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No differences in outcome of surgical sperm retrieval withintracytoplasmic sperm injection at different intervals after vasectomy
FERTILITY AND STERILITY威 VOL. 74, NO. 1, JULY 2000 Copyright ©2000 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A.
No differences in outcome of surgical sperm retrieval with intracytoplasmic sperm injection at different intervals after vasectomy Nares Sukcharoen, M.D.,a Tippawan Sithipravej, B.Sc. (Biology),b Sakchai Promviengchai, B.Sc. (Med. Tech),b Viwat Chinpilas, M.D.,b and Wisut Boonkasemsanti, M.D.a Chulalongkorn University and Nawabutra Center for Assisted Reproduction and Embryology, Bangkok, Thailand
Vasectomy is one of the most frequently performed minor operations for sterilization because of its safety and effectiveness. In view of the widespread use of vasectomy as a method of contraception, there is an increasing demand for vasectomy reversal. However, the pregnancy rate (PR) after vasectomy reversal is inversely related to the duration of the interval after vasectomy (1). Recently, intracytoplasmic sperm injection (ICSI) has been found to dramatically improve the results for the treatment of men who require surgical sperm retrieval because of obstructive azoospermia. Therefore, it is considered to be an option for the restoration of male fertility after vasectomy. To date, there are no data on the success of surgical sperm retrieval with ICSI at different intervals after vasectomy. We studied the effects of the time interval after vasectomy on the outcome of surgical sperm retrieval with ICSI. From January 1997 to August 1999, 17 patients with obstructive azoospermia from vasectomy underwent 21 cycles of ICSI and sperm retrieval at the Center for Assisted Reproduction and Embryology. Pituitary desensitization was usually achieved with the long or short protocol of GnRH-agonist administration. Superovulation was induced with individualized dose regimens of gonadotropins (2). HCG was administered as the ovulation trigger, and transvaginal oocyte retrieval was performed 36 hours later. Percutaneous epididymal sperm aspiration (PESA) was performed after oocyte retrieval. Testicular sperm extraction was performed in case of PESA failure. A comprehensive description of these procedures can be found in a previous report (2).
Received September 20, 1999; revised and accepted January 27, 2000. Reprint requests: Nares Sukcharoen, M.D., Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand (FAX: 6622549292). a Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University. b Nawabutra Center for Assisted Reproduction and Embryology. 0015-0282/00/$20.00 PII S0015-0282(00)00579-3
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After sperm retrieval, subsequent ICSI, assessment of fertilization, and embryo culture were performed using standard techniques (2). A maximum of three embryos was transferred to the uterine cavity either 72 or 96 hours after fertilization, and supernumerary embryos were cryopreserved at the two pronuclei stage. The luteal phase was supplemented with natural P pessaries given daily. Successful implantation was determined 14 days after ET by serum -hCG. A clinical pregnancy was confirmed as the presence of at least one gestational sac with a fetal heartbeat by transvaginal ultrasonography performed 3 weeks later. This clinical study was approved by the local ethics committee. The interval after vasectomy was calculated and rounded off to the nearest completed year from the actual or estimated date of vasectomy until the time of surgical sperm retrieval. Patients were classified into three groups according to the interval after vasectomy. Group I consisted of patients with an interval of 0 –10 years (n ⫽ 7); group II, 11–20 years (n ⫽ 6); and group III, ⬎20 years (n ⫽ 4). All results are expressed as means ⫾ SD. Between-group comparisons were performed with 2 test, Fisher’s exact test for categoric variables where applicable, and one-way analysis of variance for continuous variables. No statistically significant differences were noted among the groups with respect to the ages of both partners (Table 1). PESA was performed in all cases. Testicular sperm extraction was performed in two cases in which PESA failed because of severe adhesions. Although more MII oocytes were injected for women in groups I and II compared with group III, the fertilization rates were similar among the three groups. There were also no statistically significant differences in fertilization rates, implantation rates, PRs, and PRs per transfer among the groups (Table 1). The PR per transfer was lower in groups II and III but did not reach statistical significance.
