Repeat vasectomy reversal after initial failure: overall results and predictors for success

PURPOSE: We review the treatment outcomes for microsurgical reconstruction following failed vasectomy reversal and identify predictors for success. MATERIALS AND METHODS: We performed a retrospective review of our experience with microsurgical reconstruction in 41 men who underwent 1 or more prior unsuccessful vasectomy reversal procedures. Of these patients 20 underwent bilateral (16) or unilateral (4) vasoepididymostomy, 11 underwent bilateral (7) or unilateral (4) vasovasostomy and 10 underwent unilateral vasoepididymostomy with contralateral vasovasostomy. Postoperative followup consisted of serial semen analyses and telephone interviews. RESULTS: Patency and pregnancy followup data were available in 33 and 31 patients, respectively. Five couples had ongoing uncorrected female factor infertility problems and were not included in pregnancy rate calculations. Mean obstructive interval was 10.6 years. Overall patency and pregnancy rates were 79 and 31%, respectively. Mean total motile sperm count for patients demonstrating patency at followup was 38.0 million. History of conception with the current partner was predictive of future conception with 4 of 5 nonremarried couples (80%) initiating a pregnancy versus 3 of 18 remarried couples (17%) (p = 0.006). Other factors, including smoking history and obstructive interval, did not correlate with postoperative success. Reconstruction with vasovasostomy on at least 1 side trended toward improved patency (p = 0.17) and pregnancy rates (p = 0.15), although they did not assume statistical significance. CONCLUSIONS: Microsurgical reconstruction following failed vasectomy reversal is associated with high patency and moderate pregnancy rates at short-term followup. In our series previous conception with the current partner was predictive of future conception after reconstruction. Urologists performing repeat vasectomy reversal must be familiar with microsurgical techniques, since almost three-quarters of patients will require at least unilateral vasoepididymostomy.     

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.     

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.     

Pregnancy outcomes after vasectomy reversal for female partners 35 years old or older

PURPOSE: We review the outcomes after vasectomy reversal for couples with female partners 35 years old or older. MATERIALS AND METHODS: A retrospective review of experience at 2 institutions was performed. Patency was defined as the presence of motile sperm. Patients with less than 6 months of followup were excluded from the patency rate analysis unless they had sperm in the semen. Similarly, patients with less than 12 months of followup or no ongoing interest in establishing conception were excluded from the pregnancy rate analysis unless they had established a pregnancy or they were azoospermic with sufficient followup. RESULTS: A total of 46 men with partners 35 years old or older underwent vasectomy reversal at 2 institutions. Mean partner age was 37 +/- 2 years, and median obstructive interval was 10 years. Bilateral vasovasostomy was performed in 43 men, unilateral vasovasostomy in 2 and vasovasostomy/vasoepididymostomy in 1. Of the 46 men 27 had followup semen analyses with a patency rate of 81% (22). Transient patency occurred in 2 cases (7%). Pregnancy occurred in 35% of the couples (14 of 40 patients) with sufficient followup. The ongoing/live delivery rate was 33% (13 of 40 cases). The pregnancy and ongoing/delivery rates were 46% (12 of 26 patients) and 46% (12 of 26) for female partners 35 to 39 years old, and 14% (2 of 14) and 7% (1 of 14) for female partners older than 40, respectively. CONCLUSIONS: Vasectomy reversal offers reasonable chance for success when the female partner is 35 years old or older. The chance for success is similar to that of a single cycle of in vitro fertilization with intracytoplasmic sperm injection. These couples should not be eliminated from consideration for reversal simply because the female partner is 35 years old or older.     

Modified vasoepididymostomy with simultaneous double needle placement, tubulotomy and tubular invagination

PURPOSE: Recently a new technique for vasoepididymostomy was described which included tubular invagination by the triangulation method with a patency rate of 92%. Although these early data were encouraging, some technical problems were noted with the technique. After placing the first suture there was often tubular leakage and collapse. The tubulotomy was difficult and in some cases a suture was inadvertently cut. A modified technique is presented for vasoepididymostomy with tubular invagination, including some methods described in rat models. Only 2 sutures are used with simultaneous double needle placement. MATERIALS AND METHODS: The 2-suture technique was used on 19 men who had undergone at least 1 vasoepididymostomy during vasectomy reversal procedures. RESULTS: Patency was demonstrated in 7 of 9 men (77.7%) who underwent modified bilateral vasoepididymostomy and 6 of 7 (85.7%) who underwent unilateral vasoepididymostomy and unilateral vasovasostomy. Pregnancies were reported in both groups. The overall operating time for the modified technique was about 35 to 45 minutes per side. CONCLUSIONS: Modified vasoepididymostomy with simultaneous needle placement, tubulotomy and invagination resulted in early patency in a high percentage of patients. Tubular invagination may have advantages compared to other conventional methods of vasoepididymostomy but more followup is needed.     

