Vasectomy: an appraisal for the obstetrician-gynecologist.

Data regarding the efficacy of vasectomy are limited, but the procedure appears to be highly effective. Efficacy may vary by the method of vas occlusion. Death attributable to vasectomy in the United States is exceedingly rare, and major perioperative morbidity is quite uncommon. No long-term adverse health effects have been documented, and much evidence supports the conclusion that vasectomy does not increase the risk of subsequent atherosclerosis. Vasectomy, like tubal sterilization, should be considered a permanent decision, because reversal surgery is expensive and requires substantial surgical expertise. Although vasectomy reversal is often successful, it cannot be guaranteed even in the best of circumstances, and when the vasectomy has caused epididymal obstruction, reversal is often unsuccessful. Vasectomy represents a safe and effective alternative to tubal sterilization for couples who decide that the male should be sterilized.

Urologic microsurgery -- current perspectives: II. Orchiopexy and testicular homotransplantation.

Reports of microsurgical testicular autotransplantation as a method of dealing with the high undescended testis have prompted this review. Results with various methods are compared. The increasing success being reported with division of the internal spermatic vessels (when certain principles as enumerated herein are followed) leads to the conclusion that the more technically complex method of microsurgical testicular autotransplantation will not come into general use. The opportunities for testicular homotransplantation are rare, and no definitive conclusions can be made concerning this rarely reported procedure.

Microsurgical two-layer vasovasostomy. Simplified technique using hinged, folding-approximating clamp.

Microsurgical two-layer vasovasostomy appears to yield improved results over conventional methods but is not widely used because of technical difficulties. A technique is reported which utilizes a hinged folding vas approximating clamp and allows the two-layer anastomosis to be performed with greater ease because the details of the vas ends are visualized constantly. The danger of mucosal tears is lessened by posterior muscular layer approximation before mucosal approximation, thus relieving mucosal tension during suturing.

Urologic microsurgery--current perspectives: I. Vasovasostomy.

Microsurgical procedures are receiving increased attention in urology, and claims of improved results of vasovasostomy performed with operating microscope have been made. This review examines the available results, sometimes conflicting, of both macro- and microsurgical methods of vasovasostomy. The weight of the data leads to the conclusion that improved results of vasovasostomy will occur with the use of the operating microscope regardless of the type of anastomosis performed because increased appreciation of the detail of the small vasal lumen is afforded by optical magnification.

Infrapubic incision for specific vasectomy reversal situations.

Routine vasectomy reversals are performed easily through scrotal incisions. However, the infrapubic incision offers easiest access to both ends of the vas deferens when the vasectomy has been performed at an unusually high level. Similarly, when unusually long segments of the vas have been removed during the vasectomy, the infrapubic incision enables the surgeon to mobilize a sufficient length of the abdominal end of the vas so that even vasoepididymostomy may be performed without tension on the anastomosis. Technical details of the infrapubic incision, which may be used with local anesthesia, are described.

Microsurgical two-layer vasovasostomy: word of caution.

Microsurgical technique, with separate mucosal and muscular layer anastomosis, recently has been advocated as the most successful method of vasovasostomy. Unexpected difficulties may be encountered using this method; moreover, considerable practice in the microsurgical laboratory is mandatory before actual performance of the procedure. As with any innovation in surgical technique, a judgment of the clinical superiority of the two-layer anastomotic method must await substantiating results from other investigators.

PIP: A microsurgical technique, with separate mucosal and muscular layer anastomosis, has been advocated as the most successful vasovasostomy method presently available. But the 2-layer microsurgical vas anastomosis has aspects that are foreign both to the urologist and to the experienced microvascular surgeon, and suggestions are made for mastering this microtechnique. For the urologist, practice on sheet rubber edges followed by vessel anastomosis in small animals are prerequisite to successful surgical outocme. For the microvascular surgeon, certain changes must be made from usual practices because of the stiffness, thickness of wall, and small size of lumen compared with the outer diameter of vas deferens. A summary of attempts made at 2-layer anastomosis suggests that the 2-layer method in a laboratory model appeared superior to a single-layer method. Final judgement of superiority of this 2-layer technique cannot be pronounced.

