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INSIDE Demography
Vasectomy
Post-vasectomy considerations
Vasectomy reversal
Post-reversal considerations
Case studies
THE AUTHOR
DR ROBERT WOOLCOTT reproductive microsurgeon, Vasectomy Reversal Australia, Sydney; and director, Genea, VASECTOMY Sydney, NSW. and VASECTOMY REVERSAL Introduction
VASECTOMY is an elective surgical practices, family planning centres, who have had a vasectomy seeking to IVF procedures because it removes the sterilisation procedure that involves hospital outpatient clinics, day sur- restore their fertility. The other option need for repeated sperm extraction if division and occlusion of both vasa geries and general hospitals. is sperm extraction followed by IVF. pregnancy is not achieved in the first deferentia to prevent the passage of Vasectomy is the only method of Undertaking vasectomy reversal as round of IVF. sperm from the testes to the penis in male contraception that is both highly initial management provides a wider Vasectomy reversal via vasova- order to prevent conception. While effective and well accepted by patients. range of future therapeutic options sostomy and vaso epididymostomy Copyright © 2014 the intent of the procedure is to Compared with tubal occlusion meth- and a higher cumulative chance of requires advanced microsurgical Australian Doctor All rights reserved. No part of this achieve permanent contraception, ods (ligation, clips, rings, resection) pregnancy than sperm extraction with methods and is usually performed as publication may be reproduced, vasectomy can be reversed in most vasectomy is as effective in prevent- IVF. Sperm extraction may reduce the inpatient procedures in a day surgery distributed, or transmitted in any men who wish to restore their fertil- ing pregnancy; however, vasectomy is prospect of a future successful vasec- facility. This article discusses the indi- form or by any means without ity as a result of a change of mind regarded as simpler, faster, safer and tomy reversal because it may damage cations and clinical considerations for the prior written permission of the publisher. or personal circumstance. In Aust- less expensive. either the epididymis or the rete testis the procedures of vasectomy and its For permission requests, email: ralia vasectomies are performed in Vasectomy reversal is one of two where sperm collects. A vasectomy reversal. [email protected] a range of settings including general effective treatment options for men reversal simplifies and optimises future cont’d next page
www.australiandoctor.com.au 4 July 2014 | Australian Doctor | 19 How To Treat – Vasectomy and vasectomy reversal
Demography
BETWEEN 15,000 and 16,000 30-49. The age of men undergo- well as contraceptive efficacy, vasectomies are performed annu- ing vasectomy has been increas- is one factor contributing to the ally in Australia. ing consistently. reduction in the frequency of Australia is one of fewer than Over the past decade the inci- vasectomy. 10 nations in which vasectomy dence of vasectomy has decreased Men who undergo vasectomy is more common than fallopian by about one-third (about 24,000 are typically well educated, mar- tube occlusion for female sterilis- vasectomies were undertaken in ried with higher incomes and ation. It is currently six times more 2004/05). Meanwhile, the Aus- more likely to have a tertiary popular than tubal ligation as a tralian Institute of Health and education. method of contraception. This Welfare reports that one-quarter About 70% of such men are ratio has changed remarkably of men aged 40 and over have by definition in the middle to over the past 30 years, as tubal undergone a vasectomy. high socioeconomic group. They occlusion was more frequent than The steady increase in the use tend to have greater contact with vasectomy in 1980. of progestin-laden IUDs and sub- the medical system and are more Fewer than 1% of the vasecto- cutaneous implants for female likely to undergo regular medical mies performed annually are for contraception, which can have check-ups by comparison with men aged younger than 25 years the combined benefit of a reduc- those who do not have vasec- of age and 90% are for men aged tion of menstrual symptoms as tomy. Vasectomy
Preoperative considerations Effectiveness VASECTOMY is one of the most effective methods of birth control. It is about 33 times more effective than oral contraception and about 90 times more effective than condoms. Pregnancy occurs in about 15 out of 10,000 couples after vasectomy. Almost all pregnancies following vasectomy occur within the first year after the procedure.
