A prospective study of time and number of ejaculations to azoospermia after vasectomy by ligation and excision

[Vasectomy : Current information]

Vasectomy is considered to be the simplest, most effective and cheapest method of fertility control in men, with a significantly lower risk of morbidity and mortality compared to tubal ligation in women. Patient informed consent is particularly important and should include potential irreversibility, surgical options, anesthesia, possible complications as well as postoperative behavior and the need for re-evaluation. There are different access routes available with conventional and no-scalpel vasectomy as well as different techniques for closing the ends of the vas deferens. To confirm sterility the European Association of Urology (EAU) recommends that an ejaculate analysis should be performed 3 months after the procedure and after approximately 20 ejaculations. Complications are relatively rare, although particularly vasectomy failure due to recanalization has to be considered. Approximately 3-6% of vasectomized men strive for a refertilization, which with experienced surgeons is successful in about 90% of cases.

Are evidence-based vasectomy surgical techniques performed in low-resource countries?

Background:  Research evidence published 10 to 15 years ago has shown that the type of vasectomy surgical technique performed can influence the effectiveness and the safety of the procedure.  The objective of this study was to determine if evidence-based vasectomy surgical techniques are integrated in the vasectomy programs of selected low-resource countries. Methods: The surgical techniques recommended to perform the two steps of the vasectomy procedure (isolation/exposition and occlusion of the vas deferens) were extracted from current evidence-based clinical practice guidelines. Documents describing male sterilisation standards and practice from Kenya, Rwanda, India, Nepal, Mexico, Honduras, Colombia and Haiti were reviewed to assess adequacy with international guideline recommendations. Results: Best recommended techniques are 1) a minimally invasive technique including the no-scalpel technique (known as the no-scalpel vasectomy (NSV)) to isolate and expose the vas deferens, and 2) cautery of the mucosa of the vas preferably combined with interposition of the fascia (FI) to occlude the vas deferens. The NSV is largely adopted and performed to isolate the vas in selected low-resources countries. Ligation and excision (LE) of a small segment of the vas deferens combined with FI is the most common vas occlusion technique mentioned in the country standards. Cautery as recommended in the guidelines is seldom used in selected countries. Conclusions:   Effective and adapted vasectomy vas occlusion techniques are available, but are still underused in many low-resource countries. Providing the most effective vasectomy surgical techniques increases users' confidence and satisfaction regarding male sterilization and may lead to higher acceptability and uptake.

Are evidence-based vasectomy surgical techniques performed in low-resource countries?

Background:  Research evidence published 10 to 15 years ago has shown that the type of vasectomy surgical technique performed can influence the effectiveness and the safety of the procedure.  The objective of this study was to determine if evidence-based vasectomy surgical techniques are integrated in the vasectomy programs of selected low-resource countries. Methods: The surgical techniques recommended to perform the two steps of the vasectomy procedure (isolation/exposition and occlusion of the vas deferens) were extracted from current evidence-based clinical practice guidelines. Documents describing male sterilisation standards and practice from Kenya, Rwanda, India, Nepal, Mexico, Honduras, Colombia and Haiti were reviewed to assess adequacy with international guideline recommendations. Results: Best recommended techniques are 1) a minimally invasive technique including the no-scalpel technique (known as the no-scalpel vasectomy (NSV)) to isolate and expose the vas deferens, and 2) cautery of the mucosa of the vas preferably combined with interposition of the fascia (FI) to occlude the vas deferens. The NSV is largely adopted and performed to isolate the vas in selected low-resources countries. Ligation and excision (LE) of a small segment of the vas deferens combined with FI is the most common vas occlusion technique mentioned in the country standards. Cautery as recommended in the guidelines is seldom used in selected countries. Conclusions:   Effective and adapted vasectomy vas occlusion techniques are available, but are still underused in many low-resource countries. Providing the most effective vasectomy surgical techniques increases users' confidence and satisfaction regarding male sterilization and may lead to higher acceptability and uptake.

