The fate of cryopreserved sperm acquired during vasectomy reversals

PURPOSE

Intraoperative sperm banking has been recommended during vasectomy reversal. These specimens are maintained as insurance for possible future intracytoplasmic sperm injection. We evaluated the fate of specimens collected intraoperatively from 48 vasectomy reversal patients.

MATERIALS AND METHODS

Of 75 men 48 (64.0%) agreed to intraoperative sperm banking during vasectomy reversal. A total of 135 vials of epididymal sperm, 81 vials of testicular tissue and 13 vials of vasal sperm were cryopreserved.

RESULTS

Among couples who stored sperm 10 (20.8%) voluntarily discarded the specimens within 4 months of vasectomy reversal. Specimens from 31 couples (64.5%) remain in storage. Seven couples (14.6%) have used frozen sperm for intracytoplasmic sperm injection. In 3 of these couples the men were azoospermic after surgery, 2 men had 10,000 to 15,000 sperm per ml. in the ejaculate with limited motility and 2 had 1 to 2 million sperm per ml. with limited motility. The 7 women who underwent intracytoplasmic sperm injection ranged between 37 and 39 years old, which was older than the mean age of the remaining study group (32.7 years). With intracytoplasmic sperm injection fertilization was achieved in all cases and 20 of 47 eggs (42.5%) developed into embryos. Of 7 women 4 achieved biochemical pregnancies (57.1%) and 2 (28.6%) delivered newborns with epididymal sperm. Natural pregnancy occurred in 7 of 16 vasectomy reversal couples (43.7%) who were followed at least 18 months postoperatively but the time to pregnancy averaged 1 year.

CONCLUSIONS

Cryopreservation of sperm collected at vasectomy reversal is recommended for patients undergoing vasoepididymostomy or vasovasostomy. The couples who used the cryopreserved sperm for intracytoplasmic sperm injection included husbands whose postoperative ejaculate remained azoospermic or severely oligospermic and wives who were approaching 40 years old. Only a limited number of couples (14.6% of the study group) have used the cryopreserved sperm but the delivered newborn rate (28.6%) was comparable to other intracytoplasmic sperm injection data. The natural pregnancy rate after vasectomy reversal was 43.7% but the time to pregnancy after surgery was lengthy (average 1 year). These findings may be helpful for counseling couples who are planning vasectomy reversal surgery and may be considering intraoperative sperm banking.

The relationship between the vas volume and the anatomic size of the vas deferens

The anatomic sizes of 210 vas segments from 107 volunteers of vasectomy were measured by computerized image graphic technique with microphotography. The mean equivalent-round, outer and inner diameters of the vas were 2.17 +/- 0.20 mm and 0.56 +/- 0.08 mm, respectively. The calculated thickness of vas wall was 0.81 +/- 0.21 mm. The maximal volumes of 124 vas segments (1 cm in length) were tested by injecting colored solution into vas lumen until vas rupture. The mean rupture volume of 1 cm vas lumen was 0.05 +/- 0.007 mL. A significant influence of the thickness of vas wall (p < 0.05) and body height (p < 0.05) on the rupture volume was noticed in stepwise regression analysis. A tunnel-like rupturing pattern was observed in morphological observation. The obtained rupture volume provides a security line in determining the injection volume of occlusive material or the size of the implanted contraceptive device.

Vasoepididymostomy for vasectomy reversal: a critical assessment in the era of intracytoplasmic sperm injection

PURPOSE

We compared vasoepididymostomy to microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection for treatment of epididymal obstruction secondary to vasectomy.

MATERIALS AND METHODS

Results in patients who underwent vasoepididymostomy for vasectomy reversal at our institution were compared to those reported previously for microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection performed for obstructive azoospermia. The pregnancy rates, delivery rates, complications, cost per procedure and cost per delivery were compared. A cost per newborn analysis was performed using pregnancy and delivery rates, and reported cost estimates for the complications of assisted reproductive techniques.

RESULTS

A total of 55 men underwent 58 vasoepididymostomies in an attempt to restore fertility after vasectomy. Median followup was 19 months (range 0 to 115). Median obstructive interval was 12 years. There were no major complications. The patency rate after 6 months was 85%. Of the couples 20 achieved 24 pregnancies and 16 had 17 live births. The pregnancy rate at 1 year was 44%. There were 4 miscarriages and there are 3 ongoing pregnancies. The live delivery rate was 36%. Assuming a 29% delivery rate for microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection, the cost per newborn was $51,024, compared to $31,099 for vasoepididymostomy.

CONCLUSIONS

Vasoepididymostomy is more successful and more cost-effective than microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection for vasectomy reversal. It does not expose the women to complications in the treatment of a male problem and it is indicated for treatment of epididymal obstruction secondary to vasectomy. Microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection should be reserved for cases not amenable to surgical reconstruction.

