- Top of page
- SUBJECTS AND METHODS
- CONFLICT OF INTEREST
- SOURCES OF FUNDING
In the 2005–2006 financial year, the NHS performed over 20 000 vasectomies for contraceptive purposes in the UK . An average of 6% of men subsequently request that the procedure be reversed to allow further conception . There are a number of options available to men wanting to achieve conception after previous vasectomy so counselling about those options, their outcomes and factors that influence outcome, is essential for fulfilling the patient's objectives.
Broadly, four options are available for couples in this situation, depending upon the availability of each partner's gametes (Table 1). Vasal reconstruction, either by vaso-vasostomy or epididymo-vasostomy, has been shown to be the most cost-effective treatment for facilitating the use of both partner's gametes, and provides the highest birth rate for the majority of men after previous vasectomy when their partners are <40 years old [3,4] and, possibly, even if the partners are older . This is in comparison with the costs associated with the use of surgically retrieved sperm, taken from the epididymis or body of the testis, and the subsequent use of the sperm in an in-vitro fertilization (IVF) programme with intra-cytoplasmic sperm injection (ICSI) [6,7]. When gametes are only available from one partner, alternative strategies need to be considered. Intra-uterine insemination with donated sperm may be preferred when the female partner is fertile and the injection of ejaculated, or surgically retrieved, sperm into donated eggs is an alternative when ovarian function is severely compromised. Adoption is generally the least desired means of becoming a parent as there is no genetic contribution from the couple to the offspring.
Table 1. Advantages and disadvantages of the four types of treatment available to couples seeking to have a child after previous vasectomy
|Vasal/vaso-epididymal reconstruction||Allows an opportunity of natural conception|
|Most cost-effective treatment option for genetic parenting|
|Most affordable if self-funding|
|Can be combined with sperm retrieval|
|Surgical sperm retrieval with IVF and ICSI||Greatest chance of conception|
|May be less invasive for the male partner|
|Invasive for the female partner|
|Expensive if self-funding|
|Intra-uterine Insemination or IVF with donated sperm/eggs||One/both partners are not the genetic parent|
|Depends upon the availability of gametes|
|Downside of IVF if this is required|
|Expensive and depends upon the need for IVF|
|Adoption||Neither partner the genetic parent|
|Depends upon the availability of adoptive child|
|Rigorous checks of parental suitability|
It can be seen, therefore, that a thorough knowledge of both male and female factors influencing management, and the availability of different treatment options, is essential for the appropriate counselling of couples seeking to have a child after previous vasectomy.
Evidence from the WHO, the UK Human Fertilisation and Embryology Authority and The Royal College of Obstetricians and Gynaecologists (RCOG) suggest that both members of infertile couples, including those seeking treatment for secondary infertility, should be assessed and counselled together [8–10]. These bodies suggest that joint consultations enable the doctor seeing the couple to obtain all of the relevant information to formulate the most appropriate treatment plan for them and to give the couple the most realistic expectations of individual treatment options. Pragmatic counselling will also allow the couple to make an informed choice about the optimum route to achieving a live birth, and will improve their satisfaction with the outcome of the option chosen. Men seeking to achieve conception after a vasectomy also need to be appropriately advised about the morbidity and potential outcomes of each method of surgical treatment offered. Patients need to be given information about surgical sperm retrieval as well as reconstructive surgery before deciding the treatment method that is most appropriate to their situation.
Surgical sperm retrieval can be performed with extremely high expectations of sperm being retrieved when a man has previously proven fecundity and no intercurrent illness that might affect his fertility . This may be achieved by percutaneous epididymal sperm aspiration (PESA [12,13]) or testicular sperm aspiration (TeSA ), open or closed testicular sperm extraction (oTeSE or cTeSE [15,16]), or open microscopic epididymal aspiration (MESA ; Table 2). The level of invasion, and consequent morbidity, is dependent upon whether an open procedure is performed or not. Retrieved sperm is usually cryopreserved has and is then used in an IVF and ICSI programme. Men may seek surgical sperm retrieval, in preference to vasal reconstruction, when they do not wish to have an invasive procedure, would prefer only to attempt a single conception, or when the chances of successful outcome from vaso-vasostomy are limited, usually as a consequence of a significant time interval from the original vasectomy.