Microsurgical two-layer vasovasostomy: laboratory use of vasectomized segments.

A microsurgical laboratory model is described which uses optimally preserved human vasectomy segments. These preserved specimens retain their natural appearance and handling qualities, permitting ready availability of material for practice, which is mandatory before clinical performance. If laboratory facilities are not available, the model can be used for practice in a convenient area of the operating suite.

Live birth after sperm retrieval from a moribund man.

OBJECTIVE: To report a live birth with IVF-ET and intracytoplasmic sperm injection (ICSI) using sperm retrieved from a moribund man being maintained on life support systems. DESIGN: Case report. SETTING: Nonprofit private teaching hospitals. PATIENT(S): A 27-year-old man who was decorticate after an accident. INTERVENTION(S): Epididymal sperm retrieval and sperm cryopreservation, pastoral psychologic counseling, and subsequent IVF-ET with ICSI. MAIN OUTCOME MEASURE(S): Pregnancy and delivery. RESULT(S): Birth of a healthy child after IVF-ET with ICSI and single blastocyst transfer. CONCLUSION(S): First report in peer-reviewed medical literature of a live birth after sperm retrieval from a moribund man.

Development of a new alloplastic spermatocele demonstrating successful sperm retrieval in an animal model.

OBJECTIVE: To create an alloplastic spermatocele capable of repeated sperm aspiration. The alloplastic spermatocele has long been a theoretical solution to infertility for those patients with congenital absence of the vas deferens or irreversible obstruction of the male reproductive ductal system. Recent studies have suggested that sperm from efferent ducts are capable of fertilization. Clinical use of alloplastic spermatoceles for collection of epididymal sperm has resulted in unacceptably low pregnancy rates. Improvement in spermatocele function may occur if a microsurgical anastomosis is performed to the epididymis. DESIGN: A newly designed alloplastic spermatocele was implanted in 17 mature male rabbits. The faceplate of the device had a 0.7-mm orifice, allowing direct precise microsurgical anastomosis to a specific loop of the epididymal tubule. RESULTS: Sperm retrieval was possible in 16/17 (94%) animals. Repeated successful aspirations (total of 73) were performed in all but one animal. The total number of sperm collected per spermatocele averaged 115 x 10(6) (range 0 to 734 x 10(6)). The sperm motility varied widely between animals and specimens, with a maximum average of 21.6% motile sperm/aspirate per animal. All spermatoceles eventually occluded (mean time of occlusion 14 days; range 3 to 30 days). The prostheses with the attached epididymides were examined histologically. CONCLUSIONS: This prototype alloplastic spermatocele allows repeated high density sperm retrieval over a short period of time. Low sperm motility may be less problematic clinically as new techniques of IVF become available.

Principles of microsurgery.

Microsurgical techniques have been used to perform a variety of urologic procedures. Basic microsurgical principles are discussed in this article and information is presented regarding instrumentation techniques and the operation of microscopes and microsurgical instruments. Many useful hints to increase the ease of performing microsurgery are discussed and clearly defined.

The varicocele and male infertility.

Varicocele is accepted as a common cause of male subfertility, even though many men with varicocele appear to have normal fertility. The pathophysiology of the varicocele effect on fertility remains unclear, but the association of varicocele with decreased testicular size, abnormal testicular histology, and abnormal semen parameters is clearly established. Because a small varicocele may impair fertility, it must be diligently sought, and the Doppler stethoscope may be helpful in establishing the diagnosis when a venous thrill is equivocal during the Valsalva maneuver in a standing patient. Abnormal semen parameters should be demonstrated in subfertile males with varicocele prior to advising varicocelectomy. Decreased sperm motility or a "stress pattern" in the semen should be documented; however a decreased sperm count may or may not be present. Various surgical approaches are available. When suprainguinal approaches have been used, failures have been shown to be attributable to secondarily incompetent cremasteric system veins. When high inguinal approaches are used, unsuccessful operations are probably secondary to a failure to identify one of the several venous tributaries that may be present at this level. The surgeon's approach should be based on available data, and his patients should be informed that failures are possible with any method of varicocelectomy until experience indicates otherwise. In most series, improvement in semen quality and pregnancy rates have been reported in a significant percentage of patients undergoing varicocelectomy for infertility. However, prior to subjection of the patient to varicocelectomy, the wife of the varicocele patient should be thoroughly studied (and treated when indicated).