Randomized clinical trial of an absorbable stent for vasectomy reversal

PURPOSE

More successful methods of vasectomy reversal would benefit those undergoing this treatment and might also increase the popularity of vasectomy. We conducted a randomized, prospective clinical trial of vasectomy reversal methods, comparing a new absorbable stent with 2-layer reattachment.

MATERIALS AND METHODS

We studied 116 men seeking vasectomy reversal between November 1990 and March 1994. Data were analyzed primarily by intention to treat.

RESULTS

Patients in the stent (64 cases) and no stent (52) randomized groups were similar in age distribution, age of spouses, years since vasectomy, proportion who had undergone prior vasectomy reversal and proportion who had previously achieved pregnancy. Operation time was more than 19 minutes shorter in the stent randomized group (p = 0.006). Fewer patients in the stent than the no stent group had patent vasovasostomies (81.0 versus 89.6%, respectively, p = 0.2) postoperatively. Fewer stent randomized patients had motile sperm (76.2 versus 81.3%, respectively, p = 0.5) and normal total motile sperm counts (49.2 versus 52.1%, respectively, p = 0.8) than did those without a stent. Conception occurred in 22 and 51% of all couples in the stent and no stent groups. The relative risk of conception among those in the stent group was 0.42 (95% confidence interval 0.24 to 0.71, p = 0.002). A Mantel-Cox log-rank test comparing pregnancies in each group according to the number of postoperative months revealed that the no stent group achieved more earlier pregnancies (p = 0.003).

CONCLUSIONS

The 2-layer microscopic vasovasostomy results in greater pregnancy rates than vasovasostomy using the absorbable stent.

Hemizona assay: evaluation of fertility potential in patients with vasectomy reversal

Approximately 40 to 60% of men who undergo a successful vasovasostomy have "functional failure" or failure to conceive even though active sperm are present. Factors of this functional failure include sperm abnormalities (oligoasthenoteratospermia) and antisperm antibodies. Nine male patients 32 to 43 years of age who underwent vasovasostomy were included in the study group. These patients demonstrated ductal patency 3 to 6 months after surgery. After attempts at fertility with their spouses failed, the couples underwent urological and gynecological evaluation. Semen parameters were recorded and further evaluation was performed using immobilizing and agglutination antibodies as well as direct immunobead test and the hemizona assay (HZA). Semen parameters presented varying levels of sperm concentration, percent motility, and morphology (strict). Antisperm antibodies were present in 4 of the 9 patients. Three of 4 patients with antibodies and 4 of 5 patients without antibodies benefitted from hemizona assay results in that it either supported a desired therapy or gave objective data that would dictate more aggressive therapy. Six men had a hemizona index of > 35%, predictive of adequate zona bind capability. Using these individual situations combined with gynecologic findings, recommendations are made as to identifying realistic options and therapeutic recommendations.

Surgical outcome of microscopic vasectomy reversal: an analysis of 30 cases

The results of 30 consecutive microscopic vasovasostomy procedures performed at a single institution over a five-year period between 1991 and 1995 were reviewed. When the surgical outcomes of patients who were operated on less than five years after their vasectomy were compared with the outcomes of those patients who received a vasovasostomy more than five years after their vasectomy, decreases in technical success rates were observed as measured by appearance of sperm in ejaculate (56% vs. 36%), biologic recovery as measured by mean sperm counts (56 million vs. 35 million) and mean progressive sperm motility (44% vs. 21%), along with a decrease in clinical success, as measured by overall pregnancy rates (50% vs. 7%, p < 0.05). Therefore, a microscopic vasovasostomy within 5 years of a vasectomy is a favorable procedure for vasectomy reversal.

Vasectomy reversal for treatment of the post-vasectomy pain syndrome

PURPOSE

The post-vasectomy pain syndrome is a rare but troublesome complication of vasectomy. We report our experience with 32 patients who underwent vasectomy reversal for relief of the post-vasectomy pain syndrome.

MATERIALS AND METHODS

The records of 32 patients undergoing vasovasostomy or epididymovasostomy for the post-vasectomy pain syndrome were evaluated for characteristics of symptoms, previous therapy, interval from vasectomy, success of surgery and duration of relief.

RESULTS

Of 32 men who underwent vasectomy reversal for the post-vasectomy pain syndrome between 1980 and 1994, 24 had relief of symptoms after the initial procedure. Of 8 men with recurrent pain 6 underwent a second reversal procedure, and 3 of them subsequently had relief of symptoms. Overall, 27 of 32 men had resolution of pain.

CONCLUSIONS

In our experience vasectomy reversal has a high rate of success for relief of the post-vasectomy pain syndrome. It does not preclude other forms of surgical therapy and it should be considered in the treatment of the post-vasectomy pain syndrome.