Table 2. The advantages and disadvantages of surgical sperm retrieval techniques
|PESA||Minimally invasive. Doesn't necessarily need anaesthesia||May not be as effective as MESA|
|MESA||Possibly the optimum epididymal retrieval technique||Requires open surgery with attendant risks|
|TeSA||Minimally invasive. Doesn't necessarily need anaesthesia||Provides difficult samples for the embryologist to process|
|cTeSE||Minimally invasive. Needs at least local anaesthesia||Small risk of haematoma|
|oTeSE||Considered to be the optimum testicular retrieval technique*||Requires open surgery with attendant risks|
Even when the couple believe that vaso-vasostomy is still their preferred treatment option they need to be aware that the female partner's age , the length of time since vasectomy [18,19], the gap resected  and the technique used to effect restoration of vasal continuity are significant factors influencing outcome. The technique of vaso-vasostomy is of key importance; the use of a macroscopic reconstruction without intra-operative magnification has been shown to be accompanied by a postoperative vasal patency of, at best, 50% . This is increased to 80% by the use of magnifying loupes or an operating microscope. Consequently, it has been recommended that vaso-vasostomy should only be performed with intra-operative magnification [22–25]. Epididymo-vasostomy is an alternative to vaso-vasostomy when vaso-vasal anastomosis is not technically possible owing to proximal vasal division in the convoluted portion, and may be required in up to 30% of men presenting for reversal of their vasectomy [26,27]. Epididymo-vasostomy is only viable when an end-to-side tubulo-vasostomy is performed using an operating microscope .
Couples seeking to achieve conception using vasal reconstruction will ultimately wish to know the live birth rate, the primary outcome of reconstruction; this needs to be discussed in addition to the vasal patency rate as measured by a positive postoperative semen analyses. Globally, the live birth rate is, at best, 45% after reconstruction . Good practice dictates that surgeons should audit their practice prospectively, comparing their outcomes to accepted normative data, to assure patients that they will receive optimum treatment to help achieve a conception . Urologists undertaking reversal of vasectomy should therefore be expected to be able to counsel couples about their personalized outcomes from surgery.
Sub-specialist management has been shown to be the most effective strategy in achieving the best outcomes in other medical conditions [30–32] and has been suggested by the RCOG to be the optimum way of managing the infertile couple . Couples with secondary infertility attributable to the male partner's previous vasectomy should, therefore, expect to be treated by an individual with appropriate training in, detailed knowledge of, and ability to offer, or refer for, all the management options. This would allow that couple the best opportunity to have a child.
In the present study, we reviewed the practice of UK urologists managing men presenting for vasectomy reversal over a 10-year period. Given the evidence that exists about optimum practice, the objectives of this sequential re-audit was to determine the standard of knowledge of UK urologists, and how this had changed over the survey period, regarding their ability to:
Counsel couples fully about options in achieving parenthood after previous vasectomy, the local availability of these options, the expected outcomes from each type of treatment and their morbidities.
Counsel couples, about their personalized outcomes from vaso-vasostomy.
Counsel men about the details of reconstructive surgery and use appropriate surgical techniques to optimize a live birth.
Consider whether urologists with a high annual case volume or declared sub-specialist interest in andrology provided a better quality of care to couples seeking to have a child after previous vasectomy than urologists with a lower number of cases per annum or no andrological affiliation.
Ultimately, we aimed to determine the contemporary management of couples seeking to have a child after previous vasectomy, and to suggest standards of practice which might optimize their chances of a conception.