TABLE 1 Characteristics of the patients and outcomes of surgical sperm retrieval and ICSI. Interval after vasectomy (y) Variable Characteristics of the patients No. of couples No. of cycles Age (y) Male Female Indication Failed vasectomy reversal Female problems requiring assisted reproduction Outcomes of surgical sperm retrieval and ICSI Total no. of retrieved oocytes Total no. of MII oocytes Mean no. of MII oocytes Range Fertilization rate No. of ETs No. of embryos transferred Implantation ratea PR PR per transferb
0–10 (Group I)
11–20 (Group II)
6 7
7 8
46.5 ⫾ 9.2 34.2 ⫾ 5.7
47.1 ⫾ 7.7 35.9 ⫾ 3.6
2 4 110 92 16.0 ⫾ 11.9 1–25 77/92 (83.7) 6 18 4/18 (22.2) 3/6 (50) 3/6 (50)
5 2 133 107 15.1 ⫾ 8.2 1–22 85/107 (79.4) 11 33 5/33 (15.2) 4/7 (57.1) 4/11 (36.4)
⬎20 (Group III)
P value
4 6
— —
51.2 ⫾ 2.2 35.8 ⫾ 6.7
.543 .631
3 1
— —
65 44 5.7 ⫾ 2.2 4–9 39/44 (88.6) 7 18 3/18 (16.7) 2/4 (50) 2/7 (28.6)
— — .295 — .378 — — .276 .959 .724
Note: Values are n, mean ⫾ SD, or n (%), except as indicated. a Implantation rate ⫽ number of implanted embryos per number of embryos replaced in the uterine cavity. b PR per transfer ⫽ number of pregnancies per number of ETs. Sukcharoen. Surgical sperm retrieval outcome. Fertil Steril 2000.
Microsurgical vasectomy reversal has proved to be a highly successful procedure. With good surgical technique, vasectomy reversal should successfully achieve patency rates of 70% to 97% and PRs of 30% to 76%, with an inverse relation between the interval after vasectomy and fertility after vasectomy reversal (1). Several factors have been shown to influence the likelihood of success. About half of the failures of vasectomy reversal result from stenosis or blockage of the anastomosis site. The second most common cause is epididymal blockage, presumably caused by back pressure from the site of the vasectomy, causing the rupture of epididymal tubules with local sperm granuloma formation. As the time interval after the vasectomy procedure increases, the risk of secondary epididymal obstruction also increases (3). Antisperm antibody formation also has been claimed to decrease fertility after vasectomy reversal. A time-related formation of antisperm antibodies in men after vasectomy has been demonstrated (4). However, surgical sperm retrieval with ICSI can bypass all of the factors that interfere with fertility in men with a prolonged interval after vasectomy and also can improve the female fertility problems that may occur concomitantly. Our results revealed no statistically significant differences in fertilization rates, implantation rates, or PRs among the three groups with different intervals after vasectomy. In this study, sperm retrieval and ICSI at different intervals after vasectomy gave a constant clinical PR of approximately 50%. The
FERTILITY & STERILITY威
PR after vasectomy reversal exceeds the clinical PR for one cycle of surgical sperm retrieval and ICSI in couples with obstructive azoospermia for all intervals of up to 10 years after vasectomy. If the interval after vasectomy is ⬎10 years, surgical sperm retrieval may be considered an alternative option. In conclusion, our results suggest that the interval between vasectomy and surgical sperm retrieval with ICSI treatment has no effect on the outcome. Because of the small number of patients, this study may have limited power to detect a statistically significant difference. The results of this study may be helpful in counseling vasectomized men who request reestablishment of fertility after vasectomy and in selecting patients for the appropriate optional treatment. Surgical sperm retrieval with ICSI is a useful treatment option after vasectomy for selected azoospermic men.
References 1. Belker AM, Thomas AJ Jr, Fuchs EF, Konnak JW, Sharlip ID. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol 1991;145:505–11. 2. Sukcharoen N, Sithipravej T, Promviengchai S, Chinpilas V, Boonkasemsanti W. Comparison of the fertilization rate after intracytoplasmic sperm injection (ICSI) using ejaculated sperm, epididymal sperms, and testicular sperms. J Med Assoc Thai 1998;81:565–71. 3. Matthews GJ, Schlegel PN, Goldstein M. Patency following microsurgical vasoepididymostomy and vasovasostomy: temporal considerations. J Urol 1995;154:2070 –3. 4. Heidenreich A, Bonfig R, Wilbert DM, Strohmaier WL, Engelmann UH. Risk factors for antisperm antibodies in infertile men. Am J Reprod Immunol 1994;31:69 –76.
