Intraoperative decision making and challenging situations
Choosing between a VV and EV
The decision to perform a VV or an EV should be based on both the macroscopic and microscopic appearance of the fluid expressed from the testicular vasal segment. Clear fluid portends better patency and pregnancy rates while thick, pasty fluid is associated with worse outcomes (11,16). Microscopically, the presence of whole sperm predicts a better outcome than the appearance of sperm heads only or no sperm at all (17). Historically, the Silber scale has been used to evaluate the microscopic quality of the sample to guide the choice between VV and EV (11,12).
On the basis of recent work from Smith et al. which showed greater than 90% patency rates in men with a sample demonstrating sperm heads only and/or short tails, regardless of macroscopic fluid quality, the authors now put less emphasis on this variable and will perform a VV in any scenario in which sperm parts are seen (18). An EV is reserved for those cases in which neither whole sperm nor sperm parts are identified.
There are also circumstances in which fluid from the testicular vas initially shows no sperm but the quality of the sample changes over a short period of time. This is likely due to an accumulation of material near the vasectomy site that must clear in order for more proximal sperm-containing fluid to be expressed. If no sperm are seen on the initial side, the authors will often explore the contralateral side and then re-sample the first side after some time has passed. Not infrequently, this has yielded sperm-containing fluid and allowed for a VV.
The above finding is something to consider for the couple desiring a vasectomy reversal. In a sense, the decision making process is the confluence of expense, logistics of having the procedure, travel, experience of the surgeon, time since vasectomy and how important ones decision is based on whether a 10% chance of needing something that very few urologists do well or frequently (VE) makes in your “decision journey.”