Five percent of the more than 500,000 men who undergo vasectomy each year subsequently change their mind. Those patients now have two options to restore their fertility: vasectomy reversal and sperm harvesting combined with it vitro fertilization (IVF). Each procedure has its advantages and drawbacks, but vasectomy reversal is the only option that allows a couple to conceive naturally and is also the most cost-effective alternative for family building after vasectomy. IVF might allow couples to potentially conceive more rapidly than a reversal and might be necessary when a contributing female factor to the couples’ infertility is present or when a reversal is unsuccessful. The disadvantages of IVF include a significant increase in costs, the need for the female partner to take hormone injections, and the increased risk of multiple births and potential birth defects.

However, not all vasectomy reversals result in restoration of motile sperm to the ejaculate and are considered successful. A common, yet avoidable, reason for reversal failure is unrecognized epididymal obstruction resulting in the performance of a vasovasostomy in a situation that necessitated a vasoepididymostomy. It has been estimated that up to 30% of reversal failures can be attributed to the aforementioned scenario. The criteria for performing vasoepididymostomy have been clearly defined, but the procedure itself is considered the most technically challenging in reproductive surgery. As such, it yields lower patency rates than microsurgical vasovasostomy and, therefore, lower pregnancy rates as well.

Several recent advances in microsurgical techniques have increased the ease and precision of performing the delicate anastomosis between an epididymal tubule and the lumen of the vas deferens and have led to improved chances of conception. Traditionally, vasoepididymostomy is approached by way of a scrotal incision large enough for complete exteriorization of the testis to provide the surgeon with the adequate exposure to the entire epididymis and the vas deferens. Many surgeons also perform an extensive dissection of the vas deferens and spermatic cord. In contrast, vasovasostomy is commonly performed through a smaller incision without delivery of the testis. For these reasons, vasoepididymostomy is usually associated with longer recovery times and increased pain and swelling compared with vasovasostomy.

When presented with options, fertility patients generally prefer procedures that afford minimal discomfort, inconvenience, and encroachment on their lifestyle. It has been observed that men who are very active or concerned about postoperative pain and prolonged recovery might opt for a less-invasive sperm harvesting procedures and thereby steer their partners to IVF despite the increased costs, relative risks, and associated emotional stress. In an effort to reduce the discomfort and shorten the postoperative recovery associated with scrotal surgery, a less-invasive surgical approach to vasoepididymostomy has been developed and is described here.

SURGICAL TECHNIQUE

With the patient under general anesthesia, a 1.0 to 2.0-cm incision is made on the scrotal skin directly over the palpable defect at the vasectomy site. The overlying Dartos muscle layer is incised with electrocautery. A no-scalpel vasectomy ring clamp is used to grasp the vasectomy scar, and the vas deferens is dissected proximally and distally, freeing the scarred portion of the vas from the surrounding cord structures. With the aid of the operating microscope, the testicular end of the vas is transected from the vasectomy scar. A drop of vasal fluid is placed on the microscope slide and examined for the presence of sperm. Thick, white, “pasty” fluid that is devoid of sperm is indicative of an epididymal “blowout” and epididymal obstruction. This observation necessitates performance of a vasoepididymostomy rather than a vasovasostomy.

The abdominal vas is further dissected distally for a short distance and similarly transected at the junction of the vasectomy scar at a point at which the tissue appears healthy. The vas lumen is cannulated with a 24-gauge angiocatheter and irrigated with 5 ml of saline to confirm its patency. The vasectomy scar is discarded.