Preoperative counselling As with any surgical procedure, a discussion with the patient about the risks, benefits and alternatives to vasectomy is required. The box, Essential information to discuss with the patient prior to right, outlines the information that vasectomy Figure 1: A 1.5-3.0cm long midline scrotal incision in conventional vasectomy. This allows for good surgical exposure to the vas deferens. should be discussed before proceed- t7BTFDUPNZJTJOUFOEFEUPCFBQFSNBOFOUGPSNPGDPOUSBDFQUJPO ing with a vasectomy. t7BTFDUPNZEPFTOPUMFBEUPJNNFEJBUFTUFSJMJUZ While most vasectomies can be reversed, preoperative counselling t"OPUIFSGPSNPGDPOUSBDFQUJPOJTOFDFTTBSZVOUJMB[PPTQFSNJBJTDPOGJSNFE should be based on the surgery being by post-vasectomy semen analysis considered as a permanent method of t5IFSJTLPGQSFHOBODZBGUFSWBTFDUPNZJTBCPVUJOGPSNFOXIPIBWF contraception. A thoughtful explo- QPTUWBTFDUPNZB[PPTQFSNJB ration of the patient’s motives and t3FQFBUWBTFDUPNZJTOFDFTTBSZJOõPGNFO understanding is important in order to minimise the prospect of regret. t1BUJFOUTTIPVMESFGSBJOGSPNFKBDVMBUJPOGPSBCPVUPOFXFFLBGUFSWBTFDUPNZ t$PNQMJDBUJPOTTVDIBTTZNQUPNBUJDIBFNBUPNBBOEJOGFDUJPOPDDVS Preoperative assessment GPMMPXJOHPGWBTFDUPNJFT1PTUWBTFDUPNZQBJOTZOESPNFPDDVSTBGUFS A general medical history should be WBTFDUPNZJOBCPVUPGNFOBOENBZSFRVJSFBEEJUJPOBMTVSHFSZ obtained on bleeding diatheses and other possible contraindications to The two key surgical steps in ination is superfluous and not rec- surgery. performing vasectomy are: ommended. A physical examination of the r*TPMBUJPOPGUIFWBT CZFJUIFSUIF genitalia should be performed before conventional or the minimally Minimally invasive vasectomy vasectomy. This may be under- invasive technique; and Minimally invasive vasectomy uses taken immediately before the opera- r0DDMVTJPOPGUIFWBT specific instruments such as the vas Figure 2: Use of Allis forceps to grasp the vas when isolating it and dissecting it tion. Abnormality of the testis or ring clamp and vas dissector to iso- from surrounding tissue. epididymis should be noted. Conventional vasectomy late the vas and then pull it through Unilateral congenital absence of Either one midline or bilateral a small scrotal hole. The incision is the vas occurs in about 1 in 400 scrotal incisions are made with usually smaller than 1cm. The ends men; as this condition is associated a scalpel (figure 1). Incisions are are either cauterised or tied off and with cystic fibrosis gene mutations, usually 1.5-3.0cm long. No special then put back in place. The area of a full family history should be taken instruments are used. The vas is dissection around the vas is kept to and the patient and his relatives usually grasped with a towel clip a minimum. should undergo genetic testing for or Allis forceps (figure 2). The area this mutation. of dissection around the vas is usu- No-scalpel vasectomy Patients who have a history of ally larger with this technique than A common variant of the minimally other significant medical conditions occurs with no-scalpel or mini- invasive technique is known as the will require the appropriate preop- mally invasive techniques. ‘no-scalpel vasectomy’. With this erative investigations. No other spe- There are several different meth- method a vas ring clamp is applied cific tests are necessary. ods of vasal occlusion including around the vas, peri-vasal tissue cautery with or without fascial and overlying skin before mak- Surgical methods interposition, ligatures and clips ing the skin opening. Then the skin Vasectomy can be performed in (figure 3). The method of occlu- is pierced to create an opening of almost all patients with local anaes- sion should be one of personal ≤10mm. The tissue overlying the vas thesia alone using a fine bore needle preference as there is no significant is then spread with the vas dissector for infiltration (25-32 gauge). Seda- difference in their failure rates. to expose the bare anterior wall of Figure 3: Ligation of the vas to achieve vasal occlusion. tion and general anaesthesia are alt- Open-ended vasectomy, where the vas, which is then pierced with ernative options if the preoperative the testicular end of the vas is not one tip of the vas dissector. A supi- pleted with the vas dissector to of the vas is performed in a man- examination indicates that isolation occluded, is associated with less nation manoeuvre is then used to isolate the vas from surrounding ner and with a preference similar to of the vas will be particularly diff- postoperative pain but higher fail- elevate the vas above the skin open- peri-vasal tissue and vessels. The vas conventional vasectomy. Usually the icult or painful, or if they are pre- ure rates. Excision of a segment of ing. Part of the vas is then regrasped is divided with or without excision skin opening can be left unsutured. ferred by the patient or surgeon. vas deferens for histological exam- and the posterior dissection is com- of a vas segment, and then occlusion cont’d page 22
20 | Australian Doctor | 4 July 2014 www.australiandoctor.com.au How To Treat – Vasectomy and vasectomy reversal
