Vasectomy and vasectomy reversal

Vasectomy Regret or Lack Thereof

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Outpatient Vasectomy: Safe, Reliable, and Cost-effective

Vasectomy is a safe, effective, and practical option for permanent contraception in men. Vasectomy is a surgical procedure used in men to disrupt and occlude the vas deferens, which delivers sperm from the testicles. By interrupting sperm transport, this procedure provides permanent sterilization. Vasectomies are typically done under local anesthesia in outpatient settings, and patients usually go home within an hour of the surgery. Surgical techniques used for vasectomy vary widely throughout the world, with limited evidence to guide the most effective approach. Current vasectomy guidelines largely rely on information from observational studies, with few controlled clinical trials.

Surgical treatment for male infertility

Given the nature of the multiple causes of male infertility, some of them are «reversible» and can be managed with a surgical procedure to recover, in some cases, the fertilizing capacity of the male reproductive tract. With appropriate use of diagnostic tools and clinical judgement, the physician can identify the ideal candidates for these procedures. Together with the expertise and experience of the surgeon, these treatments can manage to resolve the barrier, and men may become fertile again. In this chapter, we will review some of the most commonly used surgical procedures for the treatment of male infertility and make a brief description of their technical details.

Open/close-ended vasectomy technique by single incision on vervet monkeys (Chlorocebus pygerythrus)

Vervet monkeys (Chlorocebus pygerythrus), considered a species of "least concern" by the International Union for Conservation of Nature (IUCN), are widely maintained at primate sanctuaries in South Africa. Permanent surgical contraception is a necessary method for the management of this species in captivity. In this study, a new vasectomy technique was evaluated and involves a prescrotal approach with only one surgical incision, aiming to excise a piece of vas deferens, leaving open the testicular side, and creating a loop on the prostatic side to avoid future recanalization. The birth rate was studied to assess the success of the technique. This technique significantly reduced breeding in the study population from 33 births in the first year to four births during the last year of the study. These results show that this type of vasectomy is a fast, simple, and safe technique for controlling monkey populations in sanctuaries.

Endoscopic injection of bulking agent around the ejaculatory ducts at the verumontanum for recurrent paediatric epididymitis

INTRODUCTION

Paediatric recurrent epididymitis is frequently observed in several urogenital conditions, and may result in deterioration of long-term fertility. The management of recurrent epididymitis is still a therapeutic challenge for paediatric urologists, and as yet there is no consensus for treatment.

OBJECTIVE

To present a minimally invasive endoscopic approach for the treatment of recurrent epididymitis (more than three episodes).

PATIENTS AND METHODS

Eleven boys were referred with a history of recurrent epididymitis in a context of urogenital malformations. All children underwent endoscopic transurethral injection. Dextranomer/hyaluronic acid was injected around the ejaculatory ducts at the verumontanum (Summary Fig.). The medical records and outcomes of the patients were retrospectively reviewed.

RESULTS

Of the 11 boys, two (18%) had a history of bladder exstrophy, three (27%) anorectal malformation, two (18%) peno-scrotal hypospadias, two (18%) posterior urethral valves, one (9%) seminal vesicle cyst, and one (9%) urethral stricture. The median age at injection was 3.75 years (range 8 months-14.7 years). Endoscopic injection effectively prevented recurrence in eight patients (73%) with a mean follow-up of 3 years (range 6 months-8.8 years). The mean injected volume was 0.7 ml/session. No perioperative complications were recorded. Vas clipping was performed in three patients after unsuccessful injections.

DISCUSSION

The current discussion for management of recurrent epididymitis is mainly based on vas clipping. Endoscopic injection in the verumontanum could offer several potential advantages over vas clipping; moreover, it is easy to perform for an urologist who usually uses endourological approaches. It is believed that only Kajbafzadeh et al. have reported their experience with endoscopic injection in the verumontanum in seven patients with structural anomalies, and they had a 42% success rate. Similarly, the current study did not observe perioperative or postoperative complications.

CONCLUSION

In this series, endoscopic injection of the verumontanum was considered to be a safe and effective treatment in almost 73% of children with recurrent epididymitis. It did not result in perioperative complications and not contraindicate a subsequent surgical procedure such as vas clipping.

A retrospective review of factors associated with vasovasostomies in United States military members

BACKGROUND

Men seeking a vasectomy should receive counseling prior to the procedure that includes discussion of later seeking a reversal. We sought to determine demographic factors that may predispose patients to possibly later seek a vasectomy reversal.

METHODS

All U.S. Military electronic health records were searched between 2000 and 2009 for either a vasectomy or vasovasostomy procedure code. Aggregate demographic information was collected and statistical analysis performed.

