Vasectomy reversal

Vasectomy is by far the most reliable method of birth control. It is the contraceptive method of choice in 4–15% of couples in Thailand, Korea, Canada, the Netherlands and New Zealand.1,2 The increasing popularity of vasectomy as a method of birth control has also led to an increased demand for reversal. As a consequence, vasectomy is the second most common cause of infertility, the leading cause being ductal obstruction. In 1915, the first vasovasostomy was performed on a man requesting restoration of fertility after vasectomy. Since then, numerous procedures have been described that attempt to achieve restoration of sperm in the ejaculate of men who have undergone vasectomy. In this paper, surgical skills, surgical outcomes and potential predictors for treatment results of vasovasostomy are presented along with clinical experiences. In particular, treatment options when previous vasectomy reversal has failed in the era of intracytoplasmic sperm injection (ICSI) will be discussed. Light general or regional anesthesia (usually spinal anesthesia) is preferable, and surgery can be performed on an out-patient basis under local anesthesia with sedation. Currently, I usually perform microsurgical two-layer vasovasostomy under local anesthesia, if the patient is cooperative. Slight movements are greatly magnified by the operating microscope and can disturb the performance of the anastomosis. Therefore, pre-operative and intra-operative sedation is used for patients undergoing vasovasostomy with local anesthesia. Fentanyl is injected intravenously, with blood pressure and electrocardiogram monitoring. A mixture of equal parts of 1% plain lidocaine and 0.5% marcaine (for its long duration of action), without epinephrine, is used for the local anesthetic agents. The local anesthetic may be injected throughout the spermatic cord at the level of the pubic tubercle, or in the uppermost portion of the scrotum. It should be noted that there is a small risk of inadvertent injury to the testicular artery during local anesthesia and cord block.3 Bilateral high vertical scrotal incisions provide the most direct access to the obstructed site in cases of vasectomy reversal. These incisions should be high because the abdominal portion of the vas deferens is difficult to render tension-free, whereas the testicle can be easily moved upward, freeing any tension on the testicular portion of the vas deferens. Usually, the site of the previous vasectomy can be palpated and the ends of the vas simply externalized. If this cannot be performed easily, the scrotal contents can be extruded in an extravaginal fashion. Preferably, one should not enter the tunica vaginalis during this procedure because if an epididymovasostomy is required later, the dissection will be difficult. If the vasal gap is large or the vasectomy site is high, this incision can easily be extended inguinally towards the external ring. When the vasal gap is extremely large, additional length can be achieved by dissecting the entire convoluted vas deferens free of its attachments to the epididymal tunic, allowing the testis to drop upside down. These maneuvers can provide an additional 4–6 cm of length. In order to maintain the integrity of the vasal vessels, this dissection is best performed using magnifying loupes or the operation microscope.4 In men with suspected obstruction of the inguinal vas deferens from prior herniorrhaphy or orchiopexy, an inguinal incision is the preferred approach. The vas deferens is grasped above and below the site of obstruction with two Allis clamps. Although there is a rich network of vessels on the outer vas deferens, care must be taken with the bipolar cautery to avoid excessive cauterization or stripping. The bipolar coagulation causes less tissue damage, can be used under irrigation, and causes only minimal coagulation of the parent blood vessels. The vas deferens is mobilized enough to allow a tension-free anastomosis including the vasal vessels and periadventitial sheath. After the vas deferentia have been freed, the testicular end of each vas deferens is transected with a microsurgical knife or a razor blade, with a piece of a wooden tongue blade placed beneath the vas deferentia for countertraction. The cut surface of the testicular end of the vas deferens is inspected using magnification. A healthy white mucosal ring that springs back immediately after gentle dilation should be seen. The muscularis should be smooth and soft, not gritty. If the blood supply is poor or the muscularis is gritty, the vas deferens should be recut until healthy tissue is found. The vasal artery and vein should then be clamped and ligated.4 Once a patent lumen has been established on the testicular end, the vas deferens is milked and a clean glass slide is touched to its surface. Gentle insertion of 24-guage angiocatheter sheath may be helpful in achieving capillary action. The vas deferens fluid is immediately mixed with a drop of saline and preserved under a coverslip for microscopic examination. As sperm have a reactive effect on the surrounding tissue, the field should be continuously irrigated. Microscopic examination of the vas deferens fluid for sperm from the testicular