Q. You are referred a 29-year-old man by his GP for consideration of a vasectomy. How will you assess him?
A. I will see him in my routine urology outpatients clinic. Before I see him I would send him a patient information sheet about vasectomy. I would recommend that he attends the clinic with his partner.
The important points in the history relate to his age, marital status, number of previous children and the age of the youngest child, previous contraceptive history and previous surgery in the inguino-scrotal region. Also document whether both he and his partner have considered other contraceptive measures.
Q. What are you looking for specifically on examination?
A. As well as a general examination, the specific important points on examination will relate to the laxity of the scrotum, whether the vasa are easily palpable and whether there is any other scrotal pathology present (varicocele, tumour). This also helps to decide on whether to perform the procedure under a local or general anaesthetic.
Q. How would you counsel him for a vasectomy?
A. I would provide writhen information on the procedure and invite the partner to be involved in the decision-making process. I will explain why the procedure is being performed, what the alternatives are, what the success rate is and what complications may occur. Specifically I would warn the patient that the procedure is irreversible. Importantly, they must continue some form of contraception until the patient produces an azoospermic semen sample (see later discussion). I would explain that failure may occur early (1 in 300 due to surgical error) or late (1 in 2000 due to recanalisation). I would counsel the patient that no one technique ensures 100% success and the early side effects include bruising and swelling (common), haematoma (2%) and infection (3%-4%). Long-term effects include chronic testicular or epididymal pain (1%-10%) and sperm granuloma (10%-15%). Approximately 60%-80% of patients have detectable levels of serum antisperm antibodies.
Q. You find out that he is not married, has no partner and has no children. What will you do?
A. He fits one of the criteria where patients often change their mind or are dissatisfied. These patients require careful counselling and an operation should only be performed after a full discussion with their GP and an undertaking that the patient does not want children in the future. Other groups which require careful attention are young couples, couples with two or less children, patients from lower socio-economic classes and where there is the possibility that the operation is being requested for financial or emotional reasons or that the male may be ambivalent about it. I would also ensure that there is an adequate ‘cooling off’ period before proceeding with the surgery.
Q. He is adamant that he wants a vasectomy. What is your recommendation?
A. I would make sure that the case is fully discussed with the patient’s GP. I would provide a writhen patient information sheet and a copy of the writhen consent. I would ask for a period of time between the consent and the operation so that there is sufficient time for the patient to make a fully informed choice. If after all this he is still convinced that this is what he wants and he is supported by his GP then he would be eligible for a vasectomy.
Q. What techniques are you aware of?
A. Single scrotal incision, bilateral scrotal incisions or no-scalpel technique.
Q. What methods of vasal occlusion are you aware of and do they have different success rates?
A. Suture ligation is still the most common method employed worldwide but may result in necrosis and sloughing of the cut end. If both ends slough, recanalization may occur. Vasectomy failure occurs in 1%-5% when ligatures alone are used for occlusion. Recent evidence suggests the use of Vicryl is associated with a higher rate of failure as compared to catgut.
Vasal occlusion using two medium haemoclips on each end results in failure rates of less than 1%.
Intraluminal occlusion with needle electrocautery, or battery-driven thermal cautery set at a power sufficient to destroy mucosa but not high enough to cause transmural destruction of the vas, reduces recanalization rates to less than 0.5%. Using this technique it is recommended that at least 1 cm of the lumen should be cauterized in each direction.
Q. How do you perform a vasectomy under local anaesthesia?
A. Following informed consent and with the patient supine I would perform a vasectomy using a mixture of 1% plain Lidocaine and 0.5% Bupivacaine in a 1:1 ratio. I would perform the procedure in a warm room and with warm preparation solution to relax the scrotum. I prefer bilateral small scrotal incisions. Each vas is isolated from the spermatic cord vessels and manipulated to a superficial position under the scrotal skin. The vas is then firmly trapped between the middle finger, the index finger and the thumb of the left hand (the middle finger can be behind the vas with the thumb and index finger in front thus providing a ‘three finger fixation’). The local anaesthetic is injected into the skin (in some patients a cord block at the start of the procedure can be performed) and then advanced into the peri-vasal sheath. Small bilateral transverse incisions through the dartos are performed until the vas sheath is seen and pulled though the incision. A longitudinal incision through the sheath is performed and the bare vas isolated using a vasectomy ring forcep. The vasal artery, veins and accompanying nerves are dissected free of the vas and spared. A 1 cm segment is removed between two haemostats from the straight part of the vas and sent for pathological confirmation. The ends are occluded by using intra-luminal cautery and the ends sutured in different fascial planes (fascial interposition). I then close the skin with interrupted 4-0 Vicryl Rapide. Simple gauze dressings are held in place using a scrotal support.
Q. Please explain why you use this technique?
A. I use a bilateral incision technique as this reduces the chance of dividing the same vas twice and it is also easier to divide the vas on the straight segment with bilateral incisions. I use intra-luminal cautery and fascial interposition to reduce the incidence of vasectomy failure by re-canalisation.
