Vasectomy

Question 1

vasectomy reversal

Answer 1

Male and female partner and respective health and reproductive histories
Size and consistency of both testis, gap between vasa easily palpable
Perform semen analysis
Chances of success based on expertise of surgeon, the method used to perform original procedure, patient health history age and reproductive potential of partner
6% rate of asking for reversal, remarriage and desire to have children with new spouse

Question 2

techniques vasectomy reversal

Answer 2

• Multilayer vasovasotomy – mucosal and muscularis sutures
• Modified single layer vasovasotomy
• Inguinal vasovasotomy – if obstruction of vas in inguinal canal, i.e. after hernia repair
• Epididymovasotomy- required in 20-30% if secondary obstruction at level of epididymis, greater change if longer time. Do cryopreservation of sperm using introperative epididymal sperm aspiration
Must ensure perivasal adventitia intact – ischaemia and stenosis
Can be offered sperm retrieval at the same time, then can have sperm stored for ICSI use
9-0 / 10-0 sutures

Question 3

checking for vas patency during vaso vasotomy

Answer 3

Based on quality of fluid found in the proximal vas during surgery
400x magnification using a light microscope
Perform vasoepididymostomy if
Material thick and devoid of sperm
Fluid creamy and containing debris
No fluid whatsoever when vas is milked towards cut end

Question 4

success rate reversal Belker data

Answer 4

<3 year since vasectomy = patency rate 97%, pregnancy rate 76%
3- 8 since vasectomy = 88%, 53%
9-14 = 79%, 44%
>15 71% and 30%

upto 15 yrs since vasectomy better pregnancy rate vs IVF/ICSI
Belker AM, J Urol 1991, 145: 505-11)

Question 5

time taken sperm return

Answer 5

proximal site of obstruction or longer period of obstruction increases chance of EV vs VV, which has a lower rate of success, and longer time to sperm in ejaculate up to 18months

Question 6

concurrent SSR

Answer 6

Given proximal location of site of vasectomy on left may require EV on that side

Can give option for Surgical Sperm Retrieval at same time as anatomy exposed, and allow banking of sperm tissue for future IVF/ICSI if reversal fails
Higher score if remembers needs clear viral screen pre-op if Surgical Sperm Retrieval planned within 3 months of surgery, and pt will incur additional storage costs for SSR

Question 7

how do VV

Answer 7

Appropriately consented pt – aware of risk of failure (early/ late- due to recurrent obstruction), small risk bleeding , infection and pain
Need to avoid heavy lifting post op, and to avoid ejaculation for at 2-3/12 post op
Need to be aware of 3-l6 months to optimum semen parameters if VV.

Needs to be aware of possible need for epididymo-vasostomy (EV) dependent on operative findings. This carries a lower comparative chance of success vs VV, and a possible longer delay to optimum semen parameters of up to 12-18months (Matthews et al. J.Urol. 1995; 154, 2070)