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Keywords:

  • vasectomy reversal;
  • technique;
  • screening;
  • survey

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. EDITORIAL COMMENT
  9. References

OBJECTIVE

To investigate the current incidence of vasectomy reversal procedures, the techniques used and which practitioners use them.

PATIENTS AND METHODS

Using a questionnaire, 130 general surgeons and urologists practising in Merseyside and North Wales were surveyed.

RESULTS

The response rate was 74%, with 24 urological surgeons and 14 general surgeons undertaking vasectomy reversal. Annually, urological surgeons carried out significantly more procedures than did general surgeons, at 8.5 and 5.3 (P = 0.029), respectively. They were also more likely to use double-layer closure and microsurgical techniques, whilst significantly less likely to use stents. Urologists reported significantly greater patency rates, at 76% and 52% (P = 0.017), respectively, with no significant differences in subsequent pregnancy rates (30% vs 25%). Only one practitioner checked tubal patency in the female partner before vasectomy reversal.

CONCLUSIONS

The use of vasectomy reversal is a cost-effective treatment for men wanting paternity after vasectomy. The technique used by the clinician and proper audit of the results require close attention; it would also appear to be obvious that all the partners of men seeking a vasectomy reversal should have their fertility status established before reversal, something that is clearly not done at present.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. EDITORIAL COMMENT
  9. References

Vasectomy is considered to be the most effective form of contraception [1] and remains very popular, with some 100 000 men undergoing the operation each year in the UK [2] and rates of 378 per million inhabitants in Austria, Germany and Switzerland [3]. More than 33 million couples now rely on vasectomy for contraception in the USA, the UK, India and China, and it is the contraceptive method of choice in 4–15% of couples in Thailand, South Korea, Canada and New Zealand [4]. Vasectomy is a simple day-case procedure, usually carried out under local anaesthesia. Whatever method is used the rate at which azoospermia is achieved depends on the frequency of ejaculation. When sperm are absent from two consecutive semen samples the vasectomy is considered complete. The failure rate for vasectomy, where azoospermia is not achieved, is ≈ 3%[5].

Its increasing popularity as a method of birth control, allied to an increasing frequency of marital breakdown and separation of relationships, has inevitably resulted in an increase in men requesting vasectomy reversal [6,7]. Vasectomy reversal rates in some older studies are reported at ≈ 8%[8], but more recent large studies suggest that there is a continuing increase in demand for vasectomy reversal, with current rates of ≈ 2.4% overall. These rates rise to ≈ 11% in men who undergo vasectomy before 24 years old [7]. Reasons for requesting reversal of vasectomy include divorce and remarriage, death of children, a wish for further children within the same relationship, or altered financial circumstances [9]. A survey in Australia showed that vasectomy-related infertility constituted 9.3% of referrals to a general infertility clinic [10], of whom 91% had remarried, and their new partners were on average 10 years younger. The median age of the men presenting at the clinic was 42 years, making it clear that men still wished to be parents at a relatively late age. Vasectomy reversal is possible because it is known that sperm production is well maintained after vasectomy, and normal spermatogenesis has been observed in testicular biopsies taken from 1 month to 10 years after vasectomy [11].

Various techniques for vasectomy reversal have been described, although most debates revolve around whether macroscopic or microscopic methods should be used. Results of vasovasostomy using a macroscopic technique have reported patency rates of ≥ 50%, with some quoting up to 87%[3,12,13]. Other authors warn of a success rate as low as 20%[14] and subsequent pregnancy rates of 5–25%[15].

There is a consensus that with microsurgery these results can be improved and this has been supported by results from several large series [15–17]. Silber [18,19] pioneered a two-layer approach using a microscope, ultrafine suture material (9/0 Nylon) and an exquisitely careful technique, reporting a pregnancy rate of 71% in the first 42 patients followed for> 1 year. This modern microsurgical technique remains the reference standard by which all techniques are judged, with patency expected to be> 80% in most series [2,3,15–17,20]. However, this is a lengthy operation, with a bilateral vasovasostomy taking ≥ 2 h. Therefore, some surgeons prefer to use a modified single-layer anastomosis [21–23] as it reduces operating time, and is robust and relatively reliable.

Some surgeons have favoured the use of splints or stents, but with improvements in microsurgical technique comparative studies have shown an increased obstruction rate after using splints [24], with associated reductions in pregnancy rates [25].