Q. When will you ask him to perform a semen analysis and why?
A. The 2016 Joint Association of Biomedical Andrologists (ABA), British Andrological Society (BAS) and British Association of Urological Surgeons recommend that patients should be instructed to ensure that they have had at least 20 ejaculations and preferably wait at least 12 weeks before submitting a semen sample for examination. This reduces the number of false-positive samples and thus minimises both patient inconvenience and repeat laboratory assessment [3]. A single azoospermic sample in an accredited laboratory is now acceptable.
Q. What is special clearance?
A. A successful vasectomy is based on the production of an azoospermic sample. However, persistent non-motile spermatozoa in the initial ejaculates is not uncommon, with studies reporting up to 33% non-azoospermic samples at 3 months, and 10% of ejaculates containing non-motile sperm at 6 months.
Special clearance is based on the finding of two consecutive sperm counts <100,000/ mL with no motile sperm with a minimum of 7 months after vasectomy. Discussion in the literature has suggested that the risk of pregnancy occurring from these non-motile sperm is small, and probably no more than the risk of pregnancy after two azoospermic semen samples, as a result of spontaneous recanalization.
These men with low numbers of persistent non-motile spermatozoa in their ejaculates (that is, after 7 months) may be given ‘special clearance’ by their clinician to discontinue other contraceptive precautions following appropriate oral counselling and writhen advice regarding the risk of pregnancy.
Using these criteria only 1 of 50 men examined at least 3 years after vasectomy had sperm in their analysis, the others being azoospermic. Furthermore no pregnancies occurred within the 3 years of follow-up.
Q. He returns 3 years later and is furious as his wife is now pregnant. What do you think has happened and how common is this?
A. It is likely that he has had a late failure of vasectomy which is caused by re-canalisation.
It is defined as the re-appearance of sperm after a documented semen analysis showing azoospermia. The quoted incidence is around 1 in 2000.
He needs to give a further semen analysis to make sure that this is the correct diagnosis. If late failure has occurred he should be offered a scrotal exploration, identification of the vasa and further occlusion bilaterally under a general anaesthetic. The patient should use alternate forms of contraception until he has had a further exploration and documented azoospermia.
If the repeat sample shows azoospermia then they should be referred for a paternity test. However, there have been documented pregnancies despite the test showing azoospermia where the patient is the biological father.
Q. A 55-year-old man is referred by his GP with secondary infertility. He had a vasectomy performed 22 years ago. He now wants a reversal. How will you assess him?
A. In the initial consultation, I would want to assess both the male and female partner with respect to their previous health and reproductive histories. I would examine the patient and assess the size and consistency of the testis and epididymis as well as whether the vasa and gap between the two cut ends are easily palpable. I would ask the patient to perform a semen analysis if it has not already been performed. I would explain to the patient that the chances of success (patency or pregnancy) are based on the surgical expertise of the surgeon, the method used to perform the original vasectomy, the patient’s health history, and the age and reproductive potential of his partner.
Q. Is it common for patients to ask for a reversal?
A. Approximately 6% of men who have undergone a vasectomy will subsequently request a reversal. The reason most frequently given by men requesting a vasectomy reversal is divorce and remarriage with a desire to have children with their new spouse.
Q. What techniques can be used for the vasectomy reversal?
A. Techniques vary according to the type of magnification used. This can be micro-surgical using an operating microscope, magnified vision using loupes or some will just use a macroscopic technique.
The anastomosis can be one of the following:
Multilayer vasovasostomy - Using inner mucosal sutures as well as sutures through the muscularis layer
Modified single-layer vasovasostomy - Easier technique; may be equivalent in outcome
Inguinal vasovasostomy - If obstruction of the vas is within the inguinal canal, i.e. after hernia repair
Epididymo-vasostomy - Is required in 20%-30%
Q. What are the important surgical principles required for a successful reversal?
A. ttere should be sufficient mobilization of both ends of the vas deferens to prevent any tension on the anastomosis.
The perivasal adventitia must remain intact as stripping of the adventitia surrounding the cut ends of the vas risks excising an important blood supply to the vas and may lead to ischemia and ultimately stenosis of the anastomosis.
Precise approximation of the cut lumens is mandatory to avoid sperm leakage with formation of a sperm granuloma that may disrupt the lumen and result in a failed procedure. Patients can be offered a sperm retrieval at the same time so that if the reversal is unsuccessful, then the patients have sperm stored for ICSI use.
Q. How would you perform the procedure?
A. I prefer a microsurgical technique under a general anaesthetic. With the patient supine, the cut ends of the vas deferens are brought through two bilateral scrotal incisions or a midline raphe incision. The vas is mobilised both proximally and distally allowing sufficient length for the freshly cut ends of the vas to slightly overlap one another once they are positioned for the anastomosis. The opposite side is then isolated in a similar fashion. When both vasa have been dissected free, the vasa are held in a vasectomy reversal clamp above skin level.