end is particularly important. The possibility of an epididymal blowout and secondary obstruction must be considered in patients with a long-term occlusion, whenever there is little or no fluid or thick, pasty fluid devoid of sperm. Although there is no hard and fast rule for every instance, it is appropriate for the surgeon dealing with a long-term obstruction to be prepared and capable of performing the more surgically demanding epididymovasostomy.5 The abdominal end of the vas deferens is prepared in a similar manner. Upon transecting the abdominal end of the vas deferens, it is examined and dilated gently with a microvessel dilator. Patency of the distal vas may be tested with a 2-0 nylon suture passed upon the lumen, or by injection of 2–3 mL of saline with a 24-guage angiocatheter sheath. Prior to the 1970s, vasovasostomy was done either without magnification or with magnification of 2–8 times normal size using ocular loupes. With minimal magnification, precise placement of the mucosal suture is not possible. Without precise mucosal observation, mucosal alignment may not be achieved and anastomotic stricture is more likely to occur. In general, the results of non-magnified and loupe-magnified vasovasostomy are about 10–15% inferior to the results obtained with microsurgical techniques. Because of the superior results, most practitioners of vasovasostomy use the operating microscope with either a modified one-layer or two-layer anastomosis. Both of these methods have proved to be equally effective with regard to patency and later pregnancy.6 Modified one-layer anastomosis is ideal when the vasovasostomy is performed in the straight portion of the vas deferens and the discrepancy in lumen size is minimal. On the other hand, the two-layer technique offers great precision in observation of the lumen at each end of the vas deferens, particularly when there is a significant discrepancy in size or when performing the anastomosis at the level of the convoluted vas deferens, where there is less muscle surrounding the lumen and the lumen may be offset. I routinely perform the two-layer anastomotic technique in all vasovasostomy cases. In my opinion, specialized microsurgeons dealing with male infertility should perform two-layer anastomosis to develop and maintain the microsurgical skills required to perform epididymovasostomy, which is still a difficult procedure requiring considerable microsurgical skill. Between 1987 and 1998 (11 years), I have performed 997 vasectomy reversals using microscopic two-layer vasovasostomy. When a decision has been made to perform a vasovasostomy, the distal lumen may be gently dilated with the tips of a microvessel dilator. I always perform the whole procedure sitting on the patient’s left side. From this position, the proximal lumen leading to the testicle is to the left. In my opinion, anastomosis can be facilitated from this position due to the dilated lumen of the proximal end of the vas deferens. Most surgeons use the vas deferens approximating clamps (V Mueller, ASSI and Edward Weck & Co., USA). These clamps prevent movement of the ends of the vas deferens through the clamp. Some surgeons have modified the approximating clamps for more convenience.7,8 A sterile piece of blue plastic material may be cut from a surgical drape or any other inexpensive material and placed under the two ends of the vas deferens. This provides an excellent background for observation, and puncturing this sheet with a fine needle at multiple sites allows the blood and irrigating fluid to drain, thus maintaining a clear surgical field.5 Previously, I developed a new blue plastic plate from an easily available plastic sheet. The ends of the vas deferens are fastened to the plate with two sutures through four punctures which have been made in the plate. The plate and the sutures prevent movement of the ends of the vas deferens, facilitate the approximation of the vas deferens and provide a good surgical background. The initial suture is placed through the mucosa at the zero-degree position with 10-0 nylon. A second suture is placed, tied and cut at the 180-degree position. The properly placed mucosal layer suture includes both the mucosa and approximately the inner fourth of the muscular layer. ‘Through stitches’ that catch the mucosa of the opposite side of the vas deferens must be avoided. Goldstein uses a double-armed fishhook-shaped needle.4 The double-armed sutures allow inside-out placement, eliminating the need for manipulation or dilation of the mucosa and the possibility of back-walling. I use the single-armed needle and tie and cut the 10-0 nylon immediately after suturing. ‘Dog ears’ of the mucosal edges are easily prevented by accurate spacing of the mucosal sutures. Recently, Goldstein et al. described a ‘microdot’ technique that uses an extra fine tip skin marker to map the location of placement of eight mucosal sutures.9 After completion of mucosal sutures on one half side of the lumen, muscular sutures are started with 9-0 nylon at 30-degrees and ended at 150-degrees. This maneuver is helpful in order that the mucosal sutures are not disturbed on the opposite side. Then the vas deferens is rotated 180-degrees and two or three additional mucosal sutures are placed and tied. After completion of the mucosal layer, more muscular sutures are placed. I generally use six to eight mucosal and nine to eleven muscular sutures, depending on size. The anastomosis is finished by approximation of vasal sheath with 9-0 nylon sutures. 