RESULT

A total of 82,945 patients had a vasectomy of which 4,485 had a vasovasostomy resulting in a vasovasostomy-to-vasectomy rate of 5.04%. The average age at vasovasostomy was 34.9±5.0, with an average interval of 4.1±2.2 years. Men undergoing a vasectomy at a younger age were more likely to have a vasovasostomy. Various religions did have statistically significant differences. Within ethnic groups, only Native Americans [OR=1.39 (95% CI 1.198-1.614)] and Asians [OR=0.501 (95% CI 0.364-0.690)] had statistically significant differences when compared to Caucasians. Men with more children at the time of vasectomy were more likely to have a vasovasostomy.

CONCLUSION

Younger men, Native Americans, and men with more children at vasectomy were more likely to undergo a vasovasostomy. The reason for these differences is unknown, but this information may assist during pre-vasectomy counseling.

Assisted reproductive technology outcomes in azoospermic men: 10 years of experience with surgical sperm retrieval

An azoospermic man suffers from an absence of sperm in the ejaculate and this condition is present in about 10% of infertile men. Obstructive azoospermia (OA) is characterized by an occlusion or partial absence of the reproductive tract with the presence of normal spermatogenesis. On the other hand, non-obstructive azoospermia (NOA) is characterized by impaired spermatogenesis. In these cases, spermatozoa can be obtained by percutaneous epididymal or testicular sperm aspiration (PESA and TESA, respectively) and used for intracytoplasmic injection (ICSI). To compare ICSI outcomes using spermatozoa that were surgically retrieved by PESA and TESA, azoospermic patients were divided into the following categories: (i) TESA-NOA (n = 102), (ii) TESA-OA (n = 103), and (iii) PESA-OA (n = 171). Fertilization, pregnancy, and implantation rates were compared between the groups. We noted a lower normal fertilization rate (p = 0.0017) and a higher abortion rate (p = 0.0387) among men in the TESA group who had OA when compared with men in the PESA group who had OA. On the other hand, a lower normal fertilization rate (p = 0.05) and a lower rate of non-cleaved embryos (p = 0.034) was found in the TESA group of NOA patients as compared to the TESA group of OA patients. No statistically significant differences were detected between the TESA and PESA groups and the OA and NOA groups, respectively. The clinical outcomes of embryos arising from ICSI cycles using spermatozoa harvested via PESA and TESA were similar, regardless of whether the patient had obstructive or non-obstructive azoospermia.

Necrospermia, antisperm antibodies, and vasectomy

OBJECTIVE

To present a case of necrospermia and antisperm antibodies after vasectomy reversal and in which motile sperm, subsequently used in intracytoplasmic sperm injection (ICSI) treatment, was found after testicular sperm retrieval.

DESIGN

Case report and literature review.

SETTING

Reproductive medicine unit based in a women's hospital in the United Kingdom.

PATIENT(S)

A 36-year-old man with secondary infertility who presented with necrospermia and antisperm antibodies after vasectomy reversal.

INTERVENTION(S)

Testicular sperm retrieval and IVF with ICSI.

MAIN OUTCOME MEASURE(S)

Presence of motile sperm in testicular sperm extraction biopsies.

RESULT(S)

Motile sperm found after testicular sperm retrieval successfully fertilized oocytes in an ICSI cycle.

CONCLUSION(S)

It appears difficult to dissociate the presence of antisperm antibodies from the necrospermia in our patient. Testicular sperm retrieval appeared to partially overcome the effect of the antisperm antibodies by retrieving sperm before they reach seminal plasma, where they would be exposed to the antibodies.

A comparison of post-thaw results between embryos arising from intracytoplasmic sperm injection using surgically retrieved or ejaculated spermatozoa

OBJECTIVE

To study the effect of freeze-thaw on embryos derived from intracytoplasmic sperm injection (ICSI) using surgically retrieved and ejaculated spermatozoa.

DESIGN

Retrospective study.

SETTING

Private IVF center.

PATIENT(S)

Three hundred eighty-three patients undergoing frozen-thawed ET cycles.

INTERVENTION(S)

Testicular sperm aspiration (TESA) or percutaneous epididymal sperm aspiration (PESA) were the sperm surgical retrieval methods used for ICSI. Embryos resulting from ICSI using surgically retrieved and ejaculated spermatozoa were frozen, thawed, and transferred.

MAIN OUTCOME MEASURE(S)

Post-thaw survival, implantation, and pregnancy rates.

