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Superior outcomes of microsurgical vasectomy reversal in men with the same female partners
FERTILITY AND STERILITY威 VOL. 81, NO. 5, MAY 2004 Copyright ©2004 American Society for Reproductive Medicine Published by Elsevier Inc. Printed on acid-free paper in U.S.A.
Superior outcomes of microsurgical vasectomy reversal in men with the same female partners Peter T. K. Chan, M.D.,a,b and Marc Goldstein, M.D.a Department of Urology, Cornell Institute for Reproductive Medicine, Weill Medical College of Cornell University, New York, New York
Objective: To evaluate the outcomes of vasectomy reversals in men with the same female partners. Design: Retrospective analysis with comparison with a historical cohort. Setting: University hospital. Patient(s): Among 1,048 patients who underwent microsurgical vasectomy reversal from 1986 to 2002, 27 men (2.6%) were identified who had the same partners as before their vasectomy. Intervention(s): Microsurgical vasovasostomy or vasoepididymostomy. Main Outcome Measure(s): Semen parameters, clinical pregnancy, and live birth rates. Result(s): The mean age of the men was 38.5 years, and 37.2 years for their female partners. The reasons for vasectomy reversal were death of a child in 33% of cases and desire for more children in 66% of cases. The overall patency rate was 100% at 1 month postoperatively, with an average sperm concentration of 30 million/mL and 24% motility. Among patients with follow-up beyond 1 year, the natural pregnancy rate was 86%, which was achieved at 8.3 months postoperatively, with a live birth rate of 82%. The live birth rate in couples with the death of a child was 100%. Conclusion(s): The outcomes of vasectomy reversal in men with the same female partners are better than for men with new partners. Possible reasons for these superior results are previous proven fecundity as a couple, shorter time interval since vasectomy, and emotional dedication. (Fertil Steril威 2004;81:1371⫺4. ©2004 by American Society for Reproductive Medicine.) Key Words: Vasectomy reversal, vasovasostomy, vasoepididymostomy, infertility, obstructive azoospermia Received May 28, 2003; revised and accepted September 30, 2003. Reprint requests: Peter Chan, M.D., S 6.95, Department of Urology, Royal Victoria Hospital, McGill University Health Centre, 687 Pine West, Montreal, Quebec, Canada H3A 1A1 (FAX: 514-8431552; E-mail: Peter.Chan@ muhc.mcgill.ca). a Cornell Institute for Reproductive Medicine, Center for Male Reproductive Medicine and Microsurgery, New York, New York. b Department of Urology, McGill University Health Centre, Montreal, Quebec, Canada. 0015-0282/04/$30.00 doi:10.1016/j.fertnstert.2003. 09.066
Vasectomy reversal with microsurgical vasovasostomy or vasoepididymostomy has been established by various studies (1–3) as a more cost-effective fertility management option compared with up-front assisted reproduction. With the advances in the microsurgical techniques witnessed in the recent years, the postoperative patency rate for vasoepididymostomy and vasovasostomy can be as high as 80%–99%, with approximately half of these patients being able to achieve natural pregnancy (4 – 8). Most men who opt for vasectomy reversal do so because of divorce and remarriage to new partners who desire children. In a small subgroup of patients, vasectomy reversals are performed while they are with the same female partners. The reasons for their reversal are generally due to either the death of a child or a
change of heart after vasectomy leading to a desire for more children. The objective of this study was to evaluate the surgical outcomes of vasectomy reversal in men who are with the same female partners.
MATERIALS AND METHODS From 1986 to 2002, all cases of vasectomy reversal performed in a university tertiary-care center by the same surgeon (MG) were reviewed retrospectively. All cases in which the men remained with the same female partner for more than 3 years after vasectomy reversal were included in the analysis. In addition to a complete history and physical examination performed in all patients by the surgeon, all of their female partners were also evaluated by reproductive gynecologists. 1371
TABLE 1 Preoperative parameters of subjects. Parameters No. of subjects Mean age (years) Mean serum FSH (mIU/mL) Mean serum total T (ng/dL) Mean female partner age (years) Mean time from vasectomy (years) Percentage of patients with palpable sperm granuloma of vas Previous failed vasectomy reversal (%) Surgery performed (%) Bilateral vasovasostomy Unilateral vasovasostomy Vasovasostomy ⫹ vasoepididymostomy Bilateral vasoepididymostomy Reasons for vasectomy reversal (%) Death of a child Accidents Illnesses Change of heart
Current series
Historical cohort (5)
27 38.5 (29–49) 4.6 (1.5–8.7) 446 (126–960) 37.2 (27–45) 6.2 (2–12) 37% (10/27)
100 40.2 (26–50) 4.3 (2.5–7.7) 490 (185–1,010) 29.9 (22–41) 8.1 (3–12) NA
19 (5/27)
23 (23/100)
81 NA 4 15
94 6
33 (9/27) 33 (3/9) 66 (6/9) 66 (18/27)
Chan. Vasectomy reversal in men with same partners. Fertil Steril 2004.
