Peter J. Stahl, M.D.
Columbia University College of Physicians & Surgeons, New York-Presbyterian Hospital, New York, NY, USA
Approximately 5% of men who undergo vasectomy subsequently change their minds and decide to pursue biological paternity. Historically, if men wanted to father a child after vasectomy, the only option available to them was to undergo vasectomy reversal (VR). The development of intracytoplasmic sperm injection (IVF/ICSI) in 1992 enabled reproduction using surgically retrieved sperm. Today, men who desire fertility after vasectomy have a choice. They can elect VR, or they can choose to pursue IVF/ICSI using surgically retrieved sperm.
In general, VR is favored when couples desire many children, when they have limited financial resources or personal objections to assisted reproduction, and when the female partner has normal fertility or mild but correctable infertility. In contrast, sperm retrieval for IVF/ICSI is indicated when IVF is clinically required (i.e. need for genetic screening of the embryos, severe female infertility), and may be favored when couples only want one child, when they desire immediate fertility, or when VR is unlikely to enable natural conception due to other factors.
Some men have pre-existing clinical conditions or acquire new conditions after vasectomy that can significantly impact fertility outcomes regardless of whether men choose VR or surgical sperm retrieval. Assessing for such conditions is absolutely critical to facilitate treatment selection, and so all patients considering reproduction after vasectomy should consult with a reproductive urologist. The general objectives of the evaluation are (1) to diagnose factors that can negatively impact the probability of natural conception after VR, such as sexual dysfunction, testicular dysfunction, or time interval since vasectomy; and (2) to diagnose factors that impact sperm retrieval procedure selection, such as suspected problems with sperm production, number of desired children, and female fertility.
Men who choose to pursue post-vasectomy reproduction via VR generally do very well. In the majority of these men, reconstructive surgery involves joining the two ends of the vas deferens (vasovasostomy, VV) that were interrupted by the vasectomy. After vasectomy, some men develop a secondary blockage in the epididymis (not created at the time of vasectomy); this is more likely to develop the longer it has been since the initial vasectomy. In these men, reconstructive surgery involves bypassing the blockage and joining the vas deferens to the epididymis (vasoepididymostomy, VE), which is a much more challenging operation with lower success rates.
A recent publication reviewed the results of 31 studies from 1980 to 2014 that reported on outcomes in 6633 VR patients (Herrel 2015). The authors reported return of sperm to the ejaculate and pregnancy rates of 89% and 73%, respectively. Their analysis showed a modestly higher patency rate when the time lapse since vasectomy was less than 10 years (meta-incidence ratio 1.17). They also reported similar outcomes when modified one-layer and two layer anastomotic techniques were utilized for vasovasotomy. These data continue to support VR as an effective first-line therapy for many men who desire fertility after vasectomy.
In men who choose to pursue sperm retrieval for IVF/ICSI, the urologist’s role is to select and perform the sperm retrieval procedure that best suits each individual couple. This complex decision depends upon many factors, including whether sperm production is suspected to be normal or abnormal, the financial and/or insurance resources available to the affected couple, the fertility status of the female partner, and the number of desired children. In most cases, the lack of sperm in the ejaculate after vasectomy is purely due to the obstruction created at the time of vasectomy, and any sperm retrieval procedure is likely to result in successful sperm acquisition. However, each procedure is has unique attributes (Table 1).
In general, percutaneous (needle extractions through the skin, without an incision) procedures are less expensive and can be done under local anesthesia, but sperm yield can be limited and may be insufficient for sperm cryopreservation and multiple IVF/ICSI cycles. In contrast, conventional open surgical and more advanced microsurgical procedures require more skill and increased anesthetic requirements, but typically yield sufficient sperm for multiple IVF/ICSI cycles. The last factor to consider is whether or not the sperm retrieval procedure selected impacts reproductive outcomes. Most of the published literature indicates that IVF/ICSI outcomes don not vary by anatomic sperm source (i.e., from the testis versus epididymis) or sperm retrieval technique amongst men with obstructive azoospermia.
The decision to pursue vasectomy reversal or sperm retrieval for IVF/ICSI is multifactorial and complicated. All couples who wish to pursue biological paternity after having had a vasectomy should therefore consult with a reproductive urologist who can help each affected couple select the treatment strategy that is most aligned with their specific clinical circumstances and reproductive goals.
REFERENCES
Herrel LA, Goodman M, Goldstein M, Hsiao W. Outcomes of microsurgical vasovasostomy for vasectomy reversal: a meta-analysis and systematic review. Urology. 2015 Apr;85(4):819-25
Stahl PJ, Schlegel PN, Goldstein M. Sperm retrieval and quality evaluation. Methods Mol Biol. 2014;1154:361-84.
van Wely M, Barbey N, Meissner A, Repping S, Silber SJ. Live birth rates after MESA or TESE in men with obstructive azoospermia: is there a difference? Hum Reprod. 2015 Apr;30(4):761-6
