Failed vasectomy reversal: is a further attempt using microsurgery worthwhile?

Abstract

Objective To determine, in failed vasectomy reversal, the usefulness of a revised anastomosis using microsurgery in achieving sperm in the ejaculate and fertility, and to relate the outcome to the site of the anastomosis, length of time from vasectomy, and presence or absence of sperm in the vas at surgery. Patients and methods In a series of 28 patients with con®rmed anastomotic obstruction undergoing vasectomy reversal (over a 10-year period), a microsurgical technique using an oblique end-to-end two-layer interrupted anastomosis with 10/0 Nylon was used to establish vasal continuity. Subsequent seminal analysis at 3±6 months and ensuing paternity were related to several variables. The results were compared with those obtained after 137 cases of primary microsurgical vasovasostomy. Results Sperm was restored to the ejaculate in 16 (57%) of the patients and successful fertilization was reported in nine (32%). The interval between vasectomy and reversal surgery was relevant to the outcome, with four out of four men having sperm in the ejaculate within 5 years and three achieving paternity. However, the fertility rate was still moderate after an interval of 6±10 years (two of six) and at >10 years (four of 18). The presence of sperm in the ejaculate was related to whether or not sperm were found in the testicular end of the vas at operation, but absence did not preclude a successful outcome. The overall results were not signi®cantly different from those after primary microsurgical reversal surgery. Conclusion Microscopic vasovasostomy after previous obstructive failure provides the patient with a further reasonable chance of becoming fertile; although diminishing with time from vasectomy, even after a prolonged period there can be success.

Factors predicting overall success: a review of 747 microsurgical vasovasostomies

“…The patency and pregnancy rates we report are similar to those reported in other studies. 26,27 It is hypothesized that most cases of failed primary VV occur as a result of obstruction at the anas- tomosis site. We found that in 37 (80%) of 46 cases of repeat VV, obstruction at the anastomosis site was confirmed with either a sperm granuloma (28 of 46 cases, 61%) or a stricture of the vas deferens (9 of 46 cases, 20%).…”

“…Although assisted reproductive technologies have significantly impacted the treatment of male infertility, microsurgical reconstruction of obstructed genital tracts remains the most successful, rational and cost-effective method of treating men with obstructive azoospermia due to vasectomy. 26,27 Seminal fluid contains many enzymes, including various hydrolases, which are thought to originate in the accessory reproductive structures, including the epididymis. 28 It has been previously shown that α-1-4-glucosidase disappears from the semen or decreases below 40 mU/ejaculate in men with confirmed vasectomy or genital tract obstruction.…”

“…Additional procedures and costs (e.g., drugs and number of surgical procedures) required during assisted reproductive technology are important considerations for couples seeking treatment for obstructive azoospermia following vasectomy. 26,27,29,30 Decision analysis studies have demonstrated that patency rates are an important factor in comparing cost effectiveness of the different treatment options for couples seeking treatment after the male partner has undergone vasectomy. …”

Outcome of Surgical Treatment for Obstructive Azoospermia

“…Most failures of vasovasosto my may arise through obstruction at the anastomotic site [14]. A long time interval followin g vasectomy [2,6] and no sperm in¯uid obtaine d from the testicular end of the vas during vasectomy reversal [1,16] was considered a negative predictive factor for patency af ter reanastomosis. A ll 6 patients who underwent reversal within 6 years of vasectomy had sperm in the postoperative ejaculate, while 3 of 12 patients who underwent reversal more than 6 years af ter vasectomy continued to have obstructive azoospermia (Figure 1) .…”

Microsurgical vasectomy reversal: results and predictors of success

“…These men should be treated by a repeat reversal procedure rather than ART, since both patency and pregnancy rates are acceptably high after a second procedure [8].…”