Microscopic Vasectomy Reversal 30 Years Later: A Summary of 4010 Cases by the Same Surgeon

Between 1975 and 2003, a total of 4010 patients have undergone microscopic vasectomy reversal by 1 surgeon at 1 institution. Of these cases, 3904 had available records and 1735 were successfully contacted to obtain reliable long-term data. A total of 1556 (89.7%) were able to establish a pregnancy in their female partner, resulting in 2111 pregnancies. When there was no sperm in the vas fluid at the time of vasectomy reversal, vasoepididymostomy was performed rather than vasovasostomy. A total of 1581 patients underwent bilateral vasovasostomy; 1184 underwent vasoepididymostomy on one side and vasovasostomy on the other side; and 1139 underwent bilateral vasoepididymostomy. Of patients undergoing vasovasostomy, 2.1% had no sperm in the ejaculate postoperatively, and 10.3% of patients undergoing bilateral vasoepididymostomy had no sperm in the ejaculate postoperatively. Thus on average a patency rate of 96.2% in the total group of patients was achieved. When the vasectomy was less than 10 years prior to reversal, the patency rate was 98%. When the vasectomy was 10 or more years prior to reversal, the patency rate was 93%. Among all the patients, 77.7% had sperm counts greater than 5 million/mL postoperatively. Among patients undergoing bilateral vasovasostomy and those undergoing bilateral vasoepididymostomy, 92.5% and 84.3% eventually achieved a pregnancy, respectively. The pregnancy rate did not differ with patients that had a sperm count of greater than 5 million sperm/mL. The pregnancy rate for less than 5 million sperm/mL was 78.3% and when there was greater than 5 million sperm/mL the pregnancy rate was 91.9%. Although the duration of time between vasectomy and vasectomy reversal had an impact on pregnancy rate, the greatest impact was the age of the wife. Among wives under age 30 at the time of the vasectomy reversal, 94.2% established a pregnancy, but only 61.1% of wives age 40 or older established a pregnancy. We conclude that microsurgical vasectomy reversal is preferable to sperm retrieval and intracytoplasmic sperm injection (ICSI), since the pregnancy rate appears to be higher with this technique than with sperm retrieval and ICSI. It does not appear that sperm antibodies or testicular damage are likely to account for failure to achieve pregnancy after vasectomy reversal. Rather, it is likely to be related to partial or complete obstruction following surgery, or to the fertility of the female partner. Prior to the mid 1970s, when microsurgical vasovasostomy was first introduced, vasectomy had been generally regarded as not reversible and attempts at reversal yielded very poor results (O'Connor, 1948; Derrick et al, 1973; Derrick and Frencilli, 1974). In 1948, some 135 surgeons who were polled had tried to perform vasovasostomy and reported a very poor prognosis for return of any sperm to the semen (O'Connor, 1948). In 1973, of 1630 cases performed by 542 urologic surgeons, the patency rate for vasovasostomy was only 20%, and pregnancies were considered to be unusual (Derrick et al, 1973). Attempts to improve those poor results in the 1960s and early 1970s with pull-out sutures, gold valves, magnetic ball valves, and removable silicone plugs failed to improve the dismal results (Derrick and Frencilli, 1974). Later attempts in the 1990s to use stents to improve success rates of vasovasostomy without having to resort to accurate microsurgical anastomosis have also failed (Rothman et al, 1997). The literature on this issue can be very confusing because of the relatively small number of patients (often less than 30) in most published series (Middleton et al, 1987; Fox, 1994, 1997; Matsuda et al, 1994; Witt et al, 1994; Chiang 1996; McDonald, 1996; Yamamoto et al, 1997; Carbone et al, 1998; Inaba et al, 1999; Jokelaine et al, 2001; Schrepferman et al, 2001; Huang et al, 2002). There are a remarkable number of heated controversies on this subject. Is microsurgery preferable to macrosurgery? What is the cause for nonpatency, blockage at the vasovasostomy site, or in the epididymis? What is the cause of failure of the wife to get pregnant despite patency? Do antibodies play a role? Is there testicular damage from pressure buildup? What is the effect of the wife's fertility? Why is there a discrepancy between patency after surgery and the wife's achieving pregnancy? What is the effect, if any, of partial vas blockage, partial epididymal blockage, or epididymal malfunction? What effect does the time since vasectomy or absence of sperm in the vas fluid have? Should we do only vasovasostomy at the first operation, or if there is no sperm in the vas fluid, should we perform vasoepididymostomy? Should an accompanying varicocele be repaired? In fact, should we actually do vasectomy reversal at all, or just subject all these patients to sperm retrieval and intracytoplasmic sperm injection (ICSI)? Should epididymal sperm be frozen at the time of vasectomy reversal? Is a sperm granuloma at the vasectomy site harmful or helpful? How has the changing technique for vasectomy over the last 30 years impacted the success rate for vasovasostomy or the need for vasoepididymostomy? Should vasectomy reversal be performed if the patient's wife is