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Dr. Flannigan is a fellow in male reproductive medicine. Dr. Goldstein is the Matthew P. Hardy distinguished professor of reproductive medicine, and urology, and the surgeon-in-chief of male reproductive medicine and surgery at the Center for Male Reproductive Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY.
Vasectomies are intended to be a permanent form of contraception and should be communicated as such to men pursuing them (J Urol 2012; 188:2482-91). That said, among the 42-60 million vasectomies that are performed globally (Popul Rep D 1992; 1-23); approximately 6% of men will desire post vasectomy fertility (J Urol 1999; 161:1835-9).
Fortunately, vasectomies do not negatively impact spermatogenesis but create obstruction, termed obstructive azoospermia. Men with vasal obstruction have three treatment options if one wishes to use their own sperm: First, vasal reconstruction may be performed via vasovasotomy (VV) and/or vasoepididymostomy (VE). Second, sperm retrieval may be performed via microsurgical epididymal sperm retrieval (MESA) or testicular sperm retrieval to be used for in-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). The third option is to perform vasal reconstruction and sperm retrieval simultaneously.
Among couples wishing to pursue a naturally conceived pregnancy, vasal reconstruction is the only option. The type of vasal reconstruction required is dependent upon intraoperative findings from the vasal fluid present in the testicular portion of the vas deferens. This fluid is observed under a 400-power bench microscope in search of sperm or sperm parts. If complete sperm with tails or abundant sperm heads are identified, then the procedure of choice is a VV. However, if no sperm are found, then visual characterization of the fluid is required; here, if the fluid is clear and copious, then a VV is also indicated.
However, if no sperm or only rare sperm heads are found and/or the fluid is thick and pasty on visual appearance, then epididymal obstruction is present and a VE is indicated. Clinically meaningful outcomes include patency rates (ie, at least 1 million sperm present in the ejaculate) and pregnancy rates.
Both techniques require significant skill and experience for optimal outcomes. A variety of techniques are described in the literature, and significant heterogeneity exists among the results. In a meta-analysis, the mean patency rate among VVs is 89.4% and the mean pregnancy rate is 73.0% (Urology 2015; 85:819-25), thus serving as a plausible option for couples desiring one or multiple children. VE patency rates have ranged between 50% and 85% in the literature using older end-to-end and end-to-side techniques (Asian J Androl 2013; 15:49-55).
However, with the advent of the longitudinal intussusception vaso-epididymostomy (LIVE) technique, patency rates are reported to be 80%-92% (J Urol 2005; 174:651-55; Proceedings of the 2008 Annual Meeting of the American Urological Association, May 17-22). In this study, 31% of couples achieved a natural pregnancy, and an additional 39% achieved pregnancy using ejaculated sperm with assisted reproductive techniques.
Questions often arise regarding the success of vasal reconstruction with respect to the obstructive interval (OI). Men with an OI less than 10 years are more likely to achieve anastomotic patency and achieve pregnancy post-operatively compared to OIs greater than 10 years (Urology 2015; 85:819-25). However, some studies including both VV and VEs suggest that the patency rate does not change with OIs even at 15 years (89%), but pregnancy rates are reported to be lower (44%) among OIs greater than 15 years (J Urol 2004; 171:304-6).
Thus, among couples wishing to pursue natural pregnancy, vasal reconstruction is a successful management option in couples even with a long OI, with mean natural pregnancy rates of 73% for VV and 31% for VE. Additionally, if natural pregnancy is not achieved, ejaculated sperm can be used for IUI or IVF/ICSI. Sperm retrieved at the time of vasal reconstruction can be used only for IVF/ICSI. Among couples wishing to pursue immediate attempts for fertility and desire multiple children, we recommend considering combined sperm retrieval cryopreserved at the time of vasal reconstruction for immediate IVF/ICSI, allowing potential natural conception for subsequent children, particularly in the setting of advanced maternal age. If only one child is desired, then either vasal reconstruction, or sperm retrieval for IVF/ICSI may be offered. Vasectomy counselling should focus on the permanency of the procedure. However, among vasectomized men now pursuing fertility, vasal reconstruction and/or sperm retrieval and ICSI are viable and successful options. If the couple is willing to pursue all possible options, a majority will be able to have children after prior vasectomy.
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