Electrovasography in normal and vasectomized men before and after vasectomy reversal

The electrical pattern of the vas deferens, or electrovasogram (EVG), was studied in 22 healthy volunteers, 20 vasectomy subjects and 18 individuals after vasectomy reversal. Their mean ages were 38.8 +/- 7.3, 44.3 +/- 7.9 and 58.6 +/- 6.6 years, respectively. Two electrodes were applied to the posterior aspect of the upper part of the scrotum. During the operation of vasectomy reversal, an electrode was applied directly to each of the two vasal segments before and immediately after vasovasostomy. The electrical activity and intravasal pressure were measured. In normal subjects, slow waves or pacesetter potentials (PP) were recorded. They had identical frequency and a regular rhythm from the two electrodes and were consistent in the individual subject on all test days. PP were followed randomly by bursts of action potentials (AP). In vasectomized subjects, PP from the proximal vasal segment exhibited an irregular rhythm (vasoarrhythmia). During operation for vasectomy reversal, the proximal vasal segment recorded vasoarrhythmia whereas the distal segment revealed a silent EVG. Intravasal pressure was normal (p > 0.05) in the distal segment but high (p < 0.05) in the proximal segment. EVG performed 1-6 years after vasectomy reversal showed a normal pattern in four subjects and diminished frequency and amplitude in three. These seven subjects had impregnated their wives and had an obstructive interval of < 3 years. The 11 subjects who did not produce a pregnancy had a vasoarrhythmic EVG and an obstructive interval of > 3 years. In conclusion, an EVG could be identified for normal subjects. Vasectomy resulted in a vasoarrhythmic EVG pattern which proved to be correctable by vasectomy reversal if the obstructive interval was short.

Electrovasogram in normal and vasectomized men and patients with obstructive azoospermia and absent vas deferens

The electric activity of the vas deferens (VD) or the electrovasogram (EVG) was recorded in 34 healthy volunteers (mean age 39.3 +/- 7.6 [SD] years), 22 patients with obstructive azoospermia (mean age 38.8 +/- 9.2 years), 10 after epididymovasostomy performed for obstructive azoospermia (mean age 40.6 +/- 4.8 years), 9 with bilaterally absent vasa deferentia (mean age 36.6 +/- 7.4 years), 20 after vasectomy (mean age 44.3 +/- 7.9 years), and 18 after vasectomy reversal (mean age 58.6 +/- 6.8 years). Silver-silver chloride electrodes were applied to the posterior aspect of the upper part of the scrotum and a reference electrode was applied to the lower limb. The intravascular pressure was also measured in 18 subjects during vasectomy reversal operation. Normal EVG manifested as regular slow waves or pacesetter potentials (PPs) which had the same frequency, amplitude, and regular rhythm when the test was repeated in the individual subject. Mean frequency was 6.6 +/- 1.5 cycles/min, amplitude was 0.6 +/- 0.1 mV, and velocity was 5.6 +/- 1.1 cm/s. PPs were followed randomly by action potentials (APs). The EVG in obstructive azoospermia exhibited bradyvasa, i.e., diminished PP frequency, amplitude, and velocity, in 14 patients and a "silent" EVG in 8 patients. Eight of the 10 patients in whom azoospermia persisted after epididymovasostomy had a silent EVG, and the remaining 2 patients whose semen character normalized after the operation revealed normal EVG. A silent EVG was also recorded by the 9 patients with absent vasa deferentia. In vasectomized subjects, PPs from the proximal vasal segment exhibited an irregular rhythm (vasoarrhythmia). During vasectomy reversal, the proximal vasal segment exhibited vasoarrhythmia and high pressure (p < .05) and the distal segment showed a silent EVG and normal pressure (p > .05). EVG performed postvasectomy reversal by 1-6 years showed a normal pattern in 7 subjects who have impregnated their wives and vasoarrhythmic EVG in 11 who could not produce pregnancy. In conclusion, EVG could be characterized for normal and pathologic vasa deferentia. Electrovasography is a simple, noninvasive, and nonradiologic technique that might be used as a diagnostic tool in the investigation of VD disorders and infertility.

Modified one-layer microsurgical vasovasostomy in vasectomized patients

Bilateral vasovasostomies were performed in 7 previously vasectomized patients. The method employed was a modification of a one-layer anastomotic technique. There was no correlation between the presence of absence of sperm in the vas fluid, presence or absence of sperm granuloma, and site of vasectomy. No correlation was revealed between the presence or absence of sperm in the vas fluid and the duration of obstructive period. After vasovasostomy, sperm was observed in the ejaculate in 86% of the patients. Only one patient's partner became pregnant. However, the partner of one patient with short postoperative period and good seminal finding after vasovasostomy was expected to become pregnant. This modified method of one-layer microsurgical vasovasostomy can be performed more easily and quickly, but requires further clinical experience and evaluation of usefulness.

