- Email: [email protected]
Vasovasostomy: evaluation of success
STERILITY-FERTILITY
VASOVASOSTOMY: ROGER
WICKLUND,
NANCY
J. ALEXANDER,
EVALUATION
OF SUCCESS*
M.D. PH.D.
From the Departments of Urology, Obstetrics and Gynecology, and Anatomy, University of Oregon Health Sciences Center, Portland; and Department of Reproductive Physiology, Oregon Regional Primate Research Center, Beaverton, Oregon
ABSTRACT - Our review of 2,685 cases of vasovasostomy reported between 1948 and 1977 shows that many different surgical techniques can be successful. However, various reporting practices have made case comparisons difficult. We suggest a standardized method for reporting vasovasostomy results.
Because of an increase in the number of vasectomies performed in recent years, urologists are now more frequently being approached with requests for vasovasostomies. Despite the number of requests, many urologists have had little experience with this procedure. In 1948 when O’Conor’ surveyed members of the AUA, he found that only 135 of 750 members answering the questionnaire had ever performed a vasovasostomy, and that these 135 surgeons had performed only 420 such operations (an average of only 3.1 cases per surgeon). In 1973 when Derrick, Yarbrough, and D’Agostino2 again surveyed members of the AUA they found that only 541 of the 1,363 responding surgeons had performed the procedure. Only 1,630 vasovasostomies had been performed by these 541 surgeons (an average of only 3.0 cases per surgeon). Therefore, in this decade, 61 per cent of all members of the AUA have not performed a vasovasostomy, and those who have generally have had limited experience. Urologists who are now receiving patient requests for vasovasostomies must rely on a limited number of published reports in determining which surgical techniques will result in the ultimate goal of reestablishing the fertility of their patients while achieving the lowest morbidity and the lowest cost: benefit ratio. *Supported by Grants RR0163 and HD05969 National Institutes of Health, Washington, D.C.
532
from the
Our review of 2,685 reported vasovasostomies between 1948 and 1977 shows that many different surgical techniques can be successful (Table I). l-2’ Various reporting practices, however, have made comparison of these techniques extremely difficult. We therefore suggest that surgeons should employ a standardized method for reporting vasovasostomy results. Results The 2,685 cases we reviewed were reported by 16 authors in 20 separate reports. Of these cases, 49 per cent showed return of sperm in the ejaculate. The pregnancy rate, which was determined for 2,177 men, was 21 per cent. These data also include, in addition to the cases reported by individual authors, the results of the surveys conducted by O’Conor in 1948l and Derrick and colleagues in 1973.2 When the survey results were deleted from the body of data, the rates of sperm return were much higher, 68 per cent to 100 per cent. The pregnancy rates ranged from 10 per cent to 71 per cent. The pregnancy rate was not included in 20 per cent of the reports. The reported cases were of operations performed from one month to twenty-five years prior to the date of the report, and none of the reports was based on a standard time interval after the operation. We also discovered a wide variation in the criteria used by authors in judging the success
UROLOGY
I
MAY 1979
I
VOLUME
XIII,
NUMBER
5
TABLE
I.
Success rates of reported vasovasostomies No. with Sperm After Vasovasostomy
No. of Cases
Reference 1
14
NR NR 303
9
420”
189
2 3 4 5 6 7 8 9
1,630t
10 11
35
12
1298
13
30
14
6li 10
9
3
15
35
71
12
16
13
0
NR
619
4
4
1
3
3
1
20t 5
18
9
7
10
6
76
63
22
20
4 3 NR 1 42 NR
5
27
11
113
21
21
II
Time Interval After Vasovasostomy
No. of Pregnancies
5 total
years NR NR 3.5 months-1 1 year l-11 years 2-15
year
NR
weeks-3 years Up to 13 years Up to 12 years 3 months-4 years NR 7 months-25 years Up to 10 years
5
1 1- 14 months 4 months-2 years 39 weeks
7 17
25
17
18
117
94
19
vasectomies < 10 years 8 vasectomies > 10 years 300#
22
22
20
3 26
2 months-2 years NR 3-6 months
4 months
4
30
39
18
months
NR = not reported. *From questionnnaire sent to urologists. t From questionnaire sent to urologists. $Of 27 cases, only 20 were considered feasible; 6 patients underwent more than one procedure. $Report of I29 cases considered feasible; 9 patients underwent more than one procedure. _~‘asovasostomy. llEpididymovasostomy #Total results determined on 42 cases.