older, or should they just go right to ICSI with sperm retrieval? These controversies have sometimes been remarkably hostile (even in the written literature) and emotional. We will try to address these controversies by reporting our results in an enormous series of over 4000 cases performed by one of us (S.J.S.) over the last 30 years comparing our early reports in the 1970s and 1980s with our current accumulated results in 2004 (Silber, 1975, 1976, 1977a,b, 1978a,b, 1979, 1980a; Friend et al, 1976; Owen, 1977). Our procedure over the last 3 decades has been based on results reported in our earlier papers in the 1970s. At that time, we originally performed vasovasostomy without vasoepididymostomy for all patients regardless of the quality or appearance of sperm in the vas fluid at the time of the reversal. However, our data in 1977 demonstrated that when there was no sperm in the vas fluid (with the exception of the fluid being crystal clear), patients remained azoospermic even after a very accurate vasovasostomy. Therefore, in the cases reported here, we routinely performed vasoepididymostomy rather than vasovasostomy on either side or both sides when no sperm was found in the vas fluid. Furthermore, since our data in 1977 demonstrated no difference in results between patients who had a previous failure at vasectomy reversal versus patients undergoing their first vasectomy reversal at our center, we grouped all the data together regardless of whether the patient had a previous failed attempt at reversal. In addition, if there was a varicocele discovered on physical examination prior to vasectomy reversal, varicocelectomy was not performed. A total of 4010 patients were referred to one of us (S.J.S.) over the last 30 years to undergo microsurgical reversal of vasectomy. Records were available for this study on the last 3904 of these patients. The average age of these men was 40.0 ± 7.1 (SD) years, and the average age of wives (known in 3793 of the cases), was 31.0 ± 5.0 years. 1581 (40.5%) of the patients underwent bilateral vasovasostomy, 1184 (30.3%) underwent vasoepididymostomy on one side and vasovasostomy on the other (unilateral vasoepididymostomy), and 1139 (29.2%) underwent bilateral vasoepididymostomy. On either side, patients with no sperm in the vas fluid (if the fluid was not crystal clear), underwent vasoepidymostomy instead of vasovasostomy. A total of 802 of the patients (22.3%) had a previous failed vasectomy reversal and were coming here for a rereversal. The average time between vasectomy and vasectomy reversal was 10.0 years ± 5.4 (SD). Observations recorded at the time of the surgery included the age of the patient, the age of wife, the duration of time since vasectomy, the gross appearance of the vas fluid, the microscopic analysis of the vas fluid for sperm or sperm parts, and the type of anastomosis, whether vasovasostomy or vasoepididymostomy. The number of years since vasectomy was known and was recorded in 3591 cases. Postoperative semen analysis was available in 3378 (86.5%) of the cases. Over a 6-month period of time every single chart was reviewed, and 2 counselors worked full time attempting to contact these 4010 patients. This procedure was some-what facilitated by modern internet search capabilities. Many patients during these 30 years had moved, and phone numbers were no longer valid, requiring a thorough internet search. The purpose of this telephone campaign was to fill in any missing detail about pregnancy or lack of pregnancy, at any period of time subsequent to the vasectomy reversal. Not only was pregnancy data thus updated but the delivery of a baby (the ultimate end-point in modern fertility outcome studies) was ascertained. In that respect our data follow-up approach was modeled after that described by Fuchs and Burt in 2002 (Fuchs and Burt, 2002). In their report, 48 cases out of 173 were dismissed because of lack of inability to contact the patients, and 9 were dismissed because apparently the patients were not attempting to achieve pregnancy. Also there was no clear distinction between unilateral vasoepididymostomy and bilateral vasoepididymostomy. It became obvious that follow-up information is difficult to obtain in this population of patients, and it requires an intensive telephone campaign to validate and update data. Of the 3904 patients in which records were available, including postoperative sperm count in 3591 patients, in only 1735 patients was it possible to obtain long-term follow-up on the eventual occurrence or nonoccurrence of pregnancy or delivery of a baby. Thus data were accumulated on surgical technique, demography of patients, and subsequent sperm counts in 3904 patients, and reliable pregnancy information was available in 1735 cases. Comparisons were made to results related to the age of patient, the age of the wife, the time since vasectomy, the resulting sperm count, and the type of anastomosis whether vasovasostomy or vasoepididymostomy. This represents the first detailed and massive follow-up study of vasectomy reversal performed by 1 operating surgeon. Our microsurgical technique over the last 30 years for vasovasostomy is essentially unchanged from our original reports. Our technique for vasoepididymostomy has always been "specific tubule" microanastomosis. We