Colpi GM, Negri L, Patrizio P, Pardi G.

Fertility restoration by seminal tract washout in ejaculatory duct obstruction. J Urol 1995; 153: 1948-1950.

5. VASECTOMY AND VASECTOMY REVERSAL

Vasectomy is the most simple and effective method of permanent surgical sterilization.

A man undergoing vasectomy should be interested in permanent surgical contraception.

Although the possibility of vasectomy reversal should be discussed initially, the patient should be informed about the failure rate.

Surgical techniques

The surgeon can choose the technique that is most appropriate. One standard technique is cauterization and

ligation of the vasal lumina. Fascial interposition between the vasal ends is recommended [1]. Another

recommended technique is the no-scalpel vasectomy [2].

Both techniques can be safely performed as an outpatient procedure under local anaesthesia.

Complications

Local complications include haematoma, wound infection and epididymitis.

Haematoma is the most common early complication of vasectomy, which occurs in 1 % of cases [3]. As a minor complication, chronic testicular pain may develop [1]. Vasectomy does not significantly alter spermatogenesis and Leydig cell function [1]. Epididymal tubular damage (blow-out) is common, with consequent development of sperm granuloma. Presence of antisperm antibodies after vasectomy is typical [4]. The volume of ejaculate remains unchanged.

Potential systemic effects of vasectomy, including atherosclerotic diseases and interactions with genitourinary cancer, have not been proven. From long-term studies there is no evidence of a significant increase in any systemic disease after vasectomy [1].

Vasectomy failure

The failure rate of vasectomy is less than 1 %.

Paternity consequent on recanalization can occur at any time after vasectomy and does not depend on the

surgical procedure [5]. No motile spermatozoa should be detected 6-8 weeks after vasectomy; their presence

is a sign of early recanalization [6]. If azoospermia fails to occur within 3 months, the procedure should be

repeated.

Every patient has to be informed preoperatively that long-term recanalization may occur very rarely [5].

In summary, counselling has to address the following items concerning vasectomy:

? It is not irreversible

? It has complications

? It has a failure rate

? It needs normal methods of contraception after operation until evidence of azoospermia.

5.1 Conclusion

All available data indicate that vasectomy is safe and not associated with any serious, long-term side-effects.

Vasectomy reversal

There are at present no standardized and uniform criteria in reporting the results of vasectomy reversal. A wide range of surgical success rates have been published, up to 90% [7,8], depending on time that has elapsed since vasectomy, type of vasectomy (e.g. open-ended or sealed), type of reversal (vasovasostomy or vasoepididymostomy), whether reversal was unilateral or bilateral. The reversal technique used (macrosurgical or microsurgical, one-layer or two-layer anastomosis), surgeon skill and experience, presence or absence of other pathology (e.g. varicocele) and presence or absence of sperm antibodies. When case series are reported over a long period of time, there may be an improvement of anatomical or functional success due to improved technical skill of the surgeon, magnification and smaller suture materials used. Personal experience with a particular technique is an important factor in success.

Although there are no randomized controlled trials that compare macrosurgery (loops) and microsurgery for vasovasostomy, reports from case series indicate better results after microsurgery. Therefore, microsurgical vasectomy reversal is strongly recommended as the standard method.

Reported vasovasostomy results have shown patency rates (up to 90%) superior to pregnancy rates.

Lenght of time since vasectomy

Reported vasovasostomy results have shown patency rates (up to 90%) superior to pregnancy rates. The reason for this discrepancy remains unclear [9]. However, the longer the interval from vasectomy to reversal, the lower the pregnancy rates. In a multicentre study, Belker et al. [8] followed 1,469 men who had undergone microsurgical vasectomy reversal at five different institutions in a 9-year period. Patency and pregnancy rates, respectively, were 97% and 76% if the interval had been 3 years after vasectomy, 88% and 53% for 3-8 years, 79% and 44% for 9-14 years and 71 % and 30% for 15 years or longer.

Epidiclymovasotomy

The necessity of epididymovasostomy in some cases after vasectomy has been discussed before (see above

Obstructive azoospermia).

Microsurgical vasectomy reversal versus epididymal or testicular sperm retrival and ICSI. An effectiveness analysis [10] evaluated two different initial approaches for treatment of post-vasectomy infertility. Microsurgical vasectomy reversal was compared with epididymal or testicular sperm retrieval and ICSI. The delivery rate was 47% after vasectomy reversal and 33% after one cycle of sperm retrieval and ICSI. Similar findings were reported by other authors [11] who observed a patency rate of 85% after 6 months with a pregnancy rate of 44% after one year, which led to a live delivery rate of 36%. Compared with a calculated 29% delivery rate for MESA and ICSI, this provides strong evidence for the advantage of simple vasectomy reversal over sperm retrieval and ICSI.

Conclusions

The most cost-effective approach to treatment of post-vasectomy infertility is microsurgical reversal.

The most cost-effective approach to treatment of post-vasectomy infertility is microsurgical reversal.This also has the highest chance of delivery of a child for a single intervention. Successful vasectomy reversal will also mean that further pregnancies may result and unlike ICSI, conception follows normal intercourse without intervention for the female partner with the associated risks of ovarian hyperstimulation and multiple pregnancies. ??8???8? and ICSI should be reserved for failed surgery or cases not amenable to surgical reconstruction.

References

Date: 2016-06-12; view: 266