of sperm return in the ejaculate. The sperm count per milliliter of ejaculate that was considered to be normal varied from 1 x lo6 to 40 x 106.13,14 Sperm motility was seldom mentioned, and ejaculate volume and sperm morphology were rarely reported. From our review, we have concluded that the success of vasovasostomy depends more on the experience of the surgeon than on the technique employed. This conclusion is supported by the fact that the three most successful surgeons in our review used quite different surgical techniques. In 1967 Phadke and Phadke’ obtained a sperm return of 83 per cent and a pregnancy rate of 55 per cent in 76 patients. They created a one-layer anastomosis with only three sutures (6-O arterial silk) through the seromuscular coat
UROLOGY
/
MAY 1979
/
VOLUME XIII,
NUMBER 5
and vas. until were were
one suture through the adventitia of the The anastomosis was supported by a stent the eighth postoperative day; the patients on a regimen of bed rest for one week and treated with broad-spectrum antibiotics. S&midt,6,‘8Z~,ZZ who has done a great deal of research on various vasovasostomy techniques, had used several types of stents. He now, however, prefers a stentless anastomosis with three full thicknesses of sutures and treats his postoperative patients on an outpatient basis. With this simplified technique he reports a greater than 80 per cent return of sperm and a 31 per cent pregnancy rate. Silber20 reported the best results, with a 93 per cent return of sperm and a 71 per cent pregnancy rate; he created a microscopic two-layer, stentless anastomosis.
533
Comment The results of vasovasostomy techniques are difficult to report because many factors influence the outcome of the operation regardless of the technique employed. The prevasectomy fertility of the patient is seldom known, and often the fertility of his wife has not been determined. The site and extent of the original vas resection can influence the surgeon’s ability to create an adequate anastomosis regardless of the technique employed. Granuloma formation in the vas deferens and the epididymis can prevent sperm transfer even when the anastomosis is patent. The time interval between vasectomy and vasovasostomy may be critical; Silber, Galle, and Friendlg have observed poor results if this time period is greater than ten years. Many others, however, have had good vasovasostomy results many years after vasecAn autoimmune response occurs tomy. 5,g~13~1’~18 after vasectomy, and antisperm antibodies can be found in the sera of about one half of all vasectomized men. It has been shown that in rhesus monkeys these antibody levels do not fall after vasovasostomy;23 Gupta et al. l7 reported a similar finding in men. How this immunity affects fertility is under investigation. Conclusion Even though several factors influence vasovasostomy results, we believe that the various surgical techniques could be more critically compared if a standardized method of reporting were employed by all investigators. We recommend that the reporting of vasovasostomy results include sperm counts per milliliter, the percentage of motile sperm, and the percentage of normal forms. The ejaculate volume should be stated so that total sperm counts can be calculated. The semen analysis results should be considered normal only if there are at least 20 million sperm per milliliter; 60 per cent motility, with good forward progression; and 60 per cent normal forms. Most importantly, the pregnancy rate should be a criterion of success and results should be reported two years after the procedure as an annual pregnancy rate.
534
Oregon
Regional Primate Center 505 N.W. 185th Avenue Beaverton, Oregon 97005 (DR. ALEXANDER)
