Category Archives: Georgia vasectomy reversal.

What a pleasant surprise!

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Recently in the course of a busy clinic day I entered a room to perform a vasectomy. The patient was all set up for the procedure and as I moved the instruments closer to the table, I asked if he had any questions for me before we started. He said, “No, I’ve been through this before.”

I asked, “How do you mean?”

He said, “I’ve already had a vasectomy before…and a reversal…by you.”

“Did it work, I hope,” I asked.

“Oh yes, we have two boys thanks to you.”

After the procedure I “re-met” the wife and saw the pictures of their children. The couple was very gracious to me. I was moved by their gratitude. This sequence of events certainly made my day and maybe my month and presented itself as a total surprise.

The kind of surprise one loves!

Does it matter how you seal the severed ends of the vas deferns…for a vasectomy or a reversal?

vas fulguration cropped

No…

In terms of a vasectomy, there are several ways to seal the vas. Whether you use clips, suture, or fulgurate (as seen above-which is my preferred method) the success of a vasectomy is essentially the same and is the preference of the surgeon.

In terms of performing a reversal, a vasectomy having used clips makes it a bit easier to find the affected area, but in the big scheme of things the method used does not influence outcome or affecting the ease of the reversal.

Angled vas cutter…an arrow in the quiver of the vasectomy reversal doctor.

assi-nhf3-15

Fertil Steril. 2014 Mar;101(3):636-639.e2. doi: 10.1016/j.fertnstert.2013.11.014. Epub 2013 Dec 17.

Angled vas cutter for vasovasostomy: technique and results.

Abstract

OBJECTIVE:

To describe the technique and results of bilateral vasovasostomy using a 3-mm vas cutting forceps angled at 15° (catalog no. NHF-3.15; ASSI) for vasal transection.

DESIGN:

Retrospective chart review. Institutional review board approval was granted by Western Institutional Review Board.

SETTING:

Single vasectomy reversal center.

PATIENT(S):

Men who underwent a bilateral vasovasostomy at a single institution by a single surgeon between 2001 and 2012 and had a minimum of one semen analysis postoperatively or a reported natural conception.

INTERVENTION(S):

Before September 14, 2010, a straight-edge vas cutter was used on all vasovasostomy connections; 375 men received a bilateral vasovasostomy and met follow-up criteria. Beginning on September 14, 2010, an angled cutter was used on all vasovasostomy patients, with 194 men meeting the exclusion criteria.

MAIN OUTCOME MEASURE(S):

A minimum of 1 × 10(6) sperm reported on a postoperative semen analysis, or a reported natural conception was used to establish patency.

RESULT(S):

The overall vasovasostomy patency rate using the angled vas cutter was 99.5% and was 95.7% using the straight vas cutter.

CONCLUSION(S):

The development of an angled vas cutter provides an increased surface area for vasal wound healing to allow for larger tissue diameter for better healing, resulting in high patency rates after vasovasostomy.

KEYWORDS:

Vasovasostomy; patency

Vasectomy Reversal: A “preoperative” predictor of better than average results?

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This is the isolated vas deferens at the time of a reversal. You can see the clips and a mass effect of the body’s attempt at healing the vasectomy “trauma.” This is called a sperm granuloma. Note the vas tubes going into the mass of healing and clips. Both sides are normal in appearance and normal caliber.

What a granuloma does is act as a “pop off” valve and releases some degree of pressure on the testicles. This in turn makes for less damage to the testicles and allows them to rebound sooner from a reversal. In many cases it will also improve the character of the fluid at the time of the reversal (which is also a favorable finding for the percentages of success).

So, if you are considering a reversal and in the shower examine yourself and feel a knot along the course of the vas tube above the testicle, this is a favorable sign and that you may have a better than average success rate for both patency  and pregnancy.

Just a small and interesting caveat for the couple thinking about reversing a vasectomy.

Is the VE (Vasoepididymostomy) over touted and over done?

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.”

 

Take away? Success of vasectomy reversal not always related to the age of the patient. This is a common concern.

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Time to Sperm Appearance Can Be Predicted After Vasectomy Reversal

Urology – November 30, 2007 – Vol. 23 – No. 08

After vasectomy reversal, motile sperm observed intraoperatively at the testicular vas, undergoing vasovasostomy, and an obstructive interval of <=8 years predict shorter time to appearance of sperm in the ejaculate.

Article Reviewed: The Kinetics of the Return of Motile Sperm to the Ejaculate After Vasectomy Reversal. Yang G, Walsh TJ, et al: J Urol; 2007; 177 (June): 2272-2276.

The Kinetics of the Return of Motile Sperm to the Ejaculate After Vasectomy Reversal.

Yang G, Walsh TJ, et al:
J Urol; 2007; 177 (June): 2272-2276

Objective: To study the time to appearance of sperm in the ejaculate for men undergoing vasectomy reversal. Design: Retrospective chart review of men who had undergone bilateral vasovasostomy, bilateral epididymovasostomy, or a combination of vasovasostomy on 1 side and epididymovasostomy on the other. Participants/Methods: 150 men whose records included intraoperative findings with type of reversal performed, record of sperm presence or absence, and associated fluid findings from each testicular vas deferens. Results: Presence of motile sperm in vasa was associated with a shorter time to postoperative presence of sperm observed in the ejaculate: 95% of men with motile sperm in the intraoperative vasal specimen were observed to have sperm in the ejaculate by 6 months after vasectomy reversal compared to 76% of men without motile sperm in the intraoperative specimen (P =0.04). Features correlated with a shorter onset to the observation of sperm in the ejaculate within the first 3 months after vasectomy reversal included an obstructive interval of <=8 years and vasovasostomy rather than epididymovasostomy.

