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Reversal of vasectomy using macroscopic technique

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					Ann R Coll Surg Engl 1997; 79: 420-422




Reversal of vasectomy using a macroscopic
technique: a retrospective study
            Robert G Mason FRCSGIas*                              John C Bull FRCS
            Senior House Officer in Surgery                       Consultant Surgeon
            Philip G Connell BDS LRCP MRCSt
            Senior House Officer in Surgery
            Crawley Hospital, Crawley, West Sussex


Key words: Reversal of vasectomy; Vasovasostomy


Eighty-five men underwent vasectomy reversal in our               Method
department between 1981 and 1994. All operations
were performed without the aid of magnification. The              We identified all vasectomy reversal operations that were
results of semen analysis was available in 66 and the             performed by one surgeon (JCB) from our theatre
patency rate was 74%. A postal survey was sent to                 records. To allow adequate post-procedure follow-up,
patients we could follow up, and among those who                  patients operated on after 1994 were not included. All
replied the pregnancy rate was 41% (16/39 respon-
dents). These results are similar to those found by               patients were sent a postal questionnaire asking about any
others using a macroscopic reversal of vasectomy and              subsequent pregnancies. The records of semen analysis
since the operator does not rely on the use of a                  were also reviewed. The operations were all performed
microscope, which both incurs an added cost and                   under the same conditions and the procedure changed
requires extra expertise, we feel that the operation as           little. Patients were given a general anaesthetic, the vasa
described has a part to play in the management of                 were explored through two oblique groin incisions (all
men seeking reversal of vasectomy.                                patients had a bilateral procedure), and an end-to-end
                                                                  vasovasostomy was performed. As the senior author has
                                                                  presbyopic vision, he performed the anastomosis with the
                                                                  aid of reading glasses. Neither loupes nor microscopes
Vasectomy reversal is required in up to 3% of men who             were employed. A single layer transmural anastomosis
undergo vasectomy (1). It therefore has the potential to          using eight 6/0 prolene sutures was performed and in all
impose a significant burden on any surgical practice.             cases the lumen were stented with 1/0 nylon for 5 days.
Since the first report by O'Conor (2), many techniques            The operation time averaged 1 h. After discharge, all
have been described, either macroscopic or involving the          patients were followed up in outpatients for removal of
aid of loupe or operating microscope magnification, and           the stents and given instructions to return in 12 weeks
varying success rates have been reported. We describe a           with a semen sample. They were then discharged to the
method of macroscopic vasectomy reversal and the results          care of their general practitioner.
achieved. We also review the results of similar studies and
highlight the main causes of failure.
                                                                  Results
                                                                  In all, 85 patients were identified who had vasectomy
                                                                  reversal performed between 1981 and 1994. They ranged
                                                                  in age from 26 years to 53 years (mean 38.3 years).
Present appointments:                                             Seminal analysis was available in only 66 (78%). Of these,
* Research Fellow,
                   Royal Postgraduate Medical School, London      sperm were present in 49 giving a patency rate of 74%
t Senior House Officer in Plastic Surgery, St Thomas' Hospital,   (Table I). Only 79 were sent a questionnaire (six lost to
London                                                            follow-up, or no address) and of these 39 replied, giving a
Correspondence to: Mr J C Bull, Consultant Surgeon, Crawley       response rate of 49%. The results of our questionnaire
Hospital, Crawley, West Sussex RH 1l 7DH                          revealed that four had not tried for a pregnancy (10%), 16
                                                                                           Reversal of vasectomy          421
Table I. Clinical data and results of questionnaires (mean)    Table III. Results of previous studies
Age at vasectomy reversal        26-53 years (38.3 years)                                      No of Patency Pregnancy
Interval between vasectomy                                     Author                          cases   (%)      (%)
 and reversal                     1-17 years (8.29 years)
