Fatherhood without apparent spermatozoa after vasectomy

[Clinical significance of sperm presence in post-vasectomy seminograms. Analysis of a 2,168 patients serie]

INTRODUCTION

Vasectomy is a safe and effective technique to achieve azoospermia, although the failure rate of the technique is less than 1%. Sterility is not immediate so the post-vasectomy seminogram continues o be essential to ensure the success of the technique. The aim of this trial is to establish the attitude when dealing with immobile residual sperm patients.

MATERIAL AND METHODS

Cross-sectional analysis of 2,168 vasectomies performed between January 2010 and March 2017. The first post-vasectomy seminogram was performed at 3 months. Those patients with azoospermia did not undergo further controls. Patients with immobile sperm (<100,000/ml o>100,000/ml) were considered potentially fertile and were followed with monthly seminograms until azoospermia was obtained.

RESULTS

Of a total of 1,807 patients were included; 1,297 of these had azoospermia at 3 months seminogram and 501 patients had immobile residual sperm. Only 24 patients of this last group showed more than 100.000 sperm/ml; 9 cases showed mobile sperm. All patients who presented immobile residual sperm underwent serial seminograms. Azoospermia was achieved in an average time of 4,5 months in a rage of 4-10 months, regardless of the initial sperm count. An average of 2,5 tests were performed on each patient. All of the patients with mobile sperm required a reintervention.

CONCLUSION

All patients with immobile sperm on the first post-vasectomy seminogram will achieve azoospermia regardless of the initial count. Therefore, serial controls until a negative seminogram is obtained are unnecessary.

Post-Vasectomy Semen Analysis: Optimizing Laboratory Procedures and Test Interpretation through a Clinical Audit and Global Survey of Practices

PURPOSE

The success of vasectomy is determined by the outcome of a post-vasectomy semen analysis (PVSA). This article describes a step-by-step procedure to perform PVSA accurately, report data from patients who underwent post vasectomy semen analysis between 2015 and 2021 experience, along with results from an international online survey on clinical practice.

MATERIALS AND METHODS

We present a detailed step-by-step protocol for performing and interpretating PVSA testing, along with recommendations for proficiency testing, competency assessment for performing PVSA, and clinical and laboratory scenarios. Moreover, we conducted an analysis of 1,114 PVSA performed at the Cleveland Clinic's Andrology Laboratory and an online survey to understand clinician responses to the PVSA results in various countries.

RESULTS

Results from our clinical experience showed that 92.1% of patients passed PVSA, with 7.9% being further tested. A total of 78 experts from 19 countries participated in the survey, and the majority reported to use time from vasectomy rather than the number of ejaculations as criterion to request PVSA. A high percentage of responders reported permitting unprotected intercourse only if PVSA samples show azoospermia while, in the presence of few non-motile sperm, the majority of responders suggested using alternative contraception, followed by another PVSA. In the presence of motile sperm, the majority of participants asked for further PVSA testing. Repeat vasectomy was mainly recommended if motile sperm were observed after multiple PVSA's. A large percentage reported to recommend a second PVSA due to the possibility of legal actions.

CONCLUSIONS

Our results highlighted varying clinical practices around the globe, with controversy over the significance of non-motile sperm in the PVSA sample. Our data suggest that less stringent AUA guidelines would help improve test compliance. A large longitudinal multi-center study would clarify various doubts related to timing and interpretation of PVSA and would also help us to understand, and perhaps predict, recanalization and the potential for future failure of a vasectomy.

Comparison of postal and non-postal post-vasectomy semen sample submission strategies on compliance and failures: an 11-year analysis of the audit database of the Association of Surgeons in Primary Care of the UK

BACKGROUND

Vasectomy occlusive success is defined by the recommendation of 'clearance' to stop other contraception, and is elicited by post-vasectomy semen analysis (PVSA). We evaluated how the choice of either a postal or non-postal PVSA submission strategy was associated with compliance to PVSA and effectiveness of vasectomy.

METHODS

We studied vasectomies performed in the UK from 2008 to 2019, reported in annual audits by Association of Surgeons in Primary Care members. We calculated the difference between the two strategies for compliance with PVSA, and early and late vasectomy failure. We determined compliance by adding the numbers of men with early failure and those given clearance. We performed stratified analyses by the number of test guidance for clearance (one-test/two-test) and the study period (2008-2013/2014-2019).

RESULTS

Among 58 900 vasectomised men, 32 708 (56%) and 26 192 (44%) were advised submission by postal and non-postal strategies, respectively. Compliance with postal (79.5%) was significantly greater than with non-postal strategy (59.1%), the difference being 20.4% (95% CI 19.7% to 21.2%). In compliant patients, overall early failure detection was lower with postal (0.73%) than with non-postal (0.94%) strategy (-0.22%, 95% CI -0.41% to -0.04%), but this difference was neither clinically nor statistically significant with one-test guidance in 2014-2019. There was no difference in late failure rates.