The surgical procedure for vasectomy reversal with microsurgical vasovasostomy was performed using the microdot method as described elsewhere (5–7) using six to eight interrupted 10-0 nylon sutures for the mucosa, six interrupted 9-0 nylon sutures for the muscularis layer and the vasal adventitial layers, and six 7-0 interrupted PDS sutures for the vasal sheath. Decisions to perform a vasoepididymostomy were made intraoperatively based on indications described elsewhere (7). Microsurgical vasoepididymostomy was performed using end-to-side or intussusception techniques (4, 7) with 10-0 nylon sutures for the mucosal layer. A second layer closure using eight to ten interrupted 9-0 nylon sutures was achieved by approximating the vasal muscularis and epididymal tunica.
Bilateral microsurgical vasovasostomy and vasoepididymostomy were performed in 81% (22/27) and 15% (4/27), respectively, of cases. In one case, a unilateral crossed vasovasostomy (7) was performed. Postoperatively, the median follow-up period was 18.5 [6 – 81] months. Almost 90% (24/27) returned for follow-up postoperatively. Eighty percent (22/27) of patients had a follow-up period over 1 year. The postoperative semen parameters are shown in Table 2. The natural pregnancy rate among patients with follow-up over 1 year in this cohort was 86% (19/22). The median time to achieve pregnancy was 8.3 [2–22] months. The overall live birth rate was 82% (18/22). Among the subgroup of patients that had a death of a child, the live birth rate was 100% (5/5).
Semen analyses were obtained postoperatively at 1 month, 3 months, 6 months, and every 6 months thereafter. The preoperative clinical parameters and the postoperative outcomes were analyzed. The postoperative pregnancy rates were compared with data from a historical cohort of 100 consecutive cases of vasovasostomy from our center (5) using a two-tailed Fisher’s exact test. P⬍.05 was considered statistically significant.
Compared with data from a vasovasostomy historical cohort of 100 consecutive patients from our center (5), in which the crude pregnancy rate was 54%, the pregnancy rate from our current series was significantly higher (P⬍.01). The mean age of the female partners in our current series (37.2 years) was significantly higher than that in the historical cohort (29.9 years) (P⬍.01).
RESULTS
DISCUSSION
Among the 1,048 vasectomy reversals reviewed during the study period, a total of 27 (2.6%) cases were identified in which the men were with the same female partners for more than 3 years after vasectomy reversal. The preoperative clinical parameters of these patients are shown in Table 1.
With the advances in microsurgical techniques for vasectomy reversal in recent years, the surgical outcomes in the hands of experienced microsurgeons are excellent, with a postoperative patency rate of 80%–99% (4 – 8). Several studies have established that vasectomy reversal is a more cost-
1372 Chan and Goldstein
Vasectomy reversal in men with same partners
Vol. 81, No. 5, May 2004
TABLE 2 Postoperative outcomes. Parameters Patency rate at 1 month (⬎1 million/mL) (%) Mean sperm count Mean motility (%) Mean normal morphology (%) Percentage of patients positive for antisperm antibodies (%) Median follow-up duration (months) Natural pregnancy rate (%)
Current series 100% (22/22) 30 (11–90) ⫻ 106/mL 24 (5–80) 21 (2–51) 61 (11/18) 18.5 86
Historical cohort (5) 99% (99/100) 56 (20–114) ⫻ 106/mL 38 (20–60) 42 (18–50) 75 (30/40) 17.2 54
Chan. Vasectomy reversal in men with same partners. Fertil Steril 2004.
effective approach for fertility than up-front assisted reproduction (1–3).
with the same female partners are superior to those from other reversal patients (10).
