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Kadian B, Sharma AP, Rohilla M, Gorsi U, Kaur J, Mavuduru RS. Preoperative Predictors for the Presence of Motile Spermatozoa in the Epididymis and Patency of Anastomosis during Microsurgical Vasoepididymal Anastomosis in Patients with Obstructive Azoospermia. J Hum Reprod Sci 2023; 16:22-28. [PMID: 37305778 PMCID: PMC10256949 DOI: 10.4103/jhrs.jhrs_182_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 06/13/2023] Open
Abstract
Background Following microsurgical vaso-epididymal anastomosis (VEA), anastomotic patency with sperm returning to the ejaculate is not always present and may even be delayed. The presence of motile spermatozoa is highly suggestive of future patency following surgery. Aims We prospectively analyse the factors that could predict motile spermatozoa at the epididymis intraoperatively and predictors of patency in patients with obstructive azoospermia (OA) undergoing microsurgical VEA. Settings and Design Department of Urology of a tertiary care centre in Northern India. It is a prospective observational study. Materials and Methods Over a 2-year period (July 2019 to June 2021), 26 patients with idiopathic OA were enrolled in the study. Twenty patients underwent microsurgical VEA. Patients were divided into two groups based on the presence/absence of intraoperative motile spermatozoa. Statistical Analysis Used Analysis of preoperative and intraoperative factors was done using the Mann-Whitney U-test, Chi-squared test and Fischer exact test. Results Out of 20 patients, 5 (group 2) had intraoperative motile spermatozoa in the epididymal fluid and 15 (group 1) had nonmotile spermatozoa. Low luteinising hormone (LH) levels (P = 0.01) and high testosterone levels (P = 0.05) were the predictive of presence of motile spermatozoa in epididymal fluid. Mean follow-up was 9 months (6-18 months). Predictors of higher patency were grade 2 epididymis (firm, turgid and tense) (P = 0.003), low LH levels (P = 0.03), low sertoli cell index (P = 0.006), high sperm-Sertoli index (P = 0.002) and better surgeon satisfaction (P = 0.01). Conclusion Low LH levels and high testosterone levels may be predictive of the presence of motile spermatozoa in epididymal fluid. Firm, turgid and tense epididymis, low Sertoli cell index, high sperm-Sertoli index and surgeon satisfaction suggest a greater chance of success after VEA for idiopathic azoospermia.
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Affiliation(s)
| | | | - Manish Rohilla
- Department of Cytology and Gynecology Pathology, PGIMER, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | - Japleen Kaur
- Department of Obstetrics and Gynecology, AIMS, Sahibzada Ajit Singh Nagar, Punjab, India
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Degraeve A, Roumeguere T, Tilmans G, Marotta ML, Huyghe E, Fournier G, Faix A, Spinoit AF, Decaestecker K, Herve F, Boitrelle F, Lahdensuo K, Van Damme J. European Countries have different rates of sperm cryopreservation before vasectomy and at the time of reversal. Andrology 2022; 10:1286-1291. [PMID: 35396922 DOI: 10.1111/andr.13182] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/15/2022] [Accepted: 04/04/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Effective male contraceptive options are condoms and vasectomy. Vasectomy should not be considered as a reversible method of contraception even if vasovasostomy can be offered to men to restore fertility after vasectomy. Therefore, there is a real questioning among urologist concerning cryopreservation before vasectomy. We carried out an international survey concerning the practice of cryopreservation before vasectomy and during vasovasostomy. MATERIAL AND METHODS An online anonymous survey was submitted from January to June 2021 to 6 European urological societies. The 31-items questionnaire included questions about demography, habits of cryopreservation before vasectomy or during vasectomy reversal and in case of urogenital cancers. RESULTS 228 urologists from six urological societies in five different countries (Belgium, Netherlands, Luxembourg, France, Finland) answered the questionnaire. French urologists were more in favor of cryopreservation before vasectomy than other European urologists (p<0,0001). They also significantly found that not talking about cryopreservation before vasectomy is a medical fault unlike other urologists (p<0,0001). The specialization in andrology did not influence the choice of cryopreservation before vasectomy (p = 0,9452). The majority of urologists did not perform intraoperative sperm extraction during vasovasostomy (81%; n = 127) with a significant difference between urologists with or without andrology training (p = 0,0146). Success rates after vasovasostomy are significantly better for robot-assisted surgery (p = 0.0159) or with microscope (p = 0.0456) versus without microscope. CONCLUSION Cryopreservation before definitive sterilization significantly varies among European urologists and seems to be mostly dictated by habits than by knowledge. An international consensus is needed to standardize practices and guide patient's choice. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Amandine Degraeve