Proteins in fluid from the proximal vas deferens of normal fertile and vasectomized men

Fluids were collected from the proximal vas deferens of 18 normal fertile men and 32 vasectomized men during vasectomy or vasovasostomy, respectively, and the protein concentration and pattern of proteins were then analysed by sodium dodecylsulphate polyacrylamide gel electrophoresis (SDS-PAGE). In normal fertile men and vasectomized men there were no significant differences in total protein concentrations between fluids from the left and right vas deferens. The total protein concentration of proximal vas fluid from vasectomized men (82.8 +/- 7.5 mg/ml; mean +/- SEM) was significantly higher than in normal fertile men (36.8 +/- 4.5 mg/ml). In vasectomized men there was no significant correlation between the total protein concentration in vas fluid and the duration of vasectomy. The patterns of protein bands in proximal vas fluid differed from those in seminal plasma. There was no relationship between the pattern of protein bands in vas fluid and the duration of vasectomy. Five major groups of proteins from proximal vas fluid were identified and no new major proteins were found in proximal vas fluid were identified and no new major proteins were found in proximal vas fluid after vasectomy. The percentage of 80K and 67K protein bands in vasectomized men was higher than that in normal fertile men. It is suggested that, after vasectomy, the physiological environment of the proximal vas deferens may be changed. One of these changes may be the higher total protein concentration (especially the 80K and 67K proteins) in vas fluid.

Temporal recognition of sperm autoantigens by IgM and IgG autoantibodies after vasectomy and vasovasostomy

Temporal patterns of IgM and IgG autoantibodies to sperm proteins were studied by western blot analysis at intervals after bilateral vasectomy, vasectomy followed one month later by vasovasostomy, or sham operations. Responses were detected to eight major autoantigens at 21-23, 36, 41, 51, 57, 63, 68-71 and 75-83 kDa, by study of staining patterns of sequential serum samples from individual animals and by analysis of the incidence of reaction to each protein. The four lower molecular weight antigens (21-23, 36, 41 and 51 kDa) provoked mainly IgG responses. The strongly stained set of higher molecular weight antigens (57, 63, 68-71 and 75-83 kDa) tended to show more clearly defined temporal patterns of IgM followed by IgG response, including a high incidence of IgM antibody at the 2-week interval. Three of the larger peptides (57, 63 and 68-71 kDa) appeared highly immunogenic, since some reactions were detected even in sham-operated rats. The classical patterns of IgM and IgG antibody responses to the majority of the dominant sperm autoantigens are in accord with the hypothesis that vasectomy mimics immunization with spermatozoa. The high incidence of IgM antibodies in the earliest sample, taken 2 weeks after vasectomy, suggests that the initial immunizing event takes place within about a week after the operation. Vasovasostomy did not bring about a decrease in antisperm antibodies. Instead, some animals demonstrated an increased reaction to certain antigens after reversal of vasectomy, even though the vasovasostomies were anatomically successful.

Reversal of vasectomy and the general surgeon

Reversal of vasectomy is a difficult procedure. Most surgeons still perform a macroscopic vasovasostomy. However, there is a little guidance in the current literature on the results that can be expected from such procedures. Patients may therefore be given unrealistic expectations preoperatively. Our study shows the results of macroscopic reversals of vasectomy performed over a 9-year period. A survey of Welsh surgeons is also presented concerning their preferred techniques and estimated success rates for reversals. The study clearly shows that a macroscopic vasovasostomy is the commonest method employed, with a wide variation in estimated success rates. Patients considering a macroscopic reversal of vasectomy should be warned of a less than 20% success rate.

Vasovasostomy: 10 years' experience in a district general hospital showing improved results with luminal dilatation

We report a simple and effective technique for vasovasostomy. Over 105 procedures have been performed over a 10-year period by a single consultant and his registrars with results comparable to those obtained with more time-consuming formal microsurgical techniques when routine luminal dilatation of the vas was adopted. Additionally, the chances of success were found to be greater the shorter the interval between vasectomy and vasovasostomy.

The post-vasectomy length of the testicular vasal remnant: a predictor of surgical outcome in microscopic vasectomy reversal

To identify another preoperative predictor of surgical outcome in vasal reconstruction, we prospectively measured the post-vasectomy length of the testicular vas deferens from the cauda of the epididymis to the site of the vasectomy in 26 patients undergoing vasal reconstruction. Intraoperatively, the vasal fluid was microscopically inspected and classified as whole sperm present or whole sperm absent. The length of the testicular vasal remnant was correlated with the intraoperative status of the vasal fluid. A testicular vasal remnant length greater than 2.7 cm. predicted the presence of fluid with whole sperm present in 30 of 32 testicles (94%). A testicular vasal length of less than 2.7 cm. predicted the presence of fluid without whole sperm in 17 of 20 testicles (85%). The length of the testicular vasal remnant can be measured preoperatively and knowledge of this length may be used to advise patients regarding the likelihood of successful vasal reconstruction.

