Vasectomy

Abstract

Vasectomy is a safe, standardized, and easy-to-perform method of male contraception. It bears only minimal risk of acute complications and no severe long-term complications. Moreover, vasectomy can be reversed through microsurgical refertilization procedures with a high rate of success and comparatively marginal expenses.

1 History of Vasectomy

It is impossible to date the earliest vasectomy. At the end of the nineteenth century, such operations were not performed for sterilization, but for other medical indications. At the time of the earliest vasectomies, it was believed that severing the vas deferens would improve prostate disease, heal impotence, or extend life expectancy. Vasectomy was advocated as a “fountain of youth” (Isnardi 1896; Wolfers and Wolfers 1974).

Eugenic aspects also played an important role among the indications for sterilization, as did elements of social control as advocated by Ochsner (1899) and Sharp (1902). In the 1920s and 1930s, a series of nations passed laws justifying sterilization for eugenic reasons. Along with the other cruelties practiced by the Third Reich, compulsory sterilization for eugenic purposes resulted in the abrogation of the legal basis for eugenic sterilization in most states. Some states, however, maintained these laws and later some tried to apply them. Drake et al. (1999) describe the varied history of vasectomy and its changing indications over the course of time.

Vasectomy as a means of contraception became popular in the 1960s, first in the USA, and then in Europe and Third World nations. Countries with particularly rapid population growth such as India and Thailand (Nirapathpongporn et al. 1990) established vasectomy camps. In the USA, sterilization became the form of fertility control most frequently chosen by married couples over 30 years of age (Smith et al. 1985). According to a survey, in Germany a frequency of about 50,000 vasectomies per year can be extrapolated (Deindl 1990). In 2018, a representative questionnaire showed that 2% of the German male population utilizes vasectomy as a method of contraception (Bundeszentrale für gesundheitliche Aufklärung 2018).

2 Social and Demographic Relevance

Contraceptive vasectomy is not popular in all countries, and in some it plays no role at all. In India and China, and, to a lesser extent, in Korea, Sri Lanka, and Bangladesh, vasectomy is widely performed (Ross and Huber 1983). Generally, sterilization in the male always competes directly with corresponding measures in the female, i.e., tubal ligation, which ironically has become increasingly popular because of improved techniques, although vasectomy was always technically simple (Ross and Huber 1983). In any event, the introduction of minimally invasive “no scalpel” techniques serves to make vasectomy much more acceptable (Xiaozhang and Shungiang 1993; Reynolds 1994; Ozvaris et al. 1998). These are based on percutaneous electrocoagulation or chemical denaturing of the vas, or specialized puncture instruments, which are used to minimize surgical trauma.

Particular ethical considerations concerning male sterilization apply in developing countries (Rizvi et al. 1995) and explain the former preference for female over male sterilization (3:1) with the rationale that vasectomy is hardly reversible and thus unpopular. New and advanced technologies such as sperm cryopreservation are only available in wealthy countries.

67–88% of the American population use contraceptive methods for avoidance of pregnancy, as reported by the “Behavioral Risk Factor Surveillance System.” According to this survey, women favor oral contraceptives, while men primarily rely on the surgical approach, i.e., vasectomy (Bensyl et al. 2002).

Another study found that about 25% of eligible couples in the USA rely on sterilization for birth control, with distinct differences between black and white populations: Among Caucasians, vasectomy and tubal ligation are performed about equally, while among Blacks tubal ligation is clearly preferred (Forste et al. 1995). In the USA, vasectomized men generally have above-average education, their family planning is complete, and they learned about vasectomy methods in newspapers or magazines (Kohli 1973). Thirty years later, no significant changes can be ascertained: vasectomized men in the USA are typically well-educated and married Caucasians with good medical insurance (Barone et al. 2004).