- Department of Urology, Centre Hospitalier Universitaire, Université Catholique de Louvain, Namur, Belgium
| | - Thierry Roumeguere
- Department of Urology, University Clinics Brussels, Erasme hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Gilles Tilmans
- Unit of Abdominal Surgery, Saint-Luc University Clinics, Université Catholique de Louvain, Brussels, Belgium
| | - Marie-Laura Marotta
- Department of Andrology, Centre Hospitalier Universitaire, Université Catholique de Louvain, Namur, Belgium
| | - Eric Huyghe
- Department of Urology - Kidney transplantation - Andrology - Rangueil Hopital, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Department of Reproductive Medicine, Paule de Viguier Hospital, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,UMR 1203 « DEFE » (Development - Embryo - Fertility - Environment) - INSERM - Université de Toulouse - Université de Montpellier, France
| | | | - Antoine Faix
- Department of Urology, Clinique Beau Soleil, Montpellier, France
| | | | | | - François Herve
- Department of Urology, Ghent University Hopsital, Ghent, Belgium.,Department of Urology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | - Florence Boitrelle
- Reproductive Biology, Fertility Preservation, Andrology, CECOS, Poissy Hospital, Poissy, France.,Paris Saclay University, UVSQ, INRAE, BREED, Jouy-en-Josas, France
| | - Kanerva Lahdensuo
- Department of Urology and Research Program in Systems Oncology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Julien Van Damme
- Department of Urology, Centre Hospitalier Universitaire, Université Catholique de Louvain, Namur, Belgium
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Fantus RJ, Halpern JA. Vasovasostomy and vasoepididymostomy: indications, operative technique, and outcomes. Fertil Steril 2021; 115:1384-1392. [PMID: 33926720 DOI: 10.1016/j.fertnstert.2021.03.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/29/2021] [Indexed: 12/26/2022]
Abstract
The basic principles of vasal reconstruction have endured since their initial description over a century ago, yet the nuances and technical approaches have evolved. Prior to performing vasectomy reversal, the clinician should perform a focused history, physical and laboratory assessment, all of which are critical for patient counseling and preoperative planning. Operative success is contingent on appropriate intraoperative decision making and technical precision in completing a tension-free, watertight, and patent anastomosis. Outcomes of vasectomy reversal differ on the basis of the type of reconstruction required, reconstructive technique, and patient-specific factors. Here we review the indications, surgical techniques, and outcomes of vasectomy reversal.
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Affiliation(s)
- Richard J Fantus
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joshua A Halpern
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Namekawa T, Imamoto T, Kato M, Komiya A, Ichikawa T. Vasovasostomy and vasoepididymostomy: Review of the procedures, outcomes, and predictors of patency and pregnancy over the last decade. Reprod Med Biol 2018; 17:343-355. [PMID: 30377390 PMCID: PMC6194271 DOI: 10.1002/rmb2.12207] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 04/22/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND In the era of improving assisted reproductive technology (ART), patients with obstructive azoospermia (OA) have 2 options: vasal repair or testicular sperm extraction with intracytoplasmic sperm injection. Vasal repair, including vasovasostomy (VV) and vasoepididymostomy (VE), is the only option that leads to natural conception. METHODS This article reviews the surgical techniques, outcomes, and predictors of postoperative patency and pregnancy, with a focus on articles that have reported over the last 10 years, using PubMed database searches. MAIN FINDINGS The reported mean patency rate was 87% and the mean pregnancy rate was 49% for a patient following microscopic VV and/or VE for vasectomy reversal. Recently, robot-assisted techniques were introduced and have achieved a high rate of success. The predictors and predictive models of postoperative patency and pregnancy also have been reported. The obstructive interval, presence of a granuloma, and intraoperative sperm findings predict postoperative patency. These factors also predict postoperative fertility. In addition, the female partner's age and the same female partner correlate with pregnancy after surgery. CONCLUSION In the era of ART, the physician should present and discuss with both the patient with OA and his partner the most appropriate procedure to conceive by using these predictors.