first described this in 1978 using an end-to-end approach (Silber, 1978c). In 1984 we switched from end-to-end to end-to-side specific tubule anastomosis because it seemed to be an easier approach and produced similar results. Therefore, we grouped all of our vasoepididymostomies together regardless of whether an end-to-end or end-to-side procedure had been performed (Silber, 1984). Although the debate may continue about the use of a microscope for vasovasostomy, the issue of whether the surgeon should be adept at microsurgery becomes foolish when it is apparent that vasoepididymostomy may be necessary, and nobody would suggest that vasoepididymostomy can be done properly without a microscope and special microsurgical skill (Donovan, 1995). From the very beginning of our earliest reports in 1975 there was great resistance to the use of a microscope for vasectomy reversal. We never understood this resistance since the purpose of the microscope, as opposed to loupes or the naked eye, is simply to make it easier to do the operation properly. Use of the microscope should not make the operation more difficult, it should make it easier. Yet many authors persisted in trying to advocate doing this procedure either with the naked eye or with 2× or 3× loupe magnification only. However, if one cannot do a 2-layer microlayer vasovasostomy using an operating microscope, then there is certainly no chance that person can do an adequate anastomosis for vasoepididymostomy (MacDonald and Edson, 1976; Rowland et al, 1977; Lykins and Witherington, 1978; Fenster and McLoughlin, 1981; Fallon et al, 1981; Shessel et al, 1981; Redman, 1982). After general anesthesia is induced, each scrotal sac is entered through a 1.5 inch longitudinal incision and the scrotal contents are extruded extravaginally and examined. If there is only a small segment of vas missing, a simple vasovasostomy can be performed quite readily under local anesthesia. However, because often a larger segment is missing and because vasoepididymostomy often has to be resorted to, general anesthesia is employed in most of our cases. If a large segment of vas deferens is missing, as is often the case in more recent surgeries because the urologists are very concerned about lawsuits stemming from unwanted pregnancies, the vas must be freed up considerably above and below the area of obstruction to avoid tension on the suture line. Often these incisions have to be extended up to the level of the external inguinal ring and very occasionally even more proximally, in order to free up enough vas deferens proximally so that there will be no tension on the suture line and so that the testicle will sit properly in the scrotal sac. For vasovasostomy, the proximal and distal end of the vas deferens on either side of the vasectomy site are placed in the jaws of a Silber vasovasostomy clamp (V. Mueller) and drawn into the field of the operating microscope. The 2 ends of the vas are carefully checked at this time to make sure there is no tension. The fibrotic section is then transsected proximally and distally, and all bleeders at the cut end of the vas are cauterized with microbipolar forceps during continuing pulsatile irrigation with heparinized saline. If there is any tension on the 2 ends of vas deferens, we do not try to use a holding suture to pull them together under tension, but rather extend the incision if necessary and free up the vas deferens so that there is no tension. Only if the vas fluid shows no sperm or purely sperm heads do we perform a vasoepididymostomy. If the vas fluid is crystal clear with or without sperm or if the vas fluid has only long-tailed but completely nonmotile sperm we still will perform vasovasostomy. This decision making was based upon the 1977 report of Silber (1977c). The inner mucosa of the vas is sutured with 10-0 monofilament nylon (Sharpoint DRM 4 needle black monofilament nylon, 70 microns, 135° curve). The mucosal sutures pick up a small portion of muscularis in order to facilitate the anastomosis (Figure 1). The only reason for doing 2 layers is to be certain that accurate mucosa-to-mucosa approximation is achieved. If this can be done with a 1-layer anastomosis, that is quite acceptable. However, often there is a disparity between the size of the proximal and distal lumens of the vas. The reason for that disparity is that there has been pressure buildup over many years. Throughout the anastomosis visualization is facilitated by continuous pulsatile irrigation with heparinized saline. . Picture of 2-layer microsurgical vasovasostomy. We do not delay tying the sutures until after they are all placed. Rather, we tie each interrupted suture as we go in order to avoid what we term a "marionette puppet show" in which sutures can become entangled with each other and confusing, making the operation more difficult. We find that if you tie the sutures as you go and your assistant is skilled at holding the vas open with microforceps, there is no need for double-needled sutures, and the operation is actually easier and more ergonomic. We have not used any "technical aids," which have been described in the literature such as stents, whether temporary or permanent, or the so-called muscularis inversion technique (Belker, 1982; Donovan, 1995; Fox, 1996). The outer