Interval for successful patients 1-15 years (7.7 years)*       White and Sheridan (5)            33      64        17
Interval for unsuccessful                                      Lee (6)                          300      84        35
                                  4-17 years (8.0 years)*      Dewire and Lawson (7)             32      89        41
 patients
Patency rate                              74%                  Griffiths (8)                     15      73        26.6
Pregnancy rate                            41%                  Kessler and Freiha (9)            83      92        45
                                                               Sibler (10)                      282*     91        81
*   Difference not significant (P <0.1)                        Belker et al. (11)              1012*t    86        52
                                                               Wicklund and Alexander (12)     2685t     49        21
                                                               *   Microscopic technique
Table II. Comparison of semen quality with pregnancy
outcome*                                                       t Collective review
Sperm count             No of men (%) Pregnancy rate (%)       suggest that a patency rate of between 84% and 92% is
Fertile                     13 (37)        9/13 (69)           possible and a pregnancy rate of 35% and 45% may also
Subfertile                  12 (34)        7/12 (58)           be achieved (Table III). A recent survey of Welsh
Azoospermia                 10 (28)                            surgeons and urologists revealed that 43% used no
*   Data from patients responding to questionnaire
                                                               magnification, while only 3% used a microscope (5).
                                                               Undeniably, microscopic repair, especially with a two-
                                                               layered technique, such as that described initially by
had achieved pregnancy (41%) and 19 had not been               Sibler (13) and Fox (4) gives better results. However, not
successful (49%).                                              only does the operator require an expensive operating
   We also found that the time between vasectomy and the       microscope but also the frequent use of the skills required
reversal operation varied from 1 to 17 years (mean 8.29        to maintain the necessary expertise. Whatever the
years). The mean time in 'successful' couples was 7.7          technique used, the most important considerations
years (range 1-15 years) and for 'unsuccessful' couples        appear to be meticulous surgical technique to enable the
was 8.0 years (range 4-17 years), this difference is not       production of a leak-proof anastomosis to prevent sperm
significant (P < 0.1).                                         granulomata formation and subsequent scarring/vas
   We looked further at the results of the group               obstruction as well as a limited mobilisation in order to
completing the questionnaire (Table II) and their semen        minimise disturbance to the blood supply. Variations in
quality as defined by the WHO (3). The criterion for           operative technique exist, with some authors advocating a
normal fertility is a count of >20 million sperm/ml,           side-to-side anastomosis (14) as opposed to the end-to-
progressive motility of 50% and morphologically normal         end technique used in our study. The use of a luminal
forms in at least 30%. In total, 13 men (37%) had normal       stent is also subject to debate (15), but we feel that it
postoperative sperm quality, 12 men (34%) were                 allows accurate opposition of the two ends of the vas
subfertile in one or more of the parameters, and 10 men        during a macroscopic repair and that it prevents sperm
(28%) had no sperm present. Of the 13 with 'fertile'           leakage during anastomotic healing. In our fairly large
counts, nine men (69%) had a successful outcome,               study, 85 procedures were performed over 14 years giving
whereas for the 'subfertile' group seven of 12 had a           an average of six per year. We believe this does not
successful outcome (58%).                                      constitute regular use, and we have no other applications
                                                               for a microscope on a general surgery/urology firm.
                                                                  Our results bear some comparison with other published
Discussion                                                     series on macroscopic repair (Table II) in terms of
                                                               patency rate, but obviously the pregnancy rate must be
As vasectomy is a popular and reliable form of birth           examined with caution as only 39 patients (49%)
control, it is inevitable that vasectomy reversal will         responded to our questionnaire, but this is likely to be
continue to be requested for a variety of reasons, most        owing to the mobile population presenting for reversal of
commonly owing to a change of partner following divorce        vasectomy as well as the possible bias of successful/