Microsurgical vasoepididymostomy with sperm cryopreservation for future assisted reproduction

BACKGROUND: Although obstructive azoospermia is treatable with microscopic seminal reconstruction, the number of patients who choose to undergo vasoepididymostomy is limited because of recent advances in assisted reproductive technology (ART). We attempted to define the outcome of surgical reconstruction in patients with suspected epididymal obstruction and no previous history of vasectomy. METHODS: We described 40 eligible end-to-side vasoepididymostomy procedures performed on 24 azoospermic patients who had either bilateral or unilateral epididymal obstruction. RESULTS: The overall patency rate following surgery was 54% (13/24) and for four patients (17%), natural intercourse resulted in pregnancy. Two pregnancies were initiated with intracytoplasmic sperm injections using frozen sperm collected during vasoepididymostomy. CONCLUSIONS: In the era of modern ART, microsurgical vasoepididymostomy with cryopreservation of sperm collected during the operation is recommended for patients with epididymal obstructions.     

Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group

During a 9-year period 1,469 men who underwent microsurgical vasectomy reversal procedures were studied at 5 institutions. Of 1,247 men who had first-time procedures sperm were present in the semen in 865 of 1,012 men (86%) who had postoperative semen analyses, and pregnancy occurred in 421 of 810 couples (52%) for whom information regarding conception was available. Rates of patency (return of sperm to the semen) and pregnancy varied depending on the interval from the vasectomy until its reversal. If the interval had been less than 3 years patency was 97% and pregnancy 76%, 3 to 8 years 88% and 53%, 9 to 14 years 79% and 44% and 15 years or more 71% and 30%. The patency and pregnancy rates were no better after 2-layer microsurgical vasovasostomy than after modified 1-layer microsurgical procedures and they were statistically the same for all patients regardless of the surgeon. When sperm were absent from the intraoperative vas fluid bilaterally and the patient underwent bilateral vasovasostomy rather than vasoepididymostomy, patency occurred in 50 of 83 patients (60%) and pregnancy in 20 of 65 couples (31%). Neither presence nor absence of a sperm granuloma at the vasectomy site nor type of anesthesia affected results. Repeat microsurgical reversal procedures were less successful. A total of 222 repeat operations produced patency in 150 of 199 patients (75%) who had semen analyses and pregnancy was reported in 52 of 120 couples (43%).     

Microsurgical vasovasostomy after failed vasovasostomy

PURPOSE: We analyzed our experience with repeat microsurgical vasovasostomy after failed vasovasostomy and elucidate the possible predictors of surgical outcome. MATERIALS AND METHODS: We evaluated 62 repeat vasectomy reversal cases with followup data available. Regardless of the intraoperative observation of sperm in the vasal fluid bilateral microsurgical 2-layer vasovasostomy was performed when surgically possible. Of these 62 patients 60 (97%) underwent bilateral (58) or unilateral (2) vasovasostomy and 2 (3%) underwent unilateral vasovasostomy with contralateral epididymovasostomy. RESULTS: Patency and pregnancy followup data were available on 62 and 42 patients, respectively. The overall patency and pregnancy rates achieved were 92% and 57%, respectively, and the natural birth rate was 52%. Increased age of the wife proved a negative prognostic factor for pregnancy (p = 0.018). The intraoperative detection of sperm and other factors, including obstructive interval, reconstruction type, anastomotic site, patient age and postoperative semen parameters, did not influence the surgical outcome. CONCLUSIONS: Regardless of the detection of sperm in the intravasal fluid during the operation repeat microsurgical vasovasostomy resulted in a better outcome than in other studies, in which adopted epididymovasostomy was done when sperm was absent from the vas fluid. Our study suggests that compromised anastomosis after previous surgery is the most common cause of failed vasovasostomy. We recommend that microsurgical vasovasostomy should be performed preferentially in failed vasovasostomy cases.     