- Top of page
- SUBJECTS AND METHODS
- CONFLICT OF INTEREST
- SOURCES OF FUNDING
The response rates in 2001, 2005 and 2010 were 312 (58%), 251 (48%) and 272 (37%) respectively. In 2010, owing to the perceived increase in time pressures, respondents were invited to opt out of completing the entire survey if they did not perform vasectomy reversal. Of the 272 respondents in 2010, 213 (29%) agreed to complete the survey and 59 (8%) opted out.
Of those urologists who responded, most were still performing vaso-vasostomy, 86.5%, 80.5% and 83.6% in each audit, with the majority carrying out 1–10 procedures a year. Between a quarter and a third of urologists performed 1–5 procedures per year in each audit group (33%, 27.1% and 23.8%), one half performed 6–15 procedures (50%, 43.8% and 49.2%) and ≈10% performed >16 procedures per year across all three audits.
COUNSELLING AND ASSESSMENT OF COUPLES REGARDING MANAGEMENT OPTIONS OTHER THAN VASO-VASOTOMY
Most urologists preferred seeing both partners when men were referred with a view to vasectomy reversal (71.7% in 2001, 73.2% in 2005 and 72.6% in 2010), but only a small number insisted on this (7.4%, 6.98% and 7.6% respectively). A substantial number still expressed no desire to see the female partner during the process (28.3% in 2001, 26.8% in 2005 and 19.7% in 2010). In all three audits, >90% of urologists were keen to know the male surgical history, time since vasectomy and number of children previously fathered by the male.
Detail about female factors affecting management choices were variably considered by respondents. In 2001, only 86% of urologists asked the age of the female partner but this increased to 97% in 2005, with a subsequent decline to 91% in 2010. Previous female surgical history was only sought by 70%, 78% and 77.4% of urologists in each audit. Less than half enquired about menstrual cycle irregularities, or pelvic inflammatory disease in 2001, and only a few more asked these questions in both 2005 (53%) and 2010 (53.2%).
When asked whether they counselled couples about other methods of having a child, detailed information was offered by only 40.1% of urologists in 2001. This increased marginally to 49.5% and 50.3% in subsequent audits. Around 40% gave brief counselling alternative management options and 15.2%, 13.4% and 7.6% admitted to avoiding the issue, in each audit respectively. Of those giving patients/couples options in management, 95% discussed IVF and ICSI, 60% donor insemination and 45% adoption, across each survey. Five percent discussed nothing other than vaso-vasostomy.
In 2001, 27.6% of urologists were able to perform vasal reconstruction as an NHS procedure and this decreased to 10.4% in 2005 and 5.3% in 2010. In 2010, responses suggest that only 40.1% of primary care trusts (the bodies responsible for commissioning particular treatments) allowed the procedure to be done as an NHS procedure, and this was under exceptional circumstances such as the death of an only child.
The practices of IVF with ICSI (assisted reproduction techniques, ARTs) and artificial insemination with donated sperm (donor insemination, DI) were not available locally on an NHS basis to 50–60% of UK urologists across the three surveys. ARTs were available locally to 56.3% of urologists in 2001, decreasing to 35.1% and 43.7% in 2005 and 2010, respectively. Fifty percent of urologists wanting to refer patients for DI had to do so to specialist centres in 2001and this increased to >80% in subsequent audits (80.2% and 81% in 2005 and 2010, respectively). In 2010, urologists were asked to describe their awareness of the eligibility criteria for referral for ARTs on an NHS basis. A total of 34.4% responded that they were fully conversant with the criteria of eligibility, 51% had a rough idea, 13.4% were unsure and 1.3% said ART options were unavailable to them.
