Articles

It’s important to keep up with the latest trends, studies, news stories and developments concerning vasectomy reversal and male infertility. For your convenience, here are articles to keep you abreast of what is happening in the field.

 

CONCEIVING A BABY AFTER A VASECTOMY REVERSAL: VASECTOMY REVERSAL OR SPERM RETRIEVAL AND IN-VITRO FERTILIZATION/INTRACYTOPLASMIC SPERM INJECTION (IVF/ICSI)

There are four options to conceive following a vasectomy. Adoption, donor sperm and intrauterine insemination (IUI), sperm retrieval with in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) and microsurgical vasectomy reversal. Most couples following vasectomy are choosing between sperm retrieval and IVF/ICSI versus microsurgical vasectomy reversal. A number of factors will influence which is the right choice for you.

Vasectomy reversal is the only fertility option if natural conception is desired. Many couples want to conceive naturally, and avoid the use of hormonal treatments and multiple procedures for the female partner. Sperm retrieval would be required to obtain sperm for IVF/ICSI, and the number of sperm that are retrieved are never enough for intrauterine insemination (IUI). With IUI, only ejaculated sperm can be used. Many couples wish to avoid the creation of multiple embryos, and would prefer NOT having to make decisions regarding the freezing/cryopreservation of extra embryos, the discarding or donation of these embryos.

The risk of having twins or triplets is significantly greater with IVF/ICSI than with natural conception. These pregnancies are also pose higher risk to the female partner as well as to the fetuses.

Financial factors - for instance, does insurance cover IVF or vas reversal, or which is most economical if both are out of pocket. Insurance coverage when good for either procedure will definitely influence which procedure is chosen. When all fees are out of pocket and self pay, it is more cost effective to have a vasectomy reversal than sperm retrieval and IVF. Since a vasectomy reversal restores the man's fertility to what it was prior to the vasectomy, the couple can also have numerous successful pregnancies if more than one child is desired.

How long has it been since the male partner's vasectomy - There is a misconception that when the duration from vasectomy to reversal is over 10 years, that a reversal is not as successful. This is not true. Our longest time interval is 42 years - 42 years from when the vasectomy was performed to when the reversal was successfully performed, and pregnancy resulted within six months of the reversal. We do know that the longer the time interval, the greater the liklihood of needed the more difficult reconstruction, an epididymovasostomy, but a reversal can be successfully performed even when time interval is long.

Age of the female partner or existing female partner fertility problems - This is the one factor that should influence who is having a vasectomy reversal. If the female partner has very irregular cycles, is of advanced maternal age or has had difficulty conceiving in the past, than we recommend a detailed female partner evaluation with her gynecologist. If problems exist which would make it difficult or impossible for her to conceive naturally - such as with blocked fallopian tubes or approaching menopause - than IVF/ICSI is the better option.

MEN'S AGE AND FERTILITY

It is often asked how a man's age will impact his success with vasectomy reversal, and will his age have a negative effect on a couple's ability to conceive naturally. Unlike women, men retain the ability to conceive naturally well into their 60s. It is very common for a microsurgical vasectomy reversal to be performed for men in their 60s, the results of which are equal to that of a man in his 30s or 40s.

Men do go through a period of "andropause" where they have a decline in the production of testosterone, which can result in symptoms of decreased sex drive, depression, lack of energy, erectile dysfunction and ejaculatory dysfunction. Men will often be prescribed testosterone supplementation for these symptoms, and it is this treatment which can adversely affect their sperm production. Men of any age who are taking anabolic steroids, which testosterone is, need to be counseled that it will cause sperm counts to drop precipitously, and even to zero. This is due to the effect exogenous testosterone has on the pituitary - gonadal axis. Men who are symptomatic from low testosterone, or have hypogonadism, and desire fertility should not be placed on testosterone, and should consider other treatments such as HCG.

Despite this "andropause" which can occur,  retrains his fertility well into old age does not go through a true endocrinological menopause like women, who evenutally go through menopause between the ages of 45 to 55. Men have been found to retain their fertility to an age as old as 94. Senator Strom Thurman fathered a child at age 81. There are however, some age-related declines in male fertility and spermatogenesis. Studies have shown when comparing sperm production from men in their 20s to men in their 70s to 80s that there was an average of 30 percent greater sperm production in the younger aged men. Even though, a 30 percent decline in semen parameter is unlikely sufficient to render them infertile if they had previously been fertile.

PREDICTING THE PROBABILITY OF EPIDIDYMOVASOSTOMY DURING VASECTOMY REVERSAL

 

VCRA CO-DIRECTOR CREATES MATHEMATICAL MODEL TO HELP MICROSURGEONS

 

Microsurgical epididymovasostomy is a technically challenging microsurgical procedure that should be performed by a urologist who is a microsurgeon with fellowship training.  Most commonly, a vasovasostomy (which is the standard vas to vas connection) can be performed, but occasionally an epididymovasostomy (a vas to epididymis connection) is required based on what the surgeon finds at the time of the vasectomy reversal.  This is a more complex procedure, and successful results greatly depend on the surgeon’s specialized training.  

Since it would be very useful for microsurgeons to have a good indication of whether an epididymovasostomy is needed before they begin the vasectomy reversal, Dr. David Fenig, co-director of the Vasectomy Reversal Center of America, and Dr. Larry Lipschultz, chief of Male Reproductive Medicine and Surgery at Baylor College of Medicine, developed an innovative methodology to predict this. 

The methodology is called a nomogram, which is a mathematical model that calculates risk based on two or three factors.  More than 250 patients were included in the study that was used as the basis for the nomogram.  The mean time from their vasectomies to their reversals was 9.7 years.  Dr. Fenig determined what the important predictors are before performing the patient’s reversal surgery. 

They are:

·         How long it has been since the patient’s vasectomy.

·         Whether a sperm granuloma is present, based on a physical examination of the patient.

A sperm granuloma is a small collection of sperm that can form at the end of the vasectomy site.  This creates a small lump.  A sperm granuloma is a good finding since it means that pressure from the vasectomy and backup of sperm have been released.   It indicates a small leakage or accumulation of sperm.  An epididymovasostomy is less likely to be needed when a sperm granuloma is present.

The study found that the age of the patient did not increase the need for epididymovasostomy, but the time between the vasectomy and the reversal did increase the need. 

The nomogram is very helpful to microsurgeons when they counsel patients about vasectomy reversal success rates and discuss whether there will be a need for epididymovasostomy. 

The nomogram also demonstrates that epididymovasostomies may be required for more patients than some surgeons realize, and that patients should choose a microsurgeon who is experienced in performing the epididymovasostomy.