The kinetics of the return of motile sperm to the ejaculate after vasectomy reversal

PURPOSE: In prior analyses we observed that the achievable patency rate after vasectomy reversal is a key factor in whether reversal surgery is more cost-effective than in vitro fertilization-intracytoplasmic sperm injection for fertility after vasectomy. Because pregnancies will occur sooner with an earlier time to patency, this clinical parameter becomes important with advanced maternal age. We hypothesize that there are predictors of time to patency after reversal that are valuable for patient counseling and intraoperative decision making in cases of advanced maternal age. MATERIALS AND METHODS: We retrospectively reviewed a cohort of consecutive men who underwent vasectomy reversal. Data obtained included patient demographics, semen analyses, intraoperative findings, patency rates and time to achieve patency. RESULTS: A total of 150 patients met the inclusion criteria. Mean patient age was 42.9 years (range 27 to 61) and mean followup was 12.5 months (range 1 to 90). The presence of motile sperm in vasa predicted faster patency rates postoperatively. Of patients with motile sperm 95% achieved patency by 6 months whereas 76% of patients without motile sperm achieved patency within 6 months (p = 0.04). An obstructive interval of 8 years or less and undergoing vasovasostomy instead of epididymovasostomy predicted faster time to patency within the first 3 months after reversal. Patient age was not associated with time to patency after bilateral vasovasostomy. CONCLUSIONS: Motile sperm found intraoperatively at the testicular vas, undergoing vasovasostomy and an obstructive interval of 8 years or less predict shorter time to patency after vasectomy reversal. Patient age does not appear to affect patency kinetics after reversal. Patient counseling regarding fertility after vasectomy may benefit from this information especially in the setting of advanced maternal age.     

Outcomes for vasovasostomy with bilateral intravasal azoospermia

We conducted an evaluation of outcomes for microsurgical vasectomy reversal in which sperm are absent from the vas fluid in order to determine a threshold obstructive interval when vasoepididymostomy (VE) may be indicated. Vasectomy reversal was performed for 32 patients with intravasal azoospermia: 25 received bilateral vasovasostomy (VV), 1 had a bilateral VV, 5 underwent VV/VE, and 1 had bilateral VE. Overall, the patency rate was 50% (14 of 28). Five pregnancies (20%) and 3 live births (12%) occurred in 25 patients with sufficient follow-up. One pregnancy was electively terminated and the other is ongoing, for an ongoing or delivered rate of 16%. The patency rate for VV (either bilateral or unilateral) was 55% (12 of 22). Median obstructive interval was 7 years in patent and 15 years in nonpatent cases, respectively, (P =.0027). Sperm were not observed after VV in any case n which the obstructive interval was greater than 11 years. If VV was limited to obstructive intervals of 11 years or less, then the patency rate was 80% (12 of 15) and the pregnancy rate was 38% (5 of 13). The patency rate for bilateral VV was 67% (8 of 12) if clear fluid was observed on at least one side. We conclude that VE is not required in every case of intravasal azoospermia, but it could improve success rates in this setting. Based on our experience, VE may be indicated for intravasal azoospermia if the obstructive interval is more than 11 years.     

Robotic microsurgical vasovasostomy and vasoepididymostomy: a prospective randomized study in a rat model

PURPOSE: Microsurgical vasovasostomy and vasoepididymostomy remain technically challenging procedures. Refinements in technique have continually improved patency and pregnancy rates for the 2 procedures in experienced hands. Advances in surgical robotics produced the Da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, California) with motion reduction and no tremor, features that may improve outcomes in microsurgery. We report a randomized prospective study of vasoepididymostomy and vasovasostomy using the Da Vinci robot in rats. MATERIALS AND METHODS: A total of 24 adult male Wistar rats underwent vasectomy through a midline abdominal incision. Two weeks later the animals were randomized to microsurgical multilayer vasovasostomy, longitudinal vasoepididymostomy or robotic vasovasostomy and vasoepididymostomy groups. Outcomes measured included surgical time, complications, patency and sperm granuloma formation at 9 weeks. RESULTS: Animals were sacrificed 9 weeks after microsurgery. There were no significant differences in complications among the groups. Robotic vasovasostomy was significantly faster than the conventional microsurgical technique (68.5 vs 102.5 minutes, p = 0.002). The robotic and microsurgical vasoepididymostomy groups did not differ significantly in time. Patency rates were 100% for the robotic vasovasostomy and vasoepididymostomy groups, and 90% in the microsurgical vasovasostomy and vasoepididymostomy groups. These differences were not significant. Sperm granulomas were found in 70% of microsurgical vasovasostomy anastomoses and 27% of robotic vasovasostomy anastomoses (p = 0.001). No significant difference in the sperm granuloma rate was found between the robotic or microsurgical vasoepididymostomy groups (42% and 50%, respectively, p = 0.37). CONCLUSIONS: To our knowledge we report the first randomized prospective study using the Da Vinci robot for microsurgery. We believe that the improved stability and motion reduction during microsurgical suturing with the robot helped achieve excellent patency rates for vasovasostomy and vasoepididymostomy. The robot may also allow experienced microsurgeons to perform microsurgical procedures in patients at remote locations where no experienced microsurgeons are available.     

