Outcomes of vasectomy reversal performed for men with the same female partners

Expression of the pro-inflammatory P2Y14 receptor in the non-vasectomized and vasectomized human epididymis

BACKGROUND

Vasectomy causes spermatozoa accumulation in the epididymis, which may cause epididymitis. Inflammation is triggered by alert molecules released following tissue stress or injury. These include UDP-glucose, which activates the pro-inflammatory P2Y14 receptor (P2Y14), and induces immune cell recruitment. However, little is known about P2Y14 in the epididymis and its potential activation following vasectomy.

OBJECTIVES

(i) to localize P2Y14 in the human excurrent duct; and (ii) to examine the effect of vasectomy on P2Y14 protein and P2RY14 mRNA content, the production of selected cytokines and chemokines, and immune cell recruitment in the epididymis.

MATERIAL AND METHODS

in situ hybridization, qRT-PCR, western blotting, immunohistochemistry and immunofluorescence were performed in banked human epididymis samples.

RESULTS

P2RY14 mRNA and P2Y14 protein were detected in epithelial cells in the efferent duct, epididymis and vas deferens in non-vasectomized men. Keratin 5 (KRT5)-positive basal cells were strongly labeled for P2Y14 in all epididymal segments. A progressive apical localization was detected in principal cells (negative for the proton pump V-ATPase) from the corpus to the cauda. A subset of V-ATPase-positive clear cells also showed strong P2Y14 labeling. Vasectomy induced an increase in P2RY14 mRNA in the corpus and cauda, and stronger apical labeling in principal cells in the corpus. CXCL10 mRNA increased in the cauda and CCL2 mRNA decreased in the corpus of vasectomized versus non-vasectomized men. No change in IL-8 and IL-1β mRNA was detected. Numerous CD45⁺ leukocytes were detected in the interstitium of the corpus and cauda following vasectomy, while only a few were seen in non-vasectomized men. Several CD45⁺ leukocytes, some of which containing spermatozoa, were detected in the corpus lumen following vasectomy.

DISCUSSION AND CONCLUSION

Our study indicates that vasectomy-induced spermatozoa congestion may lead to an inflamed-prone local environment characterized by potential activation of P2Y14 and recruitment of immune cells in the epididymis. This article is protected by copyright. All rights reserved.

Vasovasostomy and vasoepididymostomy: Review of the procedures, outcomes, and predictors of patency and pregnancy over the last decade

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.

Vasectomy reversal: a clinical update

Vasectomy is a safe and effective method of contraception used by 42–60 million men worldwide. Approximately 3%–6% of men opt for a vasectomy reversal due to the death of a child or divorce and remarriage, change in financial situation, desire for more children within the same marriage, or to alleviate the dreaded postvasectomy pain syndrome. Unlike vasectomy, vasectomy reversal is a much more technically challenging procedure that is performed only by a minority of urologists and places a larger financial strain on the patient since it is usually not covered by insurance. Interest in this procedure has increased since the operating microscope became available in the 1970s, which consequently led to improved patency and pregnancy rates following the procedure. In this clinical update, we discuss patient evaluation, variables that may influence reversal success rates, factors to consider in choosing to perform vasovasostomy versus vasoepididymostomy, and the usefulness of vasectomy reversal to alleviate postvasectomy pain syndrome. We also review the use of robotics for vasectomy reversal and other novel techniques and instrumentation that have emerged in recent years to aid in the success of this surgery.

Microscopic visualization of intravasal spermatozoa is positively associated with patency after bilateral microsurgical vasovasostomy

We evaluated pre-operative and intraoperative factors associated with successful patency following bilateral microsurgical vasovasostomy (VV). We retrospectively reviewed the charts of 1331 men who underwent bilateral VV by two surgeons between 2006 and 2013. Vasal fluid was examined intraoperatively for gross quality (i.e., clear or opaque and creamy/thick) and for the presence of spermatozoa on microscopy (i.e., whole spermatozoa, sperm fragments, or azoospermia). Post-operative patency was assessed by semen analysis or patient report of conception. Perioperative factors were explored using descriptive statistics and examined in logistic regression models for associations with post-operative patency. The median age at VV was 39 years [interquartile range (IQR): 35-44] and the median obstructive interval (OI) was 7 years (IQR: 4-11). Overall, 1307 patients achieved post-operative patency (98%) while 24 remained obstructed (2%). Among those who became patent, 410 reported conception. After adjustment for potential confounders, only microscopic examination of the intravasal fluid for the presence of spermatozoa (bilateral or unilateral whole spermatozoa vs. sperm parts/azoospermia) at the time of VV was significantly associated with post-operative patency with an odds ratio (OR) of 14.2 (95% CI: 5.8-34.9; p = <1 × 10(-8) ). Identification of bilateral or unilateral sperm fragments vs. azoospermia was also associated with increased odds of post-operative patency with an OR of 3.5 (95% CI: 0.9-13.6; p = 0.08). There was no statistically significant association between age at VV, OI, presence of granuloma, gross fluid quality, or surgeon and post-operative patency after controlling for potential confounders. Identification of whole spermatozoa in the vasal fluid at the time of VV was positively associated with post-operative patency. Our findings stress the need for intraoperative microscopy to aid in post-operative patient counseling.

Association between the presence of sperm in the vasal fluid during vasectomy reversal and postoperative patency: a systematic review and meta-analysis

OBJECTIVE

To investigate the association between the presence of sperm in the vasal fluid during vasectomy reversal (VR) and postoperative patency.

