Fertility Outcome After Repeat Vasoepididymostomy

0022-5347/99/1625-1626/0 THE JOURNAL OF UROLOGY Vol. 162, 1626–1628, November 1999 Copyright © 1999 by AMERICAN UROLOGICAL ASSOCIATION,INC. Printed in U.S.A. FERTILITY OUTCOME AFTER REPEAT VASOEPIDIDYMOSTOMY

FABIO F. PASQUALOTTO, ASHOK AGARWAL, MEENA SRIVASTAVA, DAVID R. NELSON AND ANTHONY J. THOMAS, JR.* From the Center for Advanced Research in Human Reproduction and Infertility, and Departments of Urology, and Biostatistics and Epidemiology, Cleveland Clinic Foundation, Cleveland, Ohio

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

KEY WORDS: infertility, male; epididymis; sterilization reversal; reoperation; spermatozoa

Treatment of patients with seminal tract obstruction con- azoospermia (unrelated to vasectomy) is dependent on the sists of microsurgical repair of obstruction or sperm retrieval etiology of obstruction.10, 11 The prognosis appears to be good and in vitro fertilization with intracytoplasmic sperm injec- for men with obstruction secondary to prior infection and tion.1–3 Despite recent advances in assisted reproductive similar to the outcome expected in those following vasoepi- techniques, microsurgical reanastomosis of the seminal tract didymostomy for epididymal obstruction due to vasectomy remains the treatment of choice when possible, as it results but those with idiopathic obstructive azoospermia (almost to in high patency and equal or better pregnancy rates with two-thirds of the entire group) have a poorer outcome.12 natural intercourse than those achieved with assisted repro- Patency and pregnancy rates after initial vasoepididymos- ductive technique.4, 5 Vasoepididymostomy is among the tomy have been reported but there is a lack of information for more difficult microsurgical procedures performed by urolo- men who choose to undergo a repeat procedure. We assess gists.6, 7 The success rate for vasoepididymostomy has im- the value of performing repeat vasoepididymostomy by ex- proved markedly with the development of specific tubule amining patency and pregnancy rates, and determining end-to-end8 and end-to-side9 microsurgical anastomoses. which patients based on the etiology of obstruction would Recent reports have demonstrated that the outcome of benefit most. microsurgical reconstruction in men with obstructive Accepted for publication May 28, 1999. * Requests for reprints: Department of Urology, A 100, Cleveland MATERIALS AND METHODS Clinic Foundation, 9500 Euclid Ave., Cleveland, Ohio 44195. Microsurgical repeat vasoepididymostomy was performed Editor’s Note: This article is the fifth of 5 published in this issue for which category 1 CME credits can be earned. In- on 18 azoospermic patients (mean age 40.6 years, range 26 to structions for obtaining credits are given with the questions 56) after failed previous vasoepididymostomy. Initial micro- on pages 1760 and 1761. surgical reconstruction was considered a failure after a mean 1626 FERTILITY AFTER REPEAT VASOEPIDIDYMOSTOMY 1627 interval of 19 months (range 12 to 41). At initial vasoepididy- minimum followup of 12 months, is shown in table 2. In 1 mostomy no sperm was aspirated for cryopreservation. A patient the initial vasoepididymal anastomosis was ob- single urologist (A. J. T.) performed initial and repeat vaso- structed after previous patency. Mean followup was 51.75 epididymostomy. The etiology of obstruction was prior vasec- months (range 13 to 156). The patency rate was 66.7% (12 of tomy in 4 cases (group 1), congenital in 7 (group 2) and 18 patients) overall, and was not significantly different be- inflammatory in 7 (group 3). Mean patient age at repeat tween patients with congenital (85.7%) compared to those vasoepididymostomy was 40.6 years (50.5, 36 and 39.4 for with acquired (54.5% after vasectomy or inflammatory groups 1, 2 and 3, respectively). Mean partner age was 31.2 causes) obstruction (p ϭ 0.32). There were no complications years (range 25 to 35). Mean interval between initial and related to repeat vasoepididymostomy. Patients with clear repeat vasoepididymostomy was 19 months (range 12 to 41). fluid and motile or immotile sperm during repeat vasoepi- Mean interval in group 1 between vasectomy and initial didymostomy had higher patency rates and sperm concentra- vasoepididymostomy was 12.3 years (range 10 to 18). Data tion on postoperative semen analysis compared to those with regarding the quality of epididymal fluid during initial and opaque fluid and motile or immotile sperm (table 3). repeat vasoepididymostomy were collected and stratified Natural conception