Post-vasectomy considerations Post-vasectomy semen analysis studies suggested an association the patient may need to undergo VASECTOMY is not immediately between vasectomy and prostate a vasovasostomy or epididy- effective. Another method of con- cancer, more recent studies dem- mectomy, and in rare instances, traception should be used until the onstrate that vasectomy and pros- orchidectomy. remaining sperm are cleared out of tate cancer do not have an overall the semen. This takes 15-20 ejacu- causal link. Sperm antibodies lations. Even then, some men will Sociodemographics play a Between 50% and 70% of men still have sperm in the semen and part — men from middle to high develop circulating anti-sperm will need to have further semen socieconomic backgrounds are antibodies following vasectomy. analyses. more likely to opt for vasectomy The precise cause of the develop- A semen analysis to assess the and are consequently more likely ment of sperm antibodies is uncer- success of vasectomy should be to be screened for prostate cancer tain. The so-called ‘testis–blood undertaken three months post- during vasectomy-related consul- barrier’ usually minimises expo- vasectomy. Patients may cease tations with a urologist or a GP sure of sperm. Leakage of sperm at using other methods of contracep- with an interest in male health. As the time of vasectomy is likely to tion when azoospermia has been prostatic cancer is usually asymp- contribute to the development of achieved. tomatic and slowly progressing, sperm antibodies. The presence of Vasectomy failure occurs in it is not generally detected in circulating anti-sperm antibodies fewer than 1% of vasectomies and men that do not undergo regular correlates poorly with the prob- is determined by the presence of screening. ability of conception post-vasec- any motile sperm six months after This also means that prostate tomy reversal. vasectomy. The recanalisation cancer in men who have had rate following initial documenta- vasectomies are more likely to be Testicular changes after tion of azoospermia is 0.51% for Just as many men after vasectomy due to Fournier’s diagnosed at an earlier stage and vasectomy vasal ligation and 0.28% where gangrene, a necrotising mixed aer- lower grade, consistent with more Pathological changes in testicular diathermy is used to ablate the (5%) report an obic and anaerobic bacterial infec- regular screening for the disease. histology commonly occur follow- vasal lumen. Where azoospermia increase in sexual tion of the perineum. There is no increase in the risk of ing vasectomy. Electron micros- is not achieved or if recanalisation The risks of intraoperative and testicular cancer. copy has shown that interstitial occurs, repeat vasectomy should satisfaction after early postoperative pain, bleeding fibrosis was present in the testis of be offered. vasectomy as and infection are related mainly to Sexual function 23% of men following vasectomy the method of vas isolation. The While many men are concerned and that some evidence of adverse Recovery those who report available evidence indicates that that vasectomy may affect sexual impact on spermatogenic cells After a vasectomy, most men go a decrease. minimally invasive vas isolation function, there is little evidence within the seminiferous tubules home the same day and, in the procedures result in less discom- that this occurs. Just as many is almost universal. There is no absence of complications, can be fort during the procedure and in men (5%) report an increase in correlation between these testicu- normally active within a week. fewer postoperative complica- sexual satisfaction after vasectomy lar changes and the presence or Sexual activity can resume after tions. as those who report a decrease. absence of anti-sperm antibodies. one week, when it is comfortable Prophylactic antibiotics are not Patients may be assured that there to do so. indicated unless the patient has a is currently no good evidence of Medicolegal aspects high risk of infection, especially any negative effect on sexual func- Vasectomy has been the sub- Risks and complications if he has multiple comorbidities. tion. ject of a considerable amount of Vasectomy is generally uncom- The failure rates of vasectomy are litigation. Cases most commonly plicated. The discomfort that related to the method of vas occlu- Other conditions reflect limited patient understand- occurs after surgery usually settles sion. There is no increase in the risk ing of the risk of pregnancy while promptly with no sequelae. Hae- of coronary or vascular disease, some sperm are still in the semen matoma, infection, chronic pain, Regret hypertension or dementia follow- post-vasectomy, and chronic post- sperm granulomas, vasectomy Rates of dissatisfaction with ing vasectomy. Vasectomy does vasectomy pain, among other failure, and patient ‘regret’ are all vasectomy and/or regret at hav- not change the risk for sexually factors. Injury to or loss of a tes- documented risks and complica- ing undergone the procedure are transmitted diseases. tis, while rare, is highly likely to tions. about 1-2%. Men who had vasec- lead to legal action. While the Haematoma, infection and tomy before the age of 30 are more Management of complications various techniques of vasectomy chronic scrotal pain sufficient to likely to feel regret and request While the common complications may result in minor variations in disrupt quality of life occur foll- vasectomy reversal. are potentially serious, conserva- the frequency of complications, if owing 1-2% of procedures. Sperm tive management mostly leads to both vasa deferentia are divided, granuloma is rarely symptomatic. Prostate cancer spontaneous resolution. To allevi- technique-related complications There has been one report of death While initial epidemiological ate significant chronic scrotal pain are seldom a cause for litigation.
