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Current status of vasectomy reversal

Nature Reviews Urology volume 10, pages 195–205 (2013)Cite this article

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Abstract

Vasectomy reversal is the most common microsurgical intervention for the treatment of male infertility. Originally introduced in 1977, microsurgical vasectomy reversal has become highly sophisticated and is a minimally invasive, highly efficient and cost-effective treatment option for men with a desire to have children after vasectomy. It can be an effective physiological method of restoring fertility in more than 90% of vasectomized men. Although assisted reproductive technology (ART) is an alternative to vasectomy reversal, it is normally associated with higher costs without offering higher cumulative chances of a pregnancy. Recovery of physiological male fertility can take up to 2 years after vasectomy reversal, especially if reversal is performed >10 years after vasectomy, owing to impaired epididymal function. Under these circumstances, ART can be used to bridge the time until recovery of natural fertility. Although the basic principles of microsurgical vasovasostomy have been established since the late 1970s, there have since been numerous technical innovations to improve the delicate operation and promising new technical modifications, particularly for vasoepididymostomy, have been described. Robotic vasectomy reversal is an emerging field in specialized urologic centers, but whether the high quality of conventional microsurgical vasectomy reversal can be matched by robotic platforms is yet to be seen.

Key Points

  • Vasectomy reversal is a very safe, minimally invasive and successful treatment option for managing male infertility after vasectomy

  • Vasectomy reversal is more cost-effective than assisted reproduction techniques (ART) and cumulative pregnancy rates are at least as high as success rates of ART, even for couples in which the female partner is >35 years old

  • The vasectomy reversal procedure demands the skills of an experienced microsurgeon who is capable of performing vasoepididymostomy—the most challenging microsurgical vasectomy reversal procedure—if indicated

  • Intussusception vasoepididymostomy and the microdot method are technical innovations that can facilitate vasectomy reversal and might further improve outcomes

  • In selected patients, vasectomy reversal and ART can be seamlessly combined; immediately starting ICSI after vasectomy reversal can bridge the interval between surgery and fertility when a longer recovery of fertility after vasectomy reversal is expected

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Figure 1: Postobstructive changes in the epididymis.
Figure 2
Figure 3: Microsurgical site of a 3-layer vasovasostomy: approximation of vasal stumps and suturing of the first (mucosal) layer
Figure 4: Microsurgical site of a 3-layer vasovasostomy: second and third layers of vasovasostomy.
Figure 5: Three-layered vasoepididymostomy.
Figure 6: Microsurgical two-suture longitudinal intussusception vasoepididymostomy.
Figure 7: Costs associated with the treatment of postvasectomy infertility in Munich, Germany.

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References

  1. Dohle, G. R. et al. European Association of Urology guidelines on vasectomy. Eur. Urol. 61, 159–163 (2012).

    Article  PubMed  Google Scholar 

  2. Schwingl, P. J. & Guess, H. A. Safety and effectiveness of vasectomy. Fertil. Steril. 73, 923–936 (2000).

    Article  CAS  PubMed  Google Scholar 

  3. Brannigan, R. E. Vasectomy reversal: indications and outcomes. J. Urol. 187, 385–386 (2012).

    Article  PubMed  Google Scholar 

  4. Kim, H. H. & Goldstein, M. History of vasectomy reversal. Urol. Clin. North Am. 36, 359–373 (2009).

    Article  CAS  PubMed  Google Scholar 

  5. Owen, E. R. Microsurgical vasovasostomy: a reliable vasectomy reversal. Aust. N. Z. J. Surg. 47, 305–309 (1977).

    Article  CAS  PubMed  Google Scholar 

  6. Silber, S. J. Microscopic vasectomy reversal. Fertil. Steril. 28, 1191–1202 (1977).

    Article  CAS  PubMed  Google Scholar 

  7. Schwarzer, J. U. Vasectomy reversal using a microsurgical three-layer technique: one surgeon's experience over 18 years with 1300 patients. Int. J. Androl. 35, 706–713 (2012).

    Article  CAS  PubMed  Google Scholar 

  8. Silber, S. J. & Grotjan, H. E. Microscopic vasectomy reversal 30 years later: a summary of 4010 cases by the same surgeon. J. Androl. 25, 845–859 (2004).

    Article  PubMed  Google Scholar 

  9. Belker, A. M., Thomas, A. J. Jr, Fuchs, E. F., Konnak, J. W. & Sharlip, I. D. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J. Urol. 145, 505–511 (1991).

