Should vasectomy reversal be performed in men with older female partners?

PURPOSE: An assumption exists that men with older female partners who seek treatment of post-vasectomy infertility should undergo in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) rather than vasectomy reversal. Although several studies have reviewed ICSI success rates with advancing maternal age, to our knowledge none has compared them to outcomes for vasectomy reversal in men with older partners. MATERIALS AND METHODS: The records of all patients with ovulating partners older than 37 years who underwent vasectomy reversal from 1994 through 1998 were reviewed. Patients were contacted to establish pregnancy and birth rates. Costs of vasectomy reversal, testicular sperm extraction, IVF and ICSI were obtained from the financial office of our institution. RESULTS: A total of 29 patients underwent vasectomy reversal with a followup of 3 to 59 months (median 25). Median male age was 46 years (range 37 to 67) and median female age was 40 years (range 38 to 48). A total of 5 pregnancies and 4 live births were achieved. In the 23 patients followed for more than 1 year the pregnancy rate was 22% and live birth rate was 17%. Using this 17% birth rate at our $4,850 cost for vasectomy reversal the cost per newborn was $28,530. In comparison, using the 8% birth rate per cycle of ICSI for women older than 36 years at a cost of $8,315 for testicular sperm extraction and 1 cycle of IVF with ICSI, the cost per newborn was estimated at $103,940. CONCLUSIONS: Vasectomy reversal appears to be cost-effective to achieve fertility in men with ovulating partners older than 37 years.     

Intravasal "toothpaste" in men with obstructive azoospermia is derived from vasal epithelium, not sperm

PURPOSE: Men undergoing vasectomy reversal many years after vasectomy are at increased risk for secondary epididymal obstruction. When this occurs the intravasal fluid is often a thick, white, toothpaste-like material devoid of sperm. In this study we characterize the vasal fluid found in men with a newly described entity, segmental dysplasia of the vas deferens, in which at least 2 distinct sites of vasal obstruction are present. We determine the significance of this fluid in men with obstructive azoospermia. MATERIALS AND METHODS: Three men who underwent scrotal exploration for obstructive azoospermia due to segmental dysplasia of the vas deferens were evaluated. Each underwent scrotal exploration including bilateral vasotomy and testicular biopsy. Intravasal fluid was collected, evaluated microscopically and sent for cytopathological evaluation. RESULTS: All men had isolated segments of the vas 2 to 5 cm in length that were not connected to the epididymis or ejaculatory ducts. We have named this condition segmental dysplasia of the vas deferens. Vasotomy was performed between aplastic segments, revealing thick, white, toothpaste-like material identical to that seen in men with secondary epididymal obstruction undergoing vasectomy reversal. Cytopathological evaluation of this fluid revealed proteinaceous concretions and rare clusters of degenerated columnar epithelial cells, but no sperm or sperm products. CONCLUSIONS: Thick, white, toothpaste-like material is produced between 2 obstructed segments as seen in men with segmental dysplasia of the vas deferens and with secondary epididymal obstruction. Our findings in men with segmental dysplasia of the vas deferens indicate that vasal "toothpaste" must be derived from vasal epithelium, not sperm.     

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.Key Words: Robotic surgery, Vasectomy reversal, Vasovasostomy     

Is physical examination useful in predicting epididymal obstruction?

Objectives. To evaluate the independent predictive value of subjective epididymal fullness in predicting obstruction in azoospermic men (group 1) and determining preoperatively the need for vasoepididymostomy (VE) in men presenting for vasectomy reversal (group 2).Methods. All men were evaluated with a medical history and physical examination. During the physical examination, the epididymis was classified as full, if any portion was palpably distended, or normal. Obstruction was confirmed at surgical exploration for group 1 after a biopsy that revealed sufficient spermatogenesis. In group 2, the indications for VE were either no fluid seen from the testicular end of the vas or thick, pasty fluid devoid of sperm. In cases in which VE was required, these units were classified as obstructed.Results. The predictive value of epididymal fullness was evaluated in 51 units (12 in group 1 and 39 in group 2). The sensitivity, specificity, and positive and negative predictive values were 67%, 100%, 100%, and 83%, respectively, in group 1 and 33%, 89%, 20%, and 94%, respectively, in group 2.Conclusions. Epididymal fullness in azoospermic men is predictive of obstruction, although a normal epididymal examination cannot rule out obstruction. In men presenting for vasectomy reversal, the absence of epididymal fullness is predictive of vasal fluid that allows for vasovasostomy. Epididymal fullness may suggest, but cannot predict, unfavorable vasal fluid that requires VE.     

