VASECTOMY REVERSAL IN THE ERA OF INTRACYTOPLASMIC SPERM INJECTION (ICSI): INDICATIONS AND TECHNIQUE

Vasectomy is an effective method of permanent contraception that has gained popularity in many countries during the last decade. Approximately one-half million men per year undergo this procedure in the United States. Between 2 to 6% percent of vasectomized men will request vasectomy reversal later in their lives. Microsurgical vasovasostomy and vasoepididymostomy are the primary surgical techniques used today for vasectomy reversal. These procedures are highly successful in the hands of experienced microsurgeons. Success after vasectomy reversal depends on several factors including the length of the interval between the vasectomy and the reversal, the experience of the surgeon, and other pre-operative and intra-operative factors. Alternative surgical techniques for reconstruction, including the use of lasers and fibrin tissue glue, are currently under investigation. Also, with the recent advances in the field of in vitro fertilization (IVF) and the development of intracytoplasmic sperm injection (ICSI), some have advocated the use of this technique to treat all types of male infertility, regardless of etiology. Recent cost-effective analyses showed that microsurgical reconstruction is a more cost-effective approach for the treatment of obstructive azoospermia after a vasectomy thus, it remains as the treatment of choice for vasectomized men who wants to re-establish fertility. Postoperative patency is generally achieved by six months after a vasovasostomy and by twelve months after a vasoepididymostomy. Patients should be followed for approximately six months to one year after reconstruction, depending on the procedure performed, before further treatment. Complications are similar to those related to scrotal surgery: scrotal hematoma, swelling and infection. Twelve percent of patients with initial patency after vasovasostomy and 25% with an initial patent anastomosis after vasoepididymostomy will develop a late obstruction within 14 months of the surgical reconstruction. Repeat reconstruction is a viable option in these cases. Since failures are common after repeat procedures, intraoperative and postoperative sperm cryopreservation is recommended. In the current era of IVF advancements and ICSI, microsurgical vasectomy reversal remains the standard of care for patients who want to re-establish fertility after vasectomy.