    Article  CAS  PubMed  Google Scholar 

  10. Matthews, G. J., Schlegel, P. N. & Goldstein, M. Patency following microsurgical vasoepididymostomy and vasovasostomy: temporal considerations. J. Urol. 154, 2070–2073 (1995).

    Article  CAS  PubMed  Google Scholar 

  11. Chan, P. T., Brandell, R. A. & Goldstein, M. Prospective analysis of outcomes after microsurgical intussusception vasoepididymostomy. BJU Int. 96, 598–601 (2005).

    Article  PubMed  Google Scholar 

  12. Horovitz, D. et al. Vasectomy reversal provides long-term pain relief for men with the post-vasectomy pain syndrome. J. Urol. 187, 613–617 (2012).

    Article  PubMed  Google Scholar 

  13. Nangia, A. K., Myles, J. L. & Thomas, A. J. Jr. Vasectomy reversal for the post-vasectomy pain syndrome: a clinical and histological evaluation. J. Urol. 164, 1939–1942 (2000).

    Article  CAS  PubMed  Google Scholar 

  14. Myers, S. A., Mershon, C. E. & Fuchs, E. F. Vasectomy reversal for treatment of the post-vasectomy pain syndrome. J. Urol. 157, 518–520 (1997).

    Article  CAS  PubMed  Google Scholar 

  15. Hsiao, W. et al. Nomograms to predict patency after microsurgical vasectomy reversal. J. Urol. 187, 607–612 (2012).

    Article  PubMed  Google Scholar 

  16. Hodes-Wertz, B. et al. Is intracytoplasmic sperm injection overused? J. Urol. 187, 602–606 (2012).

    Article  PubMed  Google Scholar 

  17. Nagler, H. M. & Jung, H. Factors predicting successful microsurgical vasectomy reversal. Urol. Clin. North Am. 36, 383–390 (2009).

    Article  PubMed  Google Scholar 

  18. Christiansen, C. G. & Sandlow, J. I. Testicular pain following vasectomy: a review of postvasectomy pain syndrome. J. Androl. 24, 293–298 (2003).

    Article  PubMed  Google Scholar 

  19. Shapiro, E. I. & Silber, S. J. Open-ended vasectomy, sperm granuloma, and postvasectomy orchialgia. Fertil. Steril. 32, 546–550 (1979).

    Article  CAS  PubMed  Google Scholar 

  20. Flickinger, C. J. The effects of vasectomy on the testis. N. Engl. J. Med. 313, 1283–1285 (1985).

    Article  CAS  PubMed  Google Scholar 

  21. Flickinger, C. J., Howards, S. S. & Herr, J. C. Effects of vasectomy on the epididymis. Microsc. Res. Tech. 30, 82–100 (1995).

    Article  CAS  PubMed  Google Scholar 

  22. Wheeler, K. et al. Regulatory T cells control tolerogenic versus autoimmune response to sperm in vasectomy. Proc. Natl Acad. Sci. USA 108, 7511–7516 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  23. Boorjian, S., Lipkin, M. & Goldstein, M. The impact of obstructive interval and sperm granuloma on outcome of vasectomy reversal. J. Urol. 171, 304–306 (2004).

    Article  PubMed  Google Scholar 

  24. Alexander, N. J. & Anderson, D. J. Vasectomy: consequences of autoimmunity to sperm antigens. Fertil. Steril. 32, 253–260 (1979).

    Article  CAS  PubMed  Google Scholar 

  25. Silber, S. J. Pregnancy after vasovasostomy for vasectomy reversal: a study of factors affecting long-term return of fertility in 282 patients followed for 10 years. Hum. Reprod. 4, 318–322 (1989).

    Article  CAS  PubMed  Google Scholar 

  26. Hollingsworth, M. R., Sandlow, J. I., Schrepferman, C. G., Brannigan, R. E. & Kolettis, P. N. Repeat vasectomy reversal yields high success rates. Fertil. Steril. 88, 217–219 (2007).

    Article  PubMed  Google Scholar 

  27. Hernandez, J. & Sabanegh, E. S. Repeat vasectomy reversal after initial failure: overall results and predictors for success. J. Urol. 161, 1153–1156 (1999).

    Article  CAS  PubMed  Google Scholar 

  28. Pasqualotto, F. F., Agarwal, A., Srivastava, M., Nelson, D. R. & Thomas, A. J. Jr. Fertility outcome after repeat vasoepididymostomy. J. Urol. 162, 1626–1628 (1999).