Vasectomy reversal BETWEEN 4% and 5% of Austral- or religious reasons. The box, left, ally predictive of outcome. It may ian men who have had vasectomy Vasectomy reversal — key points outlines the key points that should reveal that large segments of the later seek reversal. The Australian t7BTFDUPNZSFWFSTBMJTBUFDIOJDBMMZGFBTJCMFNFBOTUPSFTUPSFGFSUJMJUZJONFO be discussed with the patient con- vas deferens were removed and Institute of Health and Welfare who previously have had a vasectomy sidering vasectomy reversal. help to identify those in whom the data indicate that 500-600 vasec- standard incision may need to be t&YQFSJFODFETVSHFPOTVTJOHNJDSPTVSHJDBMUFDIOJRVFTBDIJFWFUIFIJHIFTU tomy reversal operations are per- Preoperative assessment modified. Examination also may technical success rates formed annually. Nationally, both Clinical history reveal testicular abnormalities or vasectomy and vasectomy reversal t'PSUIFBWFSBHFNBOVOEFSHPJOHWBTFDUPNZSFWFSTBM QSFHOBODZSBUFTSBOHF When taking the patient’s history, epididymal induration. Epididy- are now substantially more com- CFUXFFOBOE the GP should enquire about the mal fullness suggests obstruction mon than fallopian tube occlusion t1PTUPQFSBUJWFQBUFODZSBUFT SFUVSOPGTQFSNUPUIFTFNFO BOEQSFHOBODZ patient’s age, reproductive his- at that level but does not predict for sterilisation and microsurgical rates after vasectomy reversal procedures decrease as the interval between tory (ie, history of having fathered accurately which patients will fallopian tube reanastomosis for vasectomy and its reversal increases children or achieved pregnancy require vasoepididymostomy. sterilisation reversal. t'FNBMFBHFJTUIFTJOHMFNPTUJNQPSUBOUQSFEJDUPSPGQSFHOBODZGPMMPXJOH previously in the same or other Obesity may increase technical vasectomy reversal relationships). The duration of difficulty and increase the risk of Indications time since the vasectomy and haematoma. By far the most common reason t5IFDIPJDFCFUXFFOWBTPWBTPTUPNZBOEWBTPFQJEJEZNPTUPNZJTNBEFBU whether there were any postop- for vasectomy reversal surgery is UIFUJNFPGTVSHFSZ BGUFSEFUFSNJOJOHUIFFYUFOUBOEMFWFMPGPCTUSVDUJPO erative complications from the Investigations a desire to achieve pregnancy with t1SJPSTQFSNFYUSBDUJPOGPS*7'SFEVDFTUIFQSPTQFDUPGGVUVSFTVDDFTTGVM vasectomy should be ascertained. Preoperative testing of men con- a new partner following a change vasectomy reversal, whereas vasectomy reversal increases the chance of A general medical history should templating vasectomy reversal is of relationship. Fewer than one in GVUVSFTVDDFTTGVM*7' be taken with specific question- unnecessary except for routine 30 men who undergo vasectomy t"MUIPVHIIBSWFTUJOHTQFSNGPSDSZPQSFTFSWBUJPOBUUIFUJNFPGWBTFDUPNZ ing about hereditary or acquired preoperative tests that may be reversal are in the same relation- reversal is possible, it may not be useful or cost-effective bleeding diatheses or anticoagu- required or preferred as a result of ship that produced any children lant therapy. the patient’s general medical state. conceived pre-vasectomy. life. Although the pathogenesis of thirds of cases, with some benefit The presence of circulating sperm About 1% of men develop post- post-vasectomy pain syndrome is in about half of the remaining men. Physical examination agglutinins is not sufficiently sensi- vasectomy pain of sufficient sever- unknown, vasectomy reversal pro- Rarely a man may seek reversal Physical examination is gener- tive or specific to predict the out- ity to interfere with quality of vides effective relief in up to two- for psychological, psychosexual ally uninformative and not usu- cont’d page 24
22 | Australian Doctor | 4 July 2014 www.australiandoctor.com.au How To Treat – Vasectomy and vasectomy reversal
from page 22 Figure 4: The ends of the tomosis is generally performed come of vasectomy reversal and divided vas are mobilised with a multi-layered anastomosis has largely been abandoned by so that they can be placing five to seven interrupted reproductive microsurgeons as a approximated to avoid 8-0 or 9-0 nylon sutures through preoperative test. any tension on the site the full-thickness of each end of of the anastomosis after the vas, with additional inter- Female fertility vasectomy reversal. rupted sutures in the outer muscu- Female age is the single most lar and adventitial layers, placed important factor in determining between the full-thickness sutures the prospect of pregnancy after (figure 6). Some surgeons prefer vasectomy reversal. Before vasec- to perform vasovasostomy using tomy reversal is performed for res- a two- or three-layered microsur- toration of fertility, evaluation of gical anastomosis by first placing the female partner’s reproductive 5-8 interrupted 10-0 nylon sutures potential is prudent. A reproduc- in the inner mucosal edges of the tive history and, where indicated, ends of the vas, incorporating a assessment of ovarian function small portion of the inner muscu- and pelvic anatomy may be neces- lar layer, and then 7-10 additional sary to properly advise the patient interrupted 9-0 nylon sutures in