muscularis is then sutured with 9-0 nylon interrupted sutures (Sharpoint, 9-0 nylon black monofilament HSV 6 100 micron vas cutting needle) after 6 inner mucosal sutures of 10-0 nylon have been placed. The end-to-end anastomosis of vas-to-vas is facilitated by using the vasovasostomy clamp, which we simply rotate 180° when the anterior layer has been finished in order then to suture the posterior side. For vasoepididymostomy, the tunica vaginalis is opened and the epididymis inspected under the operating microscope. We begin at the distal cauda epididymis and work proximally until we get beyond the point of secondary obstruction (Figures 2, 3, 4, 5). This area is ascertained by taking a small window out of the tunica covering the epididymis, dissecting the epididymal tubule in that location, and then making a small longitudinal slit with a microscissors under 40× magnification. The fluid gushing from the tubule is then aspirated with a micropipette, diluted in 1/2 mL of HEPES buffered HTF media, and examined in the operating room under phase contrast microscopy. . Diagrams of preparing epididymal tubule for end-to-side vasoepididymostomy. . Diagram showing placement of first mucosa suture for end-to-side vasoepididymostomy. . Diagram showing first 3 posterior mucosal sutures for end-to-side vasoepididymostomy. . Diagram showing completed mucosal anastomosis end-to-side vasoepididymostomy. Until 1984 we had serially transsected the epididymis until we obviously passed the proximal point of obstruction, but now with the end-to-side approach we make our decision where to perform the anastomosis based upon the presence and quality of sperm in the epididymal fluid. The epididymal sperm, if motile, are then frozen and stored with a standard vapor technique for future use if the operation should prove not to be successful. Under low-power magnification the posterior muscularis of the vas is sutured to the posterior epididymal tunic using three 9-0 nylon interrupted sutures. Then the inner mucosa of the vas deferens is sutured to the longitudinal slit in the epididymal tubule, end-to-side using six 10-0 nylon (Ethicon monofilament black nylon 10-0 V75-3 taper cut needle) interrupted sutures. The first interrupted suture is placed at the 6 o'clock position going first from outside to inside of the epididymal tubule, and then inside to outside in the mucosal layer of the vas. In this fashion we then put in the remaining 10-0 nylon interrupted sutures working around anteriorly. Finally, the anterior muscularis of the vas is sutured to the anterior epididymal tunic with 5 more 9-0 nylon interrupted sutures (Figure 6A). None of these cases have been performed on an outpatient basis. In all cases, drains are left in the scrotum, the patient stays in the hospital overnight, and a nurse regularly changes the dressings. The drains are removed the next day and only then is the patient allowed to leave. With this approach there is minimal postoperative pain or risk of hematoma or swelling. Although the popular mode today is to do these procedures on an outpatient basis, patients coming to us who have had previous outpatient vasectomy reversals routinely complain about the amount of discomfort and swelling they endured going home without drains immediately after surgery. . Picture of mucosal sutures for vasoepididymostomy. Picture of completed muscularis sutures for vasoepididymostomy. Our current operating time for bilateral vasovasostomy is about 1 and in the early it was over Our operating time for bilateral vasoepididymostomy is 2 and in the earlier portion of this series it would have more than 5 Our patients are to avoid physical for 4 and to at at home for the first We do not them to begin having sperm counts until 3 postoperatively, and then we sperm every 3 The data was in data and simple were accumulated using standard and into data were by analysis and continuous were by analysis of of were for using difference data sperm were to an prior to making the the of the of the as a A of less than was considered The used during the analysis included an for and 1 the of procedures performed for vasectomy reversal during each of the 3 previous From 1975 to only of vasectomy reversals bilateral vasoepididymostomy. However, in the subsequent from to 1994, a total of of the reversals vasoepididymostomy, and over the 3 bilateral vasoepididymostomy. The of bilateral vasovasostomy from in the first to only of the cases in the last Thus in the last 2 only of our vasectomy reversals bilateral vasovasostomy, and vasoepididymostomy on either one or both What we is that the of epididymal in our vasectomy reversal population have over the last 30 years as the popular for vasectomy have more and more a of the distal vas. 2 the between the number of years since vasectomy and the type of anastomosis bilateral vasovasostomy, unilateral vasoepididymostomy, or bilateral vasoepididymostomy. the number of years between the vasectomy and the reversal the of patients undergoing simple bilateral vasovasostomy as the number of patients requiring bilateral vasoepididymostomy When the time since vasectomy was over years, only of patients underwent bilateral vasovasostomy and underwent bilateral vasoepididymostomy. The longer of duration of time since vasectomy the greater the chance of no sperm in the vas fluid, epididymal under our the greater the chance of requiring vasoepididymostomy Of the 3904 patients with records available, did not any postoperative semen Thus we had follow-up for semen on 3378 (86.5%) of the patients. 