References 1. O’Conor VJ: Anastomosis of vas deferens after purposeful division for sterility, J.A.M.A. 136: 162 (1948). 2. Derrick FC, Yarbrough W, D’Agostino J: Vasovasostomy: results of questionnaire of members of the American Urological Association, J. Ural. 110: 556 (1973). 3. Massey BD, and Nation EF: Vas deferens anastomosis: a report of four consecutive successful cases, ibid. 61: 391 (1949). 4. Humphreys RH: Vas deferens anastomosis: a review of the literature and a report of three consecutive successful cases, West. J. Surg. Obstet. Gynecol. 61: 658 (1953). 5. Dorsey JW: Surgical correction of postvasectomy sterility, J. Int. COB. Surg. 27: 453 (1957). 6. Schmidt SS: Anastomosis of the vas deferens: an experimental study, I, J. Urol. 75: 300 (1956). 7. Roland SW; Splinted and non-splinted vasovasostomy, a review, Fertil. Steril. 12: 191 (1961). 8. Wailer JI, and Turner TA: Anastomosis of the vas after vasectomy, J. 409 (1962). 9. Phadke GM. and Phadke AG: Exueriences in the reanastomosis of the vas deferens, ibid. 97: 888 (1967). 10. Mehta KC, and Ramani PS: A simple technique of reanastomosis after vasectomy, Br. J. Urol. 42: 340 (1970). 11. Hanley HG: Results of vasal anastomosis following vohmtary vasectomy, ibid. 44: 721 (1972). 12. Dorsey JW; Surgical correction of post-vasectomy sterility, J. Ural. 110: 554 (1973). 13. Pai MG, Kumar BTS, Kaundinya C, and Bhat HS: Vasovasostomy: a clinical study with 10 years’ follow-up, Fertil. SteriI. 24: 798 (1973). 14. Pardanani DS, Kothari ML, Mahendrakar MN, and Pradhan SA; The use of silicone rubber splint for post-vasectomy vas deferens anastomosis: report of a new operative technique, Contraception 7: 491 (1973). 15. Pardanani DS, Kothari ML, Parulkar GB, and Jayatilak PC: Surgical reversal of vasectomy by vas deferens anastomosis, J. Reprod. Fertil. 41: 321 (1974). 16. Cerruti RA, Jepson P, Fumas DW, and Silber I: Vasvasostomy: outpatient procedure for reversal of vasectomy, Urology 3: 209 (1974). 17. Gupta I, Dhawan S, Goel CD, and Saha K: Low fertility rate in vasovasostomized males and its possible immunologic mechanism, Int. J. Fertil. 20: 183 (1975). 18. Schmidt SS: Vas anastomosis: a return to simplicity, Br. J. Ural. 47: 309 (1975). 19. Silber SJ, GaIIe J, and Friend D: Microscopic vasovasostomy and spermatogenesis, J. Urol. 117: 299 (1977). 20. Silber SJ: Microscopic vasectomy reversal, FertiI. SteriI. 28: 1191 (1977). 21. Schmidt SS: Anastomosis of the vas deferens: an experimental study. II. Successes and failures in experimental anastomosis, J. Ural. 81: 203 (1959). 22. IDEM: Anastomosis of the vas deferens: IV. The use of fine polyethylene tubing as a splint, ibid. 85: 838 (1961). 23. Alexander NJ; Vasectomy and vasovasostomy in rhesus monkeys: the effect of circulating antisperm antibodies on fertility, FertiI. Steril. 28: 562 (1977).
u&i.88:
UROLOGY
/
MAY 1979
/
VOLUME
XIII,
NUMBER5
VASOVASOSTOMY: ROGER
WICKLUND,
NANCY
J. ALEXANDER,
EVALUATION
OF SUCCESS*
M.D. PH.D.
From the Departments of Urology, Obstetrics and Gynecology, and Anatomy, University of Oregon Health Sciences Center, Portland; and Department of Reproductive Physiology, Oregon Regional Primate Research Center, Beaverton, Oregon
ABSTRACT - Our review of 2,685 cases of vasovasostomy reported between 1948 and 1977 shows that many different surgical techniques can be successful. However, various reporting practices have made case comparisons difficult. We suggest a standardized method for reporting vasovasostomy results.
Because of an increase in the number of vasectomies performed in recent years, urologists are now more frequently being approached with requests for vasovasostomies. Despite the number of requests, many urologists have had little experience with this procedure. In 1948 when O’Conor’ surveyed members of the AUA, he found that only 135 of 750 members answering the questionnaire had ever performed a vasovasostomy, and that these 135 surgeons had performed only 420 such operations (an average of only 3.1 cases per surgeon). In 1973 when Derrick, Yarbrough, and D’Agostino2 again surveyed members of the AUA they found that only 541 of the 1,363 responding surgeons had performed the procedure. Only 1,630 vasovasostomies had been performed by these 541 surgeons (an average of only 3.0 cases per surgeon). Therefore, in this decade, 61 per cent of all members of the AUA have not performed a vasovasostomy, and those who have generally have had limited experience. Urologists who are now receiving patient requests for vasovasostomies must rely on a limited number of published reports in determining which surgical techniques will result in the ultimate goal of reestablishing the fertility of their patients while achieving the lowest morbidity and the lowest cost: benefit ratio. *Supported by Grants RR0163 and HD05969 National Institutes of Health, Washington, D.C.
