Prior to vasectomy reversal
Between 4% and 5% of Australian men who have had vasectomy later seek reversal. The Australian Institute of Heath and Welfare data indicate that 500 to 600 vasectomy reversal operations performed annually. Nationally, both vasectomy and vasectomy reversal are now substantially more common than fallopian tube occlusion for female sterilization and microsurgical fallopian tube reanastomosis for sterilization reversal.
By far the most common indication for vasectomy reversal is a desire to achieve pregnancy with a new partner due to change of relationship; less than 1 in 30 men who undergo vasectomy reversal are in the same relationship that produced their children. Approximately 1% of men develop post-vasectomy pain of sufficient severity to interfere with quality of life. Although the cause of post-vasectomy pain syndrome is unknown, vasectomy reversal provides effective relief in up to two-thirds of cases with some benefit in about half of the remaining men. Rarely a man may seek reversal for psychological, psycho-sexual or religious reasons.
Personal history includes age, prior pregnancies and children in the same and different relationships. The duration of time since the vasectomy and whether there were any post-operative complications from the vasectomy is important. A general medical history with particular emphasis on any hereditary or acquired bleeding disorders or anticoagulant therapy is wise (as each may increase the risk of post-operative haematoma).
Female age is the single most important factor influencing the prospect of pregnancy after vasectomy reversal. Before vasectomy reversal is performed for restoration of fertility, evaluation of the female partner’s reproductive potential is prudent particularly if there is evidence of prior gynaecological problems. A reproductive history and where indicated assessment of ovarian function and pelvic anatomy may be necessary.
Physical examination is generally uninformative and not predictive of outcome. It may reveal that large segments of the vas deferens were removed and help to identify those in whom the standard incision may need to be modified. Examination also may reveal testicular abnormalities or epididymal induration. Epididymal fullness suggests obstruction at that level but does not predict accurately which patients will require vasoepididymostomy. Obesity may increase technical difficulty and increase the risk of haematoma. Where appropriate examination can be carried out immediately prior to surgery.
Preoperative testing prior to vasectomy reversal is unnecessary except for routine preoperative tests that may be required or preferred due other medical conditions.
Between 50% and 70% of men develop circulating anti-sperm antibodies following vasectomy. The precise cause of the development of sperm antibodies is uncertain. The so-called ‘testis-blood barrier’ usually minimizes exposure of sperm. Leakage of sperm at the time of vasectomy is likely to contribute to the development of sperm antibodies. Some investigators have suggested that such antibodies may decrease the chance for successful pregnancy after vasectomy reversal. Studies into pregnancy rates following vasectomy reversal demonstrate mean postoperative conception rate of between 60% and 85% for patients of less than 15 years from their vasectomy undergoing microsurgical vasovasostomy. The presence of circulating anti-sperm antibodies correlates poorly with postoperative fertility and the results of testing are not sufficiently sensitive or specific to predict the outcome of vasectomy reversal. As a result sperm antibody testing has largely been abandoned by reproductive microsurgeons as a preoperative test.
Testicular changes after vasectomy
Pathologic changes in testicular histology commonly occur following vasectomy. Electron microscopy revealed that fibrosis is present in the testis of 23% of men following vasectomy and that some evidence of adverse impact on spermatogenic cells within the testis is almost universal. The fertility in men who undergo successful vasectomy reversal (as defined by both sperm in the ejaculate and conception) is strongly inversely correlated with pathological changes in the testes post-vasectomy. With this said, intention to undertake vasectomy reversal is not an indication for investigative testicular biopsy as the results of doing so is very unlikely to influence the rationale of proceeding to microsurgical reversal.
Microsurgical methods are by far the most accurate and effective way of overcoming damage reproductive organs in both men and women to restore fertility.
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