PIP: Varicocele, found in 8-22% of the general population but in 21-39% of men attending infertility clinics, is now accepted as an important cause of male infertiltiy. The mechanisms by which varicocele affects fertility remain undetermined; however, decreased testicular size, abnormal testicular histology, and abnormal semen parameters have been noted in patients with varicocele. Sinc the size of the varicocele is not related to the degree of fertility impairment, care must be taken to detect subclinical varicocele. The presence of a small varicocele is suggested by an equivocal venous thrill during the Valsalva maneuver. This can be confirmed by noninvasive diagnostic tests in which the Doppler stethoscope is utilized. Before surgical intervention, other possible causes of subfertility (including factors in the female partner) should be excluded. If no other abnormality is found, and if both decreased sperm motility and increased numbers of tapered sperm and immature germinal cells in the semen are noted, varicocelectomy is indicated. The suprainguinal and high inguinal approaches are currently used for ligation and division of the internal spermatic vein. The safety of the suprainguinal division of the internal spermatic artery in the absence of prior dissection of the spermatic cord at a lower level has been demonstrated by experimental and clinical data. Reviews of the results of varicocele ligation in subfertile men have noted improved semen quality in 55-85% and pregnancy in 25-55% of wives.

Vasectomy reversal.

A vasovasostomy may be performed on an outpatient basis with local anesthesia, but also may be performed on an outpatient basis with epidural or general anesthesia. Local anesthesia is preferred by most of my patients, the majority of whom choose this technique. With proper preoperative and intraoperative sedation, patients sleep lightly through most of the procedure. Because of the length of time often required for bilateral microsurgical vasoepididymostomy, epidural or general anesthesia and overnight hospitalization are usually necessary. Factors influencing the preoperative choice for vasovasostomy or vasoepididymostomy in patients undergoing vasectomy reversal are considered. The preoperative planned choice of vasovasostomy or vasoepididymostomy for patients having vasectomy reversal described herein does not have the support of all urologists who regularly perform these procedures. My present approach has evolved as the data reported in Tables 1 and 2 have become available, but it may change as new information is evaluated. However, it offers a logical method for planning choices of anesthesia and inpatient or outpatient status for patients undergoing vasectomy reversal procedures.

PIP: The basis for choosing either vasovasostomy or vasoepididymostomy for reversal of vasectomy or vas obstruction by microsurgical outpatient procedures, and management of these patients, are summarized, with diagrams and photographs included. Prior to surgery, it is impossible to determine whether a person needs one procedure or the other. When operative procedures have begun, those with sperm or clear vas fluid are candidates for vasovasostomy. Those without sperm, or with cloudy fluid, will require vasoepididymostomy under general or epidural anesthesia, which takes 4-6 hr. No extensive data on outcome of pregnancy after microsurgical vasoepididymostomy are available. The author's patients with outpatient 2-layer microsurgical vasovasostomy have had 62% pregnancy rate so far; 14% more men show normal mobile sperm counts. Most of the operations are done under local anesthesia using lidocaine and bupivacaine, perhaps with sedation, through a 2-3 cm incision. Only general instructions for the 2 procedures are included here. The author prefers "end-to-side" microsurgical vasoepididymostomy, combined with 1 or more microdissections to find the most caudal area of the epididymis where mobile sperm are present. For those who must contain costs, as these operations are not usually covered by health insurance, the postoperative recovery, if needed, is obtained by hospitalizing the patient overnight after the procedure. Costs of vasovasostomy, not including surgeon's fee, ranged from $1144 for local, outpatient, to $2066 for general anesthesia and inpatient care.

Sperm processing and intrauterine insemination for oligospermia.