4 the patency results for sperm in the ejaculate for all 3378 patients for these data were available, grouped by the type of A small number of early patients reported in our 1977 undergoing vasovasostomy in the early years had no sperm in the vas fluid, and by the we established in 1977 would have now undergone vasoepididymostomy rather than vasovasostomy. The of patency of sperm was for vasovasostomy, for unilateral vasoepididymostomy, and for bilateral vasoepididymostomy. The patency rate was and higher when at one side only vasovasostomy than when both sides vasoepididymostomy because of absence of sperm in the vas fluid. 5 the of patients with sperm in the ejaculate who had a known pregnancy outcome whether the wife eventually became pregnant or did not become grouped by type of With this group of patients, of we have the follow-up only 2.1% of those undergoing bilateral vasovasostomy failed to have sperm in the a patency For patients undergoing unilateral vasovasostomy with unilateral vasoepididymostomy, had sperm in the Thus of a total of patients with vasovasostomy on one or both only failed to have sperm in the ejaculate postoperatively. Among patients undergoing bilateral vasoepididymostomy, (89.7%) had sperm in the ejaculate postoperatively. Thus with this vasovasostomy when there is sperm in the vas fluid and vasoepididymostomy when there is no sperm in the vas fluid, an patency rate of 96.2% was 6 and the of patients with sperm patency those with greater than 5 million in the postoperative semen analysis to the duration of time since vasectomy. The longer the duration of time since vasectomy, the greater the risk of If the vasectomy was less than 10 years of patients had sperm However, if the vasectomy was more than years of patients had sperm patency and 9 that of patients have greater than million sperm/mL postoperatively. it is clear that the semen analysis a higher sperm count in men undergoing bilateral vasovasostomy than in men who bilateral vasoepididymostomy. 10 in a similar fashion that sperm is higher for patients with bilateral vasovasostomy than patients with bilateral vasoepididymostomy. The with bilateral vasoepididymostomy a standard is that resulting from bilateral vasovasostomy. that the pregnancy rate, patients on data are available, was There was a small in pregnancy rate for bilateral vasoepididymostomy with bilateral vasovasostomy Of the there were and There was no difference in to the type of reversal The rate for 2111 pregnancies was an average of pregnancies in that established a was out those pregnancies for which we not on follow-up whether in those patients where we pregnancy and there was no difference related to type of the pregnancy rate to type of anastomosis only for patients who had sperm Of patients with sperm patency on adequate follow-up was available, were able to their for an pregnancy rate in cases of The pregnancy rate was for patients with a anastomosis after vasovasostomy and for patients with a anastomosis after bilateral vasoepididymostomy. out those pregnancies for which we not whether or not and the pregnancy rate to the sperm count postoperatively. There is remarkably difference in pregnancy rate related to postoperative sperm the sperm count is greater than 5 million/mL there is no difference in pregnancy for those with or sperm that the pregnancy rate in to the in duration of time since the vasectomy. When the time since vasectomy is less than 5 years, the pregnancy rate is when the time since vasectomy is more than years, the pregnancy rate is The pregnancy rate is together all out those pregnancies for which we not whether or not For all of time since vasectomy, about Thus the pregnancy rate is still very for patients with duration of time since vasectomy, but than when there is a duration of time since vasectomy. the pregnancy rate for vasectomy reversal to the age of the wife. Of all the type of anastomosis, duration of time since vasectomy, and postoperative sperm count, the 1 that had the most impact on pregnancy rate was the age of the wife. When the wife was under 30 years of 94.2% of vasectomy reversals in a pregnancy. When the wife was in in a pregnancy. However, when the wife was 40 or older, only 61.1% of the reversals yielded a pregnancy. In of current in it is that over of 40 or older would become pregnant after a vasectomy reversal when pregnancy rates for that group resulting in a delivery are less than out those pregnancies for which we not and the results are out the pregnancy rate to the time since vasectomy as as the wife's analysis that both the age of the female as as the duration of time since vasectomy have on the pregnancy rate, the age of the wife is most When the vasectomy was over years and the wife was under age still achieved pregnancy. However, when the vasectomy was over years earlier and the wife was 40 years of age or older, only achieved pregnancy. shows that of all the pregnancies did not until more than 2 years after vasectomy reversal. follow-up is likely to ultimate