Circulating antisperm antibodies (ASAs) can be detected in the serum of 60–80% of men after vasectomy [11], and their presence in titres of ≥ 512 will compromise fertility if reversal is attempted [26]. Patients with high levels of ASAs usually have a severely suppressed fertility potential (< 0.5%/month pregnancy rate). The precise mechanism for ASA-mediated infertility is unclear although it is thought ASA may have an adverse effect on sperm maturation and function [27], and sperm motility [28] and concentration [29], as well as affecting sperm migration through the reproductive tract.

In the present study we assessed the current practice of vasectomy reversal, both in view of current advances and in an attempt to establish a benchmark for current practice, to define best practice and improve quality. We also compared the current surgical practices for azoospermic men in the light of current advances in assisted conception, i.e. surgical sperm retrieval and intracytoplasmic sperm injection (ICSI).

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. EDITORIAL COMMENT
  9. References

A postal questionnaire-based survey was conducted of 130 practitioners in Merseyside and North Wales. The questionnaire was designed to establish both the number of reversals performed and the techniques used by the practitioner. Further questions elicited the practitioners’ success rates in achieving patency, subsequent pregnancy rates, whether these were audited success rates, and the whether the surgeon investigated both partners before surgery. Further questions established whether sperm were cryopreserved and whether the clinician considered surgical sperm retrieval and testicular biopsy for unobstructive azoospermia.

Consultants in general surgery and urology were identified from each hospital directory in the Merseyside and North Wales region, and a questionnaire distributed; a repeat questionnaire was sent if no reply had been received after 3 weeks.

All data were entered into a database and analysed statistically using the chi-squared test to compare discrete data, including different clinical practices and pregnancy rates, or independent t-tests and the chi-squared test for comparing patency and pregnancy rates. The Mann–Whitney U-test was used for nonparametric data and P < 0.05 taken to indicate significance in all tests.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. EDITORIAL COMMENT
  9. References

Of the 130 questionnaires sent to 95 general surgeons and 35 urological surgeons (urologists) in North Wales and Merseyside, 97 (74%) replies were received. Of these 26 were from urologists and 71 from surgeons. Of the responses from surgeons, six identified themselves as vascular or breast surgeons and did not undertake general or urological surgery. The response rate from urologists was 26/35 (74%) and from surgeons 71/95 (74%).

Of the 26 urological surgeons 24 (92%) undertook vasectomy reversal, whilst of the general surgeons 14 (21%) did so (Table 1). More vasectomy reversals were carried out annually by each urological surgeon than by each general surgeon (Table 1). The maximum number by urologists was 20, with 10 (42%) undertaking ≥ 10 per year, and three doing ≥ 15, whereas for general surgeons only one carried out ≥ 10 per year and none> 15. The three surgeons performing> 15 procedures had a patency rate of 87% and a pregnancy rate of 48%, and the 15 performing < 6 procedures had significantly lower patency rates of 56% (P = 0.03) and pregnancy rates of 29%.

Table 1. Practice amongst urologists and general surgeons, the audit of practice and current practice for unobstructive azoospermia
PracticeUrologistsGeneral surgeonsP
No. using vasectomy reversal2414 
Mean (sd) no. of procedures/year  8.5 (5.0)  5.3 (2.1)0.029
Single-layer closure2214 
Double-layer closure  4  0 
Use of stents  3  80.008
Microscopic re-anastomosis12  3 
Check tubal patency (female)  1  0 
Check ASAs  3  3 
Mean (sd):
patency rate, %76 (19.3)52 (24.5)0.017
pregnancy rate, %30 (16.1)25 (9.5) 
Cryopreservation at reversal, n  1  1 
Audit
No. (patency/pregnancy)
No audit12/20  4/9 
Audit at:
3 months 11/410/5 
6 months  1/1  4/4 
1 year  0/0  2/3 
Current practice for unobstructive azoospermia, n/N
Diagnostic testicular biopsies18  3 
Offer surgical sperm retrieval17  40.018
Use Johnsen count18/18  3/3 
Process sample in in vitro fertilization laboratory  5/18  1/3 
Offer cryopreservation of retrieved spermatozoa  5/18  1/3 
Would wish to offer cryopreservation11/13  1/2 

The general surgeons exclusively used a single-layer anastomosis, whereas two urologists used a double-layer closure exclusively and two both single- and double-layer. Stents were used significantly more often by general surgeons than urologists (Table 1) but there was no significant difference in the use of microsurgery between them (Table 1).

