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.     

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.     

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 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.     

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.     

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.     

Loupe-assisted modified one-layer vasovasostomy

Several studies indicate that microsurgical modified one-layer vasovasostomy is comparable to the two-layer anastomosis with respect to patency and pregnancy rates. The objective of this study was to determine the feasibility and result of modified one-layer vasovasostomy under loupe magnification only. Thirty-two patients aged 28 to 64 years (mean 41.3 +/- 6 years) underwent vasovasostomy at CGMH from July 1997 to June 2002, with all operations being a modified on-layer anastomosis created with the aid of a 3 x loupe. The estimated duration of vasectomy ranged from 4 months to 27 years, with a mean of 9.2 +/- 4.8 years. Postoperative semen analysis and pregnancy were examined. Each patient was followed up at 1,4, and 12 weeks postoperatively. The total operation time ranged from 118 to 228 minutes (average 150 +/- 35 minutes). There was no operation-related complication such as hematoma or wound infection. The patency rate was 89% (25/28), and the pregnancy rate at 2 years or more of follow-up was 39% (11/28). The patency and pregnancy rates were similar to those obtained in most studies of microsurgical vasovasostomy. For uncomplicated vasectomy reversal, this simple loupe-assisted modified one-lyer vasovasostomy seems to provide an adequate anastomosis.     

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.     

Need for sperm retrieval and cryopreservation at vasectomy reversal

PURPOSE: Controversy exists on whether to obtain sperm for cryopreservation routinely at vasectomy reversal. With recent improvements in in vitro fertilization with intracytoplasmic sperm injection, it is now possible to obtain a small amount of testicular tissue for cryopreservation in the event of reversal failure. However, to our knowledge no studies exist of who is most likely to benefit from this procedure. MATERIALS AND METHODS: We reviewed 84 consecutive vasectomy reversals performed by 1 surgeon (J. I. S.) between July 1996 and March 2000 with followup available for 77. We grouped cases by procedure as vasovasostomy, vasoepididymostomy and vasovasostomy with vasoepididymostomy as well as bilateral or unilateral. Sperm was retrieved at reversal in 15 of 46 vasovasostomy (none used), 11 of 18 vasoepididymostomy (3 used) and 13 of 20 vasovasostomy with vasoepididymostomy (none used) cases. RESULTS: The overall anastomotic patency rate after unilateral or bilateral vasovasostomy, unilateral vasovasostomy with contralateral vasoepididymostomy and unilateral or bilateral vasoepididymostomy was 96%, 83% and 57%, respectively. The natural pregnancy rate without in vitro fertilization was 57%, 50% and 14%, respectively. The most recent vasoepididymal anastomoses were performed by the Berger triangulation technique with a 78% patency and 25% pregnancy rate. Only 8% of men with banked sperm eventually used it for assisted reproductive techniques, in whom unilateral or bilateral vasoepididymostomy failed in all. CONCLUSIONS: We currently do not recommend routine sperm retrieval for cryopreservation in men who undergoing vasovasostomy. We encourage men who require bilateral vasoepididymostomy to bank sperm at reversal. In men who undergo vasovasostomy with vasoepididymostomy we base the decision on preoperative counseling and intraoperative findings.     

Toward a sutureless vasovasostomy: use of biomaterials and surgical sealants in a rodent vasovasostomy model

PURPOSE: With 500,000 to 800,000 vasectomies performed annually and a reversal rate of 3% to 8% vasectomy reversal has become a commonly performed procedure. Two-layer microsurgical vasovasostomy remains the gold standard for surgical reconstruction of the vas. However, this procedure is technically demanding and time-consuming. We determined the ability of biomaterials and surgical sealants to decrease the number of sutures used, enhance anastomosis watertightness and decrease operative time. MATERIALS AND METHODS: Adult male Wistar rats underwent vasectomy 2 weeks prior to vasovasostomy. Standard 2-layer microsurgical repair was performed in control animals. Experimental groups underwent 3-suture mucosal approximation and then completion of the anastomosis with a biomaterial membrane and/or synthetic sealant. The rats were sacrificed 9 weeks after vasovasostomy. Anastomotic patency was assessed functionally by the presence of motile sperm in the vas distal to the testes and anastomosis, and mechanically by methylene blue vasogram. The presence and size of sperm granulomas were also recorded. RESULTS: Microsurgical vasovasostomy required significantly less time when biomaterial (42.7 minutes) or sealant (40 minutes) was used compared to the standard sutured group (102.5 minutes, each p < 0.001). There was no difference in patency between the standard sutured and biomaterial groups (90% vs 92%). Patency was significantly lower in the sealant groups, that is 70% in the suture, biomaterial and sealant group, and 75% in the suture and sealant group. The biomaterial group had only 1 sperm granuloma in 12 procedures, which was significantly better than the 7 in the control group (p <0.001). CONCLUSIONS: Using a biomaterial wrap during vasovasostomy resulted in significantly decreased operative time and fewer sperm granulomas than in the control group. Sealants were not effective. Biomaterial wrap may support vasovasostomy and by decreasing leakage improve the outcome.     

Factors predicting overall success: a review of 747 microsurgical vasovasostomies

Objectives

Advances in surgical techniques have improved the outcome of microsurgical vasovasostomy (VV). We performed a retrospective analysis of surgical procedures to determine outcomes and predictors of VV success, to develop Kaplan–Meier Curves for predicting VV outcomes and to evaluate the use of α-glucosidase (AG) to predict outcomes.