The success of IVF has led to the adaptation of IVF sperm processing methods for WIUI. When WIUI is used for treating oligoasthenospermia, there is a theoretical advantage because an isolated population of only the most motile, capacitated sperm are placed directly into the wife's uterus. The cervix and its mucus are bypassed, which may provide a mechanical or biochemical advantage for semen from subfertile males. Removal of seminal plasma (and prostaglandins contained therein) prevents the painful uterine contractions that can occur when raw semen is placed directly into the uterine cavity. The disadvantages of WIUI are related to its expense, problems with precise timing of ovulation, and the frustration that can occur when inseminating personnel are not available whenever ovulation occurs on weekends or holidays. Only truly committed couples who will try WIUI for multiple cycles should be selected for this method of infertility treatment. Although male-factor infertility currently is one of the main indications for WIUI, the widely variable pregnancy rates reported with WIUI leave some doubt regarding its ultimate role in the treatment of this condition. Our own preliminary results with WIUI for treatment of asthenospermia, oligoasthenospermia, and "cervical factor" infertility are encouraging, although the numbers of patients are small. We anticipate that with further refinement of methods of sperm processing and with the newer improved methods of home monitoring of ovulation, these results may improve. Factors that determine pregnancy rates of WIUI for the treatment of oligoasthenospermia are numerous. The degree of oligospermia and/or asthenospermia, the cooperation and persistence of the couple through the required cycles of WIUI (drop-out rate), the method and meticulousness of sperm processing, the accuracy of monitoring ovulation, the availability of insemination personnel whenever ovulation occurs (even on weekends and holidays), and possibly the duration of infertility will all play a role in the ultimate success of WIUI programs. Couples selecting WIUI must be aware that it does not now offer a high pregnancy rate when used for treatment of male-factor infertility. The apparent increased pregnancy rate of WIUI compared with other methods of AIH may have resulted from modern methods of monitoring ovulation. Studies have not yet been performed to show whether comparable pregnancy rates would be obtained if similar methods of monitoring ovulation were used with cervicovaginal methods of AIH. We believe the only clear indication for WIUI now is an abnormal sperm-cervical mucus interaction.(ABSTRACT TRUNCATED AT 400 WORDS)

Accreditation of ambulatory surgery centers.

Accreditation is required for outpatient surgery facilities not only to assure quality patient care but also to obtain a facility fee reimbursement from many insurance companies. General guidelines concerning subjects considered by the JCAH and the AAAHC in the accreditation process have been reviewed. Because actual physical construction features may affect accreditation, those planning office-based and other types of outpatient surgery facilities should be aware of accreditation requirements before construction is begun.

Pregnancy with microsurgical vas sperm aspiration from a patient with neurologic ejaculatory dysfunction.

Patients with neurologic ejaculatory dysfunction who wish to have a child commonly undergo electroejaculation, which, unfortunately, may fail to stimulate either antegrade or retrograde ejaculation of sperm. Even when sperm are obtained with electroejaculation, conception still may not be achieved. We describe the achievement of a pregnancy after the intrauterine insemination of sperm obtained from microsurgical aspiration of the vas deferens. The intrauterine insemination of electroejaculated sperm had failed to achieve a pregnancy on three previous occasions. The relative merits of vas sperm aspiration and electroejaculation as part of the assisted reproduction regimen for men who have neurologic ejaculatory dysfunction are discussed.

Müllerian inhibiting substance improves longevity of motility and viability of fresh and cryopreserved sperm.

Müllerian inhibiting substance (MIS) is a hormone present in seminal plasma, but its role is unknown. In this study, the effects of MIS on sperm survival in fresh and cryopreserved specimens were investigated. Fresh sperm motility and viability (n = 12) were evaluated in specimens after 0, 0.5, 1, 3, 5, and 22 hours of incubation in the presence or absence of MIS. Motile and nonmotile sperm were evaluated in Cell-Vu counting microscope slides, and viability was assessed by eosin-nigrosin exclusion. Sperm cryopreserved for 2 weeks in TES (N-Tris[hydroxymethyl]methyl-2-aminoethanesulfonic acid)-Tris-glycerol-egg yolk buffer and 4% glycerol with or without MIS were thawed at room temperature (n = 6) and were evaluated for motility and viability using identical methods to those used with fresh sperm. The effects of MIS were examined by coincubation with monoclonal anti-MIS antibody (6E11; n = 6). In fresh and cryopreserved sperm incubated with MIS, both motility and viability were higher than in the absence of MIS (P < 0.03; Wilcoxon signed rank test) at 5 and 22 hours. Coincubation with anti-MIS antibody eliminated the effects of MIS. Longevity of sperm motility and viability are improved both in fresh and cryopreserved sperm in the presence of MIS and may have potential for use in assisted reproductive technology.