Of the general surgeons, none checked female tubal patency before attempting reversal, whereas four urologists considered it; of the 24 urologists only one used an imaging patency test (hysterosalpingogram, high-contrast ultrasonography, or laparoscopy and a dye test) whilst the others used a history of previous pregnancy in the women as a tubal patency test (Table 1). Only six practitioners requested tests for ASAs in blood serum. Only two practitioners offered patients the option of cryopreservation of any vasal or epididymal fluid at the time of vasectomy reversal, for use in assisted reproduction technology if the patient remained persistently azoospermic after reversal.

Significantly more urologists than general surgeons would offer surgical sperm retrieval instead of a vasectomy reversal if they felt it was clinically indicated (Table 1). The reasons given by clinicians for offering surgical sperm retrieval instead of vasectomy reversal were previous failed reversal (17), impalpable epididymis (seven), elevated serum FSH levels (six), testis < 10 mL (four), presence of ASAs (four) and cystic epididymides (three).

Of all 38 practitioners 22 (58%) audited their own results for patency and nine (24%) for subsequent pregnancy. There was no significant difference between the groups in the number who audited their results for both patency and subsequent pregnancy rates (Table 1). Only three practitioners audited their results for pregnancy at 1 year (Table 1), yet 25 quoted their success rates to their patients. Success rates quoted for patency rates were significantly greater for the 24 urologists than the 14 general surgeons (Table 1), but there was no difference in the quoted pregnancy rates.

For fertility investigations for unobstructive azoospermia, 18 urologists and three general surgeons would routinely take a testicular biopsy to establish a diagnosis, with all clinicians using a Johnsen count [30] to establish spermatogenesis. Only six clinicians routinely sent tissue samples to an assisted-conception unit for processing, to establish the presence of spermatozoa for use in ICSI, with cryopreservation of any retrieved spermatozoa (thus reducing the requirement for repeated biopsies). However, 11 of the remaining 13 urologists and one of the two general surgeons taking biopsies for unobstructive azoospermia would wish to offer this service (Table 1).

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. EDITORIAL COMMENT
  9. References

This study shows clear significant differences in the management of vasectomy reversal between general surgeons and urologists. The latter are both more likely to undertake vasectomy reversal and to do so more often. However, the most reversals annually by any urologist was still only 20, by two urologists, and only 11 of 38 (29%) of all respondents undertook ≥ 10 procedures annually. In the study by Engelmann et al.[3] it is clear that success rates for patency and pregnancy are related to the operative frequency of the surgeon, with significantly better results obtained by surgeons undertaking> 15 procedures annually than in those performing < 6. These data were confirmed in the present study, albeit with fewer surgeons. Thus it seems important for surgeons with a limited case-load to carefully audit their results to establish if it is in the patients’ best interest to have their vasectomy reversed by a surgeon with a greater throughput.

Despite the clear evidence of the detrimental effect of using splints/stents [24,25] it is surprising and perhaps disappointing that these are still used by 29% of operators. There was significantly greater usage of stents by general surgeons than urologists (Table 1).

The other significant difference between urologists and general surgeons in operative technique was the use of a single- or two-layer closure, with general surgeons using the former exclusively, whereas four urologists used a double-layer technique exclusively or mostly. Urologists were also more likely to use a microscopic technique than were general surgeons (Table 1). This may reflect different referral practice, with more patients being referred after a previous failed reversal, where there is evidence that further surgery using microsurgical techniques is indicated [31]. However, significantly more urologists also stated that they would consider referring patients for surgical sperm retrieval after a previous failed vasectomy reversal. The urologists were also significantly less likely to use absorbable stents than general surgeons, despite reports showing that patency and pregnancy rates are reduced with their use [24].