The testis is grasped between the surgeon’s left thumb and forefinger and gently pushed up under the incision so that the tunica vaginalis overlying the upper pole is accessible. Two small hemostats are used to grasp the upper extent of the tunica vaginalis overlying the epididymis, and a small incision is made between the clamps, opening the tunica and providing access to the epididymis. A Babcock clamp is carefully placed around the distal (body/tail junction) portion of the epididymis, so that its jaws rest in the lateral sulcus (Fig. 1). Clamp placement should avoid compression of the epididymis or any area proximal to the future anastomotic site. The epididymis is then rotated up though the small incision and exteriorized. The Babcock clamp functions to elevate and fix the epididymis in place just outside the skin incision. The epididymis is then explored under the operating microscope to select an area of dilated tubules for the anastomosis. A small puncture is created in the upper extent of the tunica vaginalis superior and lateral to the epididymis, through which the abdominal vas is transferred down into the intratunical space. This is accomplished by placing a fine hemostat clamp into the intratunical space and creating another small hole from inside the tunica vaginalis at its cephalad extent near the vas. Through this hole, the clamp is used to grasp the perivasal tissue at the freshly cut end of the abdominal portion of the vas, and the vas is brought down so it lies next to the epididymis. A 5-0 nylon suture is placed through the edge of the upper window in the tunica vaginalis and through the perivasal tissue 1 to 2 cm distal to the cut end of the abdominal vas to secure it in position in the intratunical space. This ensures that the end of the vas lies in continuity with the epididymal tubule without tension and also prevents the abdominal vas from retracting superiorly.

A small incision is made in the tunic of the epididymis overlying the selected dilated tubules, and a single tubule is carefully dissected using the tips of a microsurgical dilating forceps or scissor. The vas is approximated to the area first by connecting the posterior wall of the vasal muscularis to the posterior epididymal tunic opening using 9-0 nylon sutures. This should bring the vasal mucosa into direct contact with the selected epididymal tubule. The mucosal anastomosis is then performed using the two-suture longitudinal intussusception technique previously described. Two double-arm 10-0 nylon sutures are placed in parallel fashion longitudinally through the anterior wall of the epididymal tubule. A small incision is made between the two sutures with a microknife or needle edge, and the exuded epididymal fluid is examined for the presence of sperm. If sperm are present, the anastomosis is continued, and the 10-0 sutures are placed through the vasal mucosa in their corresponding positions, and each suture is tied to itself, thereby intussuscepting the epididymal tubule into the vasal mucosa. The muscularis is closed interiorly with 9-0 nylon suture. (Fig. 1), completing the anastomosis. The Babcock clamp is removed from around the epididymis, and the anastamotic area is carefully rotated back into the scrotum. The scrotum is irrigated with 10 mL of bupivacaine 0.25%, and the tunica vaginalis is closed with running 4-0 Vicryl suture. The Dartos and skin layers are closed individually with running 4-0 Vicryl sutures.

RESULTS

Two patients with epididymal obstruction underwent vasoepididymostomy using the mini-incision approach. The first patient had a solitary left testis, had undergone vasectomy, and then had undergone a failed vasoepididymostomy. The operative report from the initial reversal procedure described an anastamosis to a distal epididymal tubule. The second patient presented with azoospermia and a history of bilateral epididymitis. A testicular biopsy was performed that showed normal spermatogenesis consistent with epididymal obstruction. Both patients chose to proceed with mini-scrotal exploration and vasoepididymostomy instead of sperm harvesting with IVF.

The 2 patients underwent a total of three mini-incision microsurgical vasoepididymostomies. The procedures were eneventful and were performed as described. The average total operating time was 55 minutes per side. Postoperative pain control was satisfactorily achieved with acetaminophen, obviating the need for narcotics. At the initial 1-month follow-up examination, neither patient had scrotal swelling or ecchymosis nor did either patient complain of postoperative discomfort, swelling, or bruising. This is in contrast to the experience reported by most of my patients who have undergone traditional vasoepididymostomy. Most significantly, both patients had motile sperm detected on semen analysis at 4 to 6 weeks postoperatively, demonstrating that this approach can facilitate a successful anastamosis with minimal discomfort to the patient. The first patient also reported that he achieved a pregnancy with his wife.

COMMENT

Vasectomy reversal, specifically vasoepididymostomy, is performed using a large scrotal incision with exteriorization of the scrotal contents. Until now, this level of exposure was necessary to adequately access the epididymis and the abdominal vas deferens distal to the vasectomy site. Intuitively, a large scrotal incision and extensive surgical dissection will be associated with pain, swelling, and a longer recovery time. Logically, a smaller incision with minimal dissection should lead to less pain and a quicker recovery. This technique is almost akin to a vasoepididymostomy in situ. It is less invasive, does not require exteriorization of the scrotal contents, requires less dissection and less mobilization of scrotal structures, and has led to quicker recovery and less postoperative pain than the current traditional approach for vasoepididymostomy.