Experience with macroscopic vasectomy reversal at the Medical College of Wisconsin

Thirty-two men underwent vasectomy reversal using loupe magnification at the Medical College of Wisconsin between 1984 and 1991. Semen analysis and pregnancy data were available for 27 of them, and sperm were present in the ejaculate of 24, representing a patency rate of 89%. Pregnancy was established by 11, for a pregnancy rate of 41%. These results suggest that vasovasostomy using loupe magnification provides acceptable rates of patency and pregnancy, although the pregnancy rate appears to be somewhat lower than that reported for microsurgical repair. The lower cost of macroscopic vasectomy reversal may outweigh the potential statistical advantages for some couples.

Vasovasostomy results in 66 patients related to obstructive intervals and serum agglutinin titres

In this series we present the results of a retrospective analysis of 66 vasovasostomy procedures performed between 1983 and 1991. Obstructive intervals and serum antisperm antibodies were correlated with pregnancy and patency rates. With obstructive intervals of less than 5 years a patency rate of 100% (31/31) was obtained. Even more than 10 years after reversal, pregnancy occurred in 25% (2/8) of the patients. Preoperative serum antisperm antibodies were correlated with pregnancy rates. Patients with a high agglutinin titre of 1/64 obtained a pregnancy rate of 23% (3/13). Those men who had no circulating antisperm antibodies in their blood had a significantly better chance in obtaining pregnancy (pregnancy rate 80%). In this study we accounted for an overall pregnancy rate of 51.5% (34/66) versus an overall patency rate of 84.8% (56/66). Neither long obstructive intervals nor high antisperm antibody titres should dissuade a surgeon from performing a vasovasostomy procedure.

What is the best pregnancy rate that may be expected from vasectomy reversal?

Pregnancy rates after vasectomy reversal vary among different reporting surgeons. To study those patients who are most likely to achieve pregnancy after vasectomy reversal, and to eliminate the effect of variations in surgical technique and operative findings on surgical outcome, the pregnancy rate after vasectomy reversal was calculated in men who achieved completely and consistently normal postoperative semen analyses (sperm concentration 20 x 10(6)/ml. or more and sperm motility 50% or greater). Of 95 patients who met the study criteria 58 (61.1%) achieved pregnancy and 37 (30.9%) did not. Including an allowance for some patients who will achieve pregnancy beyond the study-followup, it is concluded that the maximum pregnancy probability for vasectomy reversal is approximately 67%. Failure to achieve pregnancy in approximately a third of the patients may be explained by partner infertility, epididymal dysfunction and sperm antibodies. Studies that report pregnancy chances in excess of two-thirds must have different patient demographics and/or different methods of statistical analysis.

Anti-sperm antibodies and semen profiles in re-anastomosed men

A group of 29 re-anastomosed men were examined with respect to semen quality, anti-sperm antibody titres in serum and seminal plasma, presence of anti-sperm antibodies on sperm, and success rate in inducing pregnancy. Results indicated no association between pre-reversal serum anti-sperm antibody titres and post-reversal semen quality, but a pregnancy induction rate of zero was associated with serum anti-sperm antibody titres greater than 160. It is recommended that men considering reversal, with anti-sperm antibody titres of this level, should receive counselling about the possibility of post-reversal infertility.

Recovery of fertility after removal of polyurethane plugs from the human vas deferens occluded for up to 5 years

The present study reports the outcome of operations to remove MPU plugs from 130 men who had had occlusions of the vas deferens for between 0.5 and 5 years. The female partners of all the men achieved a pregnancy over a period of 0.5-4 years after the reversal operation.

Male sterilization

This review of recent information and advances in the area of male sterilization deals with recent epidemiologic studies that discuss potential ill effects hypothesized to be a result of vasectomy, including carcinoma of the prostate and carcinoma of the testicle. Rebuttals to these hypotheses are presented. Recent advances in techniques of vasectomy including the "no-scalpel" vasectomy technique and open-ended vasectomy are presented, including the rationale for their use. A good deal of attention is given to postvasectomy follow-up, particularly the use of the technique of measuring numbers of ejaculations following vasectomy rather than the period of time afterward to determine when a man is sterile. The final two sections deal with complications of vasectomy and the most recent percentages on reversing vasectomy with particular reference to return of sperm to the ejaculate and pregnancy rates.

[Vasovasostomy after vasectomy. The surgical results 1986-1989]

The frequency of vasovasostomy has increased dramatically in recent years. A significant percentage of men who have previously undergone vasectomy are now seeking restoration of their fertility. The most common reason for requesting a reversal is remarriage. There were 90 bilateral vasovasostomies performed in 90 patients between 1986 and 1989. The procedure was done according to the technique described by Howards, in a single layer with 7 x 0 prolene and under fourfold magnification. The success rate was 87% for presence of spermatozoa in the ejaculate, 48% for pregnancy. The fertility rate decreases slowly with increasing interval between vasectomy and reanastomosis. These results are statistically significant. In cases of good anatomical and andrological conditions, the chance of restoration of fertility is good. The experience of the urologist is often more important than the details of the technique.