Despite the high postoperative patency rate, however, only about 40%– 60% of these patients are able to achieve natural pregnancy (4 – 6). Reasons for the inability to achieve natural pregnancy despite the presence of spermatozoa in ejaculate postoperatively include inadequate quantity of sperm, inadequate quality of sperm (low percentage of normal morphology or low motility), presence of antisperm antibodies, stricture of anastomosis, and coexisting female infertility factors.
We speculate that the proven fecundity of the couples before vasectomy may contribute to the superior postreversal outcomes. However, in our previous series of vasovasostomy, the pregnancy rate in couples who do not have female infertility factor was only 64% (5). More importantly, many of these women may have had pregnancies or children in previous relationships. The fact that their pregnancy rates were not as high as the couples in our current series suggests that previously proven fecundity may not be the sole reason for the favorable postreversal outcomes in men who are with the same female partners. It is nonetheless possible that couples in our current series, who have had children together before vasectomy, have proven that they are reproductively compatible, which somehow contributes to a superior natural fertility outcome postreversal. However, further investigations are required to provide a more substantial explanation of our observation.
While a significant proportion of the vasectomy reversal patients may have difficulties achieving natural pregnancy, data from our current series indicate that in men who are with the same female partners after vasectomy reversal, the natural pregnancy rate is superior, approaching 90%, with a live birth rate over 80%. This finding is surprising considering that the mean age of the female partners in our series was 37.2 (27– 45) years, while the mean age of the female partners with men who are in a new relationship is generally below 30 years (5, 8). What is the explanation for such high pregnancy and live birth rates in men who are with the same female partners? Data from our own series from a previous study on microsurgical vasovasostomy (5) demonstrated a similar patency rate close to 100%, but with a clinical pregnancy rate of 54%. Clearly, the surprisingly high pregnancy and live birth rates in men who are with the same female partners cannot be fully explained by the differences in surgical techniques. The mean time from vasectomy in our current series was 6.2 years, compared with over 8 years in our previous vasovasostomy series (5). However, even when the time from vasectomy is controlled, the postoperative outcomes are still superior in our current series (results not shown). Although the size of our current series is small, since our initial report of this study (9) other centers have reported similar findings, namely, that the postvasectomy reversal pregnancy rates in men who are FERTILITY & STERILITY威
Additionally, the fact that the men are determined to undergo surgical reconstruction to have further children may be a sign that the couples are very dedicated to achieving pregnancy. This emotional dedication factor (which may represent a firmer commitment to timing sexual intercourse to female partner’s cycle, avoiding potential environmental toxins, stress reduction, etc.) was demonstrated by a subgroup of our patients in whom a child had died previously. It is not difficult to imagine how determined such couples must be in achieving a further pregnancy. In this subgroup of patients, the pregnancy and live birth rates were 100%. There are several limitations in our study. First, the size of our series is small, with only 27 patients, in which only 81% had follow-up for longer than 1 year. This may be related to the nature of the clinical practice of our center where most patients are referred from other states or countries. In addition, it is possible that patients who returned for follow-up were the ones who were successful in the surgery, leading to a bias in our data toward a more optimal outcome. We have 1373
reported elsewhere that in various studies up to 66% of patients undergoing surgical treatment for male factor infertility may be lost to follow-up (11). More importantly, at least in our fertility practice, the overall pregnancy rate in most patients who failed to return for follow-up after surgical treatment was similar to what was observed in the patients who voluntarily returned for follow-up (11). Nonetheless, a larger series with closer follow-up, preferably in a prospective fashion, could help to further confirm the observation we hereby described. While larger-scale studies are necessary to confirm these findings, our series suggests that vasectomy reversal outcomes in men who are with the same female partners are excellent, with a natural pregnancy rate approaching 90% and a live birth rate over 80%. These findings are important in fertility management postvasectomy in counseling couples who have either changed their mind and desire further children or who have suffered the death of a child. In conclusion, for men with the same female partner who desire to have further children after vasectomy, microsurgical reconstruction with vasovasostomy or vasoepididymostomy provides superior postoperative outcomes, with a patency rate of 100%, a clinical pregnancy rate of 86% achievable at a mean time of 8.3 months, and a live birth rate of 82%. In couples with the death of a child, the live birth rate was 100%. The reasons for such superior outcomes may be in part related to their previously proven fecundity as a couple, shorter time from vasectomy, and emotional dedication.