The use of URYX for reversible vasectomy in a rabbit model

URYX is a biocompatible polymer of ethylene vinyl alcohol dissolved in a dimethyl sulfoxide (DMSO) carrier to allow injection of a very low-viscosity fluid into tissue. Once the material comes into contact with body tissue or fluid, the DMSO rapidly dissipates from the polymer, which results in a precipitate of a coherent solid mass. The purpose of the present study was to determine whether URYX can effectively occlude the vas deferens and whether patency can be restored by redissolving the URYX in vivo using the solvent DMSO. Eight male New Zealand White rabbits (age range, 25-41 weeks; mean age, 33.9 +/- 7.5 weeks; mean weight, 4.0 +/- 0.2 kg) were used in 2 experiments (E1 and E2). In E1, 3 rabbits underwent unilateral vasectomy, and the contralateral vas was injected with either 0.05 or 0.10 mL of URYX, to determine the amount of URYX required to cause obstruction. Two animals underwent bilateral vasectomy, to serve as controls. In E2, 3 animals underwent bilateral URYX injection and were compared with the bilateral vasectomy control rabbits used in E1. After 1 month of initial bilateral URYX treatment, all animals in E2 underwent attempted unilateral reversal with 1.5 mL of DMSO injected into 1 occluded vas deferens. Two end points were evaluated-a clinical end point assessed by semen analyses and a pathological end point assessed by histological analysis of treated tissues, to assess for safety. A 1.5-cm infrapubic incision was made to expose both vasa in anesthetized rabbits. The vasal injection of URYX was performed with a 30-gauge needle. Vasectomy was performed by excision of a 1-cm segment of the vas deferens and subsequent ligation with a 6-0 prolene suture. Semen was collected using an artificial vagina 2-3 times/wk before and 1 month later, after injection treatments and vasectomy. Manual sperm counts were performed. All animals were sacrificed, and tissues (distal vas, injection site, proximal vas, cauda epididymis, caput epididymis, and testis) were harvested and examined for the presence of URYX. The inflammatory response of the wall and adventitia of the vas deferens was given a score (0-15) based on the sum of grades (0 = none, 1 = mild, 2 = moderate, and 3 = severe) for the following categories: foreign body giant cell reaction, granulation tissue, lymphocytes, eosinophils, and scarring, as evaluated by a single pathologist (J.M.). Vasal injection with 0.05 mL of URYX was not sufficient to cause occlusion. Both animals injected with 0.1 mL of URYX were effectively occluded. The injection of occluded vasa with DMSO did not dissolve the URYX plug in the vas lumen. There was no significant difference in vasal inflammatory response scores between vasal units treated with URYX only and vasal units in the vasectomy model. Vasal units subjected to URYX followed by DMSO demonstrated greater inflammatory response scores than vasal units treated with URYX followed by normal saline, URYX alone, or vasectomy. Epididymal and testicular histology remained unaffected in all vasal units in E1. The vasal units in E2 subjected to URYX followed by normal saline showed no histological abnormalities of the epididymis and testis. However, those vasal units subjected to URYX followed by DMSO in E2 showed evidence of adhesions, necrosis, and degenerating cells in the epididymis and a focal foreign body giant cell reaction in the testis. The bilateral vasal injection of URYX can result in azoospermia in the rabbit model. Reversal with subsequent DMSO injection was not achieved. A minimal inflammatory response of the vas deferens was observed with URYX injection alone; however, DMSO following URYX injection resulted in increased vasal inflammation, in addition to epididymal and testicular changes.     

Should all urologists performing vasectomy reversals be able to perform vasoepididymostomies if required?

