[Surgery to improve male fertility]

BACKGROUND

At a time when increasing attention is being paid to the limitations and risks of in vitro fertilisation techniques, surgeries to improve male fertility are attracting growing interest.

METHODS

Systematic review based on a Pubmed search of surgeries to improve male fertility.

RESULTS

Vasovasostomy (VV) gives patency rates of 70-97% and pregnancy rates of 30-76%. Vasoepididymostomy (VE) gives patency rates of 80-84%, with pregnancy rates of 40-44%. The duration of obstruction and the age of the partner are 2 predictive parameters for the occurrence of a natural pregnancy. In cases of obstructive azoospermia due to pelvic obstruction (prostatic cyst, obstruction of the ejaculatory ducts), several surgical procedures may be proposed. Transurethral resection of the ejaculatory ducts leads to an improvement in sperm parameters in 63-83% of patients, with spontaneous pregnancy occurring in 12-31% of cases. Microsurgical cure of varicocele by the subinguinal route is a benchmark technique with recurrence rates of less than 4%. It improves live birth and pregnancy rates, both naturally and by in vitro fertilization, as well as sperm count, motility and DNA fragmentation rates.

CONCLUSION

Whenever possible, the urologist should present the surgical options for improving male fertility to the ART team and to the couple, discussing the benefit/risk balance of the operation as part of a personalized approach.

Vasectomy Reversal Online Marketing Practices: What Are We Putting Out There?

OBJECTIVE

To determine characteristics of providers marketing vasectomy reversal (VR) online, degree of information available online, the ease with which patients can compare providers, and the differences in VR practice patterns between academic and private practices.

MATERIALS AND METHODS

We identified VR practices operating within the top 50 most populous metropolitan areas in the US. Practice websites were reviewed to obtain information such as provider educational background, level of magnification, ability to perform vasoepididymostomy, surgical volume, and cost. Based on information available, providers were assigned a novel REVERSAL score created by the authors. Descriptive statistics were used to compare results.

RESULTS

Of the 107 providers identified (29 academic, 78 private), the majority were male urologists with a Doctor of Medicine degree. Academic providers were more likely to have fellowship training than private practice providers, 96.6 vs 43.6%, respectively (P = 0.00001). Compared to non-urologists, urologists were less likely to purchase online ads or disclose cost. Non-urologists charged significantly less than urologists, $3,584 ± 1,554 and $6,591 ± 1,518, respectively (P = 0.00001). Only one provider provided complete information as defined by REVERSAL score of 12, with the majority (61.7%) of providers achieving score ≤6.

CONCLUSION

There is significant lack of transparency in publicly available information from VR practices. Practices should implement measures to improve dissemination of information to the public, so that patients can more easily compare providers and make informed decisions regarding VR.

Impact of surgical volume and resident involvement on patency rates after vasectomy reversal-A 14-year experience in an open access system

Objective

Evaluate the influence of fellowship training, resident participation, reconstruction type, and patient factors on outcomes after vasectomy reversals in a high volume, open access system.

Methods

Retrospective review of all vasectomy reversals performed at a single institution from January 1, 2002 to December 31, 2016 was conducted. Patient and spouse demographics, patient tobacco use and comorbidities, surgeon training and case volume, resident participation, reconstruction type, and postoperative patency were collected and analyzed.

Results

Five hundred and twenty-six vasectomy reversals were performed during the study period. Follow-up was available in 80.6% of the cohort and overall patency, regardless of reconstruction type was 88.7%. The mean time to reversal was 7.87 years (range of 0-34 years). The majority of cases included resident participation. Case volume was high with faculty and residents logging a mean of 37.0 and 38.7 (median 18 and 37) cases respectively. Bilateral vasovasostomy was the most common reconstruction type (83%) and demonstrated a significantly better patency rate (89%) than all other reconstructions (p=0.0008). Overall patency and patency by reconstruction type were not statistically different among faculty surgeons and were not impacted by fertility fellowship training, resident participation or post-graduate year. Multivariate analysis demonstrated that increased time to reversal and repeat reconstructions had a negative impact on patency (p=0.0023 and p=0.043, respectively).

Conclusions

Surgeons with a high volume of vasectomy reversals have outcomes consistent with contemporary series regardless of fellowship training in fertility. Patency was better for bilateral vasovasostomies. Patency was not negatively impacted by tobacco use, comorbidities, resident participation, or post-graduate year.

Vasovasostomy and vasoepididymostomy: indications, operative technique, and outcomes

The basic principles of vasal reconstruction have endured since their initial description over a century ago, yet the nuances and technical approaches have evolved. Prior to performing vasectomy reversal, the clinician should perform a focused history, physical and laboratory assessment, all of which are critical for patient counseling and preoperative planning. Operative success is contingent on appropriate intraoperative decision making and technical precision in completing a tension-free, watertight, and patent anastomosis. Outcomes of vasectomy reversal differ on the basis of the type of reconstruction required, reconstructive technique, and patient-specific factors. Here we review the indications, surgical techniques, and outcomes of vasectomy reversal.

