Results of Vasovasostomy or Vasoepididymostomy After Failed Percutaneous Epididymal Sperm Aspirations.

Marmar JL, Sharlip I, Goldstein M:
J Urol; 2008; 179 (April): 1506-1509

Background: 4% to 6% of men consider having children after vasectomy. Choices are either vasectomy reversal or sperm aspiration for in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI). Percutaneous sperm aspiration (PESA) is one way for sperm retrieval, but the degree of epididymal damage is unknown. The request for microsurgical reconstruction after failed PESA is limited.

Objective: To investigate the ability to perform vasectomy reversal after failed PESA-IVF-ICSI. Design: Retrospective study involving a specialized subset of patients who requested and underwent a vasectomy reversal after PESA. Participants: 8 patients who failed 1 to 4 attempts at IVF-ICSI with sperm retrieved by PESA. Methods: Patients were identified from the records of 3 experienced infertility microsurgeons. The side of the PESA was determined. Vasovasostomy (VV) or vasoepididymostomy (VE) was performed based on standard of care–intraoperative fluid from the testicular end of the vas. Two-layer VV or end-to-side/2-stitch VE was performed. Postoperative semen analysis was performed at 3-month intervals. Results: All patients had bilateral PESAs performed. Of the 8 patients, 4 had no apparent abnormality to the caput of the epididymis, 2 had small blue cysts at the caput, and 2 had small areas (<0.5 cm) that appeared necrotic or ischemic. No specific puncture site for the PESA could be seen at the time of reconstruction. Ten of 16 vasal units had sperm in the testicular end of the vas at the time of vasectomy reversal. Six of 16 vasal units had pasty fluid and required VE, and 1 patient had a bilateral VE. The time from vasectomy was from 15 to 22 years. All patients postoperatively had sperm in the ejaculate from 1 to 200 million/cc, with 15% to 90% motility. Surgery resulted in 4 pregnancies leading to deliveries. Conclusions: PESA caused only limited trauma to the epididymis with 87.5% of patients able to have a vasovasostomy on at least one side. Vasoepididymostomy was more likely related to the duration from vasectomy than due to scarring from PESA. Reviewer’s Comments: This paper reports on an important question about a simple percutaneous procedure to retrieve sperm for IVF-ICSI. A select group of men will want to undergo vasectomy reversal after a failed IVF-ICSI cycle. This paper answers the concern about possible scarring from PESA–it does not appear to. The technique did not differ in outcome despite 3 different surgeons involved for both PESA and reversals. The study is, of course, limited by the small number, but this surgery is not performed very often. The ability to bypass/avoid scarring at the epididymis may be related to several ducts coming from the rete testes to become efferent ducts before becoming a single tubule. The caput is often the target for PESA; therefore, if any scarring occurs, then the other efferent ducts may provide sperm down the epididymis. (Reviewer–Ajay K. Nangia, MBBS).