CONCLUSIONS

Postal strategy significantly increased compliance to PVSA with similar failure detection rates. This resulted in more individuals receiving clearance or early failure because of the greater percentage of postal samples submitted. Postal strategy warrants inclusion in any future guidelines as a reliable and convenient option.

2016 Laboratory guidelines for postvasectomy semen analysis: Association of Biomedical Andrologists, the British Andrology Society and the British Association of Urological Surgeons

Post-vasectomy semen analysis (PVSA) is the procedure used to establish whether sperm are present in the semen following a vasectomy. PVSA is presently carried out by a wide variety of individuals, ranging from doctors and nurses in general practitioner (GP) surgeries to specialist scientists in andrology laboratories, with highly variable results.

Key recommendations are that: (1) PVSA should take place a minimum of 12 weeks after surgery and after a minimum of 20 ejaculations. (2) Laboratories should routinely examine samples within 4 h of production if assessing for the presence of sperm. If non-motile sperm are observed, further samples must be examined within 1 h of production. (3) Assessment of a single sample is acceptable to confirm vasectomy success if all recommendations and laboratory methodology are met and no sperm are observed. Clearance can then be given. (4) The level for special clearance should be <100 000/mL non-motile sperm. Special clearance cannot be provided if any motile sperm are observed and should only be given after assessment of two samples in full accordance with the methods contained within these guidelines. Surgeons are responsible both preoperatively and postoperatively for the counselling of patients and their partners regarding complications and the possibility of late recanalisation after clearance. These 2016 guidelines replace the 2002 British Andrology Society (BAS) laboratory guidelines and should be regarded as definitive for the UK in the provision of a quality PVSA service, accredited to ISO 15189:2012, as overseen by the United Kingdom Accreditation Service (UKAS).

Vasectomy: AUA guideline

PURPOSE

The purpose of this guideline is to provide guidance to clinicians who offer vasectomy services.

MATERIALS AND METHODS

A systematic review of the literature using the search dates January 1949-August 2011 was conducted to identify peer-reviewed publications relevant to vasectomy. The search identified almost 2,000 titles and abstracts. Application of inclusion/exclusion criteria yielded an evidence base of 275 articles. Evidence-based practices for vasectomy were defined when evidence was available. When evidence was insufficient or absent, expert opinion-based practices were defined by Panel consensus. The Panel sought to define the minimum and necessary concepts for pre-vasectomy counseling; optimum methods for anesthesia, vas isolation, vas occlusion and post-vasectomy follow up; and rates of complications of vasectomy. This guideline was peer reviewed by 55 independent experts during the guideline development process.

RESULTS

Vas isolation should be performed using a minimally-invasive vasectomy technique such as the no-scalpel vasectomy technique. Vas occlusion should be performed by any one of four techniques that are associated with occlusive failure rates consistently below 1%. These are mucosal cautery of both ends of the divided vas without ligation or clips (1) with or (2) without fascial interposition; (3) open testicular end of the divided vas with MC of abdominal end with FI and without ligation or clips; and (4) non-divisional extended electrocautery. Patients may stop using other methods of contraception when one uncentrifuged fresh semen specimen shows azoospermia or ≤ 100,000 non-motile sperm/mL.

CONCLUSIONS

Vasectomy should be considered for permanent contraception much more frequently than is the current practice in the U.S. and many other nations. The full text of this guideline is available to the public at http://www.auanet.org/content/media/vasectomy.pdf.

[Ischemic testicular necrosis following vasectomy: rare and typical complications of an outpatient procedure]

Taking the clinical case of a patient who developed unilateral testicular necrosis following vasectomy as a starting point, the early and late complications of this procedure are described based on a literature review.In the USA 7% of all men undergo vasectomy, as compared to 2% in Germany. Early postoperative complications include bleeding/hematoma (0.5-18%), infection (0.3-32.9%), epididymitis (0.4-6.1%), granuloma (0.07-90%), and rare complications such as vas deferens abscess, vesicular gland abscess, vasovenous fistula, testicular necrosis, arteriovenous fistula, pulmonary embolism, endocarditis, scrotal skin necrosis and Fournier's disease which mostly have been reported in the form of case reports. Late complications are chronic pain (0.5-18%), pain during sex (2.9%), hydrocele (0-4%) as well as spermatocele (1.6%). There is a failure rate of 4.3-16% as concluded from the number of patients with nonmotile sperm in the post-vasectomy semen analysis. The postoperative paternity rate is 0-4%.Bilateral vasectomy is a secure way of contraception; perioperative and late complications are on an average rare, however, with a range up to 90%. In individual cases severe complications occur, which should be detected at an early stage. Therefore a close follow-up should be maintained after this outpatient procedure. One should ask for risk factors of endocarditis or thrombosis preoperatively. The patient should be informed of the possible loss of a testicle because of the severity of this complication. Postoperative semen analysis is obligatory.

Clearance after vasectomy: has the time come to modify the current practice?

