Paternity by a seemingly infertile vasectomised man

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.

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.

Is quality assurance in semen analysis still really necessary? A clinician's viewpoint

Quality assurance in semen analysis is now a standard procedure in most andrology laboratories. This communication is now questioning its value in any clinical situation and as a consequence asks whether the effort and the expense of such a process is really worthwhile. It concludes that semen analysis needs only to be performed competently without the need for costly and time-consuming forms of quality assurance.

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.

A randomized clinical trial of the effect of intraoperative saline perfusion on postvasectomy azoospermia

BACKGROUND

We wanted to determine whether a saline flush during vasectomy would reduce the time needed to reach azoospermia.

METHODS

During vasectomy men were randomly assigned to flush the prostatic end of the vas deferens with 10 mL of normal saline (intervention group, n = 50), while the remaining men (n = 56) served as controls. Sperm counts were performed on the immediate postprocedure urine specimen and on semen samples at 1, 6, and 12 weeks after vasectomy.

RESULTS

The postprocedure urine specimens from the intervention and control groups contained 29.2 x 106 and 0.004 x 106 sperm, respectively (P < .001). Total sperm counts in the ejaculate for intervention and control groups at 1, 6, and 12 weeks were (in millions of sperm): 14.1 and 13.8, 0.4 and 8.0, and 0.0 and 0.011, respectively (P > .05 at all time points). There was no difference in the rate at which the men in the 2 groups achieved azoospermia.

CONCLUSIONS

Vasal perfusion with saline during vasectomy was effective in removing sperm from the distal vas; however, perfusion did not increase the rate at which men achieve azoospermia.

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.

Sperm pellet analysis: a technique to detect the presence of sperm in men considered to have azoospermia by routine semen analysis

PURPOSE

In men considered to have azoospermia by routine semen analyses sperm may be identified after centrifuging the semen. Because these sperm may be used for intracytoplasmic sperm injection, we describe our technique and findings of sperm pelleting.

MATERIALS AND METHODS

Semen centrifugation for sperm pellet analysis was performed in 140 consecutive men in whom no sperm was identified on routine semen analysis and who were categorized as having obstructive or nonobstructive azoospermia. Obstructive azoospermia was defined as failed vasectomy reversal, failed reconstruction for congenital vasal or epididymal occlusion, or an acquired obstruction unrelated to ejaculatory duct obstruction. Patients with congenital absence of the vas deferens or who had undergone vasectomy were not included in the study. Nonobstructive azoospermia was defined as moderate to severe testicular atrophy with markedly elevated serum follicle-stimulating hormone (greater than 3 times normal), or a testicular biopsy that revealed maturational arrest, severe hypospermatogenesis or the Sertoli-cell-only pattern. Obstructive and nonobstructive azoospermia were present in 70 men who provided 109 samples and 70 who provided 103, respectively.

RESULTS

Motile and nonmotile sperm was identified in 13 of the 70 patients (18.6%) with obstructive and in 16 of the 70 (22.8%) with nonobstructive azoospermia. Pellet variability, that is the absence of sperm in 1 specimen and its presence in another from the same patient, was noted in 7 of the 17 men (41.2%) with obstructive and 2 of the 17 (11.8%) with nonobstructive azoospermia (not statistically significant). Motile sperm was present in the pellets of 6 of the 70 men (8.6%) with obstructive and 15 of the 70 (21.4%) with nonobstructive azoospermia. The median number of motile sperm was lower in the obstructive than in the nonobstructive group (0 sperm in 17 samples versus 5 sperm in 41 samples, p <0.001). The median value of 0 in the obstructive azoospermia group reflects the finding that 9 of the 17 samples did not contain motile sperm. Similarly the median number of nonmotile sperm was lower in the obstructive than in the nonobstructive group (5 versus 8 sperm).

CONCLUSIONS

We demonstrated the presence of motile and nonmotile sperm in a significant number of men considered to have azoospermia by routine semen analysis. Semen centrifugation (sperm pelleting) should be performed in all men considered to have this condition by routine semen analysis, especially those with testicular failure and those in whom intracytoplasmic sperm injection is possible.

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.

Population genetic and family data for the human minisatellite locus D16S309 (MS205) in Germans

The distribution of restriction fragments at the DNA minisatellite locus D16S309 was estimated by investigating blood samples from 2617 unrelated West German Caucasians and 1269 offspring. Furthermore segregation of fragments was studied in a large family and in trios. Altogether 2296 meioses were studied, revealing 7 paternal and 3 maternal mutations. Inspection of "phenotypes" did not reveal any remarkable deviation from Hardy-Weinberg equilibrium.

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.

Vasectomy and vasectomy reversal

Vasectomy remains the safest method of birth control and there is much to commend it in the setting of a stable family relationship. However, some aspects of this operation have been wrongly presented in an attempt to widen its popularity and increase public acceptance. A simple procedure it may be but it is not totally free of complications; sometimes the operation has to be repeated and rarely it may reverse spontaneously even after the most stringent precautions. The family planning officer who counsels a prospective candidate and the surgeon who undertakes the procedure must ensure that these facts are understood by the patient with crystal clarity and that this fact is duly recorded on a signed and witnessed permission slip. Any organization which includes vasectomy in its programme of family planning should include advice and referral for vasectomy reversal in exactly the same way that the pill may be stopped or a coil can be removed. Fertility can be successfully restored by vasovasostomy in 50% of men who wish to have their vasectomies reversed, which often is due to a change in circumstances beyond their direct control.