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.
An antisperm antibody test looks for special proteins (antibodies) that fight against a man’s sperm in blood, vaginal fluids, or semen. The test uses a sample of sperm and adds a substance that binds only to affected sperm. Semen can cause an immune system response in either the man’s or woman’s body.
Antisperm antibodies were measured in serum and seminal plasma in 130 males before and after vasectomy reversal and the occurrence of pregnancy was analysed in the partners of 77 who were followed for more than one year. Sperm-agglutinating antibodies were found in the serum of 79% of patients; seminal plasma antibodies were present in only 9.5% before reversal and this rose to 26% afterwards. Pregnancies occurred in the partners of 53% of those men who were trying to produce children. A pregnancy was significantly less likely when the pre-operative serum antisperm antibody titre was 512 or more, but no decrease in fertility was seen with titres below this. Several pregnancies were produced by patients with seminal plasma antibodies, but numbers and follow-up are too small to permit detailed analysis.
A randomised controlled trial of peri-operative steroids showed that they produced no benefit.
The antisperm antibodies associated with vasectomy reversal appear to differ fundamentally from those occurring in naturally subfertile males.
Even after prolonged obstructive intervals of 15 to 20 years, vasectomy reversal offers better or comparable success rates to intracytoplasmic sperm injection.
Article Reviewed: Outcomes for Vasectomy Reversal Performed After Obstructive Intervals of at Least 10 Years. Kolettis PN, Sabanegh ES, et al: Urology 2002; 60 (November): 885-888.
Outcomes for Vasectomy Reversal Performed After Obstructive Intervals of at Least 10 Years.
Kolettis PN, Sabanegh ES, et al:
Urology 2002; 60 (November): 885-888Objective: To determine the outcomes for vasectomy reversal performed after at least 10 years of obstruction. Methods: 74 vasectomy reversal procedures were performed in 70 patients after obstructive intervals of 10 to 24 years (mean, 14.5 years). These patients were retrospectively reviewed for patency and pregnancy rates. Results: The overall pregnancy rate was 37%. Patency rates for an obstructive interval of 10 to 15 years, 16 to 19 years, and >=20 years were 74%, 87%, and 75%, respectively. Pregnancy rates for these same periods were 40%, 36%, and 27%, respectively. Assuming a live delivery rate per cycle of 25% for intracytoplasmic sperm injection (ICSI), the delivery rate for vasectomy reversal would not be exceeded until an obstructive interval of at least 20 years.
Conclusions: The authors believe that even after prolonged obstructed intervals, vasectomy reversal offers better or comparable success rates to ICSI. Depending on their success rates at various medical centers, a threshold obstructive interval probably exists at which ICSI surpasses vasectomy reversal.
Reviewer’s Comments: This is, in my opinion, a clinically worthwhile paper. It clearly shows the pregnancy and delivery rates in patients who have undergone vasectomy reversal surpass the historical success rates of ICSI even after prolonged obstructive intervals. In addition, vasectomy reversal avoids the complication associated with multiple births, which is commonly seen after ICSI and is cheaper. In summary, even in patients with prolonged obstructive intervals after vasectomy, vasectomy reversal is probably more effective, cheaper, and less complicated than is ICSI. (Reviewer-George S. Benson, MD).
A lot of couples debate which of the two major methods of having a child after vasectomy they should pursue. Often times it is a decision based on cost. For that couple wanting to do IVF first, this study shows no significant scarring as a result of the aspiration and no significant negative effect to a successful vasectomy reversal.
Vasectomy Reversal Possible After PESA
Urology – July 30, 2008 – Vol. 24 – No. 07
Vasectomy reversal is possible after percutaneous sperm aspiration.
Article Reviewed: Results of Vasovasostomy or Vasoepididymostomy After Failed Percutaneous Epididymal Sperm Aspirations. Marmar JL, Sharlip I, Goldstein M: J Urol; 2008; 179 (April): 1506-1509.
Results of Vasovasostomy or Vasoepididymostomy After Failed Percutaneous Epididymal Sperm Aspirations.
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).