Several advances have been made in the anastamotic technique of vasoepididymostomy that have increased the technical success of the operation and chances of conception. The mini-incision vasoepididymostomy approach does not compromise the anastamosis or harm the epididymis, because both patients who underwent the procedure had a return of sperm to the ejaculate within several months, with 1 patient initiating a pregnancy within 1 year of the procedure. It is important to avoid placing the Babcock clamp directly on the epididymis proximal to the area of proposed anastamosis, because this could theoretically damage the delicate epididymal tubules.

When faced with the options for conception of either vasectomy reversal versus IVF with sperm harvesting, some men will chose the less-invasive sperm harvesting procedure. The anticipation of pain and prolonged recovery, whether justified or not, can influence this choice despite the significant increase in costs and risks to the female partner associated with IVF. The mini-incision approach was developed in an effort to help male patients experiencing postvasectomy infertility and to further improve the vasoepididymostomy procedure.

Presented at the American Urological Association Western Section Meeting 2010

OBJECTIVES: Spermatic cord blocks delivered via needles have increased risks of hematoma or accidental injury to the vas. We evaluated a novel needleless approach in terms of post-operative pain and time spent in recovery in a retrospective manner. Our goal was show improved pain control using this novel method.

METHODS: 31vasectomy reversal patient charts were evaluated in terms of post-operative pain scores, intravenous pain management and time to discharge. Group 1 (n=18) received local anesthetic using our needleless approach while group 2 (n=13) received no local anesthesia.

RESULTS: All Group 1 patients had a starting and ending post-operative pain score of zero and none required any pain medication while in the recovery room. Group 2 patients had an average starting and ending pain scores of 4.8 (range 0-8) and required an average of 25 mcgs of fentanyl (range 0-100 mcgs). Group 1 patients had a significant (p=0.0023) reduction in post-operative pain. The average time spent in recovery was 75 minutes for Group 1 and 80 minutes for Group 2.

CONCLUSIONS: Local anesthetic instillation with marcaine prior to closing the vasectomy reversal incision allows patients to awaken pain-free, alleviates post-operative pain and the need for narcotics in the recovery room. Patients receiving local anesthesia had a slightly shorter recovery room stay than matched controls.

Presented at the Pacific Coast Reproductive Society Annual Meeting April 2010

INTRODUCTION AND OBJECTIVES: Sperm DNA damage (fragmentation) is a known cause of male infertility and has been shown to negatively impact pregnancy outcomes in couples undergoing In-Vitro Fertilization (IVF) with Intracytoplasmic Sperm Injection (ICSI). Previous studies have shown that sperm DNA damage may occur after the sperm have exited the testicle and levels of DNA fragmentation are lower in testicular sperm than in ejaculated sperm. The object of this study was to evaluate the results of IVF/ICSI using testicular sperm in couples that failed to achieve pregnancy on prior IVF cycles and had high levels of sperm damage as a cause of their infertility.

METHODS: We retrospectively reviewed the charts of 24 consecutive patients who underwent testicular sperm extraction for use with ICSI between January 1, 2008 and August 1, 2008. All patients had sperm present in the ejaculate that tested with a high DNA Fragmentation Index (DFI) as measured by Sperm Chromatin Structure Assay (SCSA). All patients had failed to achieve pregnancy during prior IVF cycles using ejaculated sperm. In an effort to improve the chances of conception, couples elected to have sperm harvested directly from the testicle and used for IVF/ICSI. Ovarian hyperstimulation was performed by one of 10 different reproductive endocrinologists at 5 different ART laboratories in the Los Angeles area. Testicular sperm extraction was performed by a single surgeon (PW) on the day of oocyte retrieval or one-day prior.

RESULTS: All men had at least one abnormal semen parameter and a high DFI (?30%) ranging from 32 to 82% with a mean of 51.6%. The etiology of sperm damage included varicocele, pyospermia, infection, partial obstruction, cryptorchidism, steroid abuse and idiopathic. Average age of female partner was 36.4 years with a range between 32-46 years. Two couples used an egg donor and the wives’ ages were excluded from the aforementioned calculation. All couples had undergone between 1 and 7 prior ICSI attempts with a mean of 3 failed cycles. A pregnancy rate of 62.5% was achieved when testicular sperm were used. An 83% pregnancy rate was achieved when the DFI was over 65%. A 75% pregnancy rate was achieved in couples that underwent 4 or more prior failed IVF cycles.