Steroid metabolism by germ cells and spermatozoa in men after vasoepididymostomy

The ability of germ cells (spermatocytes and spermatids) and spermatozoa present in human ejaculate to metabolize steroids was studied in men with obstructive infertility who had undergone vasoepididymostomy as corrective surgery. Steroid metabolism by spermatozoa in men who had undergone vasovasostomy was also investigated. Germ cells converted testosterone mainly to androstenedione. In addition to androstenedione, dihydrotestosterone and androstanediols were also formed in incubations using spermatids. Both types of germ cells converted estradiol to estrone. Spermatozoa from subjects who had undergone vasoepididymostomy or vasovasostomy converted testosterone to androstenedione as in normal men, while spermatozoa from infertile subjects converted testosterone mainly to dihydrotestosterone. Seminal fluid, free of germ cells, did not show steroid-metabolizing capability.

Factors influencing success or failure after reversal of sterilization: a multivariate approach

Reversal of sterilization was performed in 215 patients after unipolar coagulation, Fallope ring or clip sterilization, or bipolar coagulation or a Pomeroy sterilization. All patients had a follow-up of at least 1 year. Prognostic variables were derived from the previous history, the preoperative fertility assessment, and the actual operation. Some variables were combined into a fertility reducing factor. A first selection was performed by comparing the preoperative and perioperative variable scores of the successes (defined as all intrauterine pregnancies within 1 year after surgery) with those of the failures (no intrauterine pregnancy within 1 year). Eight variables appeared to have prognostic potential. Taking account of the inter-relations of those variables by using logistic regression analysis, the localization of the anastomosis, the number of anastomosed tubes, and the presence of a fertility reducing factor were selected as the most predictive ones. Using this logistic model, an estimate of the pregnancy outcome could be calculated for each individual patient.

Antisperm antibodies and fertility after vasovasostomy: a follow-up study of 216 men

A group of 216 vasovasostomized men were tested with the mixed antiglobulin reaction for immunoglobulin (Ig)G, IgA, and secretory IgA antisperm antibodies bound to the sperm membrane. Free antisperm antibodies in serum and seminal plasma were detected with the gelatin agglutination test and the tray agglutination test. The results were related to the conception rates. In a subgroup with a pure IgG response, the conception rate reached 85.7%, whereas only 42.9% of the men who also had IgA on the sperm induced pregnancy. When 100% of the spermatozoa were covered with IgA, the conception rate was reduced to 21.7%. The combination of IgA on all sperm and a strong immune response (titer in serum greater than or equal to 256) was associated with a conception rate of zero.

Vas deferens occlusion by percutaneous injection of polyurethane elastomer plugs: clinical experience and reversibility

A non-incision method of vas occlusion based on the percutaneous injection of polyurethane elastomer solution to form plugs is described. The results are based on clinical experience in 12,000 men in which only 56 cases of minor complications were recorded. Follow-up of 500 men for up to 3 years demonstrated an azoospermia rate of 98%. Plugs have been removed from 86 men and, to date, 51 have made their wives pregnant. In those from which the plugs have been removed for more than 1 year (n = 31), the pregnancy rate is 100%.

A fifteen-year study of alterations in semen quality occurring after vasectomy reversal

Semen quality was evaluated in 256 men at 2, 4, 6, and 12 months after vasectomy reversal. Total sperm counts were normal and averaged 91 X 10(6) sperm per ejaculate. The percentage of live sperm was decreased below normal to 36% and hypo-osmolarity values indicated only 41% of the sperm with normal membranes. Progressive motility and the total progressively motile sperm count were reduced and averaged 25% and 27 million, respectively. Approximately 50% of the patients had positive titers of sperm agglutinating and/or sperm immobilizing antibodies. Sperm morphology indicated tail and head shape defects with increases in both tapered and immature sperm. A fertility score combining several sperm parameters averaged only 37% of normal. All of these values remained constant with time after reversal except for progressive motility (increased), oval head shapes (increased), and tapered sperm (decreased). This study has demonstrated that characteristic defects occur in sperm (decreased). This study has demonstrated that characteristic defects occur in sperm motility, sperm membrane function and morphology, in addition to specimen fertility scores, after a vasectomy reversal and need to be taken into consideration when advising and treating these patients for subsequent fertility difficulties.

Vasectomy reversal

A small personal series of vasovasostomies and a review of the literature on this subject are presented. The importance is stressed of good counselling before vasectomy is undertaken in the first place.