OBJECTIVE

Vasectomy is a simple, reliable and effective form of permanent contraception. Clearance after vasectomy has been the subject of much debate among urologists. Poor compliance with postvasectomy semen analysis is well recognized, with rates as low as 36%. This can leave the partner at risk of an unplanned pregnancy and, consequently, the surgeon at risk of litigation. Although there is no consensus about the requirements for postvasectomy clearance, urologists usually tend to request at least two azoospermic postvasectomy semen samples (PVSSs) before labelling patients as sterile. This study investigated whether simplifying the criteria for postvasectomy clearance can result in improved compliance.

MATERIAL AND METHODS

Medline, Embase and Cochrane databases were searched for studies on postvasectomy clearance. The main focus of the search was on the timing and number of PVSSs, their impact on patients' compliance and the significance of the rare non-motile sperm (RNMS).

RESULTS

It has been found that patients' compliance decreases when more than one PVSS is requested. One azoospermic PVSS can be as indicative of sterility as two azoospermic samples. There have been calls for a uniform protocol recommending only one routine sperm sample taken 16 weeks postoperatively. This period will allow the vasa and seminal vesicles to become clear of spermatozoa. A significant proportion of men will have RNMS in their semen after vasectomy; only 1% will ultimately fail. Therefore, RNMS samples can, for practical purposes, be considered azoospermic and one PVSS, even if containing RNMS, should be considered sufficient for clearance.

CONCLUSIONS

Provided that patients are adequately warned about the risk of vasectomy failure and appropriate consent is obtained, a single azoospermic PVSS at 16 weeks is sufficient for clearance. Patients with RNMS should be practically considered azoospermic and further sampling should be abandoned. This approach should improve patients' compliance. Evaluation in a prospective setting will be required to validate this conclusion.

Effectiveness of vasectomy techniques

The effectiveness of various vasectomy techniques is reviewed, with a focus on methods used for vas occlusion. Spontaneous recanalization of the vas is more common than generally recognized and is often transient. Simple ligation and excision has an unacceptably high risk for failure. Techniques that include cautery seem to have a lower risk for failure than techniques that do not include cautery. There is insufficient evidence to recommend a particular standardized cautery technique, but adding fascial interposition to cautery seems to be associated with the lowest risk for failure.

Clinical and consumer trial performance of a sensitive immunodiagnostic home test that qualitatively detects low concentrations of sperm following vasectomy

PURPOSE

Compliance with post-vasectomy semen analysis could be improved with the availability of a simple, rapid and accurate home test. SpermCheck Vasectomy, a highly sensitive lateral flow immunochromatographic diagnostic device, was designed to detect extreme oligospermia or azoospermia in men after vasectomy. We report the results of clinical and consumer testing of SpermCheck.

MATERIALS AND METHODS

A prospective, noncomparative observational study assessed the ability of SpermCheck Vasectomy to predict post-vasectomy sperm counts obtained using a hemacytometer procedure based on standard World Health Organization methodology. Consumer studies evaluated ease of use.

RESULTS

A cohort of 144 post-vasectomy semen samples was tested in the clinical trial. SpermCheck was 96% accurate in predicting whether sperm counts were greater or less than a threshold of 250,000 sperm per ml, a level associated with little or no risk of pregnancy. Sensitivity was 93% (95% CI 79% to 98%) and specificity was 97% (91% to 99%). The positive predictive value of the test was 93% (79% to 98%), and most importantly the negative predictive value was 97% (91% to 99%). The test gave a positive result 100% of the time at sperm concentrations of 385,000/ml or greater. Consumer studies with 109 lay volunteers showed that SpermCheck was easy to use. Volunteers obtained the correct or expected test result in every case and the correct response rate on a 20 question survey about the test was 97%.

CONCLUSIONS

SpermCheck Vasectomy, a simple and reliable immunodiagnostic test that can provide evidence of vasectomy success or failure, offers a useful alternative to improve compliance with post-vasectomy sperm monitoring. It is currently the only Food and Drug Administration approved test for this purpose.

Paternity after vasectomy with two previous semen analyses without spermatozoa

CONTEXT

The risk of paternity after vasectomy is rare but still exists. Overall failure to achieve sterility after vasectomy occurs in 0.2 to 5.3% of patients due to technical failure or recanalization. The objective of this report was to describe a rare but notable case of proven paternity in which the semen analyses had not given evidence of spermatozoa.

CASE REPORT

A 44-year-old vasectomized man whose semen analyses had shown azoospermia became a father four years after sterilization. Blood sample DNA analysis on the child and husband proved biological paternity. Vasectomy may fail in the long run even without spermatozoa in semen analysis. The patient must be aware of this possibility.

Influencia del proceso analítico en la aparición y desaparición de los espermatozoides del semen tras la vasectomía

OBJECTIVES

To evaluate if the analytical process might justify that in some patients rare non motile sperm might be seen in some but not all their post-vasectomy semen samples.

PATIENTS AND METHODS

Post vasectomy ejaculates received in our Center from january 2002 to december 2004 were reviewed. We used our own guidelines for post vasectomy semen assessment based upon those of the British Andrology Society for the evaluation of post vasectomy semen samples and the World Health Organization guidelines for semen analysis.