about his chances of achieving the outer muscular and adventitial pregnancy or fathering further layers. children with the woman in ques- tion following vasectomy reversal. Vasoepididymostomy The decision to undertake micro- Surgical methods surgical vasoepididymostomy is Placement of incision based on the surgical anatomy, the Vasectomy reversal is usually extent of collateral damage from performed through oblique inci- the prior vasectomy and position- sions on either side of the anterior ing of the vasectomy site. Vasogra- aspect of the scrotum. When the Current evidence phy is not required. Some authors vasectomy was performed high indicates that motile have recommended that the pres- in the scrotum or removed a large ence, motility and morphology or segment of the vas deferens, it may sperm are present absence of sperm at the testicular be necessary to extend the scrotal in only 35% of end of the transected vas should be incisions upward into the lower used to decide intraoperatively to inguinal region to provide ready men undergoing proceed to vasoepididymostomy. access to the vasectomy site. vasovasostomy Patency rates from microsurgical vasovasostomy in the absence of Mobilisation of vas deferens despite a higher than any visible sperm are higher than The vas should be mobilised suffi- 90% postoperative those for vasoepididymostomy ciently to avoid any tension on the and so the latter is most com- site of the anastomosis. After divi- patency rate. monly performed for redo vasec- sion of the vas deferens on either tomy reversal after an initial failed side of the vasectomy site, the procedure. prepared ends are approximated. When vasoepididymostomy is A specialised clamp designed to required, the scrotal contents must facilitate approximation and anas- be extruded to incise the tunica tomosis is extremely useful in this vaginalis. The procedure is per- process (figure 4). formed using an end-to-side anas- The entire scarred portions tomosis with a single epididymal of the vas above and below the tubule pulled up into the lumen of vasectomy site should be avoided the vas deferens. Four to six inter- to ensure anastomosis of healthy rupted 10-0 nylon sutures are used tissue. In most instances the site to oppose the mucosa of each and of the vasectomy does not require the outer muscular layer of the excision and may be left in situ. vas is approximated to the incised If it is removed, then care must edges of the epididymis tunic with be taken to ensure the completed a series of interrupted 9-0 nylon anastomosis does not come in sutures. contact with an area that has been subject to diathermy, which is Intraoperative sperm retrieval used to eliminate bleeding in the Intraoperative sperm harvesting process of excision. Diathermy for the intended purpose of pos- should not be used on the oppos- sible future attempts to conceive ing transected ends of the vas. To using IVF with intracytoplasmic prevent damage to the vas, only sperm injection (ICSI) is both con- precise microscopically directed troversial and problematic. The diathermy is used to cauterise Figure 5: Fine local laboratory needs to have blood vessels located in the sur- monofilament nylon the capacity for cryopreserva- rounding adventitia. sutures are used to tion of any harvested sperm in a join the anastomosis manner suitable for use in ICSI. Examining the sperm between the ends of Prior to the introduction of ICSI, Some authors recommend assess- the divided vas. sperm obtained during the opera- ment of the presence, concentra- tion could not be used for either tion and motility of sperm at the intrauterine insemination or con- testicular end of the vas deferens ventional IVF because their num- to see whether vasoepididymos- bers and motility were too low to tomy rather than vasovasostomy be useful. should be performed. However, The nature and quality of sperm current evidence indicates that collected from the cut testicular motile sperm are present in only end of the vas deferens is univer- 35% of men undergoing vaso- sally suboptimal. It is cytoplas- vasostomy despite a higher than mically degraded and has high 90% postoperative patency rate; levels of DNA fragmentation as a hence it is now rarely necessary to result of a combination of factors: perform this assessment. r7BTFDUPNZSFMBUFE PCTUSVDUJPO of flow along the epididymis and Suturing technique vas deferens. Most surgeons perform anastomo- r5IFQIZTJDBMEJTUBODFGSPNUFTUJT ses using fine monofilament nylon to vasectomy site. sutures (figure 5). The actual anas- r5IF SFMFBTF PG BVUPTPNBM