occurred in 3 of 12 patients (25%) with based on the presence of motile or immotile sperm and the a minimum followup of 18 months. Mean followup for these 3 gross appearance of the fluid during microsurgical explora- patients was 23 months (range 13 to 34). All 3 patients had tion (table 1). The levels of anastomosis at initial and repeat congenital obstruction. Anastomoses were in the caput in 2 vasoepididymostomy are listed in table 1. Of the patients 10 men and the cauda in 1. Of these 3 men 2 underwent unilat- underwent unilateral and 8 bilateral anastomoses. Postoper- eral microsurgical repair and 1 bilateral repair. Mean total ative semen analyses were available for all 18 patients. Mean sperm concentration was 87.3 ϫ 106 in patients who did followup was 51.75 months (range 13 to 156). Patency was compared to 15.7 ϫ 106 in those who did not establish preg- defined as presence of complete sperm with tails in a post- nancy (p ϭ 0.16). operative semen analysis within a minimum followup of 12 During surgery motile sperm was found in 11 of 18 pa- months. Data were available to determine the pregnancy tients who underwent sperm aspiration with cryopreserva- rate for 12 patients with 18 months or more of followup. tion. Pregnancy was achieved in 2 group 1 cases using cryo- Motile sperm was found during surgery in 11 of 18 men who preserved sperm with intracytoplasmic sperm injection 17 underwent aspiration and cryopreservation. and 26 months after repeat vasoepididymostomy, respec- A 2-layer microsurgical end-to-side single tubule anasto- tively, and in 1 each in groups 1 and 2 with separate micro- mosis was performed in all cases.7 To identify the site of surgical epididymal sperm aspiration and intracytoplasmic obstruction a window is made in the tunic of the epididymis sperm injection after failure of repeat vasoepididymostomy. exposing the loops of the epididymal tubule. A single loop is Patients underwent microsurgical epididymal sperm aspira- isolated and opened. The epididymal fluid is examined under tion at a mean interval of 33 months (range 19 to 47) after light microscopy and the anastomosis is performed if fully repeat vasoepididymostomy. formed motile or nonmotile sperm are present. If sperm are not found, exploration is done more proximal. When motile DISCUSSION sperm are found, aspiration for cryopreservation is performed using a 23 gauge angio-catheter attached to a tuber- The microsurgical techniques using a direct microsurgical culin syringe. A lumen-to-lumen anastomosis between the anastomosis between the vas deferens and epididymis have vas deferens and epididymis is made using 4 to 6 interrupted considerably improved the overall patency and pregnancy 10-zero nylon sutures. The tunic of the epididymis and the rates for vasoepididymostomy.5, 8, 9, 13 The patency rates re- seromuscular layer of the vas deferens are anastomosed us- ported in the literature with these techniques range from 56 ing 8 to 12, 9-zero nylon sutures. Two to 4, 9-zero nylon to 92%, and appear to depend on the level of anastomosis, etiology of obstruction and intraoperative presence of sperm sutures are placed along the vas and inner layer of the tunica 4–6, 10–11, 13–17 vaginalis to minimize tension at the site of the anastomoses. in the epididymal fluid. The tunica vaginalis is closed around the testis and the There is often a delay in the appearance of sperm in the scrotum is closed in layers with absorbable sutures. Cases ejaculate following vasoepididymostomy. Therefore, patients and physicians must wait at least 12 months to evaluate for were compared using Wilcoxon rank sum tests (continuous 6 variables) and Fisher’s exact tests (categorical variables) patency. The reason for this delay is not well understood. with p Ͻ0.05 considered significant. Possible explanations include inflammation or altered epididymal physiology. Patients with delayed appearance of sperm appear to have an equivalent prognosis with regard to RESULTS pregnancy to those with sperm in the initial postoperative 6 The decision to perform unilateral vasoepididymostomy in semen analysis. 10 cases was based on the presence of a normal solitary testis There are well documented patency and pregnancy rates with an atrophic or absent contralateral testicle. The patency for vasoepididymostomy but to our knowledge no reports are rate, defined as the presence of sperm in the semen with a available on patients who have undergone a second microsurgical anastomosis after a failed initial procedure. Consid- ering the success rates of assisted reproductive techniques,