RESULTS

During the 3 years of follow up, 984 patients underwent vasectomy. We received 1.430 semen samples, 2 samples per patient on average. Regarding the pre analytical phase, 134 samples (9.4%) were not completely collected; ejaculate volumes of less than 2 mL were delivered by 269 patients (18.8%); in these cases, we were not sure whether the whole ejaculates were submitted: pre analytical conditions of 11 samples (0.8%) were inappropriate: incorrectly labeled, spilled, provided into inadequate containers... Regarding the analytical phase, 432 ejaculates (30.5%) were extremely viscous and sperm detection might have been affected; 62 semen samples (4.3%) contained many cells which obstructed the visualization of the entire microscopy field. Regarding the post analytical phase, 153 patients (20.9%) had alternative negative/positive results with rare non motile sperm.

CONCLUSION

An elevated percentage of incidences involving both the pre analytical and the analytical phase were observed during post-vasectomy seminal analysis. Inadequate conditions may affect the results and justify that spermatozoa may be seen in some but not all the ejaculates of the same patient. We recommend that two semen samples per patient are required to ensure that he is correctly evaluated. We propose to report a negative result as a spermatozoa count bellow the detection limit of our analytical procedure similar to other laboratory magnitudes to minimize the effect of fluctuations in such a low count of rare non motile sperm.

Vasectomy: A simple snip?

Vasectomy is one of the most common forms of permanent sterilization methods currently in use and has a failure rate of <1% in most reported series. Since failure of vasectomy may result in pregnancy, adequate counseling is essential. Couples are advised that an analysis of a semen specimen after vasectomy is required to confirm success before the use of alternative contraception is abandoned. However, measuring the success of vasectomy is complicated by a lack of consistency with regards to both the number and timing of tests and the end points accepted.

Determining the success of vasectomy

OBJECTIVES

To examine patient compliance, significance of rare nonmotile sperm (RNMS) and to determine the timing and number of semen analyses required to confirm sterility.

PATIENTS AND METHODS

From November 2001 to November 2004, 436 consecutive primary vasectomies were performed by one surgeon. All patients were instructed to submit two initial semen specimens for analysis (2 and 3 months after vasectomy) and additional samples (at 1-month intervals) if sperm were identified on the initial and subsequent analyses.

RESULTS

A quarter of the patients submitted no semen specimens and only 21% followed the full instructions to provide two consecutive negative semen analyses. Three-quarters of the patients provided a semen specimen at 8 weeks after vasectomy; of these, 75% were azoospermic and 25% contained sperm. At 12 weeks after vasectomy half the patients provided a semen specimen; of these, 91% were azoospermic and 9% contained sperm. Of the 83 patients with semen containing sperm at 8 weeks, 80 had RNMS and three had rare motile sperm (one of whom subsequently proved to have vasectomy failure). Of the 80 patients with RNMS, at 3, 4, 5, 6, 8, 10 and 11 months, 65, four, three, four, two, one and one, respectively were azoospermic.

CONCLUSIONS

The present results indicate that many patients are not compliant with the protocol after vasectomy. Provided patients have been adequately counselled, we think that one negative semen analysis at 3 months or one with RNMS at 2 months may be adequate to determine the success of vasectomy. This should reduce the number of semen analyses, including reducing the number of men who must undergo repeat testing, without sacrificing the accuracy of determining paternity. Simplifying the follow-up after vasectomy is important; not only would it be cost-effective but it may also improve patient compliance.

HOW LITTLE IS ENOUGH? THE EVIDENCE FOR POST-VASECTOMY TESTING

PURPOSE

Post-vasectomy semen analysis (PVSA) is the traditional method of confirming sterility after vasectomy. However, PVSA protocols vary in the end points accepted, and the number and timing of tests. In this systematic review we make evidence based recommendations on the appropriate PVSA protocol.

MATERIALS AND METHODS

Databases (MEDLINE, Current Contents, Cochrane Library and EMBASE) were searched up to and including March 2003. Studies were included if they dealt with post-vasectomy testing and contained data on at least 1 of the time or number of ejaculations to azoospermia, pregnancy, repeat vasectomy and histological analysis of vas specimens.

RESULTS

A total of 56 studies were included in the review. Time to achieve azoospermia was variable, although the median incidence of patients with azoospermia was consistently more than 80% after 3 months and after 20 ejaculations. A small percent of patients (14,845 or 1.4%) demonstrated persistent nonmotile sperm, although some of them eventually achieved azoospermia. The reappearance of nonmotile sperm was reported in 7 studies, occurring up to 22 months after vasectomy.

CONCLUSIONS

The evidence supports a PVSA protocol with 1 test showing azoospermia after 3 months and 20 ejaculations. If the sample is positive, periodic testing can continue until azoospermia is achieved. Patients with persistent nonmotile sperm in low numbers could be given cautious assurance of success. No evidence was located to support histological testing of the excised vas deferens.