PREOPERATIVE COUNSELLING ABOUT THE EXPECTED OUTCOME OF VASO-VASOSTOMY
Approximately 0.5% of urologists in the 2001 and 2005 audits provided no data on success rates from vaso-vasostomy but encouragingly, by 2010, all urologists gave some counselling about the likelihood of success from this procedure. Thirty to forty percent of urologists quoted outcome statistics for vaso-vasostomy accrued from the literature with <25% quoting personalized outcome data in 2001 and 2005; this had increased to 41.3% in 2010.
Individualized outcomes for couples, taking into account factors such as male and female age, time elapsed since vasectomy, technique of vaso-vasostomy and the length of the resected vas were discussed in counselling by 60.6% of urologists in 2001; this increased to 73.1% in 2005 and 76.1% in 2010.
VASAL RECONSTRUCTION TECHNIQUE, DETERMINATION OF SUCCESS AND SPERM RETRIEVAL
Nearly all urologists aimed to perform a bilateral procedure, when possible, over the 10-year period. Four urologists (1.5%) routinely performed a unilateral procedure in 2001 with this number falling to 0.5% in 2005 and 1.3% in 2010.
In 2001, 33.7% of urologists performed vaso-vasostomy without any form of intra-operative magnification. Practice changed by 2005 when 87.1% had switched to using a microscopic technique but this peak declined again such that 82.6% were using intra-operative magnification in 2010. Of those using magnification, the majority of urologists used magnifying loupes. Loupe usage rose from 54.8% in 2001 to 60.2% in 2005 but fell to 49.7% in 2010. This late decline was, however, accompanied by a corresponding rise in operating microscope use from 11.5%, in 2001, to 26.9% in 2005 and 32.9% in 2010.
Approximately 85% of surgeons, in each audit, routinely performed postoperative semen analysis and in 2010, 13% of urologists routinely performed synchronous sperm retrieval at the time of vasectomy reversal.
INDIVIDUAL SURGEON'S SUB-SPECIALIST INTERESTS
In 2001, >80% of UK urologists declared a sub-specialty interest, or interests, which rose to 88.8% and 88.2% in 2005 and 2010, respectively. Their specific declared interests (from the 2005 and 2010 audits) are shown in Table 3.
Table 3. The sub-specialist interests of consultant urologist respondents in the 2005 and 2010 audits of reversal of vasectomy practice who were still carrying out vasal reconstruction
|Sub-specialistarea||2005overall, %||2010overall, %|
Urologists with an interest in andrology increased linearly from 23.3% in 2001 to 29.1% (2005) and 33.3% in 2010. The proportion of respondents who were, or intended to be, members of the BAUS section of Andrology increased from 21.9% in 2005 to 35.1% in 2010. Differential performance, against the eight indices, between members of the BAUS section of Andrology and urologists with no andrological affiliation, but who performed vaso-vasostomy, is shown in Table 4, together with the results of statistical analysis.
Table 4. Comparison of the performance of consultant urologists who were members of the BAUS section of Andrology and those with no andrological affiliation, against eight indices, in the 2010 audit of reversal of vasectomy practice.
|Index||BAUS Section of Andrology|| P |
|Members 61 (32.4%)||Non-Members 121 (64.3%)|
| N ||%|| N ||%|
|Insist on or prefer seeing both partners||46||85.2||77||80.2||0.512|
|Discuss all options for parenting in detail||34||63.0||42||43.8||0.028|
|Fully conversant with criteria for IVF||29||53.7||22||22.9||<0.001|
|Individualized information about expected outcome||45||86.5||68||70.8||0.042|
|Perform >15 vaso-vasostomies per year||15||24.6||5||4.1||<0.001|
|Routinely retrieve sperm at the time of vaso-vasostomy||9||17.6||10||10.4||0.301|
|Use loupes intra-operatively||28||53.8||48||50.5||0.732|
|Use an operating microscope||21||40.4||25||26.3||0.095|
Of the 161 respondents who provided information about case volume, 25% of those performing 1–5 cases per year were members of the BAUS section of andrology compared with 71.4% of those performing >15 cases. Again, taking the eight indices as determinants of quality, concordance with all aspects of good practice generally increased as annual case volume rose (Table 5). With regard to insisting, or preferring, to see both partners at consultation and the use of some form of intra-operative magnification, the numbers appeared to increase most when >5 procedures per year were undertaken. With regard to discussing all parenting options in detail, being fully conversant with criteria for IVF, and routinely performing synchronous sperm retrieval, performance improved when individuals performed >15 procedures per year.