PURPOSE: While vasectomy reversal is a highly successful procedure 10% to 30% of reversals may fail. Despite the general consensus that an epididymal obstruction may occur following a vasectomy and that some men should undergo vasoepididymostomy (VE) rather than vasovasostomy (VV), the practice of many urologists in our region has been to offer only VV for vasectomy reversal. We examined the potential causes for vasectomy reversal failure in patients who had undergone VV without an attempt at VE. MATERIALS AND METHODS: We conducted a retrospective review of patients who had undergone redo vasectomy reversal from January 1999 to September 2001. A total of 22 patients underwent redo reversal with a minimum followup of 2 years. The medical records of all patients were then reviewed. Patients and partners seen postoperatively in the clinic were questioned regarding any pregnancy or deliveries. RESULTS: We examined 22 patients who had undergone redo vasectomy reversal. Of 22 patients 9 (40.9%) underwent repeat VV, 8 (36.3%) underwent bilateral VE for a presumed unrecognized epididymal obstruction and 5 (22.7%) had a combination of VE and VV. Of the 44 reproductive units studied 23 (52.3%) had a failed vasal anastomosis while 21 (47.7%) had an unrecognized epididymal obstruction. Based on semen analysis patency was observed in 75% of patients who had undergone vasovasostomy as a redo procedure. A patency rate of 60% was found in patients who underwent vasoepididymostomy and vasovasostomy unilaterally, and patency rates for bilateral VE were 63%. CONCLUSIONS: Our study indicates that a large proportion of men (48%) have an epididymal obstruction as the etiology for vasectomy reversal failure. We recommend that all surgeons offering vasectomy reversals be able to offer VE if required based on intraoperative findings to serve the patient adequately as well as his partner and their future fertility.     

A late post-vasectomy syndrome

A group of 20 surgical specimens in 18 patients with a previously unappreciated syndrome of unremitting epididymal pain and induration 5 to 7 years after vasectomy was collected during a 2-year interval. These symptoms uniformly were unresponsive to conservative measures, including empiric antibiotics. Total unilateral or bilateral epididymectomy and partial vasectomy led to complete relief of symptoms, usually within 24 hours. Pathological examination of the specimens revealed features consistent with sequelae of long-standing obstruction. Recognition of this late post-vasectomy syndrome, which represents a major complication of vasectomy, might be expected to increase as cohorts of vasectomized individuals age.     

Microscopic evaluation of the vasal fluid for sperm at the time of vasectomy reversal: Do we really need to check?

IntroductionDuring vasectomy reversal, intraoperative microscopic evaluation of the vasal fluid for sperm presence/quality can inform of the possibility of epididymal obstruction and need for a vasoepididymostomy (VE). In an effort to validate the utility of microscopic vasal fluid evaluation, the current initiative correlates gross vasal fluid characteristics with sperm presence and quality in a large series of VRs.MethodsA total of 1267 vasectomy reversals yielded a total of 2522 vasal-units (right/left sides) for analysis. During vasectomy reversal, vasal fluid was sampled from the testicular-end vas and the fluid was characterized (thick-paste/opaque/translucent/clear). Each aspirate underwent microscopic evaluation for sperm quality and was categorized as: motile sperm/intact-non-motile sperm/sperm parts/no sperm. The predictive utility of the gross vasal fluid characteristics with respect to microscopic sperm presence and quality was analyzed.ResultsAmong the 2522 vasal units analyzed, the side-to-side (left-right) concordance of vasal fluid quality and microscopic vasal sperm quality was 72% and 52%, respectively. When thick-pasty fluid was observed, no sperm were seen in the samples in 53% of cases, and if present, only non-motile sperm were observed. Even in the setting of more favorable vasal fluid characteristics (clear, translucent, and opaque fluid), no sperm were seen in 6–11% of cases, suggesting the possibility of epididymal obstruction and the need for VE.ConclusionsIntraoperative microscopic evaluation of the vasal fluid for sperm is a necessary practice during vasectomy reversal to optimize surgical outcomes. Reliance on gross vasal fluid characteristics in isolation may lead to unrecognized epididymal obstruction, and the need for a VE, in approximately 11% of cases.     

Vasectomy reversal in the age of intracytoplasmic sperm injection

The advent of intracytoplasmic sperm injection has revolutionized the treatment of male infertility and offers an alternative to vasectomy reversal as a treatment option for post-vasectomy infertility. Issues including morbidity, cost and therapeutic outcomes are, however, important considerations for both treatment options. Vasectomy reversal should be considered the ideal option for couples less than 15 years since vasectomy, couples interested in more than one child, couples without in-vitro fertilization insurance coverage and couples with no interest in assisted reproductive techniques. Intracytoplasmic sperm injection may be considered as the primary option for those couples with an older female partner especially if bilateral vasoepididymostomy may be required.     