1374 Chan and Goldstein
References 1. Pavlovich CP, Schlegel PN. Fertility options after vasectomy: a costeffectiveness analysis. Fertil Steril 1997;67:133–41. 2. Kolettis PN, Thomas AJ. Vasoepididymostomy for vasectomy reversal: a critical assessment in the era of intracytoplasmic sperm injection. J Urol 1997;158:467–70. 3. Donovan JF Jr, DiBaise M, Sparks AE, Kessler J, Sandlow JI. Comparison of microscopic epididymal sperm aspiration and intracytoplasmic sperm injection/in-vitro fertilization with repeat microscopic reconstruction following vasectomy: is second attempt vas reversal worth the effort? Hum Reprod 1998;13:387–93. 4. Chan PTK, Brandell RA, Goldstein M. Prospective analysis of the post-operative outcomes of microsurgical intussusception vasoepididymostomy. J Urol 2002;167:310. 5. Goldstein M, Li PS, Matthews GJ. Microsurgical vasovasostomy: the microdot technique of precision suture placement. J Urol 1998;159: 188 –90. 6. Goldstein M, Chan PTK, Li PS. Ultra-precise multi-layer microsurgical vasovasostomy: tricks of the trade. Ortho-McNeil AUA Video HV2266. 7. Goldstein M. Surgical management of male infertility and other scrotal disorders. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell’s urology. 8th ed. Vol. 2. Philadelphia: W.B. Saunders, 2002:1532–87. 8. 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. 9. Chan PTK, Goldstein M. Outcomes of microsurgical vasectomy reversal in men with the same female partner [abstract 1261]. In: Program and abstracts of the 96th Annual Meeting of the American Urological Association. Anaheim, CA: American Urological Association, 2001: 307. 10. Kolettis PN, Woo L, Sandlow J. Outcomes for vasectomy reversal performed for men with the same female partners [abstract P-430]. In: Program and abstracts of the 58th Annual Meeting of the American Society for Reproductive Medicine. Seattle: American Society for Reproductive Medicine, 2002:S258. 11. Fazeli-Matin S, Morrison G, Goldstein M. What is the pregnancy rate in vasovasostomy and varicocelectomy patients who are “lost to followup”? [abstract 301]. In: Program and abstracts of the 89th Annual Meeting of the American Urological Association. San Francisco: American Urological Association, 1994:303A.
Vasectomy reversal in men with same partners
Vol. 81, No. 5, May 2004
Superior outcomes of microsurgical vasectomy reversal in men with the same female partners Peter T. K. Chan, M.D.,a,b and Marc Goldstein, M.D.a Department of Urology, Cornell Institute for Reproductive Medicine, Weill Medical College of Cornell University, New York, New York
Objective: To evaluate the outcomes of vasectomy reversals in men with the same female partners. Design: Retrospective analysis with comparison with a historical cohort. Setting: University hospital. Patient(s): Among 1,048 patients who underwent microsurgical vasectomy reversal from 1986 to 2002, 27 men (2.6%) were identified who had the same partners as before their vasectomy. Intervention(s): Microsurgical vasovasostomy or vasoepididymostomy. Main Outcome Measure(s): Semen parameters, clinical pregnancy, and live birth rates. Result(s): The mean age of the men was 38.5 years, and 37.2 years for their female partners. The reasons for vasectomy reversal were death of a child in 33% of cases and desire for more children in 66% of cases. The overall patency rate was 100% at 1 month postoperatively, with an average sperm concentration of 30 million/mL and 24% motility. Among patients with follow-up beyond 1 year, the natural pregnancy rate was 86%, which was achieved at 8.3 months postoperatively, with a live birth rate of 82%. The live birth rate in couples with the death of a child was 100%. Conclusion(s): The outcomes of vasectomy reversal in men with the same female partners are better than for men with new partners. Possible reasons for these superior results are previous proven fecundity as a couple, shorter time interval since vasectomy, and emotional dedication. (Fertil Steril威 2004;81:1371⫺4. ©2004 by American Society for Reproductive Medicine.) Key Words: Vasectomy reversal, vasovasostomy, vasoepididymostomy, infertility, obstructive azoospermia Received May 28, 2003; revised and accepted September 30, 2003. Reprint requests: Peter Chan, M.D., S 6.95, Department of Urology, Royal Victoria Hospital, McGill University Health Centre, 687 Pine West, Montreal, Quebec, Canada H3A 1A1 (FAX: 514-8431552; E-mail: Peter.Chan@ muhc.mcgill.ca). a Cornell Institute for Reproductive Medicine, Center for Male Reproductive Medicine and Microsurgery, New York, New York. b Department of Urology, McGill University Health Centre, Montreal, Quebec, Canada. 0015-0282/04/$30.00 doi:10.1016/j.fertnstert.2003. 09.066
Vasectomy reversal with microsurgical vasovasostomy or vasoepididymostomy has been established by various studies (1–3) as a more cost-effective fertility management option compared with up-front assisted reproduction. With the advances in the microsurgical techniques witnessed in the recent years, the postoperative patency rate for vasoepididymostomy and vasovasostomy can be as high as 80%–99%, with approximately half of these patients being able to achieve natural pregnancy (4 – 8). Most men who opt for vasectomy reversal do so because of divorce and remarriage to new partners who desire children. In a small subgroup of patients, vasectomy reversals are performed while they are with the same female partners. The reasons for their reversal are generally due to either the death of a child or a
change of heart after vasectomy leading to a desire for more children. The objective of this study was to evaluate the surgical outcomes of vasectomy reversal in men who are with the same female partners.