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Affiliation(s)
- Takeshi Namekawa
- Department of UrologyGraduate School of MedicineChiba UniversityChibaJapan
| | - Takashi Imamoto
- Department of UrologyGraduate School of MedicineChiba UniversityChibaJapan
| | - Mayuko Kato
- Department of UrologyGraduate School of MedicineChiba UniversityChibaJapan
| | - Akira Komiya
- Department of UrologyGraduate School of MedicineChiba UniversityChibaJapan
| | - Tomohiko Ichikawa
- Department of UrologyGraduate School of MedicineChiba UniversityChibaJapan
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How good is good enough? Defining normal semen parameters after vasectomy reversal. Fertil Steril 2017; 107:905. [PMID: 28366417 DOI: 10.1016/j.fertnstert.2017.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/02/2017] [Indexed: 11/21/2022]
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Kavoussi PK. Vasectomy reversal: A review of the evaluation, techniques, and outcomes. World J Clin Urol 2015; 4:48-55. [DOI: 10.5410/wjcu.v4.i1.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 01/20/2015] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
This review highlights the evaluation and treatment of men who have undergone vasectomy and desire vasectomy reversal to father children. For surgeons offering this treatment, the appropriate evaluation and treatment are crucial for acceptable outcomes. Although variations on surgical approaches have evolved over the years, one constant is the need for a high level of training and skill in microsurgical techniques.
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Wosnitzer M, Goldstein M, Hardy MP. Review of Azoospermia. SPERMATOGENESIS 2014; 4:e28218. [PMID: 25105055 PMCID: PMC4124057 DOI: 10.4161/spmg.28218] [Citation(s) in RCA: 160] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 02/13/2014] [Accepted: 02/13/2014] [Indexed: 01/29/2023]
Abstract
Azoospermia is classified as obstructive azoospermia (OA) or non-obstructive azoospermia (NOA), each having very different etiologies and treatments. The etiology, diagnosis, and management of azoospermia were reviewed and relevant literature summarized. Differentiation between these two etiologies is of paramount importance and is contingent upon thorough history and physical examination and indicated laboratory/genetic testing. OA occurs secondary to obstruction of the male reproductive tract, and is diagnosed through a combination of history/physical examination, laboratory testing, genetics (CFTR for congenital OA), and imaging studies. NOA (which includes primary testicular failure and secondary testicular failure) is differentiated from OA by clinical assessment (testis consistency/volume), laboratory testing (FSH), and genetic testing (karyotype, Y chromosome microdeletion, or specific genetic testing for hypogonadotropic hypogonadism). For obstructive azoospermia, management includes microsurgical reconstruction when feasible using microsurgical vasovasostomy or vasoepididymostomy. Microsurgical epididymal sperm aspiration with in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) is utilized for those cases not amenable to reconstruction. NOA management includes medical management for congenital hypogonadotropic hypogonadism and microdissection testicular sperm extraction with IVF/ICSI for appropriate candidates based on laboratory/genetic testing. Overall, this important review provides an updated summary of the most recent available literature describing etiology, diagnosis, and management of azoospermia.