Treatment of failed vasectomy reversal using a microsurgical two-layer anastomosis technique

Objective

To evaluate the application of a microsurgical two-layer anastomosis technique in the treatment of failed vasectomy reversal.

Methods

A microsurgical two-layer anastomosis was used in a series of 24 patients with confirmed anastomotic obstruction after previous vasectomy reversal. The patients were followed up for 9 months to 6 years, and the efficacy of the procedure was evaluated by regular seminal analysis and pregnancy records. The results were compared with those obtained from 34 patients who had received primary microsurgical vasovasostomy in our hospital using the same microsurgical technique.

Results

In the treatment group for failed vasectomy reversal patients, the postoperative patency rate was 87.5% (21/24), resulting in a pregnancy rate of 54.2% (13/24). In primary reversal group, the postoperative patency rate was 94.1% (32/34), resulting in a pregnancy rate of 67.6% (23/34). Both the patency and pregnancy rate were not significantly different between these two groups.

Conclusions

The microsurgical vasovasostomy and vasoepididymostomy provided satisfactory patency rate and natural pregnancy rate for patients with a previous failed vasectomy reversal, which is comparable with the results of patients who had undergone primary procedure.     

PATIENT CHARACTERISTICS ASSOCIATED WITH VASECTOMY REVERSAL

PURPOSE: More than 30 million couples throughout the world are using vasectomy as a method of birth control. It is estimated that up to 6% of men who undergo voluntary sterilization will eventually request reversal, despite the high cost and relatively low success rate of the procedure. We identified characteristics that predict which vasectomy patients may request reversal. We also examined the cost and effectiveness of pre-vasectomy sperm cryopreservation followed by intrauterine insemination as an alternative method of achieving pregnancy. MATERIALS AND METHODS: We reviewed medical charts of 365 patients who underwent vasectomy and 290 who underwent vasectomy reversal between 1990 and 1997. Data were collected on patient age at the time of vasectomy, religion, occupation, wife employment status, number of marriages, number of children, reason for reversal, and number of years between vasectomy and reversal. Based on previously reported values, pregnancy rates and cost per successful pregnancy were estimated for vasectomy reversal surgery, and compared with a calculated cost per pregnancy for sperm cryopreservation and intrauterine insemination. RESULTS: Patient factors significantly associated with increased vasectomy reversal included younger age at time of vasectomy (p < 0.001) and a wife who worked outside the home (p < 0.001). Vasectomy reversal occurred 12.5 times more often (95% confidence interval [CI] 7.6 to 20.7) in men who underwent vasectomy in their 20s than in men who were older. Men whose wives were not employed requested reversal 0.48 times as often (95% CI 0.33 to 0.71) as those whose wives worked. Men who were younger at vasectomy tended to wait longer before reversal (median 10 years) than other patients (p < 0.001). At 10 years our calculated pregnancy rates and cost per pregnancy were 44% and $12,727 for vasectomy reversal, and 41% and $9,512 for intrauterine insemination with banked sperm (3 attempts). CONCLUSIONS: Patients who requested vasectomy reversal most often chose voluntary sterilization at a younger age. We believe that younger men should be given better pre-vasectomy counseling. However, the success rate and cost-effectiveness of sperm cryopreservation before vasectomy, with subsequent intrauterine insemination, may make this nonsurgical alternative desirable for younger couples who choose vasectomy even when properly informed about reversal rates.     

