Larry I. Lipshultz, 6624 Fannin Street Suite #1700,
Houston, TX 77030, USA.
E-mail: larryl@bcm.edu
Ranjith Ramasamy and Douglas A. Mata
contributed equally to this study.
microscopy, vasectomy reversal, vasovasostomy
Received: 17-Dec-2014
Revised: 2-Feb-2015
Accepted: 23-Feb-2015
doi: 10.1111/andr.12033
Microscopic visualization of
intravasal spermatozoa is positively
associated with patency after
bilateral microsurgical
R. Ramasamy,
D. A. Mata,
L. Jain,
A. R. Perkins,
S. H. Marks and
L. I. Lipshultz
Department of Urology, Baylor College of Medicine, Houston, TX,
Department of Pathology,
Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, and
International Center for
Vasectomy Reversal, Tucson, AZ, USA
We evaluated pre-operative and intraoperative factors associated with successful patency following bilateral microsurgical vasova-
sostomy (VV). We retrospectively reviewed the charts of 1331 men who underwent bilateral VV by two surgeons between 2006 and
2013. Vasal Fuid was examined intraoperatively for gross quality (i.e., clear or opaque and creamy/thick) and for the presence of
spermatozoa on microscopy (i.e., whole spermatozoa, sperm fragments, or azoospermia). Post-operative patency was assessed by
semen analysis or patient report of conception. Perioperative factors were explored using descriptive statistics and examined in logis-
tic regression models for associations with post-operative patency. The median age at VV was 39 years [interquartile range (IQR): 35
44] and the median obstructive interval (OI) was 7 years (IQR: 4
11). Overall, 1307 patients achieved post-operative patency (98%)
while 24 remained obstructed (2%). Among those who became patent, 410 reported conception. After adjustment for potential con-
founders, only microscopic examination of the intravasal Fuid for the presence of spermatozoa (bilateral or unilateral whole sperma-
tozoa vs. sperm parts/azoospermia) at the time of VV was signi±cantly associated with post-operative patency with an odds ratio
(OR) of 14.2 (95% CI: 5.8
). Identi±cation of bilateral or unilateral sperm fragments vs. azoospermia was also
associated with increased odds of post-operative patency with an OR of 3.5 (95% CI: 0.9
0.08). There was no statistically sig-
ni±cant association between age at VV, OI, presence of granuloma, gross Fuid quality, or surgeon and post-operative patency after
controlling for potential confounders. Identi±cation of whole spermatozoa in the vasal Fuid at the time of VV was positively associ-
ated with post-operative patency. Our ±ndings stress the need for intraoperative microscopy to aid in post-operative patient
About 175 000
354 000 vasectomies are performed in the Uni-
ted States each year (Eisenberg & Lipshultz, 2010), but up to 6%
of men who undergo vasectomy later elect for a reversal proce-
dure (Sandlow & Nagler, 2009). The Vasovasostomy (VV) Study
Group published outcomes on 1469 men who underwent VV
et al.
, 1991). The group demonstrated that a longer
obstructive interval (OI) and the absence of sperm granuloma on
physical exam were associated with decreased success following
VV. Other factors that appeared to inFuence post-operative suc-
cess were the gross quality of the vasal Fuid and the presence of
spermatozoa or sperm fragments at the time of vasectomy rever-
sal (VR). We recently published a meta-analysis demonstrating
that the odds of post-operative patency were approximately four
times higher given the presence of intravasal spermatozoa or
sperm fragments as opposed to their absence (Scovell
et al.
During VR, the surgeon’s decision to proceed with VV rather
than epididymovasostomy (EV) depends on the gross Fuid qual-
ity expressed from the testicular end of the vas deferens and the
microscopic examination of the Fuid. The exact contribution of
each of these factors to successful patency following VV remains
unclear. Some series indicate that in the presence of whole
sperm patency after VV approaches 99.5% (Goldstein
et al.
1998). Even in cases of bilateral intravasal azoospermia, patency
approaches 80% and conception nears 40% when the OI is
11 years (Kolettis
et al.
, 2006). Unfortunately, many studies
that have evaluated intraoperative ±ndings during VR have been
, 2015, 3, 532–535
2015 American Society of Andrology and European Academy of Andrology
ISSN: 2047-2919