Paternity after vasectomy with two previous semen analyses without spermatozoa

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.

A novel laboratory procedure to validate American Urological Association guideline on vasectomy success and to diagnose obstructive azoospermia

The objective was to develop a laboratory procedure to validate American Urological Association (AUA) Guideline on vasectomy success when nonmotile spermatozoa are found in the post-vasectomy ejaculate. The neutral α-glucosidase (NAG) an epididymal protein assay modified to determine the activity at 30 and 90 min of incubation from 24 pre- and 47 post-vasectomy ejaculates. The difference between the two points in the relative activity was calculated and if the difference was nonsignificant will confirm vasectomy success. The mean differences in the relative NAG activity were significantly different in pre- and post-vasectomy ejaculates, respectively. The mean differences in the relative NAG activity were similar in post-vasectomy ejaculates with and without nonmotile spermatozoa. No difference in relative NAG activity in post-vasectomy ejaculates between two time points of incubation may be a reliable method to confirm occlusion of the vas deferens. It also validates the recommendation by AUA Guideline on vasectomy success in the presence of few nonmotile spermatozoa.

Paternity seven years after a negative post-vasectomy semen analysis: a case report

BACKGROUND

Vasectomy is one of the permanent methods of contraception; however, the risk of conception still exists. Early failure, defined as a postoperative semen analysis showing persistent motile sperm, occurs in 1 in every 250 patients. Late failure, defined as the rejoining of the severed ends of the vas deferens, occurs in 1 in every 2000 patients.

CASE PRESENTATION

A healthy 37-year-old British male presented to our clinic because his wife had conceived seven years after he had undergone a vasectomy. The result of his semen analysis after the vasectomy was negative, and the histopathological report confirmed that the sample contained tissue from both the left and right vas deferens. His wife conceived seven years after the procedure, and semen analysis at that time confirmed a total of 0.5 million sperm per milliliter of semen in a total semen sample of 6.3 ml. The total number of motile sperm recorded was 2.5 million.

CONCLUSION

This case shows that late recanalization can occur up to seven years after a vasectomy. Patients should be informed prior to the procedure that late recanalization, although rare, may still occur. Post-vasectomy paternity necessitates further counseling to ensure that the patient and the patient's partner fully understand the implications and options available to them.

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.