RESULT(S)

No differences were found between the ejaculated sperm and TESA/PESA groups in terms of post-thaw survival rate (68.4% vs. 66.1%, respectively), pregnancy rate (20.1% vs. 16.1%), and implantation rate (10.6% vs. 12.7%). Similar results were found for those variables when comparing TESA and PESA groups.

CONCLUSION(S)

Cleavage embryos arising from ICSI cycles using testicular and epididymal spermatozoa can be frozen with survival, pregnancy, and implantation rates comparable to those obtained with ejaculated spermatozoa.

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.

Endoscopic Treatment of Vesicovasal and Vesicoureteral Reflux in Infants With Persisting Mesonephric Duct

PURPOSE

We present a minimally invasive endoscopic approach for the treatment of persisting mesonephric duct in male infants.

MATERIALS AND METHODS

Five male infants 2 to 8 months old were referred with a history of recurrent sepsis, epididymo-orchitis and anorectal malformation that was treated elsewhere with initial colostomy. All infants had edematous unilateral testes, fever and poor feeding. Urine and blood cultures yielded the same microorganisms. All infections occurred while the infants were on regimens of prophylactic antibiotics. Comprehensive urological evaluations confirmed ipsilateral renal agenesis, sacral hypoplasia (3 patients), high anorectal malformation, and vesicovasal and vesicoureteral reflux.

RESULTS

All 5 infants underwent urethrocystoscopy under general anesthesia. The ectopic persisting mesonephric duct entered the bladder neck and proximal prostatic urethra. Injection of 0.4 to 0.7 ml Urocol, used as a bulking agent, was administered submucosally at the opening of the persisting mesonephric duct. In 1 patient the orifice of the anomalous duct was not found during urethrocystoscopy, and ipsilateral vas ligation by titanium clips was performed. The results in the remaining 4 patients were excellent, and no further episodes of epididymitis were observed during a mean followup of 30 months.

CONCLUSIONS

The diagnosis of persisting mesonephric duct should be considered in a male child with anorectal anomalies and recurrent epididymo-orchitis, and can be confirmed by radiological studies and cystoscopy. Endoscopic treatment of this anomaly should be considered first line therapy in these patients. However, surgical intervention is mandatory for children not responding to the procedure.

ICSI outcomes in obstructive azoospermia: influence of the origin of surgically retrieved spermatozoa and the cause of obstruction

BACKGROUND

Spermatozoa can be retrieved from the testis and epididymis of men with obstructive azoospermia (OA) and used for ICSI. However, it is unknown whether the outcome of ICSI depends on the cause of obstruction or the origin of surgically retrieved spermatozoa.

METHODS

A cohort of 171 men with OA and normal spermatogenesis were included in this retrospective study. They were divided into three groups according to the site and origin of obstruction: 83 men had congenital bilateral absence of vas deferens; 55 and 33 had acquired epididymal and deferent duct obstructions, respectively. The outcome of 368 ICSI cycles was determined and compared according to the origin of spermatozoa: epididymal (n = 253) or testicular (n = 115).

RESULTS

Fertilization and clinical pregnancy rates did not differ between spermatozoa of different origin (58.9% versus 51.9% and 22.1% versus 24.3% with epididymal and testicular spermatozoa, respectively). However, the miscarriage rate was significantly higher for testicular spermatozoa (35.7% versus. 12.5% P < 0.05, chi2 test). Findings were similar whatever the aetiology of the OA.

CONCLUSION

This study suggests that the use of testicular spermatozoa, even those generated during normal spermatogenesis, alters embryonic development and that epididymal spermatozoa should be preferentially used, irrespective of the aetiology of OA.

Enhancing contraception A comprehensive review

This review covers familiar and emerging contraceptive methods, comparing the risks and benefits of each. These basics will help you connect patients with the most acceptable form of contraception for them.

Stereological analysis of the human testis after vasectomy indicates impairment of spermatogenic efficiency with increasing obstructive interval

OBJECTIVE

To quantify germ cell loss and the extent of testicular fibrosis in vasectomized patients of varying obstructive intervals.

DESIGN

Retrospective study.

SETTING

Specialized male reproductive surgery and endocrinology service.

PATIENT(S)

Thirty-four vasectomized patients 1-20 years after surgery and 10 normal subjects.

INTERVENTION(S)

Thirty-four testicular biopsies taken at the time of vasectomy reversal (vasovasostomy). Control biopsies taken from 10 normal men at the time of vasectomy.

MAIN OUTCOME MEASURE(S)

Stereological assessment of testicular germ cell populations and testicular fibrosis.