CONCLUSIONS: These data show that use of testicular sperm/ICSI provides an efficient treatment option for couples that fail multiple IVF cycles because of high levels of sperm DNA fragmentation. Neither the degree of sperm DNA damage or the number of prior failed IVF cycles appeared to affect the ability to achieve pregnancy when testicular sperm were used.

Presented at the Americal Urological Association annual meeting June 2010

INTRODUCTION AND OBJECTIVE: Post-vasectomy pain syndrome is a nebulous term for chronic and sometimes debilitating scrotal pain following vasectomy. The syndrome and treatments have been poorly characterized. We report on a single surgeon’s 10-year experience treating patients with vasectomy reversal for chronic post-vasectomy pain.

METHODS: We reviewed the charts of 45 men (vasectomized elsewhere) who presented with the complaint of chronic pain after their vasectomy. Data was collected as to time of onset of pain, years since the vasectomy, prior treatments, nature and quality of the pain, physical findings, surgical findings and outcomes of vasectomy reversal and requirement for additional treatment.

RESULTS: 45 men were evaluated for post-vasectomy pain. 63% stated their pain began during the vasectomy, 8% within the first week thereafter, 13% within the first 5 months and remainder within six years. Median age of the vasectomy was 3.7 years with a range on 0.4-18 years. Twenty patients (45%) complained of pain after ejaculation, 45% complained of a dull testicular ache, 15 % had sharp and burning pain radiating up to their abdomen, and 10% complained of a tender lump. Two patients complained of constitutional symptoms. Sixty-seven percent of patients were initially treated by their local urologist with antibiotics and anti-inflammatory drugs and had no response. Two patients had excision of sperm granulomas with conversion to open ended vasectomy and 2 patients had failed vas reversals. Seventy percent of patients elected to undergo a microsurgical vasectomy reversal with excision of the vasectomy scar/granuloma. At the time of surgery, 40% were found to have a sperm granuloma, 15% had generalized inflammation around the vas, 29% had no unusual post-vas findings and one patient had large neuromas. Seventy-five percent of reversal patient’s experienced complete resolution of their symptoms, 10% had greater than 30% reduction in their symptoms and 10% had no change in symptoms. Two patients had only temporary relief of symptoms after reversal. Two patients went on to have microsurgical spermatic cord denervation after failed reversal and one patient ultimately elected to have a unilateral orchidectomy. One cord denervation was ultimately successful.

CONCLUSIONS: Post-vasectomy pain syndrome continues to be a problem plaguing a small number of vasectomized men. Pain appears to vary in its time to onset, is inconsistent in nature and quality, and probably has multiple pathologic etiologies. Adequate anesthesia for the vasectomy is crucial since most patients began experiencing pain during the procedure. Vasectomy reversal has a very high likelihood of producing a symptom-free outcome. Sperm granulomata, inflammatory/scar tissue, and foreign bodies should be excised at the time of reversal surgery. Open-ended vasectomy should be avoided as it made subsequent reversal surgery more difficult to perform.

Overview

Of the 15% of couples having difficulty conceiving, almost half have a male factor as the sole or contributing cause. It is currently recognized that the quality as well as the quantity of sperm greatly influences reproductive outcomes. It was once thought that assisted reproductive technologies (ART) such as Intrauterine Insemination (IUI) and more so, In-Vitro Fertilization with Intracytoplasmic Sperm Injection (ICSI) had the power to overcome almost any sperm defect but data show that this is not true for many patients. New data has repeatedly demonstrated that significantly damaged sperm leads to lower pregnancy rates with IUI or IVF as well as an increased miscarriage rate up to fivefold that of a pregnancy achieved with normal sperm. It has been said that in the last 5 years there hasn’t been any significant improvement in pregnancy rates with IVF and that is most likely because scientific techniques to improve egg and embryo quality have been maximized. The next major jump will come from focusing on sperm quality and maximizing it. Using abnormal sperm without making any attempt to quantify the level of damage, search for the cause or treat it will not be the preferred initial approach to fertility treatment because for most couples, treating the male improves outcomes.