Surgery or assisted reproduction? A decision analysis of treatment costs in male infertility

PURPOSE: Assisted reproductive technology (ART), including in vitro fertilization and intracytoplasmic sperm injection, is routinely used to treat male factor infertility. Because of the success of ART, the optimal method to achieve pregnancy with male infertility is controversial. Two examples in which ART competes with traditional male infertility treatments are varicocelectomy and vasectomy reversal. We used formal decision analysis to estimate and compare the cost-effectiveness of surgical therapy and ART for varicocele and vasectomy reversal. MATERIALS AND METHODS: Decision analysis models were created for infertile men seeking paternity with varicocele and with post-vasectomy obstruction. Outcome probabilities applied to the model were derived from institutional and published sources. Costs of interventions were calculated from institutional data. Sensitivity analyses determined which elements were most important and, thus, were used to calculate threshold values. RESULTS: Vasectomy reversal is as cost-effective as ART if bilateral vasovasostomy can be performed. However, if unilateral or bilateral vasoepididymostomy is required, sperm retrieval/intracytoplasmic sperm injection may be more cost-effective due to lower patency rates. Vasectomy reversal is more cost-effective across all pregnancy rates provided that patency rates are greater than 79%. Surgical repair of varicocele is more cost-effective when the postoperative pregnancy rate is greater than 14% in men with a preoperative total motile sperm count of less than 10 million sperm and greater than 45% in men with greater than 10 million total motile sperm. CONCLUSIONS: A decision analysis based comparison of ART and classic surgical therapy suggests that varicocelectomy and vasectomy reversal are the most economical treatments in many cases of infertility due to these lesions. Tailoring the decision models to individual centers permits more accurate comparisons using specific costs as well as the surgical outcomes and results of ART.     

恒河猴两种节育术后睾丸附睾的组织学及超微结构观察

本文介绍了12只恒河猴输精管结扎术及输精管内过滤装置节育术术后睾丸、附睾和输精管的组织学及超微结构观察结果。术后两年内,两组动物睾丸的组织学及超微结构均无异常改变。术后9月,结扎猴的尾部附睾管及近睾端输精管管腔显著扩张、上皮变薄、腔内充满大量变性、坏死精子,出现附睾郁积。附睾主细胞出现微绒毛疏短、排列紊乱等超微结构变化;而行过滤装置节育的动物附睾管及输精管的组织学及超微结构均未见异常改变。提示两种节育术对睾丸形态结构均无影响;但输精管结扎木可导致附睾郁积及其上皮的萎缩性变化,而过滤装置节育术后无此改变,值得进一步探讨。     

Questionnaire-Based Outcomes Study of Nononcological Post-Vasectomy Complications

Purpose

We conducted an outcomes analysis to determine the incidence of post-vasectomy complications.

Materials and Methods

A questionnaire (154 questions) addressing post-vasectomy complications, incidence of post-vasectomy scrotal pain and quality of life issues was sent to 470 patients. Followup telephone surveys were made.

Results

A total of 182 patients (42.3 percent) responded. Mean followup was 4.8 years. The most common complication was post-vasectomy scrotal pain in 34 men (18.7 percent), which adversely affected quality of life in 4 (2.2 percent). In retrospect, 71.4 percent of the men were satisfied with the decision for vasectomy, 19.3 percent had equivocal feelings and 9.3 percent were dissatisfied.

Conclusions

Chronic scrotal pain is the most common post-vasectomy complication that may adversely affect quality of life in men undergoing vasectomy.     

Quantitative testicular biopsy in congenital and acquired genital obstruction

To determine if congenital obstruction of the genital tract is associated with significant testicular histopathological conditions compared to acquired forms of obstruction we performed testicular biopsy in 8 vasectomized men and 5 men with vasal agenesis. Quantitative analysis of the seminiferous tubular and epithelial parameters demonstrated a statistically significant increase in tubular wall thickness in the vasectomized group. There was no significant difference among the groups with reference to the mean number of late spermatids per seminiferous tubules, mean number of Sertoli cells per seminiferous tubules, mean number of seminiferous tubules per field (100 times) or mean seminiferous tubular diameter. We conclude that despite a lifelong duration of obstruction, men with vasal agenesis demonstrate a more favorable testicular histological status compared to men after vasectomy. This finding may have therapeutic implications when considering assisted pregnancy techniques as a method of treatment of male genital tract atresia.     