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.

Successful unilateral vasectomy reversal in a lion (Panthera leo)

Background:

In 2016, the veterinarian team of Buin Zoo in Chile decided to try to increase the lion population. At that time, the zoo had three lions; two females and one male. The 9-year-old male had been vasectomized 5 years ago at the same institution for birth control. Considering the fact that in humans, vasectomy reversal has excellent reproductive outcomes, a team of human urologists, highly experienced in vasectomy reversal was contacted to perform the procedure.

Case description:

Surgery was performed on June 16, 2016 under general anesthesia, with the vasectomy site accessed through the previous scar localized in the lower groin. After opening the skin, dartos and tunica vaginalis, we were able to identify the previous vasectomy site. After liberating both vas ends and checking for permeability, a microsurgical anastomosis (magnification 25×) was performed. The surgery took 80 minutes with minimal bleeding, and no surgical complications were observed. After 2 weeks, the lion joined the lionesses and reproductive follow-up was started. Seven months after surgery, one lioness became pregnant, and 4 months later gave birth to two female lion cubs, with no incidents at the zoo. Both cubs were healthy and are still living at the zoo.

Conclusion:

Vasectomy reversal constitutes a valid perspective to reassume fertility in previous vasectomized lions.

Robot-assisted microsurgical vasovasostomy: the learning curve for a pure microsurgeon

Vasovasostomy success rates improved with the application of the operative microscope in 1975. The robotic platform offers potential advantages including: a stable, ergonomic, scalable control system with three-dimensional visualization and magnification, the elimination of physiological tremor, and simultaneous control of three instruments and a camera. A previous publication revealed a fellowship-trained microsurgeon (PKK) could transition to robot-assisted microsurgical vasovasostomy (RAVV) with comparable outcomes. The objective of this current study was to evaluate the learning curve for the purely trained microsurgeon transitioning to RAVV. A retrospective chart review was performed of a microsurgeon’s first 100 RAVVs evaluating the learning curve for patency rates, anastomosis times, operative times, and sperm concentrations at the initial postoperative semen analyses. Cases were stratified into four groups by 25 case intervals. There were no statistically significant differences in patency rates or postoperative sperm concentrations between the groups over time. There were differences in anastomosis times between groups 1 and 2, as well as between groups 2 and 3, and there were differences in operative times between groups 2 and 3. High-percentage patency rates are achievable very early in the transition from pure microsurgical vasovasostomy to RAVV across wide ranges of obstructive intervals. Postoperative mean sperm concentrations in the initial semen analyses after RAVV are consistent over time. For a single microsurgeon not formally trained in robotic microsurgery, 75 RAVV cases were required to optimize and plateau in anastomosis times and 75 cases were required to optimize operative times.

Factors predicting success after microsurgical vasovasostomy

PURPOSE

To identify factors predicting success and analyze critically the status of microsurgical double-layer vasovasostomy using predictive models.

METHODS

A cohort of 263 patients treated at our institution for vasectomy reversal between 1986 and 2010 was included in our study, and the literature was reviewed. Inclusion criteria were previous bilateral vasectomy and presence of at least two postoperative semen analyses; patients reporting pregnancy without a postoperative semen analysis were excluded. A double-layer, microscope-assisted, tension-free anastomosis vasovasostomy was performed approximating mucosa to mucosa and muscle to muscle with a 10-0 non-absorbable suture. A multivariate logistic regression backward stepwise model was used to predict combined success, and a predictive model was calculated with remaining variables.

RESULTS

Mean age was of 41.6 years (SD 7.1); mean duration of obstruction 7.2 years (SD 6.7). On multivariate analysis, uni- or bilateral granuloma and Silber grade of I-III were variable identified predicting higher probability to success (OR 3.105; 95% CI 1.108-8.702; p = 0.031 and OR 4.795; 95% CI 2.117-10.860; p < 0.001, respectively).

CONCLUSIONS

Based on our results, some factors predicting success after vasovasostomy surgery are known but others remain unknown; our predictive model may easily predict patency and success after this surgery and offers a concrete assistance in counseling patients.

Advances in male reproductive surgery: robotic-assisted vasovasostomy

It is estimated that 3-6% of all vasectomised men request vasectomy reversal for different reasons. Microsurgical vasovasostomy is the gold standard technique of vasectomy reversal. However, the microsurgical technique is time-consuming and challenging to most urological surgeons. Therefore, alternative methods of vasal anastomosis have been studied including robotic-assisted vasovasostomy. This review discusses the feasibility and practice of robotic-assisted vasovasostomy. Based on the available studies robotic-assisted vasovasostomy is feasible. The reported rate of vasal patency associated with this new technique is similar to that of microsurgical vasovasostomy. There is no clear difference between the 2 approaches in terms of operating time. Robotic-assisted vasovasostomy does not appear to afford significant advantages in the era of vasectomy reversal.