There are two fundamental treatment strategies used to address sperm deficiencies:

1. Identify and treat the problem to improve semen parameters, 2. Bypass the problem by using the sperm that are available. The classic approach is that if there are more than 5-8 million motile sperm in the washed semen sample and the strict morphology of the sperm is greater than 4% normal, the couple would be a candidate for a variable number of IUI cycles. If the semen parameters are worse than this, IVF would be employed because of higher success rates under these conditions.

Unfortunately, the way practice patterns have developed, too few men are referred for appropriate evaluation until treatment strategy #2 has failed and the couple has undergone a significant number of treatments, lost time and considerable expense. Even then only a fraction of men are referred for evaluation for their underlying problem and many couples are encouraged to use donor sperm unnecessarily.

The scope of male infertility is widespread but unfortunately the evaluation and treatment process has never been standardized among general urologists, gynecologists or reproductive endocrinologists. This has led to inconsistent diagnoses, recommendations, and treatments that patients receive from their physicians. Many clinicians are inadequately trained and ill-equipped to deal with complex patients presenting with male infertility and still provide advice based on the limited understanding of reproduction taught to them several decades ago resulting in couples undergoing inefficient care or being denied the opportunity to become biological parents. An attempt to address this problematic situation was undertaken by a joint panel of the American Urological Association and American Society of Reproductive Medicine. Best practice policy guidelines were put forth almost a decade ago but since then, many advances have been made in our understanding of male reproductive function and based on these, new treatment strategies have been developed.

Our goal in treating male infertility is to provide information and rationale for cost-effective treatment strategies by helping identify those patients who will benefit from improving their sperm such that they can conceive naturally, avoid ART procedures or decrease the number of IVF cycles needed to achieve a term pregnancy. Another important goal is to identify conditions that aside from causing infertility, directly impact a man’s health such as testicular cancer or hormonal imbalances.

Causes of Male Infertility

There are numerous causes of male infertility but no matter what the etiology, the final common pathway to sperm damage (DNA fragmentation) is through free radical peroxidation leading to overwhelming amounts of oxidative stress on the sperm. Ironically, oxidative stress is necessary for normal sperm function and sperm actually produce free radicals but when more stress is generated than the system can compensate for, the body is unable to neutralize the toxins which ultimately injure the sperm cell membrane and the sperm DNA. This leads to functional impairment of the sperm cell and ultimately infertility.

Since we now have a much better understanding of the mechanisms of sperm damage and locations in the reproductive tract where damage may occur, more sophisticated functional tests to identify problems have been developed and the information can be applied to statistically predict patient outcomes. Identifying the causes of infertility makes practical sense because the underlying source of sperm damage can potentially be removed, repaired, neutralized or bypassed to produce the desired outcome.

It is well known that heat is harmful to sperm; it causes cellular apoptosis in the testicles. This is why the testicles are located outside the body as spermatogenesis needs to occur 2 degrees cooler than core body temperature. Anything that causes scrotal temperature elevation can result in sperm damage. A high fever or prolonged use of a spa or sauna can cause a temporary decline in fertility. The most common cause of male infertility is varicocele. It is thought to cause damage to sperm by obliterating the counter-current heat exchange system normally present in the spermatic cord circulation as well as allowing reflux and pooling of venous blood with its toxins, back into the testicle. Varicocele has been shown to cause elevated levels of DNA fragmentation, heat generation and elevated seminal oxidative stress. Numerous studies demonstrated that varicocele repair can reverse these negative effects and decrease sperm DNA fragmentation.

Other causes of sperm damage are those caused by a defect in sperm storage and transport such as partial/ complete obstruction, ejaculatory dysfunction, prostatitis, pyospermia, and STDs. In these conditions, sperm are produced normally but are injured as they make their way through the reproductive tract. Numerous toxins, either environmental or medicinal can have deleterious effects on sperm. Some commonly prescribed medications as well as chemotherapy and antibiotics are well-know offenders.