1. Accurate mucosa to mucosa approximation. 2. Leakproof anastomosis. 3. Tension-free anastomosis. 4. Good blood supply. 5. Healthy mucosa and muscularis. 6. Good atraumatic anastomotic technique. Vasovasostomy performed in the convoluted portion of the vas deferens is technically more demanding than anastomosis in the straight portion. The risk of cutting back into the convoluted vas deferens in order to obtain healthy tissues may cause surgeons to complete an anastomosis in the straight portion when the testicular end of the vas deferens has poor blood supply, unhealthy or friable mucosa, or gritty fibrotic muscularis. Adherence to the following principles can facilitate anastomosis in the convoluted vas deferens to succeed equally as often as those in the straight portion. 1. A perfect transverse cut yielding a round ring of mucosa and a lumen directed straight down is essential. 2. The convoluted vas deferens should not be unraveled. 3. The sheath of the convoluted vas deferens may be carefully dissected free of its attachments to the epididymal tunic. 4. Care must be taken to avoid taking large pieces of the muscularis and adventitial layers on the convoluted side in order to prevent inadvertent perforation of the adjacent convolutions. 5. Reinforce the anastomosis by approximating the vasal sheath of the straight portion of the vas deferens to the sheath of the convoluted portion to remove all tension from the anastomosis. As previously mentioned, the results of non-magnified and loupe-magnified vasovasostomy are about 10–15% less effective than the results obtained with microsurgical techniques. Because of the superior results, most practitioners of vasovasostomy use the operating microscope either using a modified one-layer or two-layer anastomosis. Both of these methods have proved to be equally effective with regard to patency and later pregnancy.6 A summary of a microsurgical vasovasostomy series, which included a relatively large number of subjects, is presented in Table 1. Overall, microsurgical vasectomy reversal has proved to be a highly successful procedure with a patency rate of approximately 90% and a subsequent pregnancy rate of approximately 50%. In my early clinical experience of 97 subjects,12 the anatomical success rate of the two-layer microscopic vasovasostomy was 90.7% and the subsequent pregnancy rate was 67%, superior rates in comparison to the 89% and 50%, respectively, of the one-layer microscopic vasovasostomy previously done at my institute.2 Several factors may influence the outcome of the vasovasostomy. The pregnancy rate after vasectomy reversal is inversely related to the duration of the obstruction interval. It had been reported that men with obstruction intervals of 5 years or less had a better chance for fertility than those with obstruction intervals of 6–10 years, and those with intervals of 10 years or more had a very poor chance of fertility after vasectomy reversal.13 The Vasovasostomy Study Group (VSG)6 reported that there were specific time intervals for postoperative rates of patency and pregnancy, according to the obstruction intervals (< 3, 3–8 years, 9–14, ≥ 15 years). Although a sperm granuloma at the vasectomy site is associated with better sperm quality in the intra-operative vas deferens fluid, the VSG found that a sperm granuloma was not associated with better surgical outcomes.6 The presence of sperm in the vas deferens fluid during a vasovasostomy is also known to have a significant prognostic value. Silber’s grading system of sperm quality in the vas deferens fluid is useful prognostically.14 Data from The VSG reveal that the sperm content of the vas deferens fluid cannot be judged by the fluid’s gross appearance. 15 If no sperm are present in the vas deferens fluid, the cause could be back-pressure induced sperm granuloma in the epididymis,16 in which case epididymovasostomy is recommended. The VSG reported that if sperm are absent from the vas deferens fluid during planned vasovasostomy, the absence is related to the obstruction interval.17 Later, the VSG also examined the relationship between bilateral vas deferens fluid sperm absence during bilateral vasovasostomy and the result of vasovasostomy.6 Of 1247 patients undergoing vasovasostomy, only 84 had no sperm in the vas deferentia fluid on either side and had fluid of identical appearance on both sides. Of 73 patients available for follow-up, 41 (56%) either had sperm in the semen or were able to achieve a pregnancy in their partner, postoperatively. This suggested that when sperm are absent from the vas deferens fluid, the thicker the appearance of the fluid, the less likely it is that sperm will be present in the semen following a vasovasostomy, and the more likely it is that the surgeon must consider epididymovasostomy. Sharlip performed an interesting analysis of the best pregnancy rate that may be expected after a vasectomy reversal.18 Of the 95 