Is azoospermia the appropriate standard for post-vasectomy semen analysis? Or an unachievable goal of best practice laboratory guidelines

The increasingly stringent laboratory-approach to diagnosing azoospermia for post-vasectomy semen analysis (PVSA) continues to be at odds with the simpler approach desired by clinicians. This study describes the analysis of 10 years of PVSA and discusses the outcome in relation to risk, cost and assesses whether more stringent procedures are required. PVSA was performed on 4788 patients initially using a 2-test strategy (16 and 20 weeks post-surgery), moving to 1 test during 2013-2014. Azoospermia was confirmed by the analysis of 10 µl of semen followed by 10 µl of centrifuged pellet. In total, there were 9260 tests with a median of 1.93 tests/patient and 18.7 weeks to clearance. Surgical failure occurred in 1.75%, falling to 1.1% between 2011 and 2016. There were no cases of unwanted pregnancy, recanalization or complaints although misdiagnosis was detected in 1 case as a result of failure to confirm patient identification. Azoospermia performed according to World Health Organization (WHO) guidelines is sufficiently robust to confirm success/failure of vasectomy. With uncertainty surrounding the diagnosis, efforts to improve detection of occasional non-motile sperm are futile, cost more and fail to reduce risk of inappropriate clearance. Misdiagnosis is more likely from patient identification error and mitigation may include reverting to the safety net of a 2-test strategy.

The case for early post-vasectomy semen analysis combining small non-motile sperm and azoospermia

Background:

Post-vasectomy semen analysis timing and criteria guidelines have evolved over time. Through analysis of our unit’s practice of post-vasectomy semen analysis from earlier sampling protocols at 8 weeks to single sampling at 12 weeks then 16 weeks, the impact on success rates and patient compliance were assessed. In addition, the use of small numbers of non-motile sperm and azoospermia combined rates as a marker of sterility were examined.

Methods:

All patients who underwent vasectomy in 2011 (8 and 12-week samples), 2013 (12-week samples) and 2016 (16-week samples) were included. Patients were given written and verbal instructions explaining the sample delivery protocol and samples. χ2 Testing was used to compare patient compliance and the results of post-vasectomy semen analysis with significance set at P<0.05.

Results:

In total 1124 vasectomies were performed, with 21% ( N=232) of patients non-compliant with submitting samples at the requested time period. Azoospermia rates increased with a longer time to post-vasectomy semen analysis from 82% to 95%, P<0.001; however, declining compliance meant the proportion of patients given clearance remained the same (70% vs. 68%, P=0.32). Rates of small non-motile sperm declined over an increasing time to post-vasectomy semen analysis. Therefore combined azoospermia and small non-motile sperm rates remained stable over an increasing sampling time (95% vs. 99%, P=0.39).

Conclusion:

The use of earlier post-vasectomy semen analysis is recommended as patient compliance decreases with the time from vasectomy. When azoospermia and small non-motile sperm rates are combined the rates of success of the procedure remain the same over time therefore earlier testing at 8 weeks is feasible without compromising clearance rates.

Level of evidence:

Not applicable for this single centre audit.

Effect of ductus deferens lavage on the time to achieve azoospermia in patients undergoing vasectomy

OBJECTIVE

To evaluate the effect of normal saline lavage of the distal vas deferens ampulla in patients undergoing vasectomy on the time to achieve azoospermia.

METHODS

A prospective randomized study of 60 men divided into two groups, group lavage (GL, n=30) in which distal vas deferens ampulla lavage was performed with 10 ml of normal saline during the vasectomy, and group without lavage (GWL, n=30) in which control patients received only a vasectomy. The patients provided sperm for semen analysis at the 5th, 10th, 15th, 20th and 25th ejaculations.

RESULTS

Fifteen participants in GL and 16 in GWL, for a total of 31 patients, were excluded due to not completing the control spermiogram. The tests carried out at the five ejaculations showed immobile spermatozoa in 40 and 85.71%, 66.67 and 78.57%, 93.33 and 85.71%, 86.67 and 71.43%, and 93.33 and 85.71% of participants in GL and GWL, respectively.

CONCLUSION

Vas deferens duct lavage with 10 ml of normal saline during vasectomy did not decrease the time required to achieve postoperative azoospermia.

CUA guideline: Vasectomy

<p>Vasectomy is a safe and effective method of birth control. Although it is a simple elective procedure, vasectomy is associated with potential minor and major complications. The early failure rate of vasectomy (presence of motile sperm in the ejaculate at 3‒6 months post-vasectomy) is in the range of 0.3‒9% and the late failure rate is in the range of 0.04–0.08%. The no-scalpel vasectomy technique is associated with a lower risk of early postoperative complications and the use of cautery or fascial interposition will reduce the risk of contraceptive failure. As such, detailed preoperative counselling and careful assessment of the post-vasectomy ejaculate (for presence of sperm) is imperative. Failure to provide and document adequate information and counselling to patients may lead to litigation.</p><p>The focus of this guideline is the management of men presenting for vasectomy. Specifically, the topics covered include: preoperative counselling, vasectomy efficacy and complications, technical aspects of vasectomy, post-vasectomy semen testing, and interpretation-communication of post-vasectomy semen results. By performing an extensive literature review, we have generated an evidence-based consensus on the management of these men. The objective of this guideline is to help standardize the treatment of men presenting for vasectomy.</p>

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).