MATERIALS AND METHODS From 1986 to 2002, all cases of vasectomy reversal performed in a university tertiary-care center by the same surgeon (MG) were reviewed retrospectively. All cases in which the men remained with the same female partner for more than 3 years after vasectomy reversal were included in the analysis. In addition to a complete history and physical examination performed in all patients by the surgeon, all of their female partners were also evaluated by reproductive gynecologists. 1371
TABLE 1 Preoperative parameters of subjects. Parameters No. of subjects Mean age (years) Mean serum FSH (mIU/mL) Mean serum total T (ng/dL) Mean female partner age (years) Mean time from vasectomy (years) Percentage of patients with palpable sperm granuloma of vas Previous failed vasectomy reversal (%) Surgery performed (%) Bilateral vasovasostomy Unilateral vasovasostomy Vasovasostomy ⫹ vasoepididymostomy Bilateral vasoepididymostomy Reasons for vasectomy reversal (%) Death of a child Accidents Illnesses Change of heart
Current series
Historical cohort (5)
27 38.5 (29–49) 4.6 (1.5–8.7) 446 (126–960) 37.2 (27–45) 6.2 (2–12) 37% (10/27)
100 40.2 (26–50) 4.3 (2.5–7.7) 490 (185–1,010) 29.9 (22–41) 8.1 (3–12) NA
19 (5/27)
23 (23/100)
81 NA 4 15
94 6
33 (9/27) 33 (3/9) 66 (6/9) 66 (18/27)
Chan. Vasectomy reversal in men with same partners. Fertil Steril 2004.
The surgical procedure for vasectomy reversal with microsurgical vasovasostomy was performed using the microdot method as described elsewhere (5–7) using six to eight interrupted 10-0 nylon sutures for the mucosa, six interrupted 9-0 nylon sutures for the muscularis layer and the vasal adventitial layers, and six 7-0 interrupted PDS sutures for the vasal sheath. Decisions to perform a vasoepididymostomy were made intraoperatively based on indications described elsewhere (7). Microsurgical vasoepididymostomy was performed using end-to-side or intussusception techniques (4, 7) with 10-0 nylon sutures for the mucosal layer. A second layer closure using eight to ten interrupted 9-0 nylon sutures was achieved by approximating the vasal muscularis and epididymal tunica.
Bilateral microsurgical vasovasostomy and vasoepididymostomy were performed in 81% (22/27) and 15% (4/27), respectively, of cases. In one case, a unilateral crossed vasovasostomy (7) was performed. Postoperatively, the median follow-up period was 18.5 [6 – 81] months. Almost 90% (24/27) returned for follow-up postoperatively. Eighty percent (22/27) of patients had a follow-up period over 1 year. The postoperative semen parameters are shown in Table 2. The natural pregnancy rate among patients with follow-up over 1 year in this cohort was 86% (19/22). The median time to achieve pregnancy was 8.3 [2–22] months. The overall live birth rate was 82% (18/22). Among the subgroup of patients that had a death of a child, the live birth rate was 100% (5/5).
Semen analyses were obtained postoperatively at 1 month, 3 months, 6 months, and every 6 months thereafter. The preoperative clinical parameters and the postoperative outcomes were analyzed. The postoperative pregnancy rates were compared with data from a historical cohort of 100 consecutive cases of vasovasostomy from our center (5) using a two-tailed Fisher’s exact test. P⬍.05 was considered statistically significant.