In England, only minimal differences between social classes were found with respect to the acceptance of vasectomy (Wright et al. 1977). The general acceptance of vasectomy as compared to tubal ligation has increased over the years in England (Rowlands and Hannaford 2003), as well as in Canada. The use of oral contraceptives and tubal ligation in the Canadian population is decreasing, while requests for vasectomies are steadily rising (Martin and Wu 2000). With advanced and ongoing aging of the population, vasectomy is no longer only an issue for young men. Older men also engage in sexual activity and favor vasectomy for contraception. In an Australian study of middle-aged males, 25.1% had been vasectomized, 5.6% of the vasectomized men did not have children, and 37% of men above 70 years of age were still sexually active (Holden et al. 2005).

It has been demonstrated that men who are prepared to undergo vasectomy usually live in relationships with a strong emphasis on partnership. Under certain conditions, positive and beneficial effects for a relationship can even be expected (Goebel et al. 1987). This influences patient selection made by counseling and operating physicians, resulting in the fact that in Germany predominantly men living in stable relationships are vasectomized. The number of vasectomized men varies in German-speaking countries: in Germany, 422 men per million inhabitants are vasectomized annually; in Austria, the number is only 81 (Engelmann et al. 1990).

3 Indications for Vasectomy

In contrast to formerly held but still widely accepted opinions, we believe that the indication for contraceptive vasectomy is easily established.

Every man of legal age and able to give consent may decide in favor of vas ligation or occlusion for the purpose of sterilization.

No special medical or social indication is necessary, but many physicians performing vasectomy require certain preconditions, mostly to provide backup support for the physician. In such cases, for example, a certain number of children are required, a stable relationship with written consent given by the partner is desired; finally, the chances for refertilization are deliberately and falsely minimized. These measures represent a bias concerning the affected persons; only those highly determined to undergo vasectomy will be accepted. This procedure may be understandable, but it is not in the best interest of the responsible citizen and patient. He has the right to objective counseling about the chances and risks concerning the intervention he wishes. Well-meaning, but false-negative counseling of the patient must not deprive him of the possibility of deciding in favor of vasectomy. This does not limit the surgeon’s right to decline to perform a vasectomy in individual cases.

4 Informed Consent

As in all other surgical procedures, the patient must be informed and his consent obtained at least 1 day prior to the operation itself. We observe the procedures generally accepted for surgery without any special modifications. Neither consent of the female partner nor even her existence is required. Information is provided about the procedure, which is almost always carried out on an outpatient basis. The chances for subsequent refertilization are explained according to statistics in the literature with patency rates of 70–90%. Acute complications consisting of bleeding and infections, usually negligible, rarely occur, but are mentioned. Possible connections between vasectomy and other diseases, e.g., arteriosclerosis or prostate cancer, discussed in the past and, again recently, are mentioned to the patient with reference to the relevant investigations. In cases of doubt, the physician’s explanation and personal interpretation may be helpful. The need for postoperative semen analysis is stressed. As with most surgical procedures, written consent signed by the patient is necessary and should be documented.

Special considerations are involved when vasectomies are performed on patients who are not able to consent to the procedure themselves. Due to Germany’s recent past, this is a particularly sensitive subject there. Various lobbies and the German Society of Medical Law (DGMR) have discussed this subject in publications, lectures, and workshops. In Germany, vasectomy policy for patients who are not able to consent to the procedure is regulated by law. Consent demands the authorization of a guardianship court. Vasectomy of minors is forbidden in Germany. Neither the underage patient nor his parents can consent to sterilization (Hiersche and Hiersche 1995).

5 Surgical Vasectomy Techniques

Vasectomy is a good example of how simple matters can be made complicated. What is to be achieved? The goal of the operation is to occlude the ducts reliably to prevent passage by spermatozoa, permanently or as long as the patient desires it. The following procedure has been established:

In the ambulatory patient, both spermatic cords are infiltrated with an anesthetic. Only in rare and exceptional cases is the intervention performed under general or regional anesthesia. The cords are digitally localized through the scrotal skin and, if necessary, local anesthesia is supplemented by deeper infiltration. After ascertaining the effectiveness of the anesthesia, the ejaculatory duct is clamped through the skin, using a small clamp, and the scrotal skin is incised over a distance of 0.5–1 cm. The vas is separated from the sheath and divided over two mosquito clamps. The vas is then dissected, and a piece of approximately 1 cm is excised and fixed in formalin. The vasal ends are ligated and electrocoagulated. The entrance wound is sutured with a single suture (Figs. 46.1 and 46.2). The identical procedure is performed on the contralateral side. The wounds are covered with two small dressings. After 1 h, the area is checked and the patient can be discharged to home care.