Despite the few procedures undertaken, most respondents quoted their results for patency and pregnancy rates to patients, but only a quarter of respondents stated that they audited their pregnancy rates and only three audited their patients at 1-year after surgery. However, it is clear from other studies that the average time from reversal to conception is 12 months [17] and therefore with only 24% of practitioners auditing their results, and these for an inadequate period, it is clear that the quoted audited pregnancy rates are meaningless. Nonetheless, the quoted patency rates of 76% are in line with most published series [3,15–17,32]. For operators using the double-closure techniques the patency rates were 83% and 64% for microsurgical and macroscopic, respectively, and the results for single-closure microscopic and macroscopic 76% and 60%, respectively. Patency rates from all participants in the study were 5–95%.

Despite these high patency rates the pregnancy rates remained moderately low, at 28%, which is significantly lower than those quoted in some studies, with pregnancy rates up to 60–70%[18,33]. This is probably because of the inadequate follow-up, as noted previously. However, one study assessed 95 patients in whom sperm concentrations (> 20 × 106/mL) and motility (> 50%) were normal. In that study, even in this carefully selected group of patients, only 61% achieved paternity, and about a third of couples would not achieve a pregnancy because of infertility in the female partner, epididymal dysfunction or ASAs [34]. In other studies assessing patients in whom no spermatozoa were present in the vasal fluid at the time of vasovasostomy, the patency rates declined to 60% and pregnancy rates to 30%[17]. These differences in results show clearly the difficulty in comparing different studies where the men undergoing vasectomy reversal (and their partners) may differ significantly in age and interval since vasectomy, as a result of differences in healthcare provision and referral patterns.

The present study also clearly shows a lack of screening of both partners before vasectomy reversal, with only six of 38 (16%) practitioners screening for the presence of ASAs, even though they are detectable in up to 80% of men after vasectomy [35]. Although reversal is not contraindicated in the presence of ASA, high titres are associated with significantly poorer sperm values [29] and lower chances of pregnancy [36], and patients should be informed of this and offered the option of surgical sperm retrieval followed by ICSI [37], which is currently the recognized treatment for ASAs [38].

Of further concern in the present study is the lack of screening for tubal patency in the female partner. Of the respondents, only four (11%) stated that they considered female tubal patency before undertaking a reversal, and within this group only one relied on any tubal tests to establish patency, rather than a history of previous pregnancies. By failing to adequately assess tubal patency it is likely that some men undergo vasectomy reversal when the female had closed tubes, and that such patients would be far better served by being offered an assisted-conception cycle with surgical sperm retrieval.

Clearly, in the age of increasing pelvic inflammatory disease [39], and the increasing age of women attempting their first pregnancies, female factors are becoming more important in the context of infertility within the couple. Furthermore, in the present climate of clinical governance, incorporating evidence-based medicine and best practice into treatment protocols is vital for the patient, clinician and healthcare trust. Whilst it has been reported that vasectomy reversal is a far more cost-effective treatment than in vitro fertilization/ICSI with surgical sperm retrieval [32,40], it would appear to be legally indefensible to subject a patient to vasectomy reversal to restore natural fertility if the female partner has unreconstructable tubal disease that the surgeon has made no effort to detect before surgery.

As to the practice of investigating men with unobstructive azoospermia, it is clear that most clinicians take a testicular biopsy to provide a histological diagnosis, and a Johnson count to assess spermatogenesis. There is evidence from large-scale studies that the use of histology and Johnsen count [41,42] give significant false-negative (15%) and some false-positive (2%) results. Very few clinicians (six, 28%) appeared to provide an integrated diagnostic and therapeutic service by having the testicular tissue processed in an assisted-conception laboratory. If the first biopsy shows spermatozoa, all retrieved spermatozoa can then be cryopreserved for future use, thus reducing the need for further testicular biopsies. We encourage surgeons involved in managing azoospermic men of either obstructive or unobstructive causes to seek closer links with assisted-conception units that can offer full laboratory services, including sperm harvesting techniques and cryopreservation.