Simple, rapid staining method for immediate intraoperative examination of testicular biopsies.

Before patients with obstructive azoospermia undergo surgical reconstruction, testicular biopsy is required to establish that spermatogenesis is normal. To perform the corrective surgical procedure at the same time as the testicular biopsy, a touch imprint method of processing the biopsy specimen has replaced frozen section processing, which distorts the germinal cells. We report a rapid, simple method of staining a touch imprint specimen in the operating room. It requires less than 5 minutes and can be performed by the andrology laboratory technologist, operating room staff, or the surgeon, thereby avoiding the need to transport the biopsy specimen to the pathology laboratory.

Applications of microsurgery in urology.

The applications of microsurgery in urology have increased in the decade since urologists first used such techniques. The primary uses for microsurgery in urology at first were vasovasostomy, vasoepididymostomy, and testicular autotransplantation. Penile revascularization has recently become another procedure for which microsurgery is used with increasing frequency. As more urologists learn the techniques, other urologic applications for microsurgery surely will develop.

Vasectomy and its reversal.

Techniques, results, complications, and medicolegal aspects of vasectomy are discussed in this article. Emphasis is placed on techniques that prevent spontaneous recanalization of the ends of the vas deferens after vasectomy. Factors that affect the reversibility of vasectomy are discussed. New microsurgical techniques of vasectomy reversal are described, and results of these new techniques are compared with results of nonmicrosurgical techniques of vasectomy reversal. Indications for bypass vasoepididymostomy during vasectomy reversal procedures, as well as techniques for performing vasoepididymostomy, are discussed.

PIP: Frequently, patients inquire about reversible vasectomy devices, which would permit fertility if later desired. Prototype reversible vasectomy devices have been developed, but none has yet satisfied the requirements of assured permanent sterility with reversible fertility when desired. There are numerous technical factors that make the ultimate development of a satisfactory reversible vasectomy device seem unlikely. Compared with tubal ligation in women, vasectomy is simpler, less expensive, and safer. Vasectomy can be performed in the physician's office or in an ambulatory surgery facility. Vasectomy should be performed at a relatively high level in the straight scrotal portion of the vas. This level is recommended for vasectomy because later reversal of the vasectomy is easier if the procedure was performed at this level rather than in the lower, convoluted portion of the vas. After the vas has been transected, a portion of the vas is excised for identification. This identification is required for medicolegal purposes but serves no useful purpose in preventing spontaneous recanalization of the ends of the vas. Because of the extreme mobility of the vas, its severed ends may still come in contact after resection of as much as 2 or 3 cm of its length. Because of reports of spontaneous recanalizations and resulting undesired conceptions after originally successful vasectomies, the method used to seal the ends of the vas assumes paramount importance. Simple ligation of the ends of the vas, ligation of each end of the vas doubled back on itself, and application of metallic clips to the ends of the vas all have been advocated. Each of these methods has about the same rate of spontaneous recanalization postoperatively. Limitation of activity for 24-48 hours postoperatively, aspirin, and occasional use of an ice pack should relieve the usual pain after vasectomy. Couples must be cautioned that contraception is required after vasectomy until absence of sperm from the semen is documented. Local hemorrhage and wound infection occur in a small percentage of patients after vasectomy. A rare patient requires evacuation of a scrotal hematoma in the early postoperative period. Microsurgical techniques have improved considerably the results of vasovasostomy, which may be performed with local anesthesia on an outpatient basis. Factors affecting the success of vasectomy reversal are the obstructive interval (time from vasectomy until its reversal) and the sperm quality in the vas fluid at the time of the reversal procedure.