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No differences in outcome of surgical sperm retrieval with intracytoplasmic sperm injection at different intervals after vasectomy Nares Sukcharoen, M.D.,a Tippawan Sithipravej, B.Sc. (Biology),b Sakchai Promviengchai, B.Sc. (Med. Tech),b Viwat Chinpilas, M.D.,b and Wisut Boonkasemsanti, M.D.a Chulalongkorn University and Nawabutra Center for Assisted Reproduction and Embryology, Bangkok, Thailand
Vasectomy is one of the most frequently performed minor operations for sterilization because of its safety and effectiveness. In view of the widespread use of vasectomy as a method of contraception, there is an increasing demand for vasectomy reversal. However, the pregnancy rate (PR) after vasectomy reversal is inversely related to the duration of the interval after vasectomy (1). Recently, intracytoplasmic sperm injection (ICSI) has been found to dramatically improve the results for the treatment of men who require surgical sperm retrieval because of obstructive azoospermia. Therefore, it is considered to be an option for the restoration of male fertility after vasectomy. To date, there are no data on the success of surgical sperm retrieval with ICSI at different intervals after vasectomy. We studied the effects of the time interval after vasectomy on the outcome of surgical sperm retrieval with ICSI. From January 1997 to August 1999, 17 patients with obstructive azoospermia from vasectomy underwent 21 cycles of ICSI and sperm retrieval at the Center for Assisted Reproduction and Embryology. Pituitary desensitization was usually achieved with the long or short protocol of GnRH-agonist administration. Superovulation was induced with individualized dose regimens of gonadotropins (2). HCG was administered as the ovulation trigger, and transvaginal oocyte retrieval was performed 36 hours later. Percutaneous epididymal sperm aspiration (PESA) was performed after oocyte retrieval. Testicular sperm extraction was performed in case of PESA failure. A comprehensive description of these procedures can be found in a previous report (2).
Received September 20, 1999; revised and accepted January 27, 2000. Reprint requests: Nares Sukcharoen, M.D., Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand (FAX: 6622549292). a Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University. b Nawabutra Center for Assisted Reproduction and Embryology. 0015-0282/00/$20.00 PII S0015-0282(00)00579-3
174
After sperm retrieval, subsequent ICSI, assessment of fertilization, and embryo culture were performed using standard techniques (2). A maximum of three embryos was transferred to the uterine cavity either 72 or 96 hours after fertilization, and supernumerary embryos were cryopreserved at the two pronuclei stage. The luteal phase was supplemented with natural P pessaries given daily. Successful implantation was determined 14 days after ET by serum -hCG. A clinical pregnancy was confirmed as the presence of at least one gestational sac with a fetal heartbeat by transvaginal ultrasonography performed 3 weeks later. This clinical study was approved by the local ethics committee. The interval after vasectomy was calculated and rounded off to the nearest completed year from the actual or estimated date of vasectomy until the time of surgical sperm retrieval. Patients were classified into three groups according to the interval after vasectomy. Group I consisted of patients with an interval of 0 –10 years (n ⫽ 7); group II, 11–20 years (n ⫽ 6); and group III, ⬎20 years (n ⫽ 4). All results are expressed as means ⫾ SD. Between-group comparisons were performed with 2 test, Fisher’s exact test for categoric variables where applicable, and one-way analysis of variance for continuous variables. No statistically significant differences were noted among the groups with respect to the ages of both partners (Table 1). PESA was performed in all cases. Testicular sperm extraction was performed in two cases in which PESA failed because of severe adhesions. Although more MII oocytes were injected for women in groups I and II compared with group III, the fertilization rates were similar among the three groups. There were also no statistically significant differences in fertilization rates, implantation rates, PRs, and PRs per transfer among the groups (Table 1). The PR per transfer was lower in groups II and III but did not reach statistical significance.
