Laparoscopically assisted microsurgical vasovasostomy for obstructive azoospermia following bilateral inguinal hernia repair: a case series

Background: Obstructive azoospermia (OA) is a significant cause of male infertility, with iatrogenic vas deferens injury after bilateral inguinal hernia repair representing a rare etiology. Outcomes of microsurgical vasovasostomy (VV) in this setting remain poorly defined.
Methods: We conducted a retrospective case series of five patients with OA following bilateral inguinal hernia repair who underwent attempted laparoscopically assisted microsurgical VV. Inclusion criteria were azoospermia confirmed on at least two semen analyses, normal serum FSH and testosterone, preserved testicular volume, and female partners without major reproductive comorbidities. Demographic data, operative details, postoperative semen parameters, patency, and reproductive outcomes (spontaneous conception and assisted reproductive techniques – ART) were descriptively analyzed. Patency was defined as the presence of sperm in the ejaculate.
Results: Median patient age was 39 years (range 35-41), and median partner age was 35 years (range 30-40). Obstruction intervals ranged from 4 to 12 years. Four patients underwent laparoscopic dissection and bilateral VV (three two-layer, one one-layer), while one could not undergo anastomosis due to technical constraints. Operative times ranged from 150 to 420 minutes. One patient reported transient scrotal pain not requiring analgesia. Postoperative patency was achieved in three of the four anastomosed patients (75%), with sperm concentrations ranging from 3.0 Å~106/mL to 41 Å~106/mL. Four pregnancies were obtained: three through assisted reproductive techniques (ART) and one spontaneous. Among the ART cases, two required surgically retrieved sperm (patients without patency), whereas one used ejaculated sperm following VV. Importantly, a spontaneous pregnancy occurred in the patient with the highest postoperative sperm concentration (41 Å~106/mL) after a one-layer anastomosis.
Conclusions: In this small case series, laparoscopically assisted VV proved technically feasible and allowed restoration of vasal patency in selected patients with OA after bilateral hernia repair. Beyond the potential for natural conception, this approach may facilitate the use of ejaculated sperm for ART, avoiding surgical sperm retrieval in selected cases. These findings reinforce the dual role of VV: restoring natural fertility in some patients and providing ejaculated sperm for ART in others.