Table 5. Percentage comparison of the performance of consultant urologists who responded with details of their case volume per year, against eight indices, in the 2010 audit of reversal of vasectomy practice
|Index||Number of procedures per year|
|1–546 (28.6%)||6–1062 (38.5%)||11–1532 (19.9%)||16–206 (3.7%)||21–2511 (6.8%)||>254 (2.5%)|
| N ||%|| N ||%|| N ||%|| N ||%|| N ||%|| N ||%|
|Member of BAUS section of andrology||11||25.0||18||30.0||10||31.3||3||50||8||72.7||4||100|
|Insist on or prefer seeing both partners||30||65.2||52||85.2||28||87.5||5||83.3||9||81.8||4||100|
|Discuss all options for parenting in detail||20||43.5||30||49.2||15||46.9||5||83.3||6||54.5||3||75|
|Fully conversant with criteria for IVF||10||21.7||17||27.9||14||43.8||4||66.7||8||72.7||3||75|
|Individualized information about expected outcome||32||72.7||48||78.7||23||71.9||5||83.3||8||72.7||4||100|
|Perform >15 vaso-vasostomies per year||0||0||0||0||0||0||6||100||11||100||4||100|
|Routinely retrieve sperm at the time of vaso-vasostomy||1||2.3||7||11.7||5||15.6||3||50||3||27.3||1||25|
|Use loupes intra-operatively||19||43.2||32||53.3||23||71.9||0||0||3||27.3||0||0|
|Use an operating microscope||12||27.3||20||33.3||6||18.8||5||83.3||6||54.5||4||100|
- Top of page
- SUBJECTS AND METHODS
- CONFLICT OF INTEREST
- SOURCES OF FUNDING
The decision to have a child after previous vasectomy is a conscious decision made by a couple rather than the male partner alone and the outcome, ultimately measured by the live birth rate, is dependent on both male and female partner factors. Achieving the optimum outcome for a couple depends on an appreciation of the most appropriate treatment method, given their particular circumstances, and facilitating that couple's decision-making process based on the expected outcome of any treatment, and it's morbidities by comparison with other management options.
This longitudinal process re-audit found that consultant members of BAUS have made certain changes to their practice relevant to the management of men seeking to have a child after previous vasectomy. These changes have been in those areas that the individual surgeon could influence, such as taking a more detailed history about relevant female factors, particularly age, providing more individualized information about the likely outcome of vasectomy reversal in their hands and, increasingly, moving towards the use of magnification during reconstructive surgery. There has not, however, been any significant change in the depth of knowledge of British urologists about alternative treatments to vasectomy reversal, the availability of ARTs locally or the eligibility criteria for referral for it. This suggests that discussion of the use of strategies other than vaso-vasostomy is still not a routine part of the preoperative counselling of men with azoospermia after previous vasectomy.
Data from 2010 show that, between those members of BAUS with an andrological affiliation and those without, there were significant differences in the ability to discuss options for having a child, knowledge of the local eligibility criteria for IVF treatment, the ability to give individualized outcomes from vaso-vasostomy and the ability to perform a larger number of procedures. These differences exist despite there being no appreciable difference in the availability of ARTs and DI to either group. It can be inferred from these results that surgeons with an andrological sub-specialist interest give a more balanced view of the options couples might consider when counselling men presenting for vasectomy reversal. Further sub-analysis of respondents' performance against the eight indices suggests that quality improves with increased case volume per annum. Although there is a trend suggestive of improved quality after 15 procedures per year, ultimately, a prospective study is required to determine the relationship between outcome measures such as live birth rate and annual case volume.