TABLE 1 Characteristics of the patients and outcomes of surgical sperm retrieval and ICSI. Interval after vasectomy (y) Variable Characteristics of the patients No. of couples No. of cycles Age (y) Male Female Indication Failed vasectomy reversal Female problems requiring assisted reproduction Outcomes of surgical sperm retrieval and ICSI Total no. of retrieved oocytes Total no. of MII oocytes Mean no. of MII oocytes Range Fertilization rate No. of ETs No. of embryos transferred Implantation ratea PR PR per transferb
0–10 (Group I)
11–20 (Group II)
6 7
7 8
46.5 ⫾ 9.2 34.2 ⫾ 5.7
47.1 ⫾ 7.7 35.9 ⫾ 3.6
2 4 110 92 16.0 ⫾ 11.9 1–25 77/92 (83.7) 6 18 4/18 (22.2) 3/6 (50) 3/6 (50)
5 2 133 107 15.1 ⫾ 8.2 1–22 85/107 (79.4) 11 33 5/33 (15.2) 4/7 (57.1) 4/11 (36.4)
⬎20 (Group III)
P value
4 6
— —
51.2 ⫾ 2.2 35.8 ⫾ 6.7
.543 .631
3 1
— —
65 44 5.7 ⫾ 2.2 4–9 39/44 (88.6) 7 18 3/18 (16.7) 2/4 (50) 2/7 (28.6)
— — .295 — .378 — — .276 .959 .724
Note: Values are n, mean ⫾ SD, or n (%), except as indicated. a Implantation rate ⫽ number of implanted embryos per number of embryos replaced in the uterine cavity. b PR per transfer ⫽ number of pregnancies per number of ETs. Sukcharoen. Surgical sperm retrieval outcome. Fertil Steril 2000.
Microsurgical vasectomy reversal has proved to be a highly successful procedure. With good surgical technique, vasectomy reversal should successfully achieve patency rates of 70% to 97% and PRs of 30% to 76%, with an inverse relation between the interval after vasectomy and fertility after vasectomy reversal (1). Several factors have been shown to influence the likelihood of success. About half of the failures of vasectomy reversal result from stenosis or blockage of the anastomosis site. The second most common cause is epididymal blockage, presumably caused by back pressure from the site of the vasectomy, causing the rupture of epididymal tubules with local sperm granuloma formation. As the time interval after the vasectomy procedure increases, the risk of secondary epididymal obstruction also increases (3). Antisperm antibody formation also has been claimed to decrease fertility after vasectomy reversal. A time-related formation of antisperm antibodies in men after vasectomy has been demonstrated (4). However, surgical sperm retrieval with ICSI can bypass all of the factors that interfere with fertility in men with a prolonged interval after vasectomy and also can improve the female fertility problems that may occur concomitantly. Our results revealed no statistically significant differences in fertilization rates, implantation rates, or PRs among the three groups with different intervals after vasectomy. In this study, sperm retrieval and ICSI at different intervals after vasectomy gave a constant clinical PR of approximately 50%. The
FERTILITY & STERILITY威
PR after vasectomy reversal exceeds the clinical PR for one cycle of surgical sperm retrieval and ICSI in couples with obstructive azoospermia for all intervals of up to 10 years after vasectomy. If the interval after vasectomy is ⬎10 years, surgical sperm retrieval may be considered an alternative option. In conclusion, our results suggest that the interval between vasectomy and surgical sperm retrieval with ICSI treatment has no effect on the outcome. Because of the small number of patients, this study may have limited power to detect a statistically significant difference. The results of this study may be helpful in counseling vasectomized men who request reestablishment of fertility after vasectomy and in selecting patients for the appropriate optional treatment. Surgical sperm retrieval with ICSI is a useful treatment option after vasectomy for selected azoospermic men.
References 1. Belker AM, Thomas AJ Jr, Fuchs EF, Konnak JW, Sharlip ID. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol 1991;145:505–11. 2. Sukcharoen N, Sithipravej T, Promviengchai S, Chinpilas V, Boonkasemsanti W. Comparison of the fertilization rate after intracytoplasmic sperm injection (ICSI) using ejaculated sperm, epididymal sperms, and testicular sperms. J Med Assoc Thai 1998;81:565–71. 3. Matthews GJ, Schlegel PN, Goldstein M. Patency following microsurgical vasoepididymostomy and vasovasostomy: temporal considerations. J Urol 1995;154:2070 –3. 4. Heidenreich A, Bonfig R, Wilbert DM, Strohmaier WL, Engelmann UH. Risk factors for antisperm antibodies in infertile men. Am J Reprod Immunol 1994;31:69 –76.
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