    Article  CAS  PubMed  Google Scholar 

  29. Shaeer, O. K. Z. & Shaeer, K. Z. Pelviscrotal vasovasostomy: refining and troubleshooting. J. Urol. 174, 1935–1937 (2005).

    Article  PubMed  Google Scholar 

  30. Kramer, W. C. & Meacham, R. B. Vasal reconstruction above the internal inguinal ring: what are the options? J. Androl. 27, 481–482 (2006).

    Article  PubMed  Google Scholar 

  31. Schwarzer, J. U. The influence of inguinal surgery on the success of a vasectomy reversal [German]. Urologe A. 51, 1099–1105 (2012).

    Article  CAS  PubMed  Google Scholar 

  32. Sheynkin, Y. R., Hendin, B. N., Schlegel, P. N. & Goldstein, M. Microsurgical repair of iatrogenic injury to the vas deferens. J. Urol. 159, 139–141 (1998).

    Article  CAS  PubMed  Google Scholar 

  33. Shin, D. et al. Herniorrhaphy with polypropylene mesh causing inguinal vasal obstruction: a preventable cause of obstructive azoospermia. Ann. Surg. 241, 553–558 (2005).

    Article  PubMed  PubMed Central  Google Scholar 

  34. Witt, M. A., Heron, S. & Lipshultz, L. I. The post-vasectomy length of the testicular vasal remnant: a predictor of surgical outcome in microscopic vasectomy reversal. J. Urol. 151, 892–894 (1994).

    Article  CAS  PubMed  Google Scholar 

  35. Temmerman, M., Cammu, H., Devroey, P. & Amy, J. J. Evaluation of one-hundred open-ended vasectomies. Contraception 33, 529–532 (1986).

    Article  CAS  PubMed  Google Scholar 

  36. Goldstein, M. Vasectomy failure using an open-ended technique. Fertil. Steril. 40, 699–700 (1983).

    Article  CAS  PubMed  Google Scholar 

  37. Barone, M. A., Hutchinson, P. L., Johnson, C. H., Hsia, J. & Wheeler, J. Vasectomy in the United States, 2002. J. Urol. 176, 232–236 (2006).

    Article  PubMed  Google Scholar 

  38. Labrecque, M., Dufresne, C., Barone, M. A. & St-Hilaire, K. Vasectomy surgical techniques: a systematic review. BMC Med. 2, 21 (2004).

    Article  PubMed  PubMed Central  Google Scholar 

  39. Sharlip, I. D. et al. Vasectomy: AUA guideline. J. Urol. 188, 2482–2491 (2012).

    Article  PubMed  Google Scholar 

  40. Marmar, J. L., Sharlip, I. & Goldstein, M. Results of vasovasostomy or vasoepididymostomy after failed percutaneous epididymal sperm aspirations. J. Urol. 179, 1506–1509 (2008).

    Article  PubMed  Google Scholar 

  41. Sigman, M. & Jarow, J. P. Endocrine evaluation of infertile men. Urology 50, 659–664 (1997).

    Article  CAS  PubMed  Google Scholar 

  42. Carbone, D. J. Jr, Shah, A., Thomas, A. J. Jr & Agarwal, A. Partial obstruction, not antisperm antibodies, causing infertility after vasovasostomy. J. Urol. 159, 827–830 (1998).

    Article  CAS  PubMed  Google Scholar 

  43. Matsuda, T., Horii, Y., Muguruma, K., Komatz, Y. & Yoshida, O. Microsurgical epididymovasostomy for obstructive azoospermia: factors affecting postoperative fertility. Eur. Urol. 26, 322–326 (1994).

    Article  CAS  PubMed  Google Scholar 

  44. Mazumdar, S. & Levine, A. S. Antisperm antibodies: etiology, pathogenesis, diagnosis, and treatment. Fertil. Steril. 70, 799–810 (1998).

    Article  CAS  PubMed  Google Scholar 

  45. Herr, J. C. et al. The influence of vasovasostomy on antisperm antibodies in rats. Biol. Reprod. 40, 353–360 (1989).

    Article  CAS  PubMed  Google Scholar 

  46. Silber, S. J. The relationship of abnormal semen parameters to male fertility. Hum. Reprod. 4, 947–953 (1989).

    Article  CAS  PubMed  Google Scholar 

  47. Ohl, D. A. & Naz, R. K. Infertility due to antisperm antibodies. Urology 46, 591–602 (1995).

    Article  CAS  PubMed  Google Scholar 

  48. Bronson, R. A. Antisperm antibodies: a critical evaluation and clinical guidelines. J. Reprod. Immunol. 45, 159–183 (1999).

