Vasectomy reversal

Vasectomy Regret or Lack Thereof

Background

Vasectomy is a procedure that results in permanent yet reversible sterility and remains a great contraceptive option for many. Previous research studies have highlighted frequency of vasectomy utilization, defining characteristics of individuals who opt for this method, various surgical techniques, and the risks and benefits associated with the procedure. What remains to be defined is why or why not individuals may experience post-vasectomy regret and whether the previous characteristics correlate.

Objective

The objective of this review is to synthesize information regarding reasons individuals may regret their vasectomy and seek reversal, what options exist for accomplishing the reversal, and patients' fertility prognosis post-vasovasostomy.

Methods

This review utilized a combination of secondary and tertiary data analysis across a wide scope of academic databases pertaining to the topic of interest.

Results

Typically, most males who have sought a vasectomy are satisfied with their decision, however, approximately 6% of this population seeks reversal. Key factors influencing vasectomy regret include age at the time of vasectomy, parental status, pre- and post-operative relationship status, unresolved physical and psychosexual problems, and development of chronic scrotal pain following the procedure. Few options exist for vasectomy reversal including microsurgical reconstructive vasectomy reversal (VR) and sperm extraction for in vitro fertilization. There is no guarantee that fertility will be restored in any case but a major predictive factor for success is the time interval prior to reversal.

Conclusion

Vasectomy is intended to be a permanent form of contraception; however, a minor chance remains that individuals may experience post-operative regret due to various factors. This warrants proper comprehensive counseling by the patient's provider regarding benefits and risks, procedural outcomes, opportunities for reversal, and fertility prognosis.

Factors impacting couples' decision-making between vasectomy reversal versus sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection

The purpose of this study was to identify factors which impact a couples’ decision‐making between the options of vasectomy reversal vs. sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection when counseled both by a reproductive urologist and a reproductive endocrinologist. A retrospective chart review was performed of couples who wish to achieve a pregnancy with a male partner with a history of prior vasectomy, in a couples’ private fertility center. Of patients presenting for fertility options with a history of vasectomy, 175 couples elected to be counseled by both a reproductive urologist and a reproductive endocrinologist on the options between vasectomy reversal and sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection, with 78.3% of the couples opting for vasectomy reversal and 21.7% opting for sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection. The overall mean age of the male partners was 40.5 years of age, and the mean age of the female partners was 33. The mean obstructed interval was 9.7 years. Twenty‐three percent of the female partners in couples selecting vasectomy reversal had diminished ovarian reserve, and 31.6% of couples selecting sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection had female partners with diminished ovarian reserve, two of which elected to have donor oocyte in vitro fertilization/intracytoplasmic sperm injection. Male age, female age, and ovarian reserve status did not have significant roles in this decision‐making (p value 0.3578, 0.1185, and 0.3041, respectively); however, a longer obstructed interval since vasectomy was a significant factor associated with couples opting for sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection (0.0238). In this study, the majority of couples who were counseled on vasectomy reversal vs. sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection by a reproductive urologist and reproductive endocrinologist chose vasectomy reversal. Neither male partner age, female partner age, nor ovarian reserve status seemed to impact the decision; however, a longer obstructed interval was a significant factor that was associated with the decision of couples toward sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection rather than vasectomy reversal.

Contemporary outcomes of seminal tract re-anastomoses for obstructive azoospermia: a nationwide Japanese survey

OBJECTIVES

To evaluate current outcomes of seminal tract re-anastomoses in Japan, and to compare them with historical data.

METHODS

A total of 213 patients with obstructive azoospermia who underwent seminal tract re-anastomosis from April 2008 to March 2012 at 25 institutions were enrolled in the present study. The outcomes of the procedure were compared with those reported in a previous multi-institutional study carried out in 2000.

RESULTS

The percentage of partners aged over 35 years was 37%. A microsurgical double-layer anastomosis was carried out 83.0% of the time. Sperm were observed in ejaculate postoperatively in 68.9% and 41.5% of patients who underwent a vasovasostomy or a vasoepididymostomy, respectively. Natural conception occurred in 27.5% of patients after a vasectomy and 32.3% of patients with an epididymal obstruction. Except for the ratio of natural conception in patients with vasal obstruction after herniorrhaphies, there were no significant differences in final ratios of sperm appearance and natural conception between the previously reported study and the present study.

CONCLUSIONS

Compared with historical data, contemporary seminal tract re-anastomosis in Japan seems to provide equivalent or better outcomes, depending on the cause of obstruction. Seminal tract re-anastomosis is a valid treatment option for patients with obstructive azoospermia.