patients who consistently had a postoperative sperm concentration of 20 million per mL or more and sperm motility of 50% or more, 58 (61%) achieved a pregnancy. Allowing for later pregnancies after the study was completed, he concluded that the maximum pregnancy probability after vasectomy reversal is 67%. Despite the excellent results of vasectomy reversal with the advent of microsurgical reconstruction, those patients whose vasectomy reversals fail to achieve patency and pregnancy are faced with the need to choose from available treatment options such as repeat vasal reconstruction. With increasing numbers of men undergoing vasectomy reversal procedures, it is important for the surgeon to be prepared to properly advise patients about the management of a failed procedure. It has been generally accepted that repeat microscopic reconstruction is worthwhile in failed vasectomy reversal cases.19,20 However, the choice between a vasovasostomy and an epididymovasostomy is still controversial, but the latter may be required when sperm are absent from the intra-operative vas deferens fluid at the testicular end of the vas deferens. In cases of repeat microsurgical vasectomy reversal, most surgeons perform an epididymovasostomy if no sperm are found after microscopic analysis of the testicular end of the vas deferens.21,22 However, I think that an obstruction at the previous anastomosis site is the cause of failed vasectomy reversal in most cases. The surgical situations in the failed vasectomy reversal cases are probably similar to those in initial vasectomy cases, except for the fact that previous vasectomy reversal has been performed. Therefore, I have repeated a vasovasostomy using microsurgical two-layer anastomosis if surgically possible, regardless of the presence of sperm in the intra-operative vas deferens fluid.23 Between 1992 and 1998, 459 patients underwent microsurgical vasectomy reversal in this series, and 70 (15.3%) were identified with previous failure of one or more attempts at vasectomy reversal. Patency and pregnancy follow-up data were available in 62 and 42 patients, respectively. In our study of 62 cases, which underwent microsurgical vasovasostomy at least on one side, the overall patency and pregnancy rate proved to be 91.9% and 57.1%, respectively. Increase in partner’s age was a negative prognostic factor for pregnancy (P = 0.018). Other factors, including intra-operative detection of sperm, obstruction interval, type of reconstruction, site of anastomosis, age of patient and postoperative semen parameters, did not influence the surgical outcome. There are limited numbers of reports about the surgical outcome of repeat vasectomy reversal. A summary of the surgical outcome of a repeat vasectomy reversal series and an analysis of the results according to reconstruction type are shown in Table 2. The overall mean patency and pregnancy rates after repeat vasectomy reversals are 73.8% (range, 63.6–79%) and 41.3% (range, 26.6–44.4%), respectively. The patency and pregnancy rates after repeated vasectomy reversals seemed to be lower than those after a first reversal. In our study of 62 patients, who underwent (repeated) microsurgical vasovasostomy on minimal one side, the overall patency and pregnancy rate was 91.9% and 57.1%, respectively. The difference in surgical method may have brought about these superior results in this study. A surgeon’s choice between a vasovasostomy or an epididymovasostomy is based on the presence or absence of sperm in the intravasal fluid during the operation. Consequently, most surgeons perform epididymovasostomy in order to bypass an epididymal obstruction.6,20–22 However, the principle of this surgical decision is based on limited knowledge, according to Silber.16 In Silber’s study, microscopic epididymal exploration was performed in men undergoing vasectomy reversal who were found to have no sperm in the proximal vas deferens fluid. From these examinations, he concluded that persistent azoospermia after an accurate microscopic vasovasostomy resulted from the secondary epididymal obstruction induced by rupture of the epididymal duct, due to the pressure increase after the vasectomy. Previous series of repeat vasectomy reversals have shown results that include elevated epididymovasostomy rates, which occurred in from 33 to 73% of total reconstructions (Table 2). However, only 4% of procedures performed at the initial vasectomy reversal were epididymovasostomies. In the current series, sperm were observed bilaterally in 23 out of 62 cases (37.1%). Therefore, epididymovasostomy should be required in 62.9% of our cases according to the aforementioned surgical principle. However, microsurgical two-layer vasovasostomy was attempted in all failed vasovasostomy cases if surgically possible, regardless of the findings in the intravasal fluid. Epididymovasostomy combined with contralateral vasovasostomy was required in only two cases. The reason for performing epididymovasostomy was not the absence of sperm in the vasal fluid, but due to the difficulty in tension-free vasovasostomy. An inability to find sperm in the intra-operative vas deferens fluid does not necessarily indicate the presence of epididymal obstruction, and