Epididymal obstruction results in isolated sperm heads in post-vasectomy rats

The aim of this study was to determine if, following vasectomy, epididymal obstruction resulted in changes in vasal stump fluid using a rat vasectomy model. One hundred and twenty-two mature male rats underwent bilateral surgical vasectomy and subsequent unilateral epididymal obstruction. Animals were randomly assigned to one of the five cohorts, which determined the time to kill and vasal fluid assessment. Numbers of whole sperm and sperm heads were compared between the obstructed and non-obstructed sides. Parametric analysis of microscopic vasal fluid findings was performed using a paired t-test. Whole sperm and sperm heads were detected bilaterally among the initial five cohorts. On the obstructed epididymis side, percentage of whole sperm dropped from 36.9% to less than 1% and sperm heads increased from 63.2 to 99.7% at 12 weeks post-obstruction (p < 0.05 at each time interval). On the unobstructed side, percentage of whole sperm rose from 66.3 to 89.5% and sperm heads dropped from 33.7 to 10.5% (p < 0.05 at each time interval). At 12 weeks, the difference between the obstructed and non-obstructed sides for both percentage and quantity of whole sperm and heads was significant with a p value of <0.001. In this rat model, following vasectomy and subsequent epididymal obstruction, testicular vasal stump fluid will contain progressively diminishing numbers of whole sperm and increases in the percentage and absolute numbers of sperm heads.     

The Feasibility of Cryopreservation of Sperm Harvested Intraoperatively During Vasectomy Reversals

Purpose

Intracytoplasmic sperm injection during in vitro fertilization involves the microinjection of a single sperm into each egg from the partner. Pregnancies have resulted from this powerful new technology when fewer than 100 motile sperm were present in the semen, or when sperm were obtained from the epididymis or testicle by open operations or needle aspirations. Some surgeons have cryopreserved sperm obtained from the vas or epididymis during vasectomy reversals. However, cryopreservation of nonmotile sperm serves no useful purpose.

Materials and Methods

We performed a retrospective analysis of 603 vasectomy reversals in which the intraoperative vasal and/or epididymal fluid was examined microscopically. The motility of the sperm obtained intraoperatively was used as a gauge for the potential use of such sperm for in vitro fertilization and intracytoplasmic sperm injection after cryopreservation and thawing, should the vasectomy reversal fail.

Results

Motile sperm were present in the intraoperative vasal or epididymal fluid in 35% of all vasectomy reversals (34% of first and 39% of repeat procedures). The percentage of reversals in which motile sperm were present in the intraoperative fluid was not related to the time from vasectomy until reversal.

Conclusions

The absence of motile sperm in the intraoperative vasal or epididymal fluid precludes consideration of sperm cryopreservation during vasectomy reversals. Although to our knowledge the minimum percentage of sperm motility needed for in vitro fertilization and intracytoplasmic sperm injection after cryopreservation and thawing has not been established, our results provide surgeons with information to judge the merit of sperm harvesting and cryopreservation during vasectomy reversals.     

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 analyses.

Results

Of 18 men (9.7 percent) with sperm present in the pre-reversal analysis 94 percent 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 percent of pre-reversal ejaculates and predict sperm in at least 1 vas intraoperatively. These findings also suggest the possibility of late vasectomy failures.     

Surgical sperm retrieval after previous vasectomy and failed reversal: clinical implications for in vitro fertilization