Impact of the 2012 American Urological Association vasectomy guidelines on post-vasectomy outcomes

PURPOSE

The 2012 American Urological Association (AUA) vasectomy guidelines recommend the finding of rare nonmotile sperm, representing 100,000 or fewer nonmotile sperm per ml, as a metric of post-vasectomy success. At our institution success was previously defined as 2 sequential azoospermic centrifuged semen pellets. The criteria change of including rare nonmotile sperm as a success end point may simplify post-vasectomy followup and decrease the number of post-vasectomy semen analyses required to assure occlusive success.

MATERIALS AND METHODS

In the context of the new 2012 guidelines we retrospectively reviewed and analyzed the records of 972 of the 1,740 vasectomies (55.9%) performed between January 2000 and June 2012 after which at least 1 post-vasectomy semen analysis was done.

RESULTS

A total of 1,919 post-vasectomy semen analyses were obtained from 972 patients with a mean ± SE age of 39.7 ± 0.2 years. Occlusive success was evident in 337 azoospermic men (36.4%), while 514 (52.9%) underwent 2 or more post-vasectomy semen analyses and 458 (47.1%) returned for a single post-vasectomy semen analysis but were lost to followup. Of these noncompliant patients 76.0% were azoospermic, 19.7% had rare nonmotile sperm, 1.5% had greater than 100,000 nonmotile sperm per ml and 2.8% had motile sperm. Three patients underwent repeat vasectomy for persistent rare nonmotile sperm. If the criteria defined by the 2012 guidelines had been used to monitor these men, the occlusive success rate would have improved to 97.6% (949 patients) (p <0.05). Repeat vasectomies as well as 896 subsequent post-vasectomy semen analyses would have been avoided.

CONCLUSIONS

The AUA vasectomy guidelines provide clear, evidence-based criteria for vasectomy success. The guidelines simplify followup protocols, improve patient compliance and help avoid unnecessary post-vasectomy semen analyses and repeat vasectomies.

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.

A novel modification of no-scalpel vasectomy: a preliminary report

OBJECTIVE

To present a novel technique of no-scalpel vasectomy (NSV) that has the potential to decrease the failure rate.

PATIENTS AND METHODS

From 2006 until 2008 vasectomy was performed by ligating head-to-head and tail-to-tail the cut ends of the vasa deferentia. The outcome of the procedure was assessed by three semen analyses, the first two of which were carried out three months postoperatively and the third one at the end of the study period. SPSS version 13 was used to analyse data.

RESULTS

Fifty-four patients participated in this study. The operating time amounted to an average of 16 minutes. The mean duration of follow-up was 17.7 +/- 6.69 months (range: 12-34). The outcome of the procedure overall was excellent with a minimum of complications.

CONCLUSION

Vasal head-to-head and tail-to-tail ligation in NSV shows promise as a safe and effective sterilisation procedure.

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.

Vasectomie et chirurgies contraceptives déférentielles : aspects légaux et techniques

OBJECTIVES

To analyse technical innovations, their results and the changing legislation in France concerning sterilizing or contraceptive vas deferens surgery.

MATERIAL AND METHODS

A review of the literature was performed using the key words: male/contraception/vas deferens. From the 332 research articles obtained from PUBMED, we selected 54 articles for their methodological quality and the importance of their results.

RESULTS

Vasectomy remains the only validated vas deferens surgical technique. Although microsurgical reconstructive techniques have improved the vas deferens restoration rate, vasectomy must be considered to be a definitive method of sterilization. The other contraceptive (reversible) vas deferens surgical techniques have not demonstrated sufficient efficacy to be used outside of the context of clinical trials. However the encouraging results ofsome ofthese studies could allow their development in the intermediate term. From a legal point of view, since the reform of sterilizing surgery in Article L2123-1 of the French Public Health Act, vasectomy is now authorized in a regulatory framework.

CONCLUSION

The urology community must take into account progress in the field of contraceptive vas deferens surgical techniques.

