Editing Infertility: Management (section)

===Vasography===
*'''Absolute indications (must have all 3):'''
*#'''Azoospermia'''
*#'''Complete spermatogenesis with many mature spermatids on testis biopsy'''
*#'''At least one palpable vas'''
*Relative indications:
*#Severe oligospermia with normal testis biopsy
*#High level of sperm-bound antibodies, which indicates unilateral, bilateral, or partial obstruction
*#Low semen volume and very poor sperm motility (partial ejaculatory duct obstruction)
*The following diagnoses can be made with radiographic vasography
**Inguinal vasal obstruction
**Ejaculatory duct obstruction
**Seminal vesicle agenesis
**Partial agenesis of vasa deferentia
*'''If testis biopsy reveals normal spermatogenesis and the vasa are palpable,''' '''vasography, if necessary, should be performed only at the time of definitive repair of obstruction'''
**There is no need to perform vasography at the time of testis biopsy for azoospermia unless immediate reconstruction is planned and the touch or wet prep biopsy reveals mature sperm with tails.
*'''Technique of Vasography and Interpretation of Findings'''
**'''Any fluid exuding from the lumen is placed on a slide''', mixed with a drop of saline, and sealed with a coverslip for microscopic examination.
**'''If motile sperm are found in the vas''', the testicular end should be gently barbotaged with 0.2 mL of human tubal fluid medium, and '''the fluid processed by the andrology laboratory for sperm cryopreservation''' for potential future use for IVF and ICSI.
***'''Never inject fluid in direction of epididymis under pressure as it may rupture the epididymal tubules'''
***'''Always sample vasal fluid first to allow cryopreservation of motile sperm if found;''' '''this should be done before injection with indigo carmine or x-ray contrast''' '''material'''  
****'''Use indigo carmine instead of methylene blue to confirm patency; methylene blue kills sperm'''
****'''Vasography with radiographic contrast media with intraoperative radiography is rarely indicated; formal vasography with x-ray contrast is needed only to locate obstructions proximal to the internal inguinal ring'''
*****'''Vasography may reveal the vas deferens ending blindly,''' far from the ejaculatory ducts. '''This finding indicates congenital partial absence of the vas deferens and warrants testing for cystic fibrosis mutations'''
**'''If a large amount of fluid is found in the vasal lumen and microscopic examination reveals the presence of sperm, the obstruction is toward the seminal vesical end of the vas'''
**'''If the vasal fluid is devoid of sperm with repeated sampling after milking the epididymis and convoluted vas, epididymal obstruction is present.'''
*'''Complications'''
**Stricture
**Injury to the vasal blood supply
**Hematoma
**Sperm granuloma