Vasectomy follow-up: Clinical significance of rare nonmotile sperm in postoperative semen analysis

OBJECTIVES

To examine patient compliance, complications, and significance of rare nonmotile sperm (RNMS) after no-scalpel vasectomy.

METHODS

We reviewed the records of 690 consecutive men who had undergone vasectomy at our institution between 1996 and 2002. All men were instructed to submit two initial semen samples for analysis (3 and 4 months after vasectomy) and additional samples (at 2-month intervals) if sperm were identified on the initial and subsequent analyses. All patient complaints (telephone and clinic visit) were recorded.

RESULTS

A total of 315 men (45.6%) did not submit any semen samples. Of the 295 men who submitted two samples, 176 (60%) were azoospermic, 110 (37%) had RNMS, and 9 men (3%) had rare motile sperm (the vasectomy of 1 of these 9 men subsequently failed). Of the 110 men with RNMS, 83 submitted one or more additional semen samples. Of these 83 men, 62 (75%) had become azoospermic, 20 (24%) had persistent RNMS, and 1 (1%) subsequently had a failed vasectomy (with motile sperm). The 2 patients with failure underwent a repeat vasectomy (failure rate 0.67% [2 of 295]). A total of 69 patients (10%) reported a complaint, but only 9 (1.5%) of these men returned for clinical examination. No surgical complications and no pregnancies occurred.

CONCLUSIONS

Our data show that despite aggressive counseling, compliance with follow-up testing is very poor. Patient-reported complaints are common but minor. We found that most men with RNMS become azoospermic and propose that the presence of RNMS is consistent with a successful vasectomy. However, long-term, prospective studies are needed to assess the risk of late failure in men with RNMS.

[The natural history of sperm cleareance after vasectomy]

OBJECTIVE

To study the time required to obtain a negative sperm analysis after vasectomy.

MATERIAL AND METHODS

We reviewed 239 consecutive vasectomies performed between september 1998 and september 1999. All of them were done in an ambulatory basis. Follow up interval was 41-853 days (mean 144, median 104). The first semen analysis was requested between 1 and 6 months after the surgical procedure. If the sample still showed spermatozoa, then a new one was requested every two months. Probability of becoming azoospermic was studied with Kaplan-Meier curves.

RESULTS

Persistent spermatozoa could be found in 31 patients (13%) at the end of follow-up. Despite having a positive semen analysis, 10 patients (4.2%) discontinued medical visits. Time required to obtain a negative sperm count ranged from 58 to 362 days (mean 133, median 99). The probability of being azoospermic 200 and 260 days after vasectomy was 80-90% respectively. A total of 328 semen analysis were requested (range 1-4, mean 1.37, median 1)

CONCLUSIONS

A minimum of 200 days (6.6 months) are needed to clear all the spermatozoa in semen after vasectomy in 80% of our patients. Requesting the first semen sample 7 months after vasectomy is cost-effective, reducing unnecesary medical visits and increasing the rentability of this test.

The Risk of Pregnancy After Vasectomy

OBJECTIVE

To describe the pregnancy rates among women whose husbands underwent vasectomy.

METHODS

Between 1985 and 1987, 573 women aged 18-44 years whose husbands underwent vasectomy in medical centers in 5 U.S. cities were enrolled in the U.S. Collaborative Review of Sterilization, a prospective cohort study of male and female sterilization. Women were interviewed by telephone at 1, 2, 3, and 5 years after their husbands underwent vasectomy.

RESULTS

Among the 540 eligible women at risk for pregnancy, there were 6 pregnancies occurring from 6 to 72 weeks after vasectomy. The cumulative probability of failure per 1,000 procedures (95% confidence interval) was 7.4 (0.2, 14.6) 1 year after vasectomy and 11.3 (2.3, 20.3) at years 2, 3, and 5 [corrected].

CONCLUSION

Couples considering vasectomy should be counseled about the small, but real, risk of pregnancy following the procedure and that men are not sterile immediately after vasectomy.

Vasectomy effectiveness in Nepal: a retrospective study

The main purpose of this retrospective, cross-sectional study was to evaluate the effectiveness of vasectomy in an ongoing public sector program in Nepal. We evaluated semen samples from men who had previously had a vasectomy, and asked about the occurrence of pregnancies in the men's partners. In addition, the surgeons who performed the vasectomies completed a questionnaire about their techniques. A two-stage stratified sampling procedure was used to select 1263 men from among over 30,000 men, who had previously undergone a no-scalpel vasectomy, mostly by ligation and excision, in 32 districts between July 1996 and June 1999. Semen samples were preserved and analyzed at a central laboratory. A US andrology laboratory validated the lab results. Twenty-three men (2.3%, 95% confidence interval [CI] 1.1-3.6) had >/=500,000 sperm/mL in their semen. Fifteen of those men reported pregnancies conceived after their vasectomy. In addition, six men with azoospermia reported pregnancies for which conception occurred within 3 months after vasectomy. Eleven men with azoospermia reported pregnancies for which conception occurred more than 3 months after vasectomy. Reported pregnancy was more likely in younger partners. The life table pregnancy rates for all men interviewed were 0.7 (95% CI 0.2-1.1), 1.7 (95% CI 1.4-2.1) and 4.2% (95% CI 3.2-5.2) at 3, 12 and 36 months, respectively. In low-resource, programmatic settings, vasectomy failure rates may be higher than commonly cited rates, especially in younger populations. Additional research is needed to determine if other occlusion techniques could reduce failure rates. Counseling on vasectomy should always convey the possibility of failure and partner pregnancy.