Persistent Motile Sperm After Ligation Band Vasectomy

PURPOSE

We evaluated the efficacy and mechanism of failure in a small case series of VasClip vasectomies.

MATERIALS AND METHODS

Between September 2003 and March 2004, 8 patients underwent elective vasectomy using the VasClip ligation band. Microscopic semen analysis was done a minimum of 4 weeks postoperatively and after at least 15 ejaculations. The number of sperm and motility were quantified in 15 or more high power fields. Successful vasectomy was defined as 2 consecutive postoperative unspun semen analyses containing no sperm. Patients with failed vasectomy underwent bilateral surgical removal of the vas deferens segments containing the ligation band for gross and histological analysis.

RESULTS

Six of 8 patients (75%) were deemed azoospermic after 2 semen analyses at a mean followup of 7 and 11 weeks postoperatively, respectively. Two of 8 patients (25%) had semen analyses containing multiple motile sperm after vasectomy. In the 2 failed cases 1 side was patent, as demonstrated by vasal cannulation and irrigation with dilute methylene blue despite a well positioned, intact and secure ligation band. Histological analysis showed extravasation and sperm granuloma on the patent side.

CONCLUSIONS

The VasClip was found to fail at an unexpectedly high rate. Pathological analysis suggests sperm extravasation and fistula tract formation as the mechanism. One failure resulted in an unwanted pregnancy, which demonstrates the need for patient counseling regarding postoperative followup.

Frequency and patterns of early recanalization after vasectomy

Background

Our understanding of early post-vasectomy recanalization is limited to histopathological studies. The objective of this study was to estimate the frequency and to describe semen analysis patterns of early recanalization after vasectomy.

Methods

Charts displaying serial post-vasectomy semen analyses were created using the semen analysis results from 826 and 389 men participating in a randomized trial of fascial interposition (FI) and an observational study of cautery, respectively. In the FI trial, participants were randomly allocated to vas occlusion by ligation and excision with or without FI. In the cautery study, sites used their usual cautery occlusion technique, two with and two without FI. Presumed early recanalization was based on the assessment of individual semen analysis charts by three independent reviewers. Discrepancies were resolved by consensus.

Results

Presumed early recanalization was characterized by a very low sperm concentration within two weeks after vasectomy followed by return to large numbers of sperm over the next few weeks. The overall proportion of men with presumed early recanalization was 13% (95% CI 12%–15%). The risk was highest with ligation and excision without FI (25%) and lowest for thermal cautery with FI (0%). The highest proportion of presumed early recanalization was observed among men classified as vasectomy failures.

Conclusion

Early recanalization, occurring within the first weeks after vasectomy, is more common than generally recognized. Its frequency depends on the occlusion technique performed.

An implantable ligation device that achieves male sterilization without cutting the vas deferens

OBJECTIVES

To determine whether the Vasclip implant procedure would (a) be equivalent to vasectomy in producing azoospermia, (b) produce greater patient satisfaction postoperatively, and (c) result in lower complication rates, postoperative pain, hematoma formation, spermatic granuloma, and surgical site infection when compared with historical controls.

METHODS

Sterilization and complications were studied in 124 consecutive patients.

RESULTS

Successful sterilization, defined by azoospermia at 10 to 14 months, was observed in 116 of 119 subjects. The effectiveness seemed to be equivalent to that of vasectomy. The incidence of postoperative pain and hematoma formation was similar to that with standard methods. The Vasclip procedure had similar infection rates and seemed to have lower rates of sperm granuloma when compared with vasectomy. In 3 subjects with persistent presence of sperm, histologic examination after traditional vasectomy indicated that misalignment of the device led to partial vas incision with recanalization. Patient acceptability was high: of the clinical study patients, 99% of survey respondents would recommend that other men considering a vasectomy have the Vasclip procedure.

CONCLUSIONS

The Vasclip implant procedure represents a new, effective, office-based alternative to vasectomy. Physicians' benefits can include reduced procedural time and reduction of postprocedural complications. Potential patients' benefits include reduced risk of postoperative infection and sperm granuloma formation.

Vasectomy surgical techniques in South and South East Asia

Background

Simple ligation of the vas with suture material and excision of a small vas segment is believed to be the most common vasectomy occlusion technique performed in low-resource settings. Ligation and excision (LE) is associated with a risk of occlusion and contraceptive failure which can be reduced by performing fascial interposition (FI) along with LE. Combining FI with intra luminal thermal cautery could be even more effective. The objective of this study was to determine the surgical vasectomy techniques currently used in five Asian countries and to evaluate the facilitating and limiting factors to introduction and assessment of FI and thermal cautery in these countries.