Compared with data from a vasovasostomy historical cohort of 100 consecutive patients from our center (5), in which the crude pregnancy rate was 54%, the pregnancy rate from our current series was significantly higher (P⬍.01). The mean age of the female partners in our current series (37.2 years) was significantly higher than that in the historical cohort (29.9 years) (P⬍.01).
RESULTS
DISCUSSION
Among the 1,048 vasectomy reversals reviewed during the study period, a total of 27 (2.6%) cases were identified in which the men were with the same female partners for more than 3 years after vasectomy reversal. The preoperative clinical parameters of these patients are shown in Table 1.
With the advances in microsurgical techniques for vasectomy reversal in recent years, the surgical outcomes in the hands of experienced microsurgeons are excellent, with a postoperative patency rate of 80%–99% (4 – 8). Several studies have established that vasectomy reversal is a more cost-
1372 Chan and Goldstein
Vasectomy reversal in men with same partners
Vol. 81, No. 5, May 2004
TABLE 2 Postoperative outcomes. Parameters Patency rate at 1 month (⬎1 million/mL) (%) Mean sperm count Mean motility (%) Mean normal morphology (%) Percentage of patients positive for antisperm antibodies (%) Median follow-up duration (months) Natural pregnancy rate (%)
Current series 100% (22/22) 30 (11–90) ⫻ 106/mL 24 (5–80) 21 (2–51) 61 (11/18) 18.5 86
Historical cohort (5) 99% (99/100) 56 (20–114) ⫻ 106/mL 38 (20–60) 42 (18–50) 75 (30/40) 17.2 54
Chan. Vasectomy reversal in men with same partners. Fertil Steril 2004.
effective approach for fertility than up-front assisted reproduction (1–3).
with the same female partners are superior to those from other reversal patients (10).
Despite the high postoperative patency rate, however, only about 40%– 60% of these patients are able to achieve natural pregnancy (4 – 6). Reasons for the inability to achieve natural pregnancy despite the presence of spermatozoa in ejaculate postoperatively include inadequate quantity of sperm, inadequate quality of sperm (low percentage of normal morphology or low motility), presence of antisperm antibodies, stricture of anastomosis, and coexisting female infertility factors.
We speculate that the proven fecundity of the couples before vasectomy may contribute to the superior postreversal outcomes. However, in our previous series of vasovasostomy, the pregnancy rate in couples who do not have female infertility factor was only 64% (5). More importantly, many of these women may have had pregnancies or children in previous relationships. The fact that their pregnancy rates were not as high as the couples in our current series suggests that previously proven fecundity may not be the sole reason for the favorable postreversal outcomes in men who are with the same female partners. It is nonetheless possible that couples in our current series, who have had children together before vasectomy, have proven that they are reproductively compatible, which somehow contributes to a superior natural fertility outcome postreversal. However, further investigations are required to provide a more substantial explanation of our observation.
While a significant proportion of the vasectomy reversal patients may have difficulties achieving natural pregnancy, data from our current series indicate that in men who are with the same female partners after vasectomy reversal, the natural pregnancy rate is superior, approaching 90%, with a live birth rate over 80%. This finding is surprising considering that the mean age of the female partners in our series was 37.2 (27– 45) years, while the mean age of the female partners with men who are in a new relationship is generally below 30 years (5, 8). What is the explanation for such high pregnancy and live birth rates in men who are with the same female partners? Data from our own series from a previous study on microsurgical vasovasostomy (5) demonstrated a similar patency rate close to 100%, but with a clinical pregnancy rate of 54%. Clearly, the surprisingly high pregnancy and live birth rates in men who are with the same female partners cannot be fully explained by the differences in surgical techniques. The mean time from vasectomy in our current series was 6.2 years, compared with over 8 years in our previous vasovasostomy series (5). However, even when the time from vasectomy is controlled, the postoperative outcomes are still superior in our current series (results not shown). Although the size of our current series is small, since our initial report of this study (9) other centers have reported similar findings, namely, that the postvasectomy reversal pregnancy rates in men who are FERTILITY & STERILITY威