Immunological status of patients before and after vasovasostomy as determined by the immunobead antisperm antibody test

With the immunobead antisperm antibody test a prospective study was conducted to evaluate the immune status of 55 men before and after vasectomy reversal. A third of the vasectomy patients (19 of 55) had significant serum-sperm antibodies (20 per cent binding or more) detected by the indirect immunobead antisperm antibody test. Of 31 vasovasostomy patients 12 (38 per cent) had significant sperm-surface antibodies (20 per cent binding or more) by the direct immunobead antisperm antibody test. Preoperative serum assays correctly classified the antibody status of 69 per cent of the vasectomy patients. The immunological impact of spermatic granuloma formation, duration of vasal obstruction, patient age and presence of sperm in the vasal fluid at operation also were assessed. An inverse relationship between the proportion of antibody-bound sperm and the percentage of motile sperm in the ejaculate of vas reversal patients was found with videomicrographic semen analysis. The percentage motility was significantly lower among patients with greater quantities of sperm-surface antibodies. No other parameter of semen analysis showed this difference when compared for positive or negative immunobead antisperm antibody test results.

Evaluation of vasovasostomy candidates by deoxyribonucleic acid flow cytometry of testicular aspirates

Flow cytometry can be performed on testicular aspirates of vasovasostomy candidates preoperatively. On the basis of ploidy ratios and debris components, DNA histograms can be classified as normal or abnormal. Using this method, the likelihood of the presence of sperm may be predicted.

Reduced levels of T suppressor/cytotoxic lymphocytes in semen from vasovasostomized men: relationship to sperm autoantibodies

The regulation of lymphocyte populations in semen and their function remains unknown. Using monoclonal antibodies and immunohistochemical techniques we compared the levels of mononuclear cells in ejaculates obtained from 14 men with intact vas deferens and 13 men who had undergone both a vasectomy and a microsurgical vasovasostomy. The presence of antisperm antibodies was also assessed by the immunobead binding assay. Semen from both groups contained about 10(3) T and B lymphocytes and monocytes. In men with intact vasa, T suppressor/cytotoxic cells predominated. In contrast, in vasovasostomized men the levels of T suppressor/cytotoxic cells were significantly reduced (P less than 0.005) and T helper/inducer cells predominated in their semen. Concentrations of seminal T helper/inducer lymphocytes, B lymphocytes and monocytes were similar in both groups. Antisperm antibodies were detected on sperm, in seminal fluid and/or in serum of all the vasovasovasostomy patients but in none of the controls, T suppressor/cytotoxic cells may limit the immune response to sperm within the male reproductive tract. Chronic obstruction resulting in damage to the integrity of the excurrent ducts may induce alterations in T cell regulation leading to a decrease in T suppressor/cytotoxic cells and create conditions permissive for the formation of autoantibodies to sperm-specific antigens.

Vasectomy: how much is enough?

Bilateral vasectomy was performed in 30 men. The vasa were tied with radio-opaque ligatures and X-rays taken to assess the separation of the ends. There was good correlation between the length of vas excised and the resulting separation of the markers. In order to achieve a separation greater than that of sperm granulomas associated with vasectomy failure, at least 7 cm of vas would have to be removed. However, excision of this length cannot be recommended because of subsequent difficulties with vasovasostomy. It is suggested that as well as excising a length of vas during vasectomy, a second method is also used to prevent spontaneous recanalisation.

Complications of vasovasostomy

Microsurgical vasovasostomy has become a common urologic procedure. A successful anastomosis is related to good mucosal alignment and a water-tight anastomosis rather than to a specific technique. The presence of vasal or epididymal sperm granulomas as well as antisperm antibodies will also influence postoperative pregnancy rates.

Vasovasostomy with use of medical needle as a support

Between May 1981 and December 1985 we performed vasovasostomy using a needle as a support in 43 patients who had undergone vasectomy for family planning. The operation is simple with little surgical trauma and few complications. All 39 patients who underwent semen analysis had return of spermatozoa. Pregnancy resulted in 27 of 34 patients (79.41 per cent) who attempted conception. The results were satisfactory. The procedure is described, and the complication and success rates are analyzed.