24 | Australian Doctor | 4 July 2014 www.australiandoctor.com.au enzymes upon lysis of sperm in Figure 6: The anastomosis References situ. to reverse a divided vas is 1. Practice Committee of the r5IF EFMBZ GSPN QSPEVDUJPO PG usually multilayered with sperm in the testis to its avail- interrupted 8-0 or 9-0 American Society for Reproductive ability for retrieval. nylon sutures. Medicine. Vasectomy reversal. Motile sperm obtained from Fertility and Sterility 2008; 90:(5 the epididymis (by comparison Suppl)S78-S82. to the vas deferens) is of higher 2. Belker AM. Microsurgical functional capacity. In all cases, vasectomy reversal. In: Lytton B, et the technical aspects of vasova- al, (editors). Advances in Urology. sostomy or vasoepididymostomy Year Book Medical, Chicago, 1988. should have priority over attempts 3. Belker AM, et al. Results of 1,469 to harvest sperm for cryopreserva- microsurgical vasectomy reversals tion. by the Vasovasostomy Study Many authors have concluded Group. Journal of Urology 1991; that sperm harvesting during 145:505-11. vasectomy reversal is neither use- 4. Matthews GJ, et al. Microsurgical ful nor cost-effective. When it reconstruction following failed is considered, both the patient vasectomy reversal. Journal of and his partner should be pro- Urology 1997; 157:844-86. vided detailed information on 5. Hernandez J, Sabanegh ES. the nature, practicality, risks and Repeat vasectomy reversal after cost both of IVF and of long-term initial failure: overall results and sperm storage. predictors for success. Journal of Urology 1999; 161:1153-56. 6. Fox M. Failed vasectomy reversal: is a further attempt using Post-reversal considerations microsurgery worthwhile? BJU International 2000;86:474-78. Postoperative care (PESA), patency rates after vasec- of partners conceiving.1,2 Further reading POSTOPERATIVELY, the use of tomy reversal surgery are lower Vasectomy: AUA Guideline. American scrotal drains and perioperative than 30%; if the aspiration was Anti-sperm antibodies Urological Association, Linthicum antibiotics depends on the individ- unilateral this figure is higher at Some investigators have suggested MD, 2012. ual surgeon. There should be a low about 70-80%. The lower patency that anti-sperm antibodies may threshold for the short-term (four rate is because the diameter of an decrease the chance of successful hours) use of scrotal drains because epididymal tubule is considerably pregnancy after vasectomy reversal. they do decrease both haematoma smaller than that of a 25-27 gauge Studies into pregnancy rates follow- and postoperative infection rates. needle used for PESA, so damage to ing vasectomy reversal demonstrate Patients should be advised to use and subsequent obstruction of the a mean postoperative conception a scrotal supporter and to avoid epididymis is almost inevitable. rate of between 60% and 85% for sexual intercourse and strenuous For testicular sperm extraction patients who undergo microsurgical physical activity for four weeks after (TESE) the negative effect is some- vasovasostomy within 15 years of surgery. Postoperative pain gener- what less with patency rates between their vasectomy. ally can be controlled adequately 80% and 90%. The pathophysi- with oral analgesics. ological mechanism is most likely Management of operative failures outflow obstruction as consequence Repeat operation may be offered if Postoperative monitoring of inadvertent collateral damage to the primary vasectomy reversal fails. A semen analysis should be obtained the intratesticular collecting system Repeat procedures may be more diff- about three months post-opera- (rete testis), post-procedure fibro- icult technically because the remain- tively. Should the initial semen anal- sis consequent upon both multi- ing viable segments of the vas will ysis not reveal sperm or have ‘virtual ple passes of the aspirating needle be shorter. In the largest published azoospermia’ (sperm only visible through the testis and resolution of study on the topic, sperm returned following centrifugation of the sam- 80%, then 90% by 12 weeks and intratesticular haematoma. A small to the semen after repeat surgery ple) then repeat analysis should be 95% by six months. incisional biopsy of the testis is in 75% of men, and 43% of their undertaken three months later. unlikely to have a similar effect. partners subsequently conceived.3 In men who do not achieve a Effect of time since vasectomy Repeat attempts at vasectomy rever- pregnancy, further monitoring of The outcome is better for those with Microsurgery vs macrosurgery sal should be considered, particularly semen quality may identify the a shorter time from vasectomy to Microsurgical methods generally when the prior operation had been small number who develop late reversal. As the interval between lead to higher patency rates com- performed macrosurgically or by a obstruction due to scar formation vasectomy and the reversal surgery pared with macrosurgical tech- surgeon performing small numbers at the anastomotic site. The inci- increases, the patency rate declines niques. There is a direct correlation of microsurgical procedures. dence of postoperative reobstruc- from 95% at less than 10 years to between the number of cases of After a failed vasoepididymos- tion ranges from 1% to 3% after about 90% at 15 years, about 80% microsurgical vasectomy reversal tomy, a repeat procedure may or microsurgical vasovasostomy and at 20 years and 70% at 25 years previously performed by the sur- may not be possible, depending on as high as 35% following vasoe- after vasectomy. Rather than being geon and patency