Additionally, the fact that the men are determined to undergo surgical reconstruction to have further children may be a sign that the couples are very dedicated to achieving pregnancy. This emotional dedication factor (which may represent a firmer commitment to timing sexual intercourse to female partner’s cycle, avoiding potential environmental toxins, stress reduction, etc.) was demonstrated by a subgroup of our patients in whom a child had died previously. It is not difficult to imagine how determined such couples must be in achieving a further pregnancy. In this subgroup of patients, the pregnancy and live birth rates were 100%. There are several limitations in our study. First, the size of our series is small, with only 27 patients, in which only 81% had follow-up for longer than 1 year. This may be related to the nature of the clinical practice of our center where most patients are referred from other states or countries. In addition, it is possible that patients who returned for follow-up were the ones who were successful in the surgery, leading to a bias in our data toward a more optimal outcome. We have 1373
reported elsewhere that in various studies up to 66% of patients undergoing surgical treatment for male factor infertility may be lost to follow-up (11). More importantly, at least in our fertility practice, the overall pregnancy rate in most patients who failed to return for follow-up after surgical treatment was similar to what was observed in the patients who voluntarily returned for follow-up (11). Nonetheless, a larger series with closer follow-up, preferably in a prospective fashion, could help to further confirm the observation we hereby described. While larger-scale studies are necessary to confirm these findings, our series suggests that vasectomy reversal outcomes in men who are with the same female partners are excellent, with a natural pregnancy rate approaching 90% and a live birth rate over 80%. These findings are important in fertility management postvasectomy in counseling couples who have either changed their mind and desire further children or who have suffered the death of a child. In conclusion, for men with the same female partner who desire to have further children after vasectomy, microsurgical reconstruction with vasovasostomy or vasoepididymostomy provides superior postoperative outcomes, with a patency rate of 100%, a clinical pregnancy rate of 86% achievable at a mean time of 8.3 months, and a live birth rate of 82%. In couples with the death of a child, the live birth rate was 100%. The reasons for such superior outcomes may be in part related to their previously proven fecundity as a couple, shorter time from vasectomy, and emotional dedication.
1374 Chan and Goldstein
References 1. Pavlovich CP, Schlegel PN. Fertility options after vasectomy: a costeffectiveness analysis. Fertil Steril 1997;67:133–41. 2. Kolettis PN, Thomas AJ. Vasoepididymostomy for vasectomy reversal: a critical assessment in the era of intracytoplasmic sperm injection. J Urol 1997;158:467–70. 3. Donovan JF Jr, DiBaise M, Sparks AE, Kessler J, Sandlow JI. Comparison of microscopic epididymal sperm aspiration and intracytoplasmic sperm injection/in-vitro fertilization with repeat microscopic reconstruction following vasectomy: is second attempt vas reversal worth the effort? Hum Reprod 1998;13:387–93. 4. Chan PTK, Brandell RA, Goldstein M. Prospective analysis of the post-operative outcomes of microsurgical intussusception vasoepididymostomy. J Urol 2002;167:310. 5. Goldstein M, Li PS, Matthews GJ. Microsurgical vasovasostomy: the microdot technique of precision suture placement. J Urol 1998;159: 188 –90. 6. Goldstein M, Chan PTK, Li PS. Ultra-precise multi-layer microsurgical vasovasostomy: tricks of the trade. Ortho-McNeil AUA Video HV2266. 7. Goldstein M. Surgical management of male infertility and other scrotal disorders. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell’s urology. 8th ed. Vol. 2. Philadelphia: W.B. Saunders, 2002:1532–87. 8. 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. 9. Chan PTK, Goldstein M. Outcomes of microsurgical vasectomy reversal in men with the same female partner [abstract 1261]. In: Program and abstracts of the 96th Annual Meeting of the American Urological Association. Anaheim, CA: American Urological Association, 2001: 307. 10. Kolettis PN, Woo L, Sandlow J. Outcomes for vasectomy reversal performed for men with the same female partners [abstract P-430]. In: Program and abstracts of the 58th Annual Meeting of the American Society for Reproductive Medicine. Seattle: American Society for Reproductive Medicine, 2002:S258. 11. Fazeli-Matin S, Morrison G, Goldstein M. What is the pregnancy rate in vasovasostomy and varicocelectomy patients who are “lost to followup”? [abstract 301]. In: Program and abstracts of the 89th Annual Meeting of the American Urological Association. San Francisco: American Urological Association, 1994:303A.
Vasectomy reversal in men with same partners
Vol. 81, No. 5, May 2004