The vas above and below the vasectomy site is then transected until a patent lumen is seen both proximally and distally.
A few drops of fluid from the testicular end of the vas lumen are placed on a sterile glass slide and examined using a light microscope. If there are sperm or sperm parts (sperm heads, sperm with partial tails) with clear copious fluid then a vasovasostomy can be performed.
The cut ends of the vas deferens are positioned next to one another. A modified doublelayer technique is used with four to six interrupted 9-0/10-0 sutures passed through the lumen and mucosal layer followed by six interrupted 9-0 sutures through the muscularis and the adventitial layers. The technique is then repeated on the other side.
Q. Can all patients be treated with a vasovasostomy?
A. Unfortunately some patients will require a vasoepididymostomy rather than a vasovasostomy because of a secondary obstruction at the level of the epididymis. This appears to be a time- related phenomenon; the longer the time interval is from the original vasectomy, the greater the chances of an epididymal obstruction. More recently a model to pre-operatively identify patients who may require vasoepididymostomy was created which is based on time since vasectomy and patient age. The predictive model provides 84% sensitivity for detecting patients who may require vasoepididymostomy during vasectomy reversal (58% specificity). This model more accurately predicts the need for vasoepididymostomy than using a specific duration from vasectomy cut-off alone.
Q. How will you decide which patients need a vasoepididymostomy?
A. The decision to perform a vasoepididymostomy is based on the quality of fluid found in the proximal vas deferens at the time of surgery. Fluid obtained from the proximal vas lumen should be examined under 400x magnification using a light microscope. I would consider performing a vasoepididymostomy:
1. When the material coming from the proximal vas lumen is thick and devoid of sperm
2. If the fluid is creamy, containing only debris
3. If there is no fluid whatsoever when the vas is milked toward the cut end
4. If irrigation of the proximal vas with 0.1 to 0.2 mL of saline with a plastic angiocatheter attached to a tuberculin syringe fails to wash out any sperm.
Q. What are the success rates of the reversal?
A. If a vasovasostomy is performed then the success rates (patency rate and pregnancy rate) varies depending on the interval from the vasectomy until its reversal (Table 13.4). This is based upon a large series of 1469 men who underwent microsurgical vasectomy reversal procedures who were studied at five institutions [4].
Table 13.4 Patency and pregnancy rates according to interval from the vasectomy until its reversal
|
Interval from the vasectomy until its reversal (years) |
Patency rate |
Pregnancy rate |
|
<3 |
97% |
76% |
|
3-8 |
88% |
53% |
|
9-14 |
79% |
44% |
|
>15 |
71% |
30% |
Q. Are there any other factors which are important with respect to success?
A. More recently, pre-operative factors have been associated with a successful outcome including the same female partner as well as a short obstructive interval. Intraoperative factors included the use of surgical clips rather than suture at vasectomy, the presence of sperm granuloma and the presence and quality of the vasal fluid.
Q. Does the age of the female partner matter?
A. In a recent study using the microsurgical vasovasostomy technique it was reported that the pregnancy rate for couples with a female partner aged 40 or older was significantly lower than for those with the female partner aged 39 or younger (14% versus 56%). The age of the female partner is There fore important in the counselling process and it may not be cost- effective to perform vasectomy reversals in couples with a female partner older than age 40.
Q. Does it matter which technique you use?
A. There is controversy as to whether the outcomes using microsurgery, loupes or macroscopic techniques are equally effective or not. However, most experts believe that the results of microsurgical vasectomy reversal are superior to results of non-microsurgical techniques in terms of patency and pregnancy. However, microsurgery requires more training and experience to obtain the best results. Patency and pregnancy rates do not appear to be significantly different if a multilayer anastomosis is performed as opposed to a modified single-layer technique but the success is physician dependent.
Q. The patient returns 1 year after the reversal. He is upset that despite the post-operative tests showing sperm in the semen, his new partner has not been able to conceive. Does he have any other options?
A. It is important to establish whether he does indeed have sperm in his semen or not and what the fertility potential of his partner is. His other option if he still wishes to have his own biologically related children is to either use his sperm (if there is enough in the semen) or have a surgical sperm retrieval in conjunction with ICSI. He also still has the option of donor sperm and adoption.
Q. The couple now decide that they would like to be referred for IVF on the National Health Service (NHS). They ask whether they have to pay for IVF treatment.
A. Some NHS-operated fertility clinics offer free in vitro (IVF) fertilisation treatment to people who have been sponsored by their primary care trust (PCT). They need to contact their local PCT to find out how to qualify for sponsorship.
The availability of IVF treatment on the NHS is subject to guidelines that were issued by the NICE. These recommend that patients should be offered up to three cycles of IVF if:
They are between 23 and 39 years of age at the time of treatment.
One, or both, of them has been diagnosed with a fertility problem.
They have been infertile for at least 3 years.
Some PCTs also have additional criteria that may affect their eligibility for funding. For example, some PCTs will not provide funding for couples where one partner already has a child.