ORIGINAL ARTICLE

Correspondence:

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.

Keywords:

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

vasovasostomy

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

SUMMARY

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

–

34.9;

p

=<

1

9

10

). 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

–

13.6;

p

=

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

counseling.

INTRODUCTION

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

(Belker

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.

,

2014).

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

532

Andrology

, 2015, 3, 532–535

©

2015 American Society of Andrology and European Academy of Andrology

ISSN: 2047-2919

ANDROLOGY