The impact of obstructive interval and sperm granuloma on outcome of vasectomy reversal

PURPOSE: We studied the impact of the interval from vasectomy to reversal and presence of sperm granuloma on outcomes of reversal. MATERIALS AND METHODS: A total of 213 microsurgical vasectomy reversals performed by a single surgeon were stratified according to obstructive intervals of less than 5 years, 5 to 10 years, 10 to 15 years and greater than 15 years. The effects of obstructive interval on patency and pregnancy rates were assessed using multivariate logistical regression. The impact of sperm granuloma on patency and pregnancy was assessed using the chi-square test. RESULTS: Patency did not change with increasing obstructive intervals as can be seen with 91% patency at less than 5 years, 88% at 5 to 10 years, 91% at 10 to 15 and 89% at greater than 15 years. There was no difference in pregnancy rates (89%, 82% or 86%) at obstructive intervals of 0 to 5, 5 to 10 or 10 to 15 years, respectively. Pregnancy rates were significantly lower (44%, p <0.05) with obstructive intervals greater than 15 years. Men with at least unilateral sperm granuloma had patency of 95% vs 78% without granulomas, a trend which did not quite reach statistical significance (p = 0.07). There was no difference in pregnancy rates with or without granulomas. CONCLUSIONS: Vasectomy reversal patency rates are high regardless of time since vasectomy. Pregnancy rates are lower more than 15 years after vasectomy. Sperm granuloma had a favorable impact on patency. Our data indicate that for obstructive intervals less than 15 years vasectomy reversal yields much higher pregnancy rates than in vitro fertilization and intracytoplasmic sperm injection, and that even for intervals greater than 15 years reversal outcomes equal or exceed those of in vitro fertilization and intracytoplasmic sperm injection.     

Microsurgical vasovasostomy

Up to 6% of men who have undergone vasectomy will ultimately elect for reversal in the form of vasovasostomy or vasoepididymostomy for various reasons. Vasovasostomy performed to regain fertility is a technique that has undergone numerous advances during the last century, including the use of microsurgical equipment and principles to construct a meticulous anastomosis. It is important during vasovasostomy to ensure good blood supply to the anastomosis as well as to build as a tension-free anastomosis. Visual inspection to ensure healthy mucosa and inner muscularis as well as atraumatic handling of tissues is helpful. With vasovasostomy, it is essential to create a watertight anastomosis to prevent secondary scar formation. The microdot technique of vasovasostomy allows for markedly discrepant lumens to be brought together more precisely. Thereby, the planning is separated from suture placement, which prevents dog-ears and avoids subsequent leaks. In the age of in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI), it becomes even more important to clarify outcomes after vasectomy reversals, as patients now have a choice between surgical sperm retrieval coupled with IVF/ICSI versus vasectomy reversal. Little data on long-term outcomes for vasectomy reversals exist. Therefore, further research in this field needs to evaluate the rate of late failures and the predictors of late failures.     

Robotic assisted versus pure microsurgical vasectomy reversal: technique and prospective database control trial

Microsurgical vasectomy reversal is a technically demanding procedure. Previous studies have shown the possible benefit of robotic assistance during such procedures. Our goal was to compare robotic assisted vasovasostomy and vasoepididymostomy to standard microsurgical vasovasostomy (MVV) and vasoepididymostomy (MVE). The use of robotic assistance for vasectomy reversal may provide the microsurgeon with improved visualization, elimination of tremor, and decreased fatigue and obviate the need for a skilled microsurgical assistant. This study provides the first clinical prospective control trial of robotic assisted versus pure microsurgical vasectomy reversal. The use of robotic assistance in microsurgical vasovasostomy and vasoepididymostomy may have benefit over MVV and MVE with regards to decreasing operative duration and improving the rate of recovery of postoperative total motile sperm counts based on our study.     