It is clear from the present survey and published reports that clinicians who wish to provide fertility surgery for azoospermic men, both after vasectomy and of other causes, should carefully evaluate their techniques and results (including adequate follow-up). It would appear sensible that operators should be undertaking ≥ 15 reversals per year, use microsurgical techniques, and abandon the use of stents. Clearly, with many surgeons only performing a handful of operations annually, their results will be difficult to interpret and possibly meaningless. Urologists should perhaps consider that fertility surgery is an area of subspecialization that demands centralization of services to appropriately trained individuals working in appropriately equipped hospitals, that would be accessible to a licensed assisted-conception unit to allow processing and storage of epididymal fluid or testicular tissue for use in possible future assisted-conception cycles. There would also therefore be facilities for investigating the female partner for tubal patency and potential fertility at the same time as the man. This would enable these specialists to have an adequate throughput of cases, which would allow better results, and the opportunity for greater audit and research.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. EDITORIAL COMMENT
  9. References
  • 1
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    Engelmann UH, Schramek P, Tomamichel G, Deindl F, Senge T. Vasectomy reversal in central Europe. results of questionnaire of urologists in Austria, Germany and Switzerland. J Urol 1990; 143: 647
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    Jequier AM. Vasectomy related infertility: a major and costly medical problem. Hum Reprod 1998; 13: 17579
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    Bagshaw HA, Mastres JRW, Pryor JP. Factors influencing the outcome of vasectomy reversal. Br J Urol 1980; 52: 5760
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    Feber KM, Ruiz HE. Vasovasostomy: macroscopic approach and retrospective review. Tech Urol 1999; 5: 811
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    Mason RG, Connell PG, Bull JC. Reversal of vasectomy using a macroscopic technique: a retrospective study. Ann R Coll Surg Engl 1997; 79: 4202
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    White AE, Sheridan WG, Crosby DL. Reversal of vasectomy and the general surgeon. Br J Clin Pract 1994; 48: 2389
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    Cos LB, Valvo JR, Davis RS, Crockett ATK. Vasovasostomy: current status of the art. Urology 1983; 2: 56775
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    Lee HY. Twenty years experience with vasovasostomy. Br J Urol 1986; 136: 4135
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    Belker AM, Thomas AJ Jr, Fuchs EF, Konnak JW, Sharlip ID. Results of 1469 microsurgical vasectomy reversals by the vasovasostomy study group. J Urol 1991; 145: 50511
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    Silber SJ. Microscopic vasectomy reversal. Fertil Steril 1977; 28: 1191202
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    Silber SJ. Perfect anatomical reconstruction of vas deferens with a new microscopic surgical technique. Fertil Steril 1977; 28: 1
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    Sharlip ID. Vasovasostomy. comparison of two microsurgical techniques. Urology 1981; 17: 347
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    Fuse H, Kimura H, Katayama T. Modified one-layer vasovasostomy in vasectomised patients. Int Urol Nephrol 1995; 27: 451 6
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    Rothman I, Berger RE, Cummings P, Jessen J, Muller CH, Chapman W. Randomised clinical trial of an absorbable stent for vasectomy reversal. J Urol 1997; 157: 1697700
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    Thomas AJ, Pontes JE, Buddhdev H, Pierce JM. Vasovasostomy: evaluation of four surgical techniques. Fert Steril 1979; 32: 3428
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    Heidenreich A, Bonfig R, Wilbert DM, Strohmaier VL, Engelmann UH. Risk factors for antisperm antibodies in infertile men. Am J Reprod Immunol 1994; 31: 6976
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    Parslow JM, Poulton TA, Besser GM, Hendry WF. The clinical relevance of classes of immunoglobulins on spermatozoa from infertile and vasovasostimised men. Fertil Steril 1985; 43: 6217
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    Check JH, Adelson HG, Bollendorf A. Effect of antisperm antibodies on computerised semen analysis. Arch Androl 1991; 27: 613
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    Fox M. Failed vasectomy reversal: is a further attempt using microsurgery worthwhile? BJU Int 2000; 86: 4748
  • 32
    Heidenreich A, Altmann P, Engelmann U. Microsurgical vasovasostomy versus microsurgical epididymal sperm aspiration/testicular extraction of sperm combined with intracytoplasmic sperm injection. A cost benefit analysis. Eur Urol 2000; 37: 60914
  • 33
    Goldstein M, Li PS, Mathews GJ. Microdot technique of precision suture placement. J Urol 1998; 159: 18890
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    Sharlip ID. What is the best pregnancy rate that may be expected from vasectomy reversal? J Urol 1993; 149: 146971
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    Linnet L. Clinical immunology of vasectomy and vasovasostomy. Urology 1989; 22: 101
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    Matson PL, Junk SM, Masters JR, Pryor JP, Yovich JL. The incidence and influence upon fertility of antisperm antibodies in seminal fluid following vasectomy reversal. Int J Androl 1989; 12: 98103
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    Rowe PJ, Comhaire FH, Hargreave TB, Mahmoud AMA. WHO manual for the standardized investigation and diagnosis of the infertile male. Cambridge: Cambridge University Press, 1996
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    Turek P, Ljung B, Cha I, Conaghan J. Diagnostic findings from testis fine needle aspiration mapping in obstructed and non obstructed azoospermic men. J Urol 2000; 163: 170916
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Abbreviations
ASA

antisperm antibody

ICSI

intracytoplasmic sperm injection.