Sperm auto-immunity associated with vasectomy, vasovasostomy and epididymovasostomy in Korean males

The prevalence and pattern of circulating antisperm antibodies were assessed in the serum of Korean males undergoing vasectomy, vasovasostomy, epididymovasostomy and in a control group of men with normal semen by means of the gelatin agglutination test and the tray agglutination test. Sperm-agglutinating antibodies in serum were positive at a titre of 1:32 or greater in 3% of normospermic control males and in 27% of vasectomized men. No significant changes were observed in prevalence of the antibodies over the period following vasectomy. There were no significant differences in prevalence of antibodies in patients with and without postoperative sperm granulomas. Antibodies were positive in 35% of vasectomized men just prior to vasovasostomy and in 29% of patients 12 months after a successful (patent) reversal operation. There was no significant difference in prevalence of antibodies in patients with successful and unsuccessful vasovasostomies. Antibodies were positive in 20% of men who achieved pregnancies and in 43% of those with persisting infertility in the presence of a patent vasovasostomy. Sperm agglutinating antibodies were present in 5% of the patients with pathological epididymal obstruction. They were negative in patients with a patent epididymovasostomy and positive in 17% of those with an unsuccessful epididymovasostomy. The four patients who achieved a pregnancy after epididymovasostomy were antibody-negative. The prevalence of antibodies in the serum of patients with azoospermia due to surgical vasal obstruction was higher than that in patients with azoospermia due to pathological epididymal obstruction. The agglutination patterns produced by sperm antibodies in the total group of positive sera were tail-to-tail in 56%, head-to-head in 30% and mixed in 14%.

Vasovasostomy

The popularity of vasovasostomy in recent years can be attributed to improvements in operative techniques, instruments, optics, and most importantly, results. This article addresses the evolution of vasovasostomy, a method of training, the equipment necessary to perform the procedure, and various operative techniques, both macroscopic and microscopic. A brief comparison of postoperative results is included.

The effects of vasectomy on the autonomic innervation of the human vas deferens

Neurohistochemical and fine structural techniques have been employed to examine the intramural autonomic innervation of the human vas deferens following surgical division of the duct one to 15 years previously. Samples from sites on the distal (testicular) and proximal (urethral) aspects of the original vasectomy have been compared with control specimens obtained at vasectomy as to the arrangement and distribution of autonomic nerves. In contrast with tissue from the proximal part and from controls, the distal samples revealed a marked reduction in the noradrenergic innervation of the muscle coat. In addition acetylcholinesterase-containing nerves associated with the basal aspect of the epithelium were usually absent from the distal portion of the vas deferens. These findings have been considered in relation to the contractile and secretory activities of the organ following vasovasostomy and may be of importance to the maturation and fertility of spermatozoa.

Vasectomy and vasovasostomy have no effect on seminal plasma zinc concentrations

Mean zinc concentrations were determined for human seminal plasma obtained from 110 nonvasectomized men (139 micrograms. per ml.), 43 recently vasectomized men (144 micrograms. per ml.), 25 long-term vasectomized men (139 micrograms. per ml.) and 25 men who had undergone vasovasostomy (129 micrograms. per ml.). The results indicate that there is no significant short-term or long-term effect of these surgical procedures on prostatic secretory function as measured by seminal plasma zinc concentration.

Laser-assisted vasal anastomosis in the rat and man

In order to study the efficacy of laser-assisted vasal anastomosis (LAVA), a microscopic carbon dioxide surgical laser (Xanar) was utilized in the anastomoses of human vas deferens in vitro and the Sprague-Dawley rat vas deferens in vivo. The longitudinal tensile and internal hydrostatic pressure strengths of laser-assisted vasal anastomoses were compared to conventional microsurgical suture anastomoses in the human vas deferens. The LAVA group had a greater mean internal hydrostatic pressure strength (p less than 0.001) and a lesser mean longitudinal tensile strength (p less than 0.001) than the conventional microsurgical group. Further evaluation was performed in the Sprague-Dawley rat model, comparing post-operative fertility, patency, healing and sperm granuloma occurrence among four surgically treated groups and a control group: LAVA, conventional suture anastomosis, sham operated, and vasectomized. Light and scanning electron microscopic examination revealed equivalent healing in both the LAVA and conventional groups. Fertility was not statistically different in the LAVA, conventional, control, and sham operated groups. However, the incidence of gross sperm granulomas observed in the LAVA group (80%) was much higher than in the conventional suture anastomosis group (0%). In conclusion, laser-assisted vasal anastomosis is a fast and simple technique for vasal reanastomosis and was as successful (in pregnancies) as conventional suture anastomosis in producing fertility in rats undergoing vasal reanastomosis, but the incidence of sperm granuloma is higher.

A 20-year experience with vasovasostomy

A total of 624 of 699 vasovasostomy patients was followed during the last 20 years. Better results were obtained when there was shorter duration of obstruction, bilateral straight vas-to-straight was anastomosis and bilateral presence of sperm in the vas fluid during vasovasostomy. Results of end-to-end and side-to-side macrosurgical anastomosis, as well as of 1-layer and 2-layer microsurgical anastomosis were similar. Macrosurgical success rates were 84 per cent for patency and 35 per cent for pregnancy in the 300 cases. Microsurgical success rates were 90 per cent for patency and 51 per cent for pregnancy in 324 cases. Failure of patency was caused mainly by anastomotic scar formation with sperm and suture granulomas. Failure of pregnancy was owing mainly to inadequate postoperative semen quality.