles under microscopy can be safely performed by a skilled andrologist with most patients Revised 26 May 2017
subsequently experiencing an improvement in semen quality. This is the first case in which Accepted 28 May 2017
obstructive azoospermia occurred after high inguinal varicocelectomy. The vas deferens was KEYWORDS
disrupted near the internal inguinal ring by fibrous tissue. A vasovasostomy was performed and Low ligation; obstructive
semen parameters subsequently recovered. azoospermia;
varicocelectomy

Introduction
Varicocelectomies are widely performed in male
patients of infertile couples who show abnormal
semen parameters. The varicocele is ligated at the ingu-
inal or subinguinal level under surgical microscopy.
Commonly, during the procedure, the vas deferens,
including the accompanying blood vessels, is first iso-
lated. Therefore, there rarely is damage to the vas
deferens. Herein, we report a rare and unfortunate
case in which obstructive azoospermia developed after
an inguinal varicocelectomy was performed.
Case report
A 29-year-old male was admitted to our hospital for
treatment of azoospermia. One year prior, the patient
had been visiting another clinic with his wife over a
period of two years, during which they had complained
of infertility. His right testis was congenitally atrophic
and he had a left varicocele. His semen parameters were
indicative of oligozoospermia. Prior to varicocelectomy,
the couple used intrauterine insemination which
resulted in a pregnancy. He underwent an inguinal
microsurgical varicocelectomy in another hospital.
One year later, he visited the former clinic hoping for
a second child; however, the semen analysis indicated
azoospermia.
The right testis was impalpable and the size of the
left testis was 18 mL, which was calculated using a
punched-out orchidometer. No varicocele was found
as determined by palpation and ultrasonography. The
semen analyses, which were conducted in our hospital
according to the World Health Organization laboratory
manual [WHO 2010], were also indicative of azoosper-
mia (Table 1). To confirm the existence of sperm,
conventional testicular sperm extraction was performed
and pathological examination indicated a Johnsen’s
score count of 7 (score for assessing the spermatogen-
esis; score 7 represents no spermatozoa but many sper-
matids observed) [Johnsen 1970]. Additionally,
vasogram revealed that the duct was disrupted at the
inguinal canal (Figure 1). We speculated that the vas
deferens had become obstructed after the varicocelect-
omy. Therefore, a vasovasostomy was subsequently
performed. The inguinal canal was opened through
the same skin incision of the former varicocelectomy.
The testicular side of vas deferens was easily identified,
while the more abdominal side of the vas deferens was
disrupted over a length of 2 cm and exhibited severe
inflammation and scar tissue near the internal inguinal
ring. Vas deferens-like structure or ligated suture was
not found in this area. The seminal vesicle side of the
vas deferens was found adjacent to the internal inguinal
ring. To avoid the tension at the anastomosis site due to
the high obstruction point and shortened vas deferens,
we isolated the seminal vesicle side of the vas deferens
from surrounding tissue and pulled out as possible.
After trimming the scar tissue, they were re-anasto-
mosed in a double layer under surgical microscopy
using 8-0 and 9-0 nylon. Post-operative semen analyses
were performed several times, with sperm being
observed in the semen (Table 1). Presently, this couple

CONTACT Jun Hagiuda junhagi@hotmail.com Department of Urology, Ichikawa General Hospital, Tokyo Dental College, 5-11-13 Sugano, Ichikawa,
Chiba 272-8513, Japan.
© 2017 Taylor & Francis

Table 1. Semen analyses.
Semen
Date (mL)
Before varicocelectomy* 2.6
Before VV 2.1
3 months after VV 4.1
4 months after VV 3.7
5 months after VV 4.0
*Semen analyses performed in former clinic; VV: vasovasostomy.
Figure 1. Vasogram. The duct was disrupted near the left
internal inguinal ring (arrow).
is attempting to conceive naturally. The informed con-
sent was obtained from the patient for submitting the
article.
Discussion
Varicocele repair is an important and useful treatment
method that can improve the semen parameters of male
infertile patients. Although it requires experience to
perform the techniques of inguinal or subinguinal liga-
tion under surgical microscopy, the safety of the pro-
cedure is evidenced by its low rate of complication.
Currently, there have been a few documented compli-
cations associated with the procedure, such as hydro-
cele formation, artery damage, or recurrence of
varicocele; however, this is the first report that varico-
celectomy caused the obstruction of vas deferens.
During the procedure, most surgeons may identify
and isolate the vas deferens along with the vassal veins
and arteries when they first open the external and
internal spermatic fascia. Therefore, ligation of the vas
deferens rarely occurs. Kordzadeh et al. [2017] sug-
gested that dissection and tissue handling, rather than
SYSTEMS BIOLOGY IN REPRODUCTIVE MEDICINE 339
Concentration Motility Morphology
(106/mL) (%) (%)
800 66
0 0 0
1800 2.2 1.8
2700 24.4 2.0
5500 25.5 2.7
the interaction or inflammatory response of mesh, are
related to damaging the vas deferens in their review of
male infertility following inguinal hernia. Shiraishi and
Matsuyama [2014] discussed in their report that dena-
turation following exposure to heat produced by mono-
polar or bipolar electrocautery could damage the vas
deferens in herniorrhaphy during childhood. In our
case, because we could not find any sutures around
the obstruction point, we suspected that disruption of
the vas deferens may be caused by indirect tissue
damage around the duct during a dissection or hemos-
tasis procedure involving electrocautery.
Microsurgical inguinal or subinguinal varicocele
treatments are common operations, which is due, in
part, to its safety and low rate of complication.
However, careful handling of the vas deferens is neces-
sary to avoid adverse outcomes and instead improve
the semen parameters of male partners of infertile
couples.
Declaration of interest
The authors declare that they have no conflict of interest.
Notes on contributors
Collected samples: JH, HI; Wrote the manuscript: J H. All
authors contributed to the discussion and have read and
approved the final version of the paper.
References
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WHO (2010) WHO laboratory manual for the examination
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