rates. Therefore, the amount of scar tissue that forms pididymostomy. directly related to anastomotic in order to provide optimal patency around the epididymis after the first If sperm do not return to the patency, this decline in patency rates and pregnancy rates, surgeons who operation. semen by six months after vaso- over time is more likely to be the perform vasectomy reversal should vasostomy or by 18 months after result of either vasal or epididymal undertake formal microsurgical Risks and complications vasoepididymostomy, the procedure obstruction by inspissated cellular training. Complications following microsur- should be considered to have failed. debris accumulating on the testicu- Patency rates following macro- gical vasectomy reversal are uncom- Most pregnancies that are achieved lar side of the vasectomy site. This surgical vasovasostomy are about mon. Haematoma is by far the most without further intervention occur accumulation of cellular debris may 70% and for microsurgical vasoe- frequent, varying between 0.5% and within 24 months of surgery. form concretions within the vas or pididymostomy performed by 3%, which is markedly reduced by epididymis, thereby leading to addi- experienced microsurgeons about drainage of the operation site. Infec- Return of sperm tional sites of occlusion. Early publi- 65%.1,2 It should be noted, how- tion either of the wound or under- Fertility after successful vasectomy cations that hypothesise epididymal ever, that vasoepididymostomy is lying haematoma occurs in fewer reversal (as defined by both sperm blowout as a primary mechanism of usually only carried out in the most than 1% of operations. Rarer still in the ejaculate and conception) has surgical failure remain controversial surgically challenging of cases. are wound problems and chronic a strong inverse correlation with and need to be validated. postoperative pain. pathological changes in the testes Pregnancy rates Occasionally patients may post-vasectomy. Effect of prior IVF procedures Depending on the interval between develop short-term urinary reten- Technical success for the aver- Importantly, if epididymal sperm vasectomy and reversal and on the tion following surgery. Fournier’s Declaration of interest age man undergoing microsurgi- aspiration and testicular needle age of the patient’s partner, the over- gangrene has not been reported fol- statement cal vasovasostomy is high with aspiration have been performed to all postoperative pregnancy rate after lowing vasectomy reversal. Medi- %S3PCFSU8PPMDPUUJTBOPO patency rates (ie, return of sperm) obtain sperm for IVF before vasec- microsurgical vasectomy reversal is colegal action is rare provided that FYFDVUJWFEJSFDUPSPG(FOFB of 90-95%. Sperm usually returns tomy reversal, patency rates are sig- between 50% and 80%. Following patients are well informed about the which provides assisted gradually in a progressive manner. nificantly reduced. microsurgical vasoepididymostomy nature of the procedure and the reproductive treatments About 50% of men will have sperm When the patient had previously it is 30% to 50%. The pregnancy potential postoperative complica- JODMVEJOH*7' present by six weeks after the rever- undergone bilateral percutane- rates following macrosurgical vaso- tions, along with its success and sal surgery; by 10 weeks this rises to ous epididymal sperm aspiration vasostomy are lower, with 20-40% failure rate. cont’d next page
www.australiandoctor.com.au 4 July 2014 | Australian Doctor | 25 How To Treat – Vasectomy and vasectomy reversal
Conclusion Online resources Vasectomy Reversal Australia VASECTOMY is an effective Even at 25 years [author’s own website] method of male contraception. It www.vasectomyreversal is a straightforward procedure and post-vasectomy, australia.com.au has few risks and complications. the patency rate Preoperative counselling and Urology Care Foundation detailed discussions exploring following reversal 7BTFDUPNZSFWFSTBM the patient’s understanding of surgery is still a high IUUQCJUMZK/.&I the procedure and expectations 70%. helps prevent patient regret after Andrology Australia the procedure. Close adherence Expert video: 7BTFDUPNZ 8IBUJT to postoperative instructions and *U BOE)PX%PFT*U8PSL follow-up is important to ensure IUUQCJUMZNN"C82 its success and minimise potential risks of failure, pain and haema- Fact Sheet: Understanding toma. Microsurgical techniques 7BTFDUPNZ help reduce these risks further. IUUQCJUMZK/.&I Vasectomy is not associated with a higher risk of prostate or testicular Wikipedia — Vasectomy cancer, sexual dysfunction, coro- Reversal [a seriously good nary or vascular disease, hyper- review] tension or dementia. The patient FOXJLJQFEJBPSHXJLJ should be reminded that vasec- 7BTFDUPNZ@SFWFSTBM tomy does not change their risk for sexually transmitted diseases. ous epididymal sperm aspiration gery are similar to the initial vasec- Vasectomy reversal is more suc- and testicular sperm extraction tomy. cessful if it were performed ear- can both negatively affect the suc- It is important to address the fac- lier rather than later. However, cess rate of vasectomy reversal. tors that affect the fertility of the even at 25 years post-vasectomy, This should be discussed with the patient’s partner and discuss how the patency rate following rever- patient who has had a vasectomy this can lessen the rate of successful sal surgery is still a high 70%. and is considering IVF with his pregnancies post-reversal surgery Past IVF-associated percutane- partner. The risks of reversal sur- despite a high patency rate.
