Heidenreich A, Altmann P, Neubauer S, Engelmann U H
Klinik und Poliklinik für Urologie, Medizinische Einrichtungen, Universität zu Köln.
Urologe A. 2000 May;39(3):240-5. doi: 10.1007/s001200050348.
WS represents the standard procedure of choice for the treatment of obstructive azoospermia following vasectomy. However, recently, ICSI has been suggested by some to represent the solution for all cases of male factor infertility regardless of its etiology based on its success rates. Therefore, we compared VVS to MESA/TESE and ICSI in terms of pregnancy, complications, and costs. Between 1/93 and 6/98 157 VVS was performed microsurgically using the 2-layer technique in 157 patients following prior vasectomy. Between 9/94 and 9/97 69 couples underwent MESA/ICSI for epididymal obstruction not amenable to micro-surgical reconstruction such as post-inflammatory obstruction and congenital absence of the vas deferens; in the same time period 42 couples underwent TESE/ICSI for azoospermia of testicular origin due to cryptorchidism, testicular atrophy, obstruction of the rete testis. In most cases MESA or TESE and ICSI were performed metachronously. Mean intervall of vasal obstruction was 7.6 (0.5-18) years; patency after VVS was 77%, pregnancy rate was 52%. Local complication rate was 4.7%, no major complications were observed. Costs per life birth after VVS were as high as 5,447,-DM or 2,800 Euro. Pregnancy rates after MESA/TESE and ICSI were 22.5% and 19.5%, respectively with 16 singletons, 3 twins and 3 abortions; local complications occurred in 3.9% of the men. Multiple birth were noticed in 15.8% following ICSI, but only in 0.7% following VVS. 5.7% and 1.4% of the female partners experienced serious complications as a mild or severe ovarian hyperstimulation-syndrome, respectively. Costs per life birth after MESA/TESE cycle were as high as 28,804,-DM or 14,100 Euro. Even in the era of ICSI microsurgical vasovasostomy represents the standard approach for obstructive azoospermia following vasectomy. Based on a cost-benefit analysis VVS is more successful in terms of pregnancy rates (52% vs. 22.5%). We conclude that MESA/ICSI should be reserved for patients not amenable for microsurgical reconstruction.
输精管吻合术（VVS）是输精管结扎术后梗阻性无精子症治疗的标准首选方法。然而，最近一些人认为，基于其成功率，卵胞浆内单精子注射（ICSI）可作为所有男性因素不育病例的解决方案，无论其病因如何。因此，我们比较了输精管吻合术（VVS）与睾丸细针抽吸精子结合卵胞浆内单精子注射（MESA/TESE+ICSI）在妊娠率、并发症和成本方面的差异。1993年1月至1998年6月，对157例输精管结扎术后患者采用双层技术进行了显微外科输精管吻合术（VVS）。1994年9月至1997年9月，69对夫妇因附睾炎梗阻（如炎症后梗阻和先天性输精管缺如）无法进行显微外科重建而接受了睾丸细针抽吸精子结合卵胞浆内单精子注射（MESA/ICSI）；同期，42对夫妇因隐睾、睾丸萎缩、睾丸网梗阻等睾丸源性无精子症接受了睾丸切开取精术结合卵胞浆内单精子注射（TESE/ICSI）。在大多数情况下，MESA或TESE与ICSI是分期进行的。输精管梗阻的平均间隔时间为7.6（0.5-18）年；输精管吻合术后的通畅率为77%，妊娠率为52%。局部并发症发生率为4.7%，未观察到重大并发症。输精管吻合术后每例活产的成本高达5447德国马克或2800欧元。MESA/TESE+ICSI后的妊娠率分别为22.5%和19.5%，有16例单胎、3例双胎和3例流产；3.9% 的男性出现局部并发症。ICSI后多胎出生率为15.8%，而输精管吻合术后仅为0.7%。5.7% 和1.4% 的女性伴侣分别经历了轻度或重度卵巢过度刺激综合征等严重并发症。MESA/TESE周期后每例活产的成本高达28804德国马克或14100欧元。即使在ICSI时代，显微外科输精管吻合术仍是输精管结扎术后梗阻性无精子症的标准治疗方法。基于成本效益分析，输精管吻合术在妊娠率方面更成功（52% 对22.5%）。我们得出结论，MESA/ICSI应保留给无法进行显微外科重建的患者。