532
from the
Our review of 2,685 reported vasovasostomies between 1948 and 1977 shows that many different surgical techniques can be successful (Table I). l-2’ Various reporting practices, however, have made comparison of these techniques extremely difficult. We therefore suggest that surgeons should employ a standardized method for reporting vasovasostomy results. Results The 2,685 cases we reviewed were reported by 16 authors in 20 separate reports. Of these cases, 49 per cent showed return of sperm in the ejaculate. The pregnancy rate, which was determined for 2,177 men, was 21 per cent. These data also include, in addition to the cases reported by individual authors, the results of the surveys conducted by O’Conor in 1948l and Derrick and colleagues in 1973.2 When the survey results were deleted from the body of data, the rates of sperm return were much higher, 68 per cent to 100 per cent. The pregnancy rates ranged from 10 per cent to 71 per cent. The pregnancy rate was not included in 20 per cent of the reports. The reported cases were of operations performed from one month to twenty-five years prior to the date of the report, and none of the reports was based on a standard time interval after the operation. We also discovered a wide variation in the criteria used by authors in judging the success
UROLOGY
I
MAY 1979
I
VOLUME
XIII,
NUMBER
5
TABLE
I.
Success rates of reported vasovasostomies No. with Sperm After Vasovasostomy
No. of Cases
Reference 1
14
NR NR 303
9
420”
189
2 3 4 5 6 7 8 9
1,630t
10 11
35
12
1298
13
30
14
6li 10
9
3
15
35
71
12
16
13
0
NR
619
4
4
1
3
3
1
20t 5
18
9
7
10
6
76
63
22
20
4 3 NR 1 42 NR
5
27
11
113
21
21
II
Time Interval After Vasovasostomy
No. of Pregnancies
5 total
years NR NR 3.5 months-1 1 year l-11 years 2-15
year
NR
weeks-3 years Up to 13 years Up to 12 years 3 months-4 years NR 7 months-25 years Up to 10 years
5
1 1- 14 months 4 months-2 years 39 weeks
7 17
25
17
18
117
94
19
vasectomies < 10 years 8 vasectomies > 10 years 300#
22
22
20
3 26
2 months-2 years NR 3-6 months
4 months
4
30
39
18
months
NR = not reported. *From questionnnaire sent to urologists. t From questionnaire sent to urologists. $Of 27 cases, only 20 were considered feasible; 6 patients underwent more than one procedure. $Report of I29 cases considered feasible; 9 patients underwent more than one procedure. _~‘asovasostomy. llEpididymovasostomy #Total results determined on 42 cases.
of sperm return in the ejaculate. The sperm count per milliliter of ejaculate that was considered to be normal varied from 1 x lo6 to 40 x 106.13,14 Sperm motility was seldom mentioned, and ejaculate volume and sperm morphology were rarely reported. From our review, we have concluded that the success of vasovasostomy depends more on the experience of the surgeon than on the technique employed. This conclusion is supported by the fact that the three most successful surgeons in our review used quite different surgical techniques. In 1967 Phadke and Phadke’ obtained a sperm return of 83 per cent and a pregnancy rate of 55 per cent in 76 patients. They created a one-layer anastomosis with only three sutures (6-O arterial silk) through the seromuscular coat
UROLOGY
/
MAY 1979
/
VOLUME XIII,
NUMBER 5
and vas. until were were
one suture through the adventitia of the The anastomosis was supported by a stent the eighth postoperative day; the patients on a regimen of bed rest for one week and treated with broad-spectrum antibiotics. S&midt,6,‘8Z~,ZZ who has done a great deal of research on various vasovasostomy techniques, had used several types of stents. He now, however, prefers a stentless anastomosis with three full thicknesses of sutures and treats his postoperative patients on an outpatient basis. With this simplified technique he reports a greater than 80 per cent return of sperm and a 31 per cent pregnancy rate. Silber20 reported the best results, with a 93 per cent return of sperm and a 71 per cent pregnancy rate; he created a microscopic two-layer, stentless anastomosis.
533
Comment The results of vasovasostomy techniques are difficult to report because many factors influence the outcome of the operation regardless of the technique employed. The prevasectomy fertility of the patient is seldom known, and often the fertility of his wife has not been determined. The site and extent of the original vas resection can influence the surgeon’s ability to create an adequate anastomosis regardless of the technique employed. Granuloma formation in the vas deferens and the epididymis can prevent sperm transfer even when the anastomosis is patent. The time interval between vasectomy and vasovasostomy may be critical; Silber, Galle, and Friendlg have observed poor results if this time period is greater than ten years. Many others, however, have had good vasovasostomy results many years after vasecAn autoimmune response occurs tomy. 5,g~13~1’~18 after vasectomy, and antisperm antibodies can be found in the sera of about one half of all vasectomized men. It has been shown that in rhesus monkeys these antibody levels do not fall after vasovasostomy;23 Gupta et al. l7 reported a similar finding in men. How this immunity affects fertility is under investigation. Conclusion Even though several factors influence vasovasostomy results, we believe that the various surgical techniques could be more critically compared if a standardized method of reporting were employed by all investigators. We recommend that the reporting of vasovasostomy results include sperm counts per milliliter, the percentage of motile sperm, and the percentage of normal forms. The ejaculate volume should be stated so that total sperm counts can be calculated. The semen analysis results should be considered normal only if there are at least 20 million sperm per milliliter; 60 per cent motility, with good forward progression; and 60 per cent normal forms. Most importantly, the pregnancy rate should be a criterion of success and results should be reported two years after the procedure as an annual pregnancy rate.
