Sperm granulomas: Predictive factors and impacts on patency post vasectomy reversal.

The objective of this study was to identify factors that predict for sperm granuloma formation and the impact of sperm granuloma presence and quantity on vasectomy reversal (VR) outcomes. A cross sectional retrospective review of prospectively collected data, on the impact of granuloma on VR outcomes from a single academic center was performed. The impact of age, obstructive interval, intraoperative vasal fluid findings, anastomosis type, body mass index, tobacco use and total motile count (TMC) was determined. A total of 1550 men underwent VR between January 2000 and August 2019. Granulomas were present unilaterally in 23.3% (n = 361) and bilaterally in 14.2% (n = 220). On univariate analysis, increasing patient age negatively correlated with a larger number of granulomas (p = .011). Granuloma presence was associated with finding intact and motile sperm from the vasal stump intraoperatively (p = .001), and vasoepididymostomy anastomosis (p < .001). However, granuloma presence (and quantity) did not correlate with obstructive interval or maximum TMC. Tobacco use and body mass index (BMI) were not associated with granuloma presence. On multivariate analysis, granuloma quantity was not associated with TMC. Obstructive interval and vasovasostomy anastomosis were associated with higher TMC, while BMI was negatively associated with TMC. In conclusion, increasing age was negatively correlated with granuloma formation. Granuloma presence was associated with more favourable intraoperative fluid findings and anastomosis type, but not post-VR TMC, suggesting men with and without granulomas undergoing skilled microsurgery will have similar patency rates. Heavier men should be encouraged for weight loss prior to vasectomy reversal as increasing BMI was associated with lower TMC.

Challenges in completing a successful vasectomy reversal.

Although a wide array of interventions exist for men seeking fertility after vasectomy, up to 6% of them will elect for a vasectomy reversal. While the widespread adoption of telemedicine promises convenience and improved access, lack of ability to do a physical examination may hinder appropriate counselling. Although vasectomy reversal is successfully completed in most of the men either with a vasovasostomy or a vasoepididymostomy, there could be various reasons for the inability to successfully complete the operation. Our commentary outlines the reasons why a vasectomy reversal is not possible or successful. We also discuss a pre-operative management algorithm in men seeking vasectomy reversal to ensure appropriate counselling with a thorough pre-operative history, physical examination and on occasion, hormonal evaluation.

Predictors of success after bilateral epididymovasostomy performed during vasectomy reversal: A multi-institutional analysis.

INTRODUCTION: Vasectomy reversal (VR) represents an excellent option for paternity in men who desire to expand their family following vasectomy. Traditional VR via vasovasostomy has a success rate upwards of 90% but when sperm or sperm parts are not present in vasal fluid, epididymovasostomy (EV) must be performed instead. Our objective was to determine which factors influence success after bilateral EV. METHODS: A prospectively maintained database with data from the U.S. and Canada was used to identify men who underwent bilateral EV at time of VR. Success was defined as motile sperm in any postoperative semen analyses. Multivariable logistic regression was used to identify predictors of success. RESULTS: A total of 200 men had at least one postoperative semen analysis, and 171 men were included in the analysis. Average age was 44.7 years, with average followup of seven months. Median time elapsed between vasectomy and EV was 15 years (interquartile range [IQR] 10-18). Overall success rate was 50%. Despite the study being adequately powered, factors such as years since vasectomy (odds ratio [OR] 1.01, confidence interval [CI] 0.95-1.06), age (OR 0.96, CI 0.91-1.01), intraoperative presence of motile sperm (OR 0.81, CI 0.41-1.62), and epidydimal fluid characteristics did not predict success. CONCLUSIONS: Bilateral EV at time of VR is successful in 50% of cases in a multi-institutional, North American cohort. Microsurgeons can be reassured that neither time elapsed nor epididymal fluid characteristics negatively impact success rates as long as sperm or sperm parts are present. Surgeons performing VR should be comfortable and prepared to perform EV if indicated.

The Effect of Male Age Over 50 Years on Vasectomy Reversal Outcomes.

OBJECTIVE: Advancing paternal age is associated with impaired semen parameters. We sought to evaluate reproductive outcomes in men undergoing vasectomy reversal (VR) aged ≥50 vs <50 years. METHODS: Reproductive outcomes (obstructive interval, female age, anastomosis type, post-VR total motile count (TMC), and pregnancy) after VR were assessed for men aged <50 and ≥50 years. Statistical analysis was performed using Kruskal-Wallis rank sum or Chi-squared tests. Multiple logistic regression was used to identify factors associated with achieving pregnancy. RESULTS: A total of 2777 men <50 years and 353 men ≥50 years were included. The mean obstructive interval was 8.7 years less for men <50 years (8.9 vs 17.6 years, P <.001). The chances of needing a vasoepididymostomy were higher in men ≥50 years (19.5% vs 10.1%, P <.001). Post-VR total motile count was higher in men <50 years (59.3 vs 29.1 × 106/mL, P <.001). About 33.4% of men <50 years and 26.1% ≥50 years contributed to a pregnancy (P = .007). On multiple logistic regression analysis, obstructive interval <10 years (OR 1.295, P = .002) and female age <35 (OR 1.659, P <.001) were associated with achieving a pregnancy. A history of smoking was associated with decreased odds of achieving a pregnancy (OR 0.523, P <.001). Age <50 or ≥50 years at VR was not associated with achieving pregnancy (OR 0.852, P = 0.254). CONCLUSION: Compared to those ≥50 years, more men <50 years achieved a pregnancy after VR. However, on adjusted multivariable analysis, age at VR was not an independent predictor of achieving pregnancy. Shorter obstructive interval and female age were associated with achieving pregnancy, while a history of smoking was associated with decreased odds. Successful outcomes after VR can be achieved in older men, and VR should be considered in men ≥50 years, when performed by a trained microsurgeon.

Angled vas cutter for vasovasostomy: technique and results.

OBJECTIVE: To describe the technique and results of bilateral vasovasostomy using a 3-mm vas cutting forceps angled at 15° (catalog no. NHF-3.15; ASSI) for vasal transection. DESIGN: Retrospective chart review. Institutional review board approval was granted by Western Institutional Review Board. SETTING: Single vasectomy reversal center. PATIENT(S): Men who underwent a bilateral vasovasostomy at a single institution by a single surgeon between 2001 and 2012 and had a minimum of one semen analysis postoperatively or a reported natural conception. INTERVENTION(S): Before September 14, 2010, a straight-edge vas cutter was used on all vasovasostomy connections; 375 men received a bilateral vasovasostomy and met follow-up criteria. Beginning on September 14, 2010, an angled cutter was used on all vasovasostomy patients, with 194 men meeting the exclusion criteria. MAIN OUTCOME MEASURE(S): A minimum of 1 × 10(6) sperm reported on a postoperative semen analysis, or a reported natural conception was used to establish patency. RESULT(S): The overall vasovasostomy patency rate using the angled vas cutter was 99.5% and was 95.7% using the straight vas cutter. CONCLUSION(S): The development of an angled vas cutter provides an increased surface area for vasal wound healing to allow for larger tissue diameter for better healing, resulting in high patency rates after vasovasostomy.