    Article  CAS  PubMed  Google Scholar 

  49. Haidl, G. Characterization of fertility related antisperm antibodies- a step towards causal treatment of immunological infertility and immuno-contraception. Asian J. Androl. 12, 793–794 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  50. Gerrard, E. R. Jr et al. Effect of female partner age on pregnancy rates after vasectomy reversal. Fertil. Steril. 87, 1340–1344 (2007).

    Article  PubMed  Google Scholar 

  51. Nicopoullos, J. D. M., Gilling-Smith, C., Almeida, P. A. & Ramsay, J. W. A. Effect of time since vasectomy and maternal age on intracytoplasmic sperm injection success in men with obstructive azoospermia after vasectomy. Fertil. Steril. 82, 367–373 (2004).

    Article  PubMed  Google Scholar 

  52. Kolettis, P. N. et al. Pregnancy outcomes after vasectomy reversal for female partners 35 years old or older. J. Urol. 169, 2250–2252 (2003).

    Article  PubMed  Google Scholar 

  53. Hsieh, M.-L., Huang, H. C., Chen, Y., Huang, S. T. & Chang, P. L. Loupe-assisted vs microsurgical technique for modified one-layer vasovasostomy: is the microsurgery really better? BJU Int. 96, 864–866 (2005).

    Article  PubMed  Google Scholar 

  54. Donovan, J. F. Jr. Microscopic vasovasostomy: current practice and future trends. Microsurgery 16, 325–332 (1995).

    Article  PubMed  Google Scholar 

  55. Practice Committee of American Society for Reproductive Medicine. Vasectomy reversal. Fertil. Steril. 90, S78–S82 (2008).

  56. Lipshultz, L. I., Rumohr, J. A. & Bennett, R. C. Techniques for vasectomy reversal. Urol. Clin. North Am. 36, 375–382 (2009).

    Article  PubMed  Google Scholar 

  57. Lipshultz, L. I., Thomas, A. J. & Khera, M. in Campbell-Walsh Urology (eds Wein, A. J., Kavoussi, L. R., Partin, A. W., Peters, C. A. & Nowick, A. C.) 698–699 (Saunders, 2007).

    Google Scholar 

  58. Silber, S. J. Sperm granuloma and reversibility of vasectomy. Lancet 2, 588–589 (1977).

    Article  CAS  PubMed  Google Scholar 

  59. Goldstein, M. & Tanrikut, C. Microsurgical management of male infertility. Nat. Clin. Pract. Urol. 3, 381–391 (2006).

    Article  PubMed  Google Scholar 

  60. Kolettis, P. N., Burns, J. R., Nangia, A. K. & Sandlow, J. I. Outcomes for vasovasostomy performed when only sperm parts are present in the vasal fluid. J. Androl. 27, 565–567 (2006).

    Article  PubMed  Google Scholar 

  61. Goldstein, M., Li, P. S. & Matthews, G. J. Microsurgical vasovasostomy: the microdot technique of precision suture placement. J. Urol. 159, 188–190 (1998).

    Article  CAS  PubMed  Google Scholar 

  62. Sandlow, J. I. & Kolettis, P. N. Vasovasostomy in the convoluted vas deferens: indications and outcomes. J. Urol. 173, 540–542 (2005).

    Article  PubMed  Google Scholar 

  63. Patel, S. R. & Sigman, M. Comparison of outcomes of vasovasostomy performed in the convoluted and straight vas deferens. J. Urol. 179, 256–259 (2008).

    Article  PubMed  Google Scholar 

  64. Mulhall, J. P., Stokes, S., Andrawis, R. & Buch, J. P. Simultaneous microsurgical vasal reconstruction and varicocele ligation: safety profile and outcomes. Urology 50, 438–442 (1997).

    Article  CAS  PubMed  Google Scholar 

  65. Berger, R. E. Triangulation end-to-side vasoepididymostomy. J. Urol. 159, 1951–1953 (1998).

    Article  CAS  PubMed  Google Scholar 

  66. Marmar, J. L. Modified vasoepididymostomy with simultaneous double needle placement, tubulotomy and tubular invagination. J. Urol. 163, 483–486 (2000).

    Article  CAS  PubMed  Google Scholar 

  67. Schiff, J., Chan, P., Li, P. S., Finkelberg, S. & Goldstein, M. Outcome and late failures compared in 4 techniques of microsurgical vasoepididymostomy in 153 consecutive men. J. Urol. 174, 651–655 (2005).