TABLE 1. Quality of epididymal fluid and level of anastomoses during initial and repeat vasoepididymostomy TABLE 2. Patency rates according to etiology and level of Initial Repeat Vasoepididymostomy Vasoepididymostomy epididymal anastomosis Quality of epididymal fluid: No. % Pts. (No. pts./total No.) Etiology Clear, motile sperm 6 7 Pts. Caput Corpus Cauda Overall Clear, immotile sperm 3 3 Opaque, motile sperm 11 9 Vasectomy 4 0 75 (3/4) 75 (3/4) Opaque, immotile sperm 6 7 Congenital 7 83.3 (5/6) 100 (1/1) 85.7 (6/7) Site of anastomosis: Inflammatory 7 33.3 (1/3) 50 (2/4) 43 (3/7) Cauda 10 1 All etiologies 18 66.7 (6/9) 62.5 (5/8) 100 (1/1) 66.7 (12/18) Corpus 4 13 Acquired* 11 33.3 (1/3) 62.5 (5/8) 54.5 (6/11) Caput 12 12 * Comprises patients with vasectomy and inflammatory etiologies. 1628 FERTILITY AFTER REPEAT VASOEPIDIDYMOSTOMY

TABLE 3. Patency rate and sperm concentration according to REFERENCES epididymal fluid quality 1. Nagy, Z., Liu, J., Cecile, J., Silber, S., Devroey, P., Van Steirteghem, % Patency Sperm A.: Using ejaculated, fresh and frozen-thawed epididymal and Epididymal Fluid (No. pts./total No.) Concentration (106) testicular spermatozoa gives rise to comparable results after Clear, motile ϩ immotile sperm 77.8 (7/9) 32.1 intracytoplasmic sperm injection. Fertil. Steril., 63: 808, 1995. Opaque, motile ϩ immotile sperm 55.6 (5/9) 1.5 2. Sharma, R. K., Padron, O. F., Thomas, A. J., Jr. and Agarwal, A.: Factors associated with the quality before freezing and after thawing of sperm obtained by microsurgical epididymal aspiration. Fertil. Steril., 68: 626, 1997. one should be able to advise patients as to the option of 3. Silber, S. J., Van Steirteghem, A. C., Liu, J., Nagy, Z., Tournaye, reoperation, and the chance of success regarding patency and H. and Devroey, P.: High fertilization and pregnancy rate after pregnancy. Previous studies have demonstrated that patency intracytoplasmic sperm injection with spermatozoa obtained from testicle biopsy. Hum. Reprod., 10: 148, 1995. rates of initial vasoepididymostomy are similar for anasto- 5, 6, 18 4. Belker, A. M., Thomas, A. J., Jr., Fuchs, E. F., Konnak, J. W. and moses at all 3 levels of epididymis. Our patency rate was Sharlip, I. D.: Results of 1,469 microsurgical vasectomy rever- 100% (1 of 1 case) for anastomosis performed to the cauda, sals by the Vasovasostomy Study Group. J. Urol., 145: 505, 62.5% (5 of 8) for the corpus and 66.7% (6 of 9) for the caput. 1991. The patency rates in groups 1, 2 and 3 were 75, 85.71 and 5. Schlegel, P. N. and Goldstein, M.: Microsurgical vasoepididy- 42.85%, respectively (overall 66.7%), and are similar to those mostomy: refinements and results. J. Urol., 150: 1165, 1983. published in the literature for initial vasoepididymos- 6. Jarow, J. P.: Epididymovasostomy. Microsurgery, 16: 333, 1995. tomy.4, 5, 7, 10, 11, 13–17 7. Thomas, A. J., Jr.: Vasoepididymostomy. Urol. Clin. N. Amer., Natural conceptions have occurred in 3 patients to date, all of 14: 527, 1987. whom had congenital obstruction and were followed more than 8. Silber, S. J.: Microscopic vasoepididymostomy: specific microa- 18 months. Previous reports of pregnancy rates for initial vaso- nastomosis to the epididymal tubule. Fertil. Steril., 30: 565, epididymostomy range from 13 to 44%.4, 5, 7, 10, 11, 14–17 Higher 1978. 