OBJECTIVE: To investigate the effect of the interval between previous vasectomy reversal on retrieval rates of epididymal and testicular spermatozoa using percutaneous epididymal sperm aspiration (PESA), or testicular sperm extraction (TESE), and the subsequent reproductive potential of these gametes in intracytoplasmic sperm injection (ICSI) cycles. PATIENTS AND METHODS: Sixty-six consecutive sperm retrievals were considered in patients who were azoospermic after previous vasectomy, of whom 54 had had a previous failed reversal, the remainder deciding against a reversal. PESA and TESE retrieval rates were noted, as were the time since vasectomy and the interval between vasectomy and unsuccessful reversal. The presence of palpable epididymal cysts was noted, with their effect on sperm retrieval rates. Fertilization and pregnancy rates were analysed in subsequent ICSI cycles using freshly retrieved spermatozoa or frozen-thawed cryopreserved spermatozoa. RESULTS: All 66 patients had sperm retrieved successfully; the success rates for PESA were not significantly affected by previous failed reversal when compared with patients who had not had a reversal, at 14 of 54 (26%) vs five of 12 (P=0.3). The interval since vasectomy did not affect PESA retrieval rates but there was a significantly poorer retrieval rate for PESA in the presence of palpable epididymal cysts, at seven of 35 (20%) vs 12 of 23 (52%) (P=0.012). Fertilization rates were significantly lower using cryopreserved spermatozoa retrieved from either the epididymis or testis (50% vs 70%, P=0.007), although subsequent implantation and pregnancy rates were not significantly different. CONCLUSION: Surgical sperm retrieval is successful in all cases of azoospermia secondary to vasectomy, either by PESA or TESE. There are no clinical markers to indicate which patients will have successful PESA after vasectomy, although the presence of epididymal cysts is associated with significantly lower retrieval rates. The reduction in fertilising ability of cryopreserved spermatozoa does not affect clinical pregnancy rates in ICSI cycles.     

Vasectomy in Male Contraception and its Reversal

Vasectomy is an important option for male contraception. It is highly effective, but many questions about patient selection and information, surgical technique, postoperative follow-up, and complications have to be defined. The use of the no-scalpel technique to access the vasa is associated with the fewest complications. The technique with the lowest failure rate is catheterization of the vasa with fascial interposition. A single postvasectomy semen sample at 3 mo showing rare, azoospermia or nonmotile sperm is acceptable to confirm sterility. No data show that vasectomy is associated with the risk of prostate or testicular cancer.Up to 6% of men who have undergone vasectomy will demand reversal in the form of vasovasostomy or vasoepididymostomy for various reasons. In the age of in vitro fertilization, it becomes even more important to report outcomes after vasectomy reversals.The operative microscope for andrologic procedures has provided enhanced magnification and accuracy for vasectomy reversal. Now robot-assisted microsurgery is used more and more in andrology, but what is its interest in this particular indication?     

Vasovasostomy and predictors of vasal patency: a systematic review

About 3-6% of vasectomized men requested vasectomy reversal, for various reasons. Vasal patency (VP) is an important surrogate outcome of vasectomy reversal. This article reviews the impact of surgical skills, surgical approaches, intraoperative vasal fluid characteristics and the length of obstructive interval on VP. Based on the best available evidence, the rate of patency is related to the operative frequency of the surgeons, with better results obtained by surgeons who perform the operations at least 10 times annually. Microsurgical vasovasostomy is the preferred technique for durable good results. One-layer vasovasostomy and two-layer vasovasostomy seem to be equal with regard to VP. The rate of patency following vasovasostomy in the convoluted vas and vasovasostomy in the straight vas is comparable. The patency rate is high in men with clear intraoperative vasal fluid in at least one vas. VP is still high among patients with a long obstructive interval. In conclusion, surgical skills and intraoperative vasal fluid characteristics are the most important predictors of VP. Postoperative semen quality and the age of the female partner determine the chance of spontaneous conception in these couples.     

Chronic testicular pain following vasectomy.

The incidence of chronic testicular pain following vasectomy has not been previously assessed. We have carried out a survey by postal questionnaire and telephone interview of 172 patients 4 years after vasectomy to assess the incidence of chronic testicular pain. Significant early post-operative complications occurred in 6 patients (3.5%): 2 infection, 3 haematoma and 1 orchitis. Chronic testicular discomfort was present in 56 patients (33%), considered by 26 (15%) to be troublesome but not by the other 30 (17%). Testicular discomfort related to sexual intercourse occurred in 9 cases (5%). Of the 9 patients who had sought further medical help only 2 had had further surgery (1 an epididymectomy and 1 excision of a hydrocele). Only 3 patients regretted having had the vasectomy because of chronic pain. On ultrasound examination, epididymal cysts were a common finding on both asymptomatic and symptomatic patients following vasectomy. Prior to vasectomy, all patients should be counselled with regard to the risk of chronic testicular pain.