A 25-year-old married male presents with infertility. He had undergone retroperitoneal lymph node dissection at age of 15 years for embryonal carcinoma of right testis. Semen analysis shows-quantity-0.5 ml, no. sperm, no fructose. Biopsy of testis shows normal spermatogenesis. Best treatment here would be –
**Reconstructive Surgery for Obstruction**
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**Core Concept**
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Infertility in this patient is likely due to obstruction of the vas deferens, which was likely damaged during the retroperitoneal lymph node dissection (RPLND) surgery for embryonal carcinoma of the testis. The absence of fructose in the semen, which is produced by the seminal vesicles, further supports this diagnosis. The normal spermatogenesis on testicular biopsy indicates that the issue lies with the delivery of sperm rather than their production.
**Why the Correct Answer is Right**
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The correct answer is reconstructive surgery for the vas deferens obstruction. This involves rejoining the severed ends of the vas deferens to restore sperm transport. The epididymis, where sperm mature and are stored, is also involved in the procedure. The surgeon will attempt to connect the vas deferens to the epididymis or another part of the reproductive tract to facilitate sperm delivery.
**Why Each Wrong Option is Incorrect**
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* **Option A:** Hormone replacement therapy would not address the physical obstruction of the vas deferens and would not be effective in this case.
* **Option B:** Testicular sperm extraction (TESE) or testicular sperm aspiration (TESA) may be considered for patients with obstructive azoospermia, but they are not the best initial treatment for this patient, who has a potentially correctable physical obstruction.
* **Option D:** In vitro fertilization (IVF) or intrauterine insemination (IUI) may be considered for patients with non-obstructive azoospermia or other forms of infertility, but they are not the best initial treatment for this patient, who has a potentially correctable physical obstruction.
**Clinical Pearl / High-Yield Fact**
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RPLND surgery can cause significant damage to the vas deferens and other structures in the retroperitoneum, leading to obstructive azoospermia. Patients who have undergone RPLND should be evaluated for vasal obstruction and considered for reconstructive surgery to restore fertility.
**Correct Answer: C.**