Patients and Methods

We undertook a retrospective analysis of 747 modified 1-layer microsurgical VV procedures performed between 1984 and 2000. Obstructive interval, partner status, social status preoperatively and method of vasal obstruction, vasal fluid quality and sperm granuloma intraoperatively were compared with outcome results. Parameters evaluated at follow-up included semen analysis, AG concentration in ejaculate fluid and pregnancy rates.

Results

The overall patency rate was 86% and pregnancy rates were 33% and 53% at 1 and 2 years after primary VV, respectively. Preoperative factors associated with successful outcome and pregnancy included shorter obstructive interval and same female partner (p < 0.05). Intraoperative factors predicting success included the use of surgical clips instead of suture at vasectomy, the presence of a sperm granuloma, the presence and quality of vasal fluid, and the presence and quality of sperm in vasal fluid. Further, increased AG in the postoperative semen predicted improved patency and pregnancy outcomes.

Conclusion

This study confirms the effectiveness of VV for vasectomized men who wish to father children. It also demonstrates that preoperative and intraoperative factors are predictive of the VV outcome. Postoperative AG is also a useful marker of patency and it appears to predict pregnancy outcome.     

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.     

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.     

Vasovasostomy--a 15-year experience.

OBJECTIVE: This study aimed to evaluate the results of vasovasostomies performed in the authors' clinic over 15 years. MATERIAL AND METHODS: Between 1983 and 1998 39 vasovasostomies were performed using a macroscopic technique. The medical charts were reviewed and a postal survey was sent to 36 of these patients. The patients were invited to visit the outpatient department and to give semen for analysis and a blood sample for determination of serum antisperm antibodies and serum follicle-stimulating hormone. Twenty-five patients filled in the questionnaire and 10 patients were obtained for further semen and serum analyses. RESULTS: The overall pregnancy rate was 56% (14/25 respondents). Three of these 14 men used an assisted reproduction method with their own ejaculated sperm. The postoperative patency was recorded in the medical charts only sporadically. The age and the interval between the vasectomy and vasectomy reversal averaged 42 years and 8.6 years, respectively. Those men who could father a child had a somewhat shorter mean obstructive interval than those who failed (8.0 vs 9.3 years), although the difference was not statistically significant in this small patient sample. The serum follicle-stimulating hormone concentrations were normal, with no association with the pregnancy rate. CONCLUSION: Macroscopic vasovasostomy is an effective means of re-establishing fertility in vasectomized men.     

Laser-assisted vasectomy reversal: experience in 32 patients

A Food and Drug Administration approved protocol using a microsurgical carbon dioxide laser to assist in vasectomy reversal was instituted in January 1987. Between January 1987 and December 1988 the procedure was performed on 32 patients, 31 of whom submitted sperm and were available to evaluate. Success rates for sperm in the ejaculate in patients who underwent vasectomy less than 10 years previously were excellent, approaching 95%. The pregnancy rate in this group was 35%. In patients whose vasectomy was performed more than 10 years before reversal the results were much poorer. The success rate for sperm in the ejaculate was only 36% and the pregnancy rate was only 9%. The advantage of laser-assisted vasectomy reversal is that it is a simpler technical procedure that requires considerably less time than a 2-layer microsurgical technique. There were no significant complications, sperm granuloma, or even significant swelling or hematoma in any patient operated upon. Laser-assisted vasectomy reversal is at least equal to conventional microsurgical techniques and definitely easier to perform surgically.     

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.     

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 ASSOCIATED WITH INCREASED REACTIVE OXYGEN SPECIES PRODUCTION BY SEMINAL FLUID LEUKOCYTES AND SPERM

Purpose

Reactive oxygen species, which are primarily produced by leukocytes, are generally detrimental to sperm. High reactive oxygen species levels are found in men with abnormal sperm function. Since men often have poor sperm characteristics and infertility after vasectomy reversal, fertile men to determine if reactive oxygen species were elevated in the former group.

Materials and Methods

We studied semen samples of men with proved fertility (39) and those with previously proved fertility who had undergone vasectomy reversal (45). The presence of leukocytes was determined by Bryan-Leishman staining. Reactive oxygen species endogenous activity was monitored by luminol dependent chemiluminescence in washed cells, including all cells in the semen, and Percoll density gradient purified sperm.

Results

After vasovasostomy men had significantly lower sperm concentration, motility and computerized motility measurements than fertile men. Mean reactive oxygen species in washed seminal cells after vasovasostomy was 684 relative light units per second compared to 49 for fertile controls (p <0.0001). Density gradient purified sperm had 53 and 0.64 relative light units per second, respectively (p <0.0001). When men with leukocytospermia were excluded from analysis, differences between the groups remained, although 9 times more reactive oxygen species were detected in men after vasectomy reversal with than those without leukocytes in semen.

Conclusions

Higher levels of reactive oxygen species are found in washed seminal cells and purified sperm after vasectomy reversal than in those of fertile men. Although leukocytes are probably a significant source of reactive oxygen species in these groups, they may not account for all of the increased reactive oxygen species after vasovasostomy. Low motility after vasectomy reversal may be related to the detrimental effects of reactive oxygen species produced by leukocytes or sperm, even in men without clinical leukocytospermia.     

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.     

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