534
Oregon
Regional Primate Center 505 N.W. 185th Avenue Beaverton, Oregon 97005 (DR. ALEXANDER)
References 1. O’Conor VJ: Anastomosis of vas deferens after purposeful division for sterility, J.A.M.A. 136: 162 (1948). 2. Derrick FC, Yarbrough W, D’Agostino J: Vasovasostomy: results of questionnaire of members of the American Urological Association, J. Ural. 110: 556 (1973). 3. Massey BD, and Nation EF: Vas deferens anastomosis: a report of four consecutive successful cases, ibid. 61: 391 (1949). 4. Humphreys RH: Vas deferens anastomosis: a review of the literature and a report of three consecutive successful cases, West. J. Surg. Obstet. Gynecol. 61: 658 (1953). 5. Dorsey JW: Surgical correction of postvasectomy sterility, J. Int. COB. Surg. 27: 453 (1957). 6. Schmidt SS: Anastomosis of the vas deferens: an experimental study, I, J. Urol. 75: 300 (1956). 7. Roland SW; Splinted and non-splinted vasovasostomy, a review, Fertil. Steril. 12: 191 (1961). 8. Wailer JI, and Turner TA: Anastomosis of the vas after vasectomy, J. 409 (1962). 9. Phadke GM. and Phadke AG: Exueriences in the reanastomosis of the vas deferens, ibid. 97: 888 (1967). 10. Mehta KC, and Ramani PS: A simple technique of reanastomosis after vasectomy, Br. J. Urol. 42: 340 (1970). 11. Hanley HG: Results of vasal anastomosis following vohmtary vasectomy, ibid. 44: 721 (1972). 12. Dorsey JW; Surgical correction of post-vasectomy sterility, J. Ural. 110: 554 (1973). 13. Pai MG, Kumar BTS, Kaundinya C, and Bhat HS: Vasovasostomy: a clinical study with 10 years’ follow-up, Fertil. SteriI. 24: 798 (1973). 14. Pardanani DS, Kothari ML, Mahendrakar MN, and Pradhan SA; The use of silicone rubber splint for post-vasectomy vas deferens anastomosis: report of a new operative technique, Contraception 7: 491 (1973). 15. Pardanani DS, Kothari ML, Parulkar GB, and Jayatilak PC: Surgical reversal of vasectomy by vas deferens anastomosis, J. Reprod. Fertil. 41: 321 (1974). 16. Cerruti RA, Jepson P, Fumas DW, and Silber I: Vasvasostomy: outpatient procedure for reversal of vasectomy, Urology 3: 209 (1974). 17. Gupta I, Dhawan S, Goel CD, and Saha K: Low fertility rate in vasovasostomized males and its possible immunologic mechanism, Int. J. Fertil. 20: 183 (1975). 18. Schmidt SS: Vas anastomosis: a return to simplicity, Br. J. Ural. 47: 309 (1975). 19. Silber SJ, GaIIe J, and Friend D: Microscopic vasovasostomy and spermatogenesis, J. Urol. 117: 299 (1977). 20. Silber SJ: Microscopic vasectomy reversal, FertiI. SteriI. 28: 1191 (1977). 21. Schmidt SS: Anastomosis of the vas deferens: an experimental study. II. Successes and failures in experimental anastomosis, J. Ural. 81: 203 (1959). 22. IDEM: Anastomosis of the vas deferens: IV. The use of fine polyethylene tubing as a splint, ibid. 85: 838 (1961). 23. Alexander NJ; Vasectomy and vasovasostomy in rhesus monkeys: the effect of circulating antisperm antibodies on fertility, FertiI. Steril. 28: 562 (1977).
u&i.88:
UROLOGY
/
MAY 1979
/
VOLUME
XIII,
NUMBER5