METHODS

We performed a systematic review and meta-analysis of the English-language literature reporting on the association between the presence of sperm in the intraoperative vasal fluid (ie, whole or parts vs none) and patency (ie, patent or not) after microsurgical vasovasostomy for men with obstructive azoospermia due to vasectomy. Odds ratios (OR) and 95% confidence intervals were calculated to quantify the strength of the association reported by each study. Meta-analysis was performed using a random-effects model.

RESULTS

Four case series and 2 retrospective cohort studies of a total of 1293 eligible patients were identified. The mean age at VR was 37.8 years, and the mean obstructive interval was 7.1 years. The unadjusted OR of postoperative patency was 4.1 times higher (95% confidence interval, 2.3-7.3) given the presence of intravasal sperm or sperm parts as opposed to their absence at the time of VR (Q = 3.4; df = 5; P = .6; I(2) = 22%). The pooled OR should be interpreted with caution as only the 2 retrospective cohort studies reported meaningful data on this association. Because of inconsistent reporting, analysis of other vasal fluid characteristics (eg, consistency) and outcomes (eg, pregnancy) was not possible.

CONCLUSION

The presence of whole sperm or sperm parts in the vasal fluid during VR is positively associated with postoperative patency. Our review highlights the poor methodological quality of existing evidence and underscores the need for more thorough follow up and higher standards of reporting in future studies.

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.

Preoperative factors influencing postoperative results after vasovasostomy

PURPOSE

The purpose of this study is to evaluate the preoperative factors that influenced postoperative sperm concentration after vasovasostomy.

MATERIALS AND METHODS

We retrospectively reviewed 97 consecutive single-layer vasovasostomy procedures performed by a single surgeon between March 2003 and September 2010. The patients were stratified into three groups based on sperm concentration at 1 month follow-up: group I-azoospermia, group II-oligospermia, and group III-normal. We evaluated the preoperative factors that may have influenced sperm concentration at postoperative 1 month. Patients with serial semen analysis were divided into four groups according to the change in postoperative sperm concentration at the 6-month visit: group II-N-from oligospermia to normal, group II-O-from oligospermia to oligospermia, group III-O-from normal to oligospermia, group III-N-from normal to normal. We compared the pregnancy rate among the four groups.

RESULTS

The mean obstructive interval was 9.69 years in group I, 6.02 years in group II, and 7.82 years in group III. There were significant differences found among the groups (p=0.035). There was significantly different change in sperm concentration, sperm motility, and sperm morphology between each of the groups. A total of 32 patients underwent serial semen analyses at 1 month, 3 months, and 6 months after vasovasostomy. There was no significant difference in patient age, obstructive interval, or follicle-stimulating hormone among the groups. The natural pregnancy rate in group II-O was lower than that in group II-N, and in group III-O was lower than that in group III-N. However, there was no significant difference among each of the groups.

CONCLUSIONS

The sperm concentration after vasovasostomy was significantly related to the obstructive interval between vasectomy and reversal.

Lipid rafts: keys to sperm maturation, fertilization, and early embryogenesis

Cell membranes are composed of many different lipids and protein receptors, which are important for regulating intracellular functions and cell signaling. To orchestrate these activities, the cell membrane is compartmentalized into microdomains that are stably or transiently formed. These compartments are called "lipid rafts". In gamete cells that lack gene transcription, distribution of lipids and proteins on these lipid rafts is focused during changes in their structure and functions such as starting flagella movement and membrane fusion. In this paper, we describe the role of lipid rafts in gamete maturation, fertilization, and early embryogenesis.

Prolactinoma presenting as a failed vasectomy reversal

OBJECTIVE

To present a case of prolactinoma presenting as a failed vasectomy reversal.

DESIGN

Case report.

SETTING

University-affiliated teaching hospital.

PATIENT(S)

A 46-year-old male with severe oligospermia after bilateral vasovasostomy and his 31-year-old female partner who had normal cycles.

INTERVENTION(S)

Bromocriptine, carbegoline, and l IVF.

MAIN OUTCOME MEASURE(S)

Correction of hyperprolactinoma, improved semen analysis, and pregnancy achieved by assisted reproductive technologies.

RESULT(S)

Semen analysis showing low volume (0.65 mL) and severe oligospermia (16 sperm) with zero motility on presentation. Endocrine evaluation showed prolactin of 650 ng/mL, T 0.37 ng/mL, and FSH 2.0 mIU/mL. A head CT scan showed a 1.2 cm pituitary adenoma. This was managed initially with bromocriptine, but due to side effects he was switched to carbegoline. In 1 month his PRL decreased to 16.9 ng/mL. Testosterone and FSH normalized. Repeat semen analysis after 5 months showed a volume of 4.5 mL and a concentration of 15 million/mL with 1% motility. Antisperm antibodies were positive. Because of antisperm antibodies and oligoasthenospermia, intracytoplasmic sperm injection with ejaculated sperm and, later, testicular extraction, were attempted without success. Donor sperm was eventually used.

CONCLUSION(S)

This is the first reported case of prolactinoma as a cause of infertility after vas reversal and demonstrates that not all cases of suspected failed vasectomy reversals are due to recurrent obstruction.

Robot-assisted vasovasostomy

Robot-assisted vasovasostomy is an attractive alternative to traditional microscopic techniques for several reasons. The normal physiologic tremor is removed and greater ease and precision of suture placement is possible. The training period or learning curve for robot-assisted vasovasostomy is shorter than traditional microscopic techniques. This will allow more surgeons to provide quality technical surgical care for their patients. Additional costs are only a few hundred dollars. As surgical robots become increasingly available and used for a wider variety of procedures, the feasibility of robotic vasovasostomy becomes more realistic and vasoepididymostomy is likely. Although robotic surgery has improved prostate surgery, its contribution to microsurgical technique has the potential for a more profound impact.