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Affiliation(s)
- Matthew Wosnitzer
- Department of Urology and Institute for Reproductive Medicine; Weill Cornell Medical College of Cornell University; New York, NY USA
| | | | - Matthew P Hardy
- Department of Urology and Institute for Reproductive Medicine; Weill Cornell Medical College of Cornell University; New York, NY USA ; Director of the Center for Male Reproductive Medicine and Microsurgery; Weill Cornell Medical College of Cornell University; New York, NY USA ; Center for Biomedical Research; The Population Council; New York, NY, USA
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Abstract
Up to 6% of men who have undergone vasectomy will ultimately elect for reversal in the form of vasovasostomy or vasoepididymostomy for various reasons. Vasovasostomy performed to regain fertility is a technique that has undergone numerous advances during the last century, including the use of microsurgical equipment and principles to construct a meticulous anastomosis. It is important during vasovasostomy to ensure good blood supply to the anastomosis as well as to build as a tension-free anastomosis. Visual inspection to ensure healthy mucosa and inner muscularis as well as atraumatic handling of tissues is helpful. With vasovasostomy, it is essential to create a watertight anastomosis to prevent secondary scar formation. The microdot technique of vasovasostomy allows for markedly discrepant lumens to be brought together more precisely. Thereby, the planning is separated from suture placement, which prevents dog-ears and avoids subsequent leaks. In the age of in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI), it becomes even more important to clarify outcomes after vasectomy reversals, as patients now have a choice between surgical sperm retrieval coupled with IVF/ICSI versus vasectomy reversal. Little data on long-term outcomes for vasectomy reversals exist. Therefore, further research in this field needs to evaluate the rate of late failures and the predictors of late failures.
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Grey BR, Thompson A, Jenkins BLD, Payne SR. UK practice regarding reversal of vasectomy 2001-2010: relevance to best contemporary patient management. BJU Int 2012; 110:1040-7. [PMID: 22321163 DOI: 10.1111/j.1464-410x.2011.10853.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
UNLABELLED Study Type - Practice trends (survey) Level of Evidence 2c What's known on the subject? and What does the study add? Approximately 6% of men who have had a vasectomy subsequently decide to have it reversed. For such men there are various options available, including vasal reconstruction, surgical sperm retrieval with assisted reproductive techniques, use of donated sperm or adoption. The decision-making process with regard to the most appropriate management is challenging and the urologist requires both an intimate knowledge of the advantages and disadvantages of each of the available options and the opportunity to counsel a couple appropriately. The study confirms that patient management after previous vasectomy is a complex process, demanding detailed knowledge about the availability and outcomes of alternatives to vasectomy reversal. It recommends that couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome and the available management options and their costs. Urologists should also have appropriate facilities to offer intra-operative demonstration of and, potentially, storage of sperm. OBJECTIVES To review the management of men presenting for reversal of vasectomy amongst consultant members of the British Association of Urological Surgeons (BAUS) between 2001 and 2010. • To make recommendations for contemporary practice. SUBJECTS AND METHODS Three consecutive questionnaire-based surveys were undertaken by BAUS consultant members in 2001, 2005 and 2010. • Standard questionnaires were sent on each occasion asking urologists about their counselling of couples regarding options in achieving a conception, expectation of outcome from reconstructive surgery and the techniques of vaso-vasostomy used. • In 2005 additional information was obtained about the availability of fertility treatments and sub-specialization of the urologist and in 2010 about the eligibility criteria for in-vitro fertilization (IVF) treatment and synchronous sperm retrieval. RESULTS Overall there was a 47% response rate with >80% of respondents still performing vaso-vasostomy. • More than 75% of respondents were doing <15 procedures a year and <50% of respondents counselled couples about other management options. • Only 41% gave their personalized outcomes from vaso-vasostomy, whilst >80% were using some form of magnification intra-operatively. • Members of the BAUS section of andrology were more likely to discuss options for becoming a parent and criteria for IVF treatment, to present their individualized outcomes from vaso-vasotomy and to carry out >15 procedures a year than urologists with no andrological affiliation. CONCLUSIONS • Patient management after previous vasectomy is a complex process necessitating detailed knowledge concerning the availability and outcomes of alternatives to vaso-vasostomy. • Couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome. • Vaso-vasostomy should no longer be seen as a procedure within the remit of any adequately trained urologist but as one option to be considered by a sub-specialist with access to appropriate micro-surgical training and assisted reproductive technologies.
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Affiliation(s)
- Benjamin R Grey
- Department of Urology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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