EDITORIAL COMMENT

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. EDITORIAL COMMENT
  9. References

The authors present a very interesting study on the current practice of vasectomy reversal among general surgeons and urologists of a regional district in the UK, which should result in significant consequences. The data of the study are very important to improve the outcome of vasectomy reversals and to introduce or to establish instruments for quality control of this type of delicate surgery. If a surgeon wishes to undertake vasectomy reversals the following key issues must be considered:

  • (i)
    The development of optical magnification systems has dramatically improved the surgical options in reconstructive surgery of the vas deferens over the last decades. Whereas macroscopic vasovasostomy resulted in a patency rate of only 35%, the availability of operating microscopes has improved patency and pregnancy rates to 85–90% and 50–60%, respectively [1,2]. Macroscopic vasovasostomy must be abandoned and microsurgical vasovasostomy represents the standard procedure of choice.
  • (ii)
    Of the surgeons surveyed, 29% still used absorbable stents for vasectomy reversal, although the detrimental effect of stents on surgical outcome was shown in numerous trials. Most recently, Rothmann et al.[3] reported on a prospective randomized trial of an absorbable stent for vasectomy reversal, and found a significantly lower pregnancy rate in the stent group than in the no-stent group (22% vs 51%). Absorbable stents should be abandoned in the surgical approach for vasectomy reversals.
  • (iii)
    The success rate of vasectomy reversal correlates with the operative frequency, as reported by Engelmann et al.[4] and others [5]. Centres with a high frequency of ≥ 15 vasectomy reversals per year reached a cumulative patency rate of 70% and a pregnancy rate of 33%. Institutions with a comparably low frequency of ≤ 6 cases per year obtained a cumulative patency rate of 45% and a pregnancy rate of 8.8%. The median number of only 8.5 vasectomy reversals annually and only 29% of the surgeons performing ≥ 10 procedures annually are reflected by the low patency and pregnancy rates reported in this paper.
  • (iv)
    The success of vasectomy reversal also depends on intact fertility in the spouse. Female fertility decreases with increasing age, so that all surgeons performing vasectomy reversal should at least consider a gynaecological consultation of the female partner of their male patients.

Altogether, microsurgical vasovasostomy is still a valuable tool for managing male infertility, even when ICSI is available. However, it is mandatory to have this type of surgery performed by experienced microsurgeons. Every urologist being contacted by a patient about vasectomy reversal should objectively reflect on his/her personal skills before starting the surgery.

Axel Heidenreich Department of Urology, Phillips Universitat Marburg, Germany

References

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. EDITORIAL COMMENT
  9. References
  • 1
    Silber SJ. Pregnancy after vasovasostomy for vasectomy reversal: a study of factors affecting long-term return of fertility in 282 patients followed 10 years. Hum Reprod 1989; 4: 31824
  • 2
    Sharlip ID. What is the best pregnancy rate that may be expected from vasectomy reversals? J Urol 1993; 149: 146971
  • 3
    Rothman I, Berger RE, Cummings P, Jessen J, Müller CH, Chapman M. Randomized clinical trial of an absorbable stent for vasectomy reversal. J Urol 1997; 157: 1697700
  • 4
    Engelmann UH, Schramek P, Tomamichel G, Deindl F, Senge Th. Vasectomy reversal in Central Europe: results of a questionnaire of urologists in Austria, Germany and Switzerland. J Urol 1990; 143: 647
  • 5
    Heidenreich A, Altmann P, Engelmann UH. Microsurgical vasovasostomy versus microsurgical epididymal sperm aspiration/testicular extraction of sperm combined with intracytoplasmic sperm injection. Eur Urol 2000; 37: 60914