British Andrology Society guidelines for the assessment of post vasectomy semen samples (2002)

The British Andrology Society guidelines for the assessment of post vasectomy semen samples recommend that initial assessment is undertaken 16 weeks post vasectomy and after the patient has produced at least 24 ejaculates. The laboratory should examine a freshly produced seminal fluid specimen by direct microscopy and if no sperm are seen the centrifugate should be examined for the presence of motile and non-motile spermatozoa. It is recommended that the clinician should give clearance after the production of two consecutive sperm free ejaculates. In cases of persistent identification of non-motile spermatozoa the referring clinician should advise the patient regarding the cessation of other contraceptive precautions. Surgeons are responsible both preoperatively and postoperatively for the counselling of couples regarding complications and the possibility of late recanalisation after clearance.

The effect of perioperative distal vasal lavage on subsequent semen analysis after vasectomy: a prospective randomized controlled trial

OBJECTIVE

To determine the effect of perioperative distal vasal lavage with 50 mL of normal saline on subsequent time to azoospermia after vasectomy.

PATIENTS AND METHODS

Seventy-two patients were prospectively enrolled and randomized to undergo vasectomy with or without vasal lavage. Infertility rates at 8, 10 and 12 weeks were compared for both groups and for those undergoing the procedure under local or general anaesthesia. Patient compliance for returning postoperative semen for analysis was also assessed.

RESULTS

There was no statistically significant difference in infertility rates at 8, 10 or 12 weeks after vasectomy with or without vasal lavage. Vasectomies performed under local and general anaesthesia had comparable rates of infertility at 12 weeks after surgery. Compliance in providing semen for analysis was poor.

CONCLUSION

The routine adoption of distal vasal lavage during vasectomy for contraception cannot be recommended. As compliance in providing semen for analysis was poor, the clinician has a responsibility to remind the patient of the consequences of such action.

Vasectomy

Vasectomy is regarded as the safest method now available for male fertility control. Almost 100 million men worldwide have relied on vasectomy for family planning. This review discusses all currently relevant operative techniques, including no-scalpel vasectomy, complications, possible long-term effects on the testis and epididymis, and diseases for which associations with vasectomy have been suggested, such as arteriosclerosis, autoimmune diseases and cancer of the prostate and testis. Other topics of discussion include the timing of post-operative semen analysis, patient noncompliance concerning post-operative controls, persistent cryptozoospermia and transient reappearance of spermatozoa after vasectomy, vasectomy failure and legal aspects.

Review of current practice to establish success after vasectomy

BACKGROUND

This study aimed to examine the criteria used by surgeons in a district general hospital to confirm success following vasectomy, to establish the proportion of men undergoing vasectomy in whom the procedure was unsuccessful according to those criteria, and to evaluate their subsequent management.

METHODS

All 15 surgeons performing vasectomy indicated that they required two consecutive azoospermic postvasectomy semen specimens before they advised couples that the vasectomy was successful. Results of postvasectomy semen analysis (PVSA) for all 240 primary vasectomies performed over a 12-month interval were analysed. Minimum follow-up was 30 (range 30-42; median 37) months.

RESULTS

At follow-up 72 men (30 per cent) had not returned postvasectomy samples that fulfilled the criteria, including 18 who were azoospermic on the first PVSA 3 months after vasectomy but who failed to produce a second specimen. In 24 men (10 per cent) who failed to comply with the PVSA protocol, there was no documentation of any further action being taken. No pregnancies were reported in the partners of the study group during this interval and only one patient underwent repeat vasectomy.

CONCLUSION

The results suggest that the strict requirement of two consecutive azoospermic postvasectomy semen specimens may be unjustified, leads to a high level of non-compliance and causes unnecessary delay in confirming success of the procedure.

Semen analysis after vasectomy: when and how many?

OBJECTIVE

To assess patient compliance for semen analysis after vasectomy, and to determine the timing and number of semen analyses required to confirm sterility.

PATIENTS AND METHODS

The study included 1321 men who underwent vasectomy between October 1995 and June 1998. They were followed up in two groups; in group 1 (one-test method) 961 consecutive patients were asked to provide a semen sample for analysis 4 months after vasectomy. Sterility was defined as the absence of sperm in one sample. If sperm were present in the sample, the test was repeated at monthly intervals until there were no sperm. In group 2 (two-test method) 360 consecutive patients were advised to provide semen samples 3 and 4 months after vasectomy. The absence of sperm in two consecutive samples was defined as the criterion to declare the man azoospermic. The presence of sperm in one sample required further samples every month until two consecutive azoospermic samples were produced.