FERTILITY OUTCOME AFTER REPEAT VASOEPIDIDYMOSTOMY

PURPOSE: Historically, epididymal obstruction has been treated with surgical reconstruction. We determine whether it is worthwhile for patients to undergo repeat surgical reconstruction after failed vasoepididymostomy or whether they should be advised only to undergo sperm acquisition for assisted reproductive technique. MATERIALS AND METHODS: A total of 18 patients underwent repeat vasoepididymostomy performed by a single urologist (A. J. T.). Cases were divided based on the etiology of obstruction into groups 1--prior vasectomy (4), 2--congenital (7) and 3--inflammatory (7). Data were available regarding time of obstruction between initial and repeat vasoepididymostomy, quality of epididymal fluid, levels of anastomoses, semen analyses at least 12 months after surgery for all 18 men and pregnancy rates based on more than 18 months of followup in 12. RESULTS: Mean patient age at repeat vasoepididymostomy was 40.6 years (50.5, 36 and 39.4 years for groups 1, 2 and 3, respectively). Mean interval between vasectomy and initial vasoepididymostomy was 12.3 years (range 10 to 18). Mean interval between initial and repeat vasoepididymostomy was 19 months (range 12 to 41). Of the patients 10 underwent unilateral and 8 bilateral anastomoses, for a total of 26 repeat anastomoses. Overall patency rate was 66.7% (12 of 18) with sperm in the ejaculate in 75, 85 and 43% of patients in groups 1, 2 and 3, respectively. The patency rates according to the levels of the anastomosis were 66.7, 62.5 and 100% in the caput, corpus and cauda, respectively. Natural conception occurred in 3 of 12 couples (25%, 2 caput and 1 caudal anastomosis) during a mean followup of 23 months (range 13 to 34). All 3 cases had congenital obstruction. Pregnancy was achieved in 2 group 1 cases with cryopreserved sperm extracted at repeat vasoepididymostomy, and in 1 case each in groups 1 and 2 with microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection. CONCLUSIONS: After repeat vasoepididymostomy two-thirds of men have sperm in the semen. Natural conception occurred in 25% of patients (3 of 12) followed for more than 18 months. Inability to establish pregnancy in the remaining 7 of 9 patients with sperm in the semen with a followup longer than 18 months may be due to epididymal dysfunction or partial obstruction and subsequent poor sperm quality. Aspiration of motile sperm and cryopreservation were possible in 11 of 18 cases at repeat vasoepididymostomy and should be recommended in case azoospermia remains or occurs after surgery. It appears worthwhile to offer patients repeat vasoepididymostomy after a failed initial procedure.     

The relationship between intravasal sperm quality and patency rates after vasovasostomy

PURPOSE: Most surgeons examine the intravasal fluid at vasectomy reversal. Vasovasostomy is performed when sperm are identified in the intravasal fluid or when sperm are absent but the fluid is copious and clear. When sperm are absent and the intravasal fluid is not copious and clear, vasoepididymostomy is often performed. Frequently the intravasal fluid contains only fragments of sperm. This study examines patency rates after microsurgical vasovasostomy as a function of the quality of sperm in the intravasal fluid. MATERIALS AND METHODS: The records of patients who had undergone microsurgical vasovasostomy were reviewed. The intravasal fluid was examined and sperm quality was recorded as no sperm, sperm heads, sperm with short tails or whole sperm. Results of postoperative semen analyses were recorded. Patency rates and postoperative semen parameters were compared. RESULTS: A total of 53 patients satisfied the entrance criteria. Ages ranged from 25 to 53 (mean age 39). Mean obstructive interval was 9.9 years (range 1 to 20). Overall patency was 98% (52 of 53 cases). Patency rates were 95% for the group with sperm heads and 100% for whole sperm, sperm with short tails and absent sperm groups. Patency rates did not vary significantly as a function of intravasal sperm quality. CONCLUSIONS: Modern microsurgical techniques yield excellent patency rates. The presence of sperm parts compared to whole sperm does not adversely affect patency rates after vasovasostomy. Vasovasostomy should be performed if any sperm parts are identified in the intravasal fluid.     

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.     

Vasectomy reversal

A vasovasostomy may be performed on an outpatient basis with local anesthesia, but also may be performed on an outpatient basis with epidural or general anesthesia. Local anesthesia is preferred by most of my patients, the majority of whom choose this technique. With proper preoperative and intraoperative sedation, patients sleep lightly through most of the procedure. Because of the length of time often required for bilateral microsurgical vasoepididymostomy, epidural or general anesthesia and overnight hospitalization are usually necessary. Factors influencing the preoperative choice for vasovasostomy or vasoepididymostomy in patients undergoing vasectomy reversal are considered. The preoperative planned choice of vasovasostomy or vasoepididymostomy for patients having vasectomy reversal described herein does not have the support of all urologists who regularly perform these procedures. My present approach has evolved as the data reported in Tables 1 and 2 have become available, but it may change as new information is evaluated. However, it offers a logical method for planning choices of anesthesia and inpatient or outpatient status for patients undergoing vasectomy reversal procedures.