that it is therefore not mandatory to perform epididymovasostomy in such situations. It is unlikely that so much epididymal blowout has occurred after initial vasectomy reversals. Factors other than epididymal obstruction must play a role in causing the intra-operative absence of sperm in the vasal fluid, for example, reversible abnormalities of sperm transport mechanisms and/or epididymal anatomy and functions. Sharlip reported that vasovasostomy in ten cases with bilateral intra-operative sperm absence resulted in recovery of normal sperm counts in six patients and subsequent pregnancy in five of the patient’s partners.24 The VSG also examined the relationship between bilateral vas deferens fluid sperm absence during bilateral vasovasostomy and the result of vasovasostomy.6 Despite the absence of sperm in the intravasal fluid, 60.2% (50 / 83) of these men had sperm in the postoperative ejaculate and 30.8% (20 / 65) achieved pregnancy. In my series, 29 out of 62 (46.8%) men showed a bilateral absence of sperm in the intravasal fluid during the operation. The rate of patency and pregnancy in these patients was 86.2% (25 / and (11 / This result that there is no difference in surgical outcome according to the presence of sperm in the intravasal fluid. Although there is a possibility of a of vas deferens fluid all of these results that the absence of sperm in the vasal fluid is not always an that an epididymovasostomy is In our series, five cases showed persistent azoospermia the initial follow-up semen of these patients were cases with bilateral absence of sperm in the intra-operative vas deferens fluid. In these four cases, epididymal obstruction is likely to be the cause of intravasal azoospermia during the and reported that the 23 patients who had a vasectomy reversal that failed to their there was a secondary epididymal obstruction in only four cases The of secondary epididymal obstruction be much less than was previously The results of our study When failed the ends are found to be The cause of this is likely to be due to anastomotic tension during the first procedure. of a length of the testicular end and the abdominal end of the vas deferens, that successful can be performed without when long of the vas deferens are during the previous procedure. our vasovasostomy cases, the anastomotic sites were on the convoluted vas deferens in cases Although a anastomosis has been reported to results similar to that of a two-layer anastomosis accurate has been out under microscopic a two-layer anastomosis is likely to achieve a more approximation without or possibility of as out by The two-layer anastomosis can be performed as in the convoluted as the straight parts of the vas deferens, and this is important in failed vasectomy reversal cases. If azoospermia is due to epididymal epididymovasostomy must be obstruction of the is very difficult to advise that the following factors enter into the decision to perform vasovasostomy or epididymovasostomy when sperm are absent from the vas deferens fluid at the time of vasectomy time from vasectomy until its available vas deferens gross appearance of vas deferens of the for of and the surgeon’s to perform an epididymovasostomy. are to for epididymovasostomy in repeat vasectomy reversal cases. Because are more common at repeat vasectomy reversal than initial vasectomy reversal, the lower patency and pregnancy rates observed for repeat vasectomy reversal probably an increased epididymovasostomy vasovasostomy on at least one side has led to a towards who underwent vasovasostomy on at least one side had patency and pregnancy rates of and respectively, whereas those undergoing epididymovasostomy had rates of and (Table 2). Since the of the microsurgical anastomosis technique by in the success rate of epididymovasostomy has However, epididymovasostomy is still a difficult procedure requiring considerable microsurgical and the fertility outcomes are not The of intracytoplasmic sperm injection (ICSI) has the management of male Because of the of it is to this treatment to all cases of male is a treatment for failed vasectomy reversals. However, the rate following is about reports from This is not a outcome with the results expected from a series of repeat vasectomy reversals performed by when one the additional and the possibility of repeated surgery in order to obtain sperm from microscopic epididymal sperm or testicular sperm it has been shown that these cannot repeat vasectomy reversal in the management of failed vasectomy reversal et al. the of repeat vasectomy reversal to that for combined and that the per by was times the per obtained through repeat vasectomy In to the of there are about a to the of techniques. In cases of failed vasectomy reversal, there is a specific and successful for the man that does not the to these pregnancy by is more likely after repeat vasectomy reversal. sperm injection in is still and there is a need to and results for these As sperm are by the is using In this era of by the role of repeat vasectomy reversal is important. In cases of failed vasectomy reversal, and should not to repeat vasectomy reversal of a sperm procedure combined with

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