RESULTS

In group 1, 810 patients provided semen samples, of which 783 (97%) had no sperm and the men were thus declared azoospermic. The remaining 27 (3%) samples contained sperm; six men withdrew from follow-up at various times but 21 patients produced a negative sample at some time within 7 months and were declared azoospermic. At the end of the follow-up, 804 (84%) patients had been declared azoospermic. In group 2, 294 (82%) patients provided a semen sample after 3 months but only 259 (72%) did so after 4 months. Of the patients providing the first sample, 287 (98%) were azoospermic, and after the second 252 (97%) were azoospermic. At the end of the follow-up 255 (71%) patients were declared azoospermic. There was no reported paternity in any of the men.

CONCLUSION

These results suggest that compliance was better in group 1; when the patients in group 2 were asked to provide a second sample the compliance decreased significantly. The percentage of patients producing an azoospermic sample was similar for semen provided after 3 and 4 months. Thus, provided that the patient is adequately warned about the risk of failure of the vasectomy at any time during his life, a single semen analysis after 3 months is sufficient grounds for discontinuing other contraceptive precautions.

Paternity after bilateral vasectomy

OBJECTIVES

To determine whether the occurrence of recanalization depends on the technique of vasectomy.

MATERIALS AND METHODS

A survey was conducted among Dutch urologists using a questionnaire in which information was gathered about the surgical procedure, postoperative complications, results of semen analysis after vasectomy, time between vasectomy and occurrence of paternity, results of semen analysis after paternity, performance of revasectomy, results of histological examination of the revasectomy specimen and whether the event had changed the protocol of the urologists.

RESULTS

In all, 32 cases of paternity after vasectomy were registered. Surgical techniques and the criteria for a successful vasectomy differed among the responding urologists. There was a difference in time to paternity between men who did and did not correspond with the criteria. In most cases, semen analysis after paternity showed numerous motile sperm. Six men initiated litigation after paternity and the vasectomy protocol was modified by five urologists.

CONCLUSION

Paternity consequent on recanalization can occur at any time after bilateral vasectomy and does not depend on the surgical procedure or criteria for sterility. Because of the major consequences of paternity after vasectomy for both the man and urologist, accurate information about the possibility of recanalization should be given to the man beforehand.

Is the timing of post-vasectomy seminal analysis important?

OBJECTIVE

To review the practice in two hospitals with differing protocols in the timing of seminal analysis after vasectomy.

PATIENTS AND METHODS

The results from 245 vasectomies carried out at Hospital A, where semen was assessed 3 months after vasectomy, were reviewed and compared with those from 100 consecutive vasectomies at Hospital B, where semen was assessed 6 months after vasectomy. The results of seminal analysis at Hospital A were also audited after changing to the 6-month protocol. The patients' preferences for the timing of seminal analysis were also obtained.

RESULTS

Of the 245 patients at Hospital A, 58 (24%) failed to provide samples, leaving 187 (76%) for evaluation; 528 samples were examined (mean 2.8 per patient, range 1-13). The first sample was positive in 36 (19.3%) and the second positive in 10 (5.3%), the first being negative. Four (2%) patients had persistent spermatozoa at 6 months, one subsequently undergoing exploration. Thirty-one (17%) patients provided further samples despite providing two consecutive clear ones. At Hospital B, 24 (24%) patients failed to provide samples; 10 (13%) patients had persistent spermatozoa at 6 months and live spermatozoa were detected in one patient's samples. All eventually produced clear samples, with none requiring exploration. After changing the protocol, 87 vasectomies were performed, with 18 (21%) patients failing to provide samples; seven (10%) of the samples collected showed occasional nonmotile spermatozoa at 6 months in either the first, second or both samples, with all samples clear by 8 months after vasectomy.

CONCLUSIONS

The complete disappearance of spermatozoa after vasectomy takes longer than is generally believed and we therefore suggest that given adequate counselling, seminal analysis 6 months after vasectomy is cost-effective and in the patient's interest.

Persistence or reappearance of nonmotile sperm after vasectomy: does it have clinical consequences?

OBJECTIVE

To determine the percentage of patients with nonmotile sperm 12 weeks after vasectomy, to estimate the time needed for eventual azoospermia in these patients, and to record the percentage of patients with recurrence of nonmotile sperm after initial azoospermia after vasectomy.

DESIGN

A review of the semen analysis of vasectomies performed in a 2-year period. Semen analysis in a group of volunteers from 4 months until 24 months after vasectomy.

SETTING

Vasectomies performed in an outpatient department of the University Hospital of Maastricht.

PATIENT(S)

Men referred by the general practitioner for a vasectomy.

INTERVENTION(S)

Vasectomy.

MAIN OUTCOME MEASURE(S)

Amount and motility of sperm in postvasectomy semen samples.

