Fertility Treatment Options After Vasectomy

CLINICAL Luke Witherspoon, MD, MSc, Ryan Flannigan, MD Fertility treatment options after vasectomy Couples who wish to achieve a pregnancy following a vasectomy should discuss the various treatment options with their specialists and consider the differences in pregnancy rates, timing to pregnancy, cost, and invasiveness to patient and partner. ABSTRACT: Canadian men and their female part en have been having vasectomies history (specifically, hernia repairs), time since ners are increasingly turning to vasectomy as a for more than 200 years.1 Every vasectomy, and erectile and ejaculatory func- means of birth control. Although vasectomy is year, approximately 6% of men tion should be assessed. His current and recent thought of as a permanent form of birth control, (500 000) in the United States undergo a vasec- medication use should also be fully reviewed, men who wish to attain fertility after having the M2 tomy. In Canada, approximately 15% of men with a focus on the use of any anabolic steroids procedure may undergo a vasectomy reversal to have the procedure, as the shift away from fe- or testosterone supplementation. Discussion achieve pregnancy with their partner or undergo male sterilization continues.3 However, the in- about the couple’s family planning is likely war- sperm retrieval and in vitro fertilization/intra crease in vasectomy rates has led to an increased ranted, and should include the number of chil- cytoplasmic sperm injection (IVF/ICSI). Vasectomy need for fertility options following vasectomy, dren desired and the future desire for sterility.6 reversal patency rates are typically 90.0% to 99.5% as approximately 7.4% of men ultimately regret A focused physical examination should in- when gold standard surgical techniques, such as having a vasectomy and pursue some type of clude an exam of the inguinal region for sur- the Goldstein microdot multilayer anastomosis, fertility assessment.4 Four treatment options gical scars, and a full assessment of the testes are used. Cumulative pregnancy rates with IVF/ exist: vasectomy reversal; sperm retrieval and and scrotal contents. The entire cord structure ICSI range from 18.2% to 69.4%, depending on in vitro fertilization (IVF) with intracytoplas- should be palpated, with the location of the va- the female partner’s age. However, sperm retrieval mic sperm injection (ICSI); acquisition of a sectomy identified. The presence of granulomas procedures and IVF/ICSI, or vasectomy reversal pro sperm donor for intrauterine insemination or on the testis side of the vas deferens should be cedures can yield similar efficacy for appropriately IVF/ICSI; or child adoption. Approximately noted, as it may reflect a positive prognosis.6 selected couples. 60% of men who request a vasectomy reversal Most men who undergo vasectomy reversal are in a new relationship; the rest are in the have a history of fertility,7 but if a man has same relationship they were in when they had no documented fertility prior to undergoing a a vasectomy.5 We review the considerations, vasectomy, a formal fertility workup, including Dr Witherspoon is a sexual medicine and prognostic factors, and outcomes associated hormonal profile, may be undertaken.8 infertility fellow in the Department of with vasectomy reversals and sperm retrieval An assessment of the female partner is also Urologic Sciences, University of British with IVF/ICSI as potential fertility options required. Although there are no clear guide- Columbia, and the Department of for couples seeking fertility after a vasectomy. lines about which women require full fertility Urology, Ottawa Hospital, Ontario. assessments, some guidelines suggest that all Dr Flannigan is an assistant professor Evaluation and considerations women over 35 years of age should be offered in the Department of Urologic Sciences, Both partners who are proceeding with a fertil- an expedited fertility evaluation.9 Prior docu- University of British Columbia, and an ity assessment after vasectomy should have a mented fertility, especially if it was within the adjunct clinical assistant professor in thorough history taken and undergo a physical same relationship in which they achieved a prior the Department of Urology, Weill Cornell examination to determine if additional causes pregnancy, is a positive prognostic factor for Medicine, New York. of infertility may be present. In addition, the pregnancy and live births in couples undergoing male partner’s fertility history (previous associ- vasectomy reversal.10 This article has been peer reviewed. ated pregnancies and children), inguinal surgery 62 BC MEDICAL JOURNAL VOL. 63 NO. 2 | MARCH 2021 Witherspoon L, Flannigan R CLINICAL Vasectomy reversal Compared to historical vasectomy reversals, contemporary subspecialized