9. Fogdestam, I. and Fall, M.: Microsurgical end-to-end and end- total sperm counts were seen in patients who did compared to to-side epididymovasostomy to correct occlusive azoospermia. those who did not establish pregnancies. Inability to establish a Scand. J. Plast. Reconstr. Surg., 17: 137, 1983. pregnancy in the remaining patients (7 of 9) with sperm in the 10. Niederberger, C. and Ross, L. S.: Microsurgical epididymovasos- semen and appropriate followup may be due in part to persis- tomy: predictors of success. J. Urol., 149: 1364, 1993. tent epididymal dysfunction or partial obstruction and subse- 11. Matsuda, T., Horii, Y., Mugurama, K., Komatz, Y. and Yoshida, quent poor sperm function. Aspiration of motile sperm with O.: Microsurgical epididymovasostomy for obstructive cryopreservation was done in more than 60% of patients at azoospermia: factors affecting postoperative fertility. Eur. repeat vasoepididymostomy. These cryopreserved sperm can be Urol., 26: 322, 1994. used for assisted reproductive techniques if azoospermia per- 12. Berardinucci, D., Zini, A. and Jarvi, K.: Outcome of microsurgi- sists. cal reconstruction in men with suspected epididymal obstruction. J. Urol., 159: 831, 1998. 13. Berger, R. E.: Triangulation end-to-side vasoepididymostomy. CONCLUSIONS J. Urol., 159: 1951, 1998. Our study demonstrates a patency rate of 66.7% after 14. Jarow, J. P., Oates, R. D., Buch, J. P., Shaban, S. F. and Sigman, 12-month followup and a natural pregnancy rate of 25% in M.: Effect of level of anastomosis and quality of intraepididy- men followed for more than 18 months after repeat vasoepi- mal sperm on the outcome of end-to-side epididymovasostomy. didymostomy. Patients with congenital obstruction had a Urology, 49: 590, 1997. better fertility outcome compared to the other 2 groups. Lack 15. Marmar, J. L.: Management of the epididymal tubule during and of pregnancy in the remaining patients with sperm in the end-to-side vasoepididymostomy. J. Urol., 154: 93, 1995. semen after surgery may be due to lower sperm concentra- 16. Kolettis, P. N. and Thomas, A. J., Jr.: Vasoepididymostomy for vasectomy reversal: a critical assessment in the era of intra- tion, persistent epididymal dysfunction or partial obstruction cytoplasmic sperm injection. J. Urol., 158: 467, 1997. with resulting faulty sperm function. Sperm aspiration and 17. Kim, E. D., Winkel, E., Orejuela, F. and Lipshultz, L.: Patholog- cryopreservation were possible in 60% of our patients. There ical epididymal obstruction unrelated to vasectomy: results were no complications associated with surgery. Repeat mi- with microsurgical reconstruction. J. Urol., 160: 2078, 1998. crosurgical reconstruction remains a reasonable choice for 18. Silber, S. J.: Results of microsurgical vasoepididymostomy: role some patients with epididymal obstruction after failed vaso- of epididymis in sperm maturation. Hum. Reprod., 4: 298, epididymostomy. 1989.