INSTRUCTIONS Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. How to Treat Quiz We no longer accept quizzes by post or fax. Vasectomy and vasectomy reversal The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. GO ONLINE TO COMPLETE THE QUIZ — 4 July 2014 www.australiandoctor.com.au/education/how-to-treat
1. Which TWO statements are correct B 7BTFDUPNZBMNPTUBMXBZTOFFETUPCF regarding preoperative counselling for JOUFSDPVSTFGPSGPVSXFFLTBGUFSWBTFDUPNZ regarding preoperative counselling for performed under sedation vasectomy reversal surgery? reversal surgery vasectomy? C $POWFOUJPOBMWBTFDUPNZSFRVJSFTBTVSHJDBM B 5IFQBUJFOUTIPVMECFBEWJTFEUIBUUIF E "OZQPTUPQFSBUJWFQBJOJTTJHOJGJDBOUBOE B 1BUJFOUTTIPVMECFBEWJTFEUIBUWBTFDUPNZ JODJTJPOPGDNMPOH pregnancy success rate for vasectomy should prompt immediate review by the while reversible, is intended to be a permanent D &YDJTJPOPGBTFHNFOUPGWBTEFGFSFOTGPS SFWFSTBMJTBCPVU surgeon form of contraception IJTUPMPHJDBMFYBNJOBUJPOJTOPUSFDPNNFOEFE C 1BUJFOUFYQFDUBUJPOTTIPVMECFUFNQFSFEXJUI C 1BUJFOUTTIPVMECFXBSOFEUIBUWBTFDUPNZ E $BVUFSZBTBNFUIPEGPSWBTBMPDDMVTJPOIBTB the advice that female age is the single most 9. Which TWO statements are correct is not as effective as condoms or oral much higher failure rate than using ligature important predictor of pregnancy success regarding the risks and complications of contraceptives following vasectomy reversal vasectomy reversal? D 1BUJFOUTTIPVMECFSFBTTVSFEUIBUWBTFDUPNZ 4. Which TWO statements are correct D 1BUJFOUTTIPVMECFBEWJTFEUPIBWFTQFSN B )BFNBUPNBDPNQMJDBUFTPG provides sterility straightaway regarding postoperative care after a FYUSBDUJPOQSJPSUPUIFSFWFSTBMQSPDFEVSFUP microsurgical vasectomy reversal surgery E (1TTIPVMEEJTDVTTFYQFDUBUJPOTXJUIUIF vasectomy? increase their chances of achieving pregnancy C 8PVOEJOGFDUJPOPDDVSTJOBCPVUPG patient and advise that repeat vasectomy is B .PTUNFOHPIPNFUIFTBNFEBZBTUIF with their partner vasectomy reversal surgery OFDFTTBSZJOõPGNFO vasectomy E 'PSNFOXJUIQPTUWBTFDUPNZQBJOSFRVFTUJOH D 6SJOBSZGMPXJTOPUBGGFDUFECZWBTFDUPNZ C "TFNFOBOBMZTJTJTVTVBMMZVOEFSUBLFOUISFF reversal surgery, advice should be given that reversal surgery 2. Which TWO statements are correct months post-vasectomy the procedure provides effective relief in up to E 1PTUPQFSBUJWFSFPCTUSVDUJPOPDDVSTJO regarding the preoperative assessment for D 1BUJFOUTTIPVMEBCTUBJOGSPNTFYVBMBDUJWJUZGPS two-thirds of cases PGQBUJFOUTBGUFSNJDSPTVSHJDBM vasectomy? three months after vasectomy vasovasostomy B 5IFQSFPQFSBUJWFBTTFTTNFOUTIPVMEJODMVEF E 1BUJFOUTBSFFODPVSBHFEUPFKBDVMBUF 7. Which THREE preoperative assessments a general medical history that identifies any UJNFTJOUIFGJSTUXFFLBGUFSWBTFDUPNZ should be obtained before vasectomy 10. Which THREE statements are correct bleeding diatheses reversal surgery? regarding the successful outcome and C "QIZTJDBMFYBNJOBUJPOPGUIFHFOJUBMJBNBZ 5. Which TWO statements are correct B 5IFQBUJFOUTSFQSPEVDUJWFIJTUPSZ return of sperm following vasectomy CFVOEFSUBLFOJNNFEJBUFMZQSJPSUPUIF regarding the risks and complications of C 5IFMFOHUIPGUJNFTJODFUIFWBTFDUPNZ reversal surgery? vasectomy vasectomy? D 5IFGFNBMFQBSUOFSTPWBSJBOGVODUJPO B .PTUQSFHOBODJFTUIBUBSFBDIJFWFEXJUIPVU D 1BUJFOUTGPVOEUPIBWFVOJMBUFSBMDPOHFOJUBM B $PNQMJDBUJPOTTVDIBTTZNQUPNBUJD E 5IFMFWFMPGDJSDVMBUJOHTQFSNBHHMVUJOJOT further intervention after vasectomy reversal absence of the vas in the preoperative haematoma and infection occur following occur within three months of surgery assessment should have full chromosomal PGWBTFDUPNJFT 8. Which TWO statements are correct C 3FUVSOPGTQFSNGPMMPXJOHNJDSPTDPQJD analysis prior to the operation C 7BTFDUPNZGBJMVSFPDDVSTJOBCPVUPG regarding postoperative care after WBTPWBTPTUPNZPDDVSTJOBCPVUPG E 1BUJFOUTXJUIOPTJHOJGJDBOUNFEJDBMDPOEJUJPOT vasectomies vasectomy reversal surgery? men will still require an urogram in the preoperative D &WJEFODFTIPXTUIBUWBTFDUPNZTJHOJGJDBOUMZ B 4IPSUUFSNVTFPGTDSPUBMESBJOTMPXFST D 5IFTVDDFTTSBUFPGWBTFDUPNZSFWFSTBM assessment SFEVDFTTFYVBMGVODUJPO the rate of postoperative haematoma and decreases with the length of time since the E 5FTUJDVMBSJOUFSTUJUJBMGJCSPTJTPDDVSTJOPG infection vasectomy 3. Which TWO statements are correct men following vasectomy C /PGVSUIFSTFNFOBOBMZTJTJTOFFEFEJGTQFSN E 7BTFDUPNZSFWFSTBMJTDPOTJEFSFEUPIBWF regarding the surgical methods when is visible after centrifugation failed if sperm do not return to the semen by performing a vasectomy? 6. Which TWO statements are correct D 1BUJFOUTTIPVMECFBEWJTFEUPBWPJETFYVBM TJYNPOUITBGUFSWBTPWBTPTUPNZ
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