or separation (1). Vasectomy reversal holds a fairly low       unsuccessful repondents. The length of time between
priority in an ever stretched national health service and      vasectomy and its reversal has been found to have an
the provision of a quick, reliable and low cost technique is   important bearing on the success of the operation (11),
therefore desirable. Many recent reports of techniques for     but we found that there was no significant difference
vasectomy reversal have relied on the use of an operating      between the means in our successful and unsuccessful
microscope and the results, both in terms of patency rate      cases. Furthermore, it was found when looking at the
and pregnancy rate appear to be superior to those              results of those with patent vasa after surgery, that an
achieved by surgeons employing a macroscopic techni-           equal percentage of those operated on 10 years or more
que    (4).                                                    after vasectomy, and those who were being reversed after
    The best reported results of a macroscopic repair          less than 10 years, had a normal sperm count. However,
422      R G Mason et al.
since our study yielded a patency rate lower than that in         4 Fox M. Vasectomy reversal-microsurgery for best results.
some reports it is possible that a number of cases which            BrJ7 Urol 1994; 73: 449-53.
may have been reversed by a superior technique have               5 White AET, Sheridan WG. Reversal of vasectomy and the
artificially lowered the percentage achieving a normal              general surgeon. Br J Clin Pract 1994; 48: 238-9.
sperm count 1-9 years after vasectomy. Failure to achieve         6 Lee HY. A 20 year experience with vasovasostomy. J Urol
                                                                    1986; 136: 413-15.
fertility after reversal of vasectomy can often be attributed     7 Dewire DM, Lawson RK. Experience with macroscopic
to the production of antisperm antibodies which, when               vasectomy reversal at the Medical College of Wisconsin.
present in high titres, leads to impairment of fertility;           Winsconsin Med J 1994; March: 107-9.
however, despite the immunological basis of the problem,          8 Griffiths CL. Reversal of vasectomy: vasovasostomy. J R
it remains refractory to treatment (16). Anastomotic                Army Med Corp 1987; 133: 87-8.
blockage or stenosis appears to be the most important             9 Kessler R, Freiha F. Macroscopic vasovasostomy. Fertil
cause of failure. In one reported series of patients                Steril 1981; 36: 531-2.
undergoing exploration of the scrotum after unsuccessful         10 Sibler SJ. Pregnancy after vasovasostomy for vasectomy
reversal procedures, 12 out of 23 azoospermic cases were            reversal: a study of factors affecting long term return of
found to have blocked vasa and repeat vasovasostomy                 fertility in 282 patients followed for 10 years. Hum Reprod
resulted in normal sperm counts (17).                               1989; 4: 318-22.
                                                                 11 Belker et al. Results of 1469 microsurgical vasectomy
   To summarise, we feel that macroscopic techniques                reversals by the vasovasostomy study group. J Urol 1991;
have a place in the reversal of vasectomy, as it offers             145: 505-11.
satisfactory results and is an easier procedure for the          12 Wicklund R, Alexander NJ. Vasovasostomy: evaluation of
surgeon dealing with relatively few cases. Good counsel-            success. Urology 1979; 13: 532-4.
ling to prospective patients detailing the possibility of        13 Sibler SJ. Microscopic vasectomy reversal. Fertil Steril 1977;
success is necessary. A cost saving benefit is also apparent        28: 1191-1202.
in units where the hardware for microscopic surgery is not       14 Hendry WF. Vasectomy and vasectomy reversal. Br J Urol
available.                                                          1994; 73: 337-44.
                                                                 15 Thomas AJ, Pontes JE, Buddhdev H, Pierce JM. Vasova-
                                                                    sostomy: evaluation of four surgical techniques. Fertil Steril
References                                                          1979; 32: 324-8.
                                                                 16 Hendry WF et al. Comparison of prednisolone and placebo
                                                                    in subfertile men with antibodies to spermatozoa. Lancet
 1 Howard G. Who asks for vasectomy reversal and why? BMJ           1990; 335: 85-8.
   1982; 285: 490-92.                                            17 Royle MG, Hendry WF. Why does vasectomy reversal fail?
 2 O'Conor VJ. Anastomosis of the vas deferens after                BrJ Urol 1985; 57: 780-83.
   purposeful division for sterility. J Urol 1948; 59: 229-33.
 3 World Health Organisation. WHO Laboratory Manual for          Received 18 April 1997
   the Examination of Human Semen and Sperm-Cervical Mucus
   Interaction. 3rd Edition. New York: Cambridge University
   Press, 1992: 43-4.

				
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