Some men are born with genetic conditions such as Kleinfelter’s Syndrome, chromosomal translocations, Y-chromosome microdeletions or carriers of cystic fibrosis and these lead to either azoospermia (absence of sperm in the ejaculate) or severely low sperm counts. For obvious reasons, it is important to detect these conditions prior to using sperm from patients with genetic abnormalities as diseases may be passed on to the child through IVF and we now have the technology to genetically screen embryos.

Testing

The semen analysis is an excellent screening tool for male infertility in that it identifies most men who might have a problem conceiving. The semenalysis is quite variable and normally fluctuates to some degree over time, which is why it is recommended that at least 2 tests be performed separated by some degree of time. Unfortunately, the semen analysis is a poor predictive tool as to who will eventually be able to father a child. The reason is that the test is observational, not functional, meaning we can tell patients how many sperm are present compared to normal (sperm count), how many are moving (motility) and what the sperm look like (morphology) but unless a patient is at the very low ends of the spectrum, we can’t tell much about how the sperm will work or how damaged they really are. Newer tests have been developed that measure the level of sperm susceptibility to DNA damage, the degree of sperm maturity and the level of oxidative stress in the semen sample. All of these parameters independently correlate with infertility and give some predictive information as to how and in what ways we should be using the sperm to most efficiently establish a healthy pregnancy and who might be at higher risk for miscarriage. They also allow us to differentiate those patients who will most benefit from attempting to improve their sperm quality versus those who might go directly to ART with an expected high level of success. Of course no single test has 100% positive predictive value and all give a different piece of the puzzle that allows us to draw conclusions and make recommendations to patients. With fertility things get even more complicated because there are so many variables or “moving parts” including timing and the ability of a woman’s egg to overcome certain deficiencies within a given sperm cell.

The exciting thing is that with these newer tests, our understanding of the causes of infertility have increased, more research is being undertaken and with that, our ability to tailor treatment to a patient’s situation is leading to higher pregnancy rates and couples achieving their ultimate goal.

Who Should be Evaluated

The recommendation of the ASRM and AUA joint panel on best practice policies for male infertility is that all men with 2 abnormal semen analyses be evaluated by a physician with expertise in treating male infertility. The evaluation should consist of a detailed patient history and well as a complete physical examination. Advanced sperm testing as well as hormone evaluation, genetic testing and radiological imaging may be performed as indicated

New Treatment Strategies

Research on sperm DNA fragmentation has led to the development of new treatment alternatives for men with abnormal sperm. It ha shown that men with high levels of DNA fragmentation who have varicoceles benefit from surgical repair of the condition because it lowers the amount of damage to normal and thereby allows for increased chances of conception. It has also shown that the source of the sperm does influence outcomes of IVF. Sperm retrieved from the testicles seems to have lower levels of damage than poor quality ejaculated sperm in men with sperm storage and transport problems. In these cases, sperm are damaged in the reproductive tract after they leave the testicle. Sperm inside the testicle seem to be protected because of the high level of antioxidants within the testicle. In couples who have failed multiple cycles of IVF, using testicular sperm during a subsequent IVF cycle has lead to over 60% pregnancy rate in several studies and provides a new option to help improve outcomes in these selected patients.
This research has also provided the rationale for treating male infertility with high levels of antioxidants and supplements. If free radical peroxidation leads to sperm DNA fragmentation and if antioxidants can neutralize or reduce oxidative stress in the semen, then it would make sense that supplements containing a combination of vitamins, minerals, bioflavinoids and antioxidants can improve sperm quality to some extent. Research is currently ongoing in this area.

Another condition where new techniques have helped improve outcomes is non-obstructive azoospermia (no sperm in the ejaculate because of a production problem). Over the last decade, it has become evident that sperm production in the abnormal testicle is not uniform, it can be limited to small pockets in some situations. Rondom testicular biopsies may miss a pocket of sperm production and fail to retrieve sperm in a percentage of men who may actually have small amount of sperm production. A microsurgical approach allows these pockets to be visually detected and increases the sperm retrieval rate to up to 75% of patients. The technique is called testicular microdissection or MicroTESE and this can be the difference between failure and the ability to father a biological child. Men who have had prior negative random biopsies may have sperm retrieved via this approach.

Conclusion

New testing methods and treatments for male infertility continue to evolve and improve our ability to help men become fathers such that very few men can not become a biological parent.