RESULT(S)

Vasectomy caused a significant decrease in germ cells in the later stages of spermatogenesis, with significant reductions in pachytene spermatocytes (by 18%), round spermatids (by 40%), elongating spermatids (by 23%), and elongated spermatids (by 39%). The loss of spermatids showed a significant relationship with obstructive interval. A significant 2.7-fold increase in total (peritubular plus interstitial) fibrosis was observed, which showed a positive relationship with obstructive interval. Decreased germ cell populations and fibrosis did not seem to be related to sperm antibody levels nor to sperm counts obtained up to 2 years after vasovasostomy.

CONCLUSION(S)

Vasal obstruction results in significant reductions in germ cells in the later stages of spermatogenesis and increases in testicular fibrosis, both worsening with an increasing obstructive interval. Testicular damage after vasectomy might impact upon the prospects for reversal.

Canadian Contraception Consensus

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

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.

Role of the urological surgeon in the age of intracytoplasmic sperm injection

In the last few years, it has been demonstrated that intracytoplasmic sperm injection is an effective procedure for treating patients with severe male infertility. Before this technique was available, the urological surgeon involved in the reproduction field dealt mainly with reconstructive (vasoepididimostomy, vasovasostomy) or endoscopic surgery of the seminal duct as well as varicocelectomy. Nowadays, the urological surgeon continues to participate in the field of reproductive surgery by applying methodologies which enable natural conception, and has to be involved in all aspects of sperm retrieval techniques.

Frozen-thawed epididymal sperm is effective for intracytoplasmic sperm injection: implications for the urologist

OBJECTIVE

To evaluate the pregnancy potential of frozen-thawed surgically retrieved epididymal sperm when used with intracytoplasmic sperm injection (ICSI).

PATIENTS AND METHODS

From August 1994 to January 1997, 20 thawed samples of sperm from 19 patients, surgically retrieved and frozen after percutaneous or open epididymal aspiration, were used for ICSI. The results were compared with those obtained using fresh sperm obtained at the same procedure.

RESULTS

Of the specimens of surgically retrieved sperm which had been frozen, stored and thawed, 15 had sufficient motile sperm for use with ICSI. The fertilization, cleavage and pregnancy rates in those cycles were similar to the same couples' previous cycle using fresh sperm from the same collection and to the overall results in the NURTURE ICSI programme obtained with fresh epididymal sperm.

CONCLUSION

Scrotal exploration for diagnostic testicular biopsy and/or reconstructive surgery without having access to sperm-freezing and storage facilities could represent a lost opportunity for the patient.

Sterilization in Finland: from eugenics to contraception

The purpose of this paper was to describe the transition of sterilization in Finland from an eugenic tool to a contraceptive. Historical data were drawn from earlier reports in Finnish. Numbers of and reasons for sterilizations since 1950 were collected from nationwide sterilization statistics. Prevalence, characteristics of sterilized women, and women's satisfaction with sterilizations were studied from a 1994 nationwide survey (74% response rate). Logistic regression was used for adjustments. In the first half of the 20th century, eugenic ideology had influence in Finland as in other parts of Europe, and the 1935 and 1950 sterilization laws had an eugenic spirit. Regardless of this, the numbers of eugenic sterilizations remained low, and in practice, family planning was the main reason for sterilization. Nonetheless, prior to 1970 not all sterilizations were freely chosen, because sterilizations were sometimes used as a precondition for abortion. Female sterilizations showed remarkable fluctuation over time. Male sterilizations have been rare. The reasons stipulated by the law did not explain the numbers of sterilizations. In a 1994 survey, 9% of Finnish women reported they were using sterilization as their current contraceptive method (n = 189). Compared to women using other contraceptive methods, sterilized women were older, had had more births and pregnancies, and came from lower social classes. Sterilized women were satisfied with their sterilization, but there were women (8.5%) who regretted it. In conclusion, sterilizations have been and are likely to continue to be an important family planning method in Finland. The extreme gender ratio suggests a need for promoting male sterilizations, and women's expressed regrets suggest consideration of a higher age limit.

Vasectomy review: sequelae in the human epididymis and ductus deferens

Following vasectomy, spermatogenesis continues, the human epididymis and ductus deferens may distend and leak, and the extravasated spermatozoa stimulate formation of a sperm granuloma. Granulomas may occur at 60% of vasectomy sites and are usually asymptomatic and relieve intraluminal pressure. About 3-5% of patients experience pain. Intraluminal phagocytosis may explain why some reproductive tracts become depleted of spermatozoa. Distension of the epididymis is common after vasectomy and may lead to granuloma formation there. Up to 6% of patients have symptoms, but many with epididymal changes have no discomfort. Most episodes of painful epididymitis and granulomas resolve with conservative treatment, but < 1% require vasectomy reversal or, if this is ineffective, excision of the epididymis and obstructed ductus deferens.