reproductive mi- crosurgery has evolved significantly and refined the procedure to provide excellent outcomes for patients. Although some practitioners still perform the procedure using surgical loupes,11,12 most specialists use an operating microscope, which allows for a precise microscopic anastomosis. Should further surgical complexity be encountered intraoperatively, use of a microscopic approach is typically necessitated for epididymal reconstruction, thereby limiting the use of loupes.11 The need for epididymal reconstruction on at least one side occurs in approximately 30% to 60% of vasectomy reversal procedures, and is not reliably predicted preoperatively; thus, the general standard of FIGURE 1. Goldstein microdot multilayer anastomosis. Six 10-0 mucosal anastamotic sutures are placed. care is to perform reversals with an operating Three additional layers of sutures are placed for a precise and watertight anastomosis. microscope.13,14 Procedure two techniques, although inconsistent reporting Impact of time since vasectomy Vasectomy reversal procedures are typically of outcome measures, exclusion of papers with Several prognostic factors for successful re- performed through two small incisions in the highest patency rates using multilayer tech- turn of sperm, and ultimately pregnancy, have scrotum, where the obstructed vas deferens is niques, and suspected publication bias make been highlighted within the fertility literature. identified. The obstructed ends are then tran- meta-analyses of this topic difficult.16 Reported One of the most discussed, but controversial, sected, and fluid is expressed from the testicular patency rates following these procedures have factors has been interval of obstruction. Early end of the vas deferens. Microscopic inspection been reported to range widely from 80.0% to reports described reduced success with increas- of the fluid is vital because it dictates whether 99.5% depending on the series reported.16 ing time since vasectomy, particularly beyond a vasovasostomy can be performed or a more 10 years postsurgery;19 however, several articles complicated vasoepididymostomy must be Gold standard technique have shown no differences 15 years following carried out. If full sperm or sperm parts are The highest reported success rate for vaso- vasectomy.20,21 The concept of reduced success identified, or if there is copious clear fluid, vasostomy is the Goldstein microdot multilayer rates following longer obstructive intervals is then a vasovasostomy is performed. Several anastomosis (patency rate of 99.5%), where related to secondary obstruction of the epi- techniques for performing vasectomy rever- six ink dots are placed equidistantly beyond didymis. During the obstructive interval, the sals have been described since the procedure’s the mucosal-muscularis junction of the vas testis continues to make sperm and fluid. This inception. An ongoing debate has centred on deferens [Figure 1].17 This allows for mapping results in increased epididymal tubule pressure the use of either multilayered or single-layered of planned suture locations to ensure consis- and may lead to rupture and scarring. Thus, in closures for the connection between the ends tent suture spacing and to maximize lumen the presence of an epididymal obstruction, a of the vas deferens. Multilayer closures allow approximation and minimize the chance of regular vasectomy reversal that connects the for precise mucosal approximation and ensure leakage.17 This technique has undergone con- two ends of the vas deferens will not work, a leak-proof alignment. However, a potential tinued improvement with the addition of a and an epididymal reconstruction will be nec- disadvantage of this approach is that sutures 15-degree angled cut of the vas deferens prior essary to achieve success. Upon intraoperative are tied adjacent to the vas deferens mucosa, to anastomosis, contributing to a patency rate inspection of vasal fluid, epididymal obstruc- which may promote fibrosis and anastomotic of 99.5%.18 Furthermore, recent reports that tion can be confirmed if no sperm parts are stricture.15 Single-layer approaches are techni- have formalized tension-relieving suture tech- identified, no fluid can be expressed, or thick cally easier, although there is some concern that niques (e.g., ReVas) suggest that sperm counts toothpaste-like fluid is encountered.22 Therefore, a good mucosal approximation is less possible and pregnancy rates improve following vasec- a discussion about reversal as a treatment op- and may promote anastomotic misalignment or tomy reversal. The ReVas reduces anastomotic tion should be held with couples in which the leak leading to failure.15 A recent meta-analysis tension, a factor that may lead to anastomotic

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