The marked decrease in the availability of NHS-funded treatments, over the timeframe of these audits, has undoubtedly had an influence on the management options available to many couples and may have an influence on the advice given to them by their urologist . Financial considerations may well now influence their chosen management, with reversal of vasectomy, in isolation, being the cheapest treatment option for the majority of self-funding couples. The issue of cost-benefit analysis raises the question of whether vaso-vasostomy should be performed at all if sperm are not evident at the cut proximal vasal end, at the time of scrotal exploration, and whether micro-surgical epididymovasotomy should be used as an alternative intra-operative treatment strategy if the vasal smear is devoid of sperm. As only a relatively small number of UK urologists are using a microscope intra-operatively, this is not currently a viable option in the UK but should, perhaps, be a consideration for future sub-specialist training.
Additionally, the preoperative demonstration of vasal, or epididymal, sperm by smear or aspiration allows the potential for cryopreservation of that sperm, should the reconstruction fail. Synchronous sperm retrieval is not currently widely practiced by UK urologists, possibly because a US-based study  has suggested that it is not a cost-effective strategy. The health economic assumptions of this publication may not, however, be relevant to the UK where the live birth rate after reversal of vasectomy appears much lower and the partner age tends to be older. Epididymal sperm retrieval techniques have not been shown to prejudice the outcome from vaso-vasostomy [36,37] but do demand the ability for microscopic analysis of a smear, or aspirate, intra-operatively. Analysis, together with the ability to process and store sperm, can only be achieved when surgery is carried out in a facility with a dedicated embryologist available. Currently, this would restrict the ability to carry out reconstructive surgery to a small number of urologists operating in surgical facilities within an ART unit.
In conclusion, it is evident that patient management after previous vasectomy is a complex process, demanding detailed knowledge about the availability, and outcome, of alternatives to vaso-vasostomy. Ideally, couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome, the available management options, and their costs, and by those who have appropriate facilities to offer intra-operative demonstration of and, potentially, storage of sperm. Vaso-vasostomy should, consequently, no longer be seen as a procedure within the remit of any adequately trained urologist but as one of a number of surgical options to be considered by a sub-specialist with access to appropriate micro-surgical training and assisted reproductive technologies.
On the basis of the data from our sequential re-audits we would suggest the following recommendations regarding the future management of men seeking vasectomy reversal in the UK:
Men who wish to have a child after vasectomy should be encouraged to attend counselling appointments with their partner so that factors that might influence the couple's likelihood of conception can be assessed for both partners.
All options for having a child, including reconstruction, surgical sperm retrieval, the use of donor sperm and adoption should be discussed, and the couple advised about the morbidity and availability of each, together with their chance of success with each option. They should be advised about the management option most appropriate to their individual circumstances to optimize their chances of achieving a live birth. When the ability to provide this counselling is not available, the couple should be referred to a specialist centre, unless the couple are aware of the potential limitations of having their management locally.
Couples should be made aware of the vasal patency and live birth rates that might be provided by the surgeon carrying out a vaso-vasostomy. If these are not available, or not comparable with normative data, then the couple should be referred to a specialist centre for reconstructive surgery.
Vasal reconstruction should only be performed with intra-operative magnification, ideally the use of an operating microscope, and after confirmation of the presence of sperm at the end of the vas or in the epididymis. Patients should be made aware that epididymo-vasostomy may be a treatment option when vaso-vasosotomy is not technically possible and that synchronous sperm retrieval is another option which will not prejudice the outcome, should reconstruction be performed.
The couple's management after reconstruction should be determined by a routine postoperative semen analysis and they should be advised about alternative treatment strategies, including surgical sperm retrieval and assisted reproductive technologies, dependent upon that result.