Methods

Between December 2003 and February 2004, 3 to 6 major vasectomy centers from Cambodia, Thailand, India, Nepal, and Bangladesh were visited and interviews with 5 to 11 key informants in each country were conducted. Vasectomy techniques performed in each center were observed. Vasectomy techniques using hand-held, battery-driven cautery devices and FI were demonstrated and performed under supervision by local providers. Information about interest and open-mindedness regarding the use of thermal cautery and/or FI was gathered.

Results

The use of vasectomy was marginal in Thailand and Cambodia. In India, Nepal, and Bangladesh, vasectomy was supported by national reproductive health programs. Most vasectomies were performed using the No-Scalpel Vasectomy (NSV) technique and simple LE. The addition of FI to LE, although largely known, was seldom performed. The main reasons reported were: 1) insufficient surgical skills, 2) time needed to perform the technique, and 3) technique not being mandatory according to country standards. Thermal cautery devices for vasectomy were not available in any selected countries. Pilot hands-on assessment showed that the technique could be safely and effectively performed by Asian providers. However, in addition to provision of supplies, introducing cautery with FI could be associated with the same barriers encountered when introducing FI in combination with LE.

Conclusion

Further studies assessing the effectiveness, safety, and feasibility of implementation are needed before thermal cautery combined with FI is introduced in Asia on a large scale. Until thermal cautery is introduced in a country, vasectomy providers should practice LE with FI to maximize effectiveness of vasectomy procedure.

Delayed vasectomy success in men with a first postvasectomy semen analysis showing motile sperm

OBJECTIVE

To determine the frequency of and factors associated with delayed vasectomy success in men with first postvasectomy semen analysis showing motile sperm.

DESIGN

Descriptive study.

SETTING

One hospital-based family planning clinic and two private clinics from the Quebec City area, Canada.

PATIENT(S)

Three hundred nine men vasectomized between 1990 and 2001 and who had a first semen analysis showing motile sperm.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Vasectomy success, based on the last available semen analysis-either in the medical record or as requested for the study-and on sterility as established by a telephone-based questionnaire in 2003.

RESULT(S)

Among the 309 men, 174 (56.3%, 95% confidence interval 50.7%-61.7%) had delayed vasectomy success. Significant independent factors associated with delayed vasectomy success were lower sperm count in the first postvasectomy semen analysis and shorter interval between vasectomy and first postvasectomy semen analysis.

CONCLUSION(S)

Delayed vasectomy success occurs in more than half of men with a first postvasectomy semen analysis showing motile sperm. The decision to repeat vasectomy should not rely on a single semen analysis showing motile sperm.

Rates of suppression and recovery of human sperm output in testosterone-based hormonal contraceptive regimens*

BACKGROUND

Practical hormonal male contraceptive regimens are likely to have delayed onset and offset of reliable contraception dictated by the length of the spermatogenic cycle and clearance rate of pre-formed sperm from the ductular system. While delayed onset of contraceptive efficacy is an accepted feature of vasectomy, reliable time estimates for a hormonal male contraceptive of time to onset and offset of reliable contraception and of resumption of normal male fertility are required.

METHODS AND RESULTS

We utilized the sperm output data from three male contraceptive efficacy studies to define quantitative estimates of suppression and recovery rates from an androgen alone (testosterone enanthate) and an androgen/progestin (testosterone/depot medroxyprogesterone acetate) study. Using nearly 14,000 semen samples from World Health Organization (WHO) studies #85921 and #89903 with identical protocols, the rate of suppression of sperm output was best modelled as a two-parameter, single exponential decay function with effective half-time to suppression of 5.5 weeks and times of 6.8 weeks to 10 x 10(6)/ml, 8.7 weeks to 5 x 10(6)/ml, 10.0 weeks to 3 x 10(6)/ml and 13.0 weeks to 1 x 10(6)/ml. The rate of recovery using absolute sperm concentration was best modelled as a three-parameter, sigmoidal curve with effective time to reach half of the recovery plateau of 10.5 weeks and times of 9.0 weeks to 3 x 10(6)/ml, 9.9 weeks to 5 x 10(6)/ml, 11.5 weeks to 10 x 10(6)/ml, and 13.6 weeks to 20 x 10(6)/ml. Using relative sperm output, defined as a percentage of the participants' own baseline, recovery approached an asymptotic plateau of approximately 85% of geometric mean pre-treatment sperm concentration. In the combination androgen/progestin study, suppression rate was significantly faster (effective time to reach half maximal suppression of 3.0 weeks) and recovery significantly slower (effective time to reach half of recovery plateau of 14.7 weeks) and less complete (asymptotic recovery plateau of 43% of baseline) than in the androgen-alone WHO studies.