    Article  PubMed  Google Scholar 

  68. Monoski, M. A., Schiff, J., Li, P. S., Chan, P. T. K. & Goldstein, M. Innovative single-armed suture technique for microsurgical vasoepididymostomy. Urology 69, 800–804 (2007).

    Article  PubMed  Google Scholar 

  69. Kolettis, P. N. et al. Secondary azoospermia after vasovasostomy. Urology 65, 968–971 (2005).

    Article  PubMed  Google Scholar 

  70. Shridharani, A. & Sandlow, J. I. Vasectomy reversal versus IVF with sperm retrieval: which is better? Curr. Opin. Urol. 20, 503–509 (2010).

    Article  PubMed  Google Scholar 

  71. Malizia, B. A., Hacker, M. R. & Penzias, A. S. Cumulative live-birth rates after in vitro fertilization. N. Engl. J. Med. 360, 236–243 (2009).

    Article  CAS  PubMed  Google Scholar 

  72. Liu, K. & Case, A. Advanced reproductive age and fertility. J. Obstet. Gynaecol. Can. 33, 1165–1175 (2011).

    Article  PubMed  Google Scholar 

  73. Fuchs, E. F. & Burt, R. A. Vasectomy reversal performed 15 years or more after vasectomy: correlation of pregnancy outcome with partner age and with pregnancy results of in vitro fertilization with intracytoplasmic sperm injection. Fertil. Steril. 77, 516–519 (2002).

    Article  PubMed  Google Scholar 

  74. Robb, P. & Sandlow, J. I. Cost-effectiveness of vasectomy reversal. Urol. Clin. North Am. 36, 391–396 (2009).

    Article  PubMed  Google Scholar 

  75. Hansen, M., Bower, C., Milne, E., De Klerk, N. & Kurinczuk, J. J. Assisted reproductive technologies and the risk of birth defects-a systematic review. Hum. Reprod. 20, 328–338 (2005).

    Article  PubMed  Google Scholar 

  76. Pavlovich, C. P. & Schlegel, P. N. Fertility options after vasectomy: a cost-effectiveness analysis. Fertil. Steril. 67, 133–141 (1997).

    Article  CAS  PubMed  Google Scholar 

  77. Yang, G., Walsh, T. J., Shefi, S. & Turek, P. J. The kinetics of the return of motile sperm to the ejaculate after vasectomy reversal. J. Urol. 177, 2272–2276 (2007).

    Article  PubMed  Google Scholar 

  78. Tournaye, H. Surgical sperm recovery for intracytoplasmic sperm injection: which method is to be preferred? Hum. Reprod. 14 (Suppl. 1), 71–81 (1999).

    Article  PubMed  Google Scholar 

  79. Schwarzer, J. U. et al. Sperm retrieval procedures and intracytoplasmatic spermatozoa injection with epididymal and testicular sperms. Urol. Int. 70, 119–123 (2003).

    Article  PubMed  Google Scholar 

  80. Murphy, D., Challacombe, B., Khan, M. S. & Dasgupta, P. Robotic technology in urology. Postgrad. Med. J. 82, 743–747 (2006).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  81. Fleming, C. Robot-assisted vasovasostomy. Urol. Clin. North Am. 31, 769–772 (2004).

    Article  PubMed  Google Scholar 

  82. Parekattil, S. J. & Moran, M. E. Robotic instrumentation: Evolution and microsurgical applications. Indian J. Urol. 26, 395–403 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  83. Parekattil, S. J., Atalah, H. N. & Cohen, M. S. Video technique for human robot-assisted microsurgical vasovasostomy. J. Endourol. 24, 511–514 (2010).

    Article  PubMed  Google Scholar 

  84. Parekattil, S. J., Gudeloglu, A., Brahmbhatt, J., Wharton, J. & Priola, K. B. Robotic assisted versus pure microsurgical vasectomy reversal: technique and prospective database control trial. J. Reconst. Microsurg. 28, 435–444 (2012).

    Article  Google Scholar 

  85. Ida, Y. et al. Microsurgical robotic system for vitreoretinal surgery. Int. J. Comput. Assist. Radiol. Surg. 7, 27–34 (2012).

    Article  PubMed  Google Scholar 

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  1. Department of Microsurgery, Andrologie Centrum München, Lortzingstrasse 26, D-81241, München, Germany

    J. Ullrich Schwarzer & Heiko Steinfatt

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Schwarzer, J., Steinfatt, H. Current status of vasectomy reversal. Nat Rev Urol 10, 195–205 (2013). https://doi.org/10.1038/nrurol.2013.14

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