RESULT(S)

Nonmotile sperm was found in 33% of the patients 12 weeks after vasectomy. The mean time to azoospermia was 6.36 months. Nonmotile sperm after initial azoospermia was found in 5 of 65 patients.

CONCLUSION(S)

Azoospermia as a criterion for sterility leads to unnecessary prolonged semen analysis in a large percentage of the vasectomized patients. Reappearance of nonmotile sperm was found in an unexpectedly high percentage.

Intracytoplasmic sperm injection: a treatment for extreme oligospermia

PURPOSE

We evaluated the efficacy of intracytoplasmic sperm injection in patients with extreme oligospermia.

MATERIALS AND METHODS

A total of 67 intracytoplasmic sperm injection cycles was attempted in 58 infertile couples in which the husbands had extreme oligospermia (less than 100,000 spermatozoa per ml. ejaculate).

RESULTS

Fertilization was achieved in 65 of 67 cycles. Mean fertilization rate per cycle was 66.4%. A total of 18 clinical pregnancies was obtained, for a pregnancy rate of 26.8% per started cycle. There were 4 miscarriages and 8 live births from 5 deliveries. Nine pregnancies are ongoing.

CONCLUSIONS

Intracytoplasmic sperm injection in patients with extreme oligospermia is associated with high fertilization rates and offers the chance of pregnancy to these otherwise intractably infertile couples.

Presence of sperm in the pre-vasectomy reversal semen analysis: incidence and implications

PURPOSE

We determined the incidence of sperm in the ejaculate before vasectomy reversal, and correlated this result with intraoperative and postoperative findings.

MATERIALS AND METHODS

Before vasectomy reversal semen was analyzed and granulomas were palpated in 186 men. The results were correlated with intraoperative vasal fluid and postoperative semen analyses.

RESULTS

Of 18 men (9.7%) with sperm present in the pre-reversal analysis 94% had sperm in at least 1 vas intraoperatively. The presence of palpable granulomas at the vasectomy site did not correlate with either pre-reversal or post-reversal semen analyses, or the presence of sperm in the vasal fluid intraoperatively.

CONCLUSIONS

Sperm are present in 9.7% of pre-reversal ejaculates and predict sperm in at least 1 vas intraoperatively. These findings also suggest the possibility of late vasectomy failures.

Hypo-osmotic swelling test: a reliable screening assay for routine semen specimen quality screening

We investigated whether the hypo-osmotic swelling (HOS) test is a reliable screening method for routine semen specimen quality screening. Of 159 male patients, 171 semen samples were investigated using the HOS test as well as routine semen specimen screening used in our clinic. There was a significant correlation between the HOS test and most semen parameters. There was no significant correlation between the HOS test and the percentage of morphologically normal spermatozoa in the initial semen sample. The HOS test is a reliable screening method for routine semen quality screening.

Hormonal male contraception: progress and prospects for the 21st century

During the second half of the 20th century, progress in developing novel, practical contraceptive methods for men has lagged significantly behind developments for women. Despite the lack of reliable, reversible methods, men throughout the world continue to be strongly involved in family planning but a greater involvement will require more attractive and reliable contraceptive options for men. The closest to fruition are hormonal methods the features of which are reviewed. Landmark WHO contraceptive efficacy studies have established that hormonally-induced azoospermia provides highly effective and reversible contraception for at least 12 months with minimal short-term side effects. Even among the small subgroup of men who remain oligozoospermic during hormonal suppression, good contraceptive efficacy is achieved. The present goals are to develop improved second generation hormonal regimens which provide more uniform azoospermia to obviate the need for monitoring of sperm output and to develop long-acting depot testosterone formulations used alone or with additional gonadotrophin suppressive agents such as progestins or GnRH antagonists. Significant obstacles to progress are the flight of industry from contraceptive R&D dur to the financial deterrent posed by the product liability crisis as well as the low priority accorded male reproductive health. Together those will determine whether the range of contraceptive options available to our children in the 21st century will improve, or whether the historically recent unbalanced increase in reliance on women for family planning will continue.

Temporary reappearance of sperm 12 months after vasectomy clearance

OBJECTIVES

To determine the incidence of positive semen analysis 12 months after vasectomy clearance.

SUBJECTS AND METHODS

A prospective study was undertaken, starting in 1990, of men undergoing vasectomy. Azoospermia was confirmed by two successive semen analyses 16 weeks after vasectomy. One year later a further sample was analysed for the presence of sperm.

RESULTS

Of 1000 men who provided a sample for analysis, six men (0.6%) have had positive semen analyses 1 year after the initial tests showed azoospermia. In all six the sperm count was <10,000 per mL. Five of the six men produced a repeat sample 1 month later which, in all five cases, showed azoospermia. No pregnancies have been reported to date.

CONCLUSION

Transitory reappearance of sperm following successful vasectomy occurs in about 0.6% of men. This incidence is 18 times greater than the reported pregnancy rate following successful vasectomy.