Patient age did not affect time to the observation of sperm in the ejaculate after vasectomy reversal.

Conclusions: Motile sperm observed intraoperatively at the testicular vas, undergoing vasovasostomy, and an obstructive interval of <=8 years predict shorter time to the appearance of sperm in the ejaculate after vasectomy reversal. Reviewer’s Comments: The similarity with previous studies by other investigators of time to sperm seen in the ejaculate, with an average of 3.2 months for vasovasostomy and 6.3 months for epididymovasostomy, provides excellent counseling information for couples considering vasectomy reversal. (Reviewer–Craig S. Niederberger, MD).

 

Predictive factors in sperm appearance after vasectomy reversal.

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Patient’s often ask, “What is your success rate?” The successful reversal is heavily influenced by the quality of the fluid at the testicular end at the time of the reversal and the time interval since the vasectomy. JM

Time to Sperm Appearance Can Be Predicted After Vasectomy Reversal

Urology – November 30, 2007 – Vol. 23 – No. 08

After vasectomy reversal, motile sperm observed intraoperatively at the testicular vas, undergoing vasovasostomy, and an obstructive interval of <=8 years predict shorter time to appearance of sperm in the ejaculate.

Article Reviewed: The Kinetics of the Return of Motile Sperm to the Ejaculate After Vasectomy Reversal. Yang G, Walsh TJ, et al: J Urol; 2007; 177 (June): 2272-2276.

The Kinetics of the Return of Motile Sperm to the Ejaculate After Vasectomy Reversal.

Yang G, Walsh TJ, et al:
J Urol; 2007; 177 (June): 2272-2276

Objective: To study the time to appearance of sperm in the ejaculate for men undergoing vasectomy reversal. Design: Retrospective chart review of men who had undergone bilateral vasovasostomy, bilateral epididymovasostomy, or a combination of vasovasostomy on 1 side and epididymovasostomy on the other. Participants/Methods: 150 men whose records included intraoperative findings with type of reversal performed, record of sperm presence or absence, and associated fluid findings from each testicular vas deferens.

Results: Presence of motile sperm in vasa was associated with a shorter time to postoperative presence of sperm observed in the ejaculate: 95% of men with motile sperm in the intraoperative vasal specimen were observed to have sperm in the ejaculate by 6 months after vasectomy reversal compared to 76% of men without motile sperm in the intraoperative specimen (P =0.04). Features correlated with a shorter onset to the observation of sperm in the ejaculate within the first 3 months after vasectomy reversal included an obstructive interval of <=8 years and vasovasostomy rather than epididymovasostomy. Patient age did not affect time to the observation of sperm in the ejaculate after vasectomy reversal.

Conclusions: Motile sperm observed intraoperatively at the testicular vas, undergoing vasovasostomy, and an obstructive interval of <=8 years predict shorter time to the appearance of sperm in the ejaculate after vasectomy reversal. Reviewer’s Comments: The similarity with previous studies by other investigators of time to sperm seen in the ejaculate, with an average of 3.2 months for vasovasostomy and 6.3 months for epididymovasostomy, provides excellent counseling information for couples considering vasectomy reversal. (Reviewer–Craig S. Niederberger, MD).

 

Vasectomy Reversal vs. IVF…which is better?

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Rev Hosp Clin Fac Med Sao Paulo. 2004 Oct;59(5):312-5. Epub 2004 Oct 29.

The best infertility treatment for vasectomized men: assisted reproduction or vasectomy reversal?

Abstract

In men with prior vasectomy, microsurgical reconstruction of the reproductive tract is more cost-effective than sperm retrieval with in vitro fertilization and intracytoplasmic sperm injection if the obstructive interval is less than 15 years and no female fertility risk factors are present. If epididymal obstruction is detected or advanced female age is present, the decision to use either microsurgical reconstruction or sperm retrieval with in vitro fertilization and intracytoplasmic sperm injection should be individualized. Sperm retrieval with in vitro fertilization and intracytoplasmic sperm injection is preferred to surgical treatment when female factors requiring in vitro fertilization are present or when the chance for success with sperm retrieval and intracytoplasmic sperm injection exceeds the chance for success with surgical treatment.

How important is the intravasal fluid in patient undergoing a vasectomy reversal?

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The essence of the below study is that it is reasonable and proper to perform a vasovasotomy (cut out the vasectomy scar and and reconnect good vas to good vas) when the fluid is not “favorable.” That indeed the vasoepididymostomy may be performed too often and unnecessarily and with less favorable results.

Indian J Urol. 2014 Apr-Jun; 30(2): 164–168.

Conclusion:

This study suggests that VV (vasovasostomy) is the preferred method of reconstruction during vasectomy reversal (VR) when SHST (sperm heads and short tails) are present within the intravasal fluid.

The high patency rates in this cohort exceed the expected patency of EV (epididymovasostomy), despite poor fluid quality and longer occlusive intervals.

Our study adds further credence to the growing body of literature suggesting that VV is preferred in this subpopulation of men undergoing VR. Urologic microsurgeons may be reassured about performing VV in the setting of SHST irrespective of fluid quality and occlusive interval.