CONCLUSION

These findings therefore provide large sample estimates of the suppression and recovery rates from an androgen-alone hormonal male contraceptive regimen as a basis for comparison with other second-generation combination androgen/progestin regimens that are the most promising approach to developing practical male hormonal regimens.

Effectiveness of vasectomy using cautery

Background

Little evidence supports the use of any one vas occlusion method. Data from a number of studies now suggest that there are differences in effectiveness among different occlusion methods. The main objectives of this study were to estimate the effectiveness of vasectomy by cautery and to describe the trends in sperm counts after cautery vasectomy. Other objectives were to estimate time and number of ejaculations to success and to determine the predictive value of success at 12 weeks for final status at 24 weeks.

Methods

A prospective, non-comparative observational study was conducted between November 2001 and June 2002 at 4 centers in Brazil, Canada, the UK, and the US. Four hundred men who chose vasectomy were enrolled and followed for 6 months. Sites used their usual cautery vasectomy technique. Earlier and more frequent than normal semen analyses (2, 5, 8, 12, 16, 20, and 24 weeks after vasectomy) were performed. Planned outcomes included effectiveness (early failure based on semen analysis), trends in sperm counts, time and number of ejaculations to success, predictive value of success at 12 weeks for the outcome at 24 weeks, and safety evaluation.

Results

A total of 364 (91%) participants completed follow-up. The overall failure rate based on semen analysis was 0.8% (95% confidence interval 0.2, 2.3). By 12 weeks 96.4% of participants showed azoospermia or severe oligozoospermia (< 100,000 sperm/mL). The predictive value of a single severely oligozoospermia sample at 12 weeks for vasectomy success at the end of the study was 99.7%. One serious unrelated adverse event and no pregnancies were reported.

Conclusion

Cautery is a very effective method for occluding the vas. Failure based on semen analysis is rare. In settings where semen analysis is not practical, using 12 weeks as a guideline for when men can rely on their vasectomy should lessen the risk of failure compared to using a guideline of 20 ejaculations after vasectomy.

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 by ligation and excision, with or without fascial interposition: a randomized controlled trial [ISRCTN77781689]

BACKGROUND

Randomized controlled trials comparing different vasectomy occlusion techniques are lacking. Thus, this multicenter randomized trial was conducted to compare the probability of the success of ligation and excision vasectomy with, versus without, fascial interposition (i.e. placing a layer of the vas sheath between two cut ends of the vas).

METHODS

The trial was conducted between December 1999 and June 2002 with a single planned interim analysis. Men requesting vasectomies at eight outpatient clinics in seven countries in North America, Latin America, and Asia were included in the study. The men were randomized to receive vasectomy with versus without fascial interposition. All surgeons performed the vasectomies using the no-scalpel approach to the vas. Participants had a semen analysis two weeks after vasectomy and then every four weeks up to 34 weeks. The primary outcome measure was time to azoospermia. Additional outcome measures were time to severe oligozoospermia (<100 000 sperm/mL) and vasectomy failure based on semen analyses.

RESULTS

We halted recruitment after the planned interim analysis, when 841 men had been enrolled. Fascial interposition decreased time to azoospermia (hazard ratio [HR], 1.35; P < 0.0001) and time to severe oligozoospermia (HR, 1.32; P < 0.0001) and reduced failures based on semen analysis by about half, from 12.7% (95% confidence interval [CI], 9.7 to 16.3) to 5.9% (95% CI, 3.8 to 8.6) (P < 0.0001). Older men benefited less from fascial interposition than younger men in terms of the speed of achieving azoospermia. However, the number of vasectomy failures was reduced to a similar degree in all age groups. Slightly more adverse events occurred in the fascial interposition group, but the difference was not significant. These failure rates may appear high to practitioners in countries such as the USA, but they are similar to results from other careful studies of ligation and excision techniques.

CONCLUSION

Fascial interposition significantly improves vasectomy success when ligation and excision is the method of vas occlusion. A limitation of this study is that the correlation between postvasectomy sperm concentrations and risk of pregnancy is not well quantified.