The significance of sperm heads and tails within the vasal fluid during vasectomy reversal

INTRODUCTION

The finding of only sperm heads and/or short tails (SHST) during vasectomy reversal (VR) creates a difficult decision for the best method of vasal reconstruction, i.e. vasovasostomy (VV) or epididymovasostomy (EV). Using outcome analyses, we report the impact of SHST alone and combined with qualitative analysis of gross fluid quality in predicting successful VR.

MATERIALS AND METHODS

The records of 356 men who underwent VR by a single surgeon from 2005 to 2012 were retrospectively reviewed. Intravasal fluid was assessed for gross quality (i.e., clear, opaque, pasty or creamy) as well as microscopic composition (i.e., motile or non-motile whole sperm, SHST or no sperm). The post-operative patency rates and semen analysis parameters were assessed.

RESULTS

Fourteen men (3.9%) demonstrated SHST bilaterally in the vasal fluid. The median duration from vasectomy was 6.0 years (interquartile range 4.0-9.8). Bilateral VVs were performed on 12 men (86%), while two men (14%) had a unilateral VV and a contralateral EV. Of the 26 vasa undergoing VR, the majority of the fluid quality was classified as creamy (n = 20 vasa, 76.9%). The remaining fluid was classified as pasty (n = 3 vasa, 11.5%), opaque (n = 2 vasa, 7.7%) and clear (n = 1 vasa, 3.8%). In cases undergoing bilateral VV with only SHST, patency rates were 90.9%, and both cases of unilateral EV were patent (100%).

CONCLUSIONS

VV was successful in 90.9% of patients undergoing VR in the setting of SHST alone. Even when creamy or pasty fluid was present, the results surpassed the expected patency rate for an EV. Therefore, the presence of only SHST, regardless of fluid quality, should not dissuade the surgeon from performing a VV.

CONCLUSIONS

VV was successful in 90.9% of patients undergoing VR in the setting of SHST alone. Even when creamy or pasty fluid was present, the results surpassed the expected patency rate for an EV. Therefore, the presence of only SHST, regardless of fluid quality, should not dissuade the surgeon from performing a VV.

Robotic assisted andrological surgery

The introduction of the operative microscope for andrological surgery in the 1970s provided enhanced magnification and accuracy, unparalleled to any previous visual loop or magnification techniques. This technology revolutionized techniques for microsurgery in andrology. Today, we may be on the verge of a second such revolution by the incorporation of robotic assisted platforms for microsurgery in andrology. Robotic assisted microsurgery is being utilized to a greater degree in andrology and a number of other microsurgical fields, such as ophthalmology, hand surgery, plastics and reconstructive surgery. The potential advantages of robotic assisted platforms include elimination of tremor, improved stability, surgeon ergonomics, scalability of motion, multi-input visual interphases with up to three simultaneous visual views, enhanced magnification, and the ability to manipulate three surgical instruments and cameras simultaneously. This review paper begins with the historical development of robotic microsurgery. It then provides an in-depth presentation of the technique and outcomes of common robotic microsurgical andrological procedures, such as vasectomy reversal, subinguinal varicocelectomy, targeted spermatic cord denervation (for chronic orchialgia) and robotic assisted microsurgical testicular sperm extraction (microTESE).

Increased sperm DNA fragmentation in patients with vasectomy reversal has no prognostic value for pregnancy rate

PURPOSE

We evaluated sperm DNA fragmentation in patients with vasectomy reversal and its prognostic value to determine spontaneous and assisted reproductive technique pregnancy rates.

MATERIALS AND METHODS

We prospectively assessed DNA fragmentation with the sperm chromatin structure assay in postoperative semen samples of 70 patients with vasectomy reversal. At a median +/- SD followup of 4.3 +/- 0.5 years pregnancy rates were recorded.

RESULTS

DNA fragmentation in patients with vasectomy reversal was significantly increased vs that in proven fertile controls (30.2% +/- 20.1% vs 15.3% +/- 5.4%, p <0.001). Significant negative correlations were found between DNA fragmentation index and total sperm count, progressive motility, total number of progressive sperm, normal morphology and sperm vitality (-0.325 <r <-0.805). The obstructive interval did not correlate with DNA fragmentation. The spontaneous pregnancy rate was 46%. Significantly higher log total progressive sperm motility (p = 0.021) and a trend toward lower female age (p = 0.064) were detected in the spontaneous vs the no pregnancy group. No association was found between DNA fragmentation and the pregnancy rate.

CONCLUSIONS

Increased DNA fragmentation is present in semen samples of men after vasectomy reversal vs fertile controls but DNA fragmentation is not associated with spontaneous or assisted reproductive technique pregnancy rates in these patients.