Fig. 46.1

Following a longitudinal incision of the scrotal skin along the vas deferens the vas is lifted by a small clamp

Fig. 46.2

Distal ligation of the vas deferens and cauterization of the proximal lumen

The following is important: The patient must be well-informed and not be afraid of the procedure. In dubious cases, premedication is highly effective. In sensitive patients, placement of a venous catheter is recommended. It should not be forgotten that even in such minor surgery emergency measures may become necessary. Acute complications are rare, but when they do occur, they are extremely irritating. Even minor bleeding can spread throughout the soft tissue, resulting in scrotal hematoma up to the size of a fist.

6 Technical Modifications

The technique described above, practiced and well-documented for over 30 years, represents a combination of several important features. The use of a special puncture device has obtained general acceptance as a “no scalpel” technique; the same is true for electrocoagulation of the cut edges of the vas deferens or the interposition of connective tissue (fascial interposition: FI). Labrecque et al. (2004) concluded in a systematic review that the “no scalpel” vasectomy is the safest surgical approach to the vas deferens and that a combination of FI and electrocoagulation yields the most effective occlusive results. Comparable data were reported by Cook et al. (2007a, 2007b) in two Cochrane Reviews: The “no scalpel” technique is associated with a lower rate of hematoma and infection and less postoperative pain compared to the conventional technique. Moreover, fascial interposition reduces the occurrence of vasectomy failures (Cook et al. 2014).

7 Effectiveness and Cost Efficiency

When correctly performed, vasectomy is among the safest contraceptive methods. With a pearl index of 0.1, vasectomy belongs to the safest contraceptive methods (Trussell et al. 2018). This makes vasectomy even more effective than tubal ligation (PI = 0.2–0.3). Failure is due to recanalization of the divided duct in up to 1.5% of cases (even possible in the form of late recanalization after two negative semen samples in 0.04–0.2% of patients), or to the extremely rare occurrence of a double vas or incomplete division of the duct. Failure rates increase with lack of experience, inferior operating techniques, and difficult anatomical circumstances. In Germany, as part of the health insurance modernization law, methods of sterilization such as vasectomy are not reimbursable. Therefore, the cost of such procedures must be borne by the patients themselves. When performed under local anesthesia, the costs usually amount to around 300–500€. (Deutscher Bundestag 2017).

Vasectomy is the most cost-efficient method of contraception (Nakhaee et al. 2002); thus, its implementation could achieve considerable cost savings in public health (Sonnenberg et al. 2004).

8 Complications

Acute postoperative complications must be distinguished from long-term complications. Hematoma of various degrees, epididymitis, or wound infections up to formation of an abscess occurs with a frequency of up to 1–6% (Alderman 1991; Schwingl and Guess 2000; Adams and Wald 2009). While this rate seems high, it should be remembered that vasectomy is a minor operation performed by many surgeons with only limited experience with this procedure. Its supposed harmlessness tempts some surgeons to perform it on an outpatient basis, quickly and inattentively. The price is necessarily an increased rate of acute complications. These lead to short-term absence from work of an average of 2.3 days (Randall and Marcuson 1985). Serious complications virtually never occur; deaths during or after vasectomy have not been reported, whereas in the USA 14 deaths/year are attributed to female sterilizations. Concerning costs, vasectomy is more economical than tubal ligation, with the short-term costs of tubal ligation about 3–4 times higher (Smith et al. 1985; Hendrix et al. 1999).

Long-term surgical complications include recanalization on the one hand and the development of sperm granuloma on the other hand. Recanalization rates are reported to be about 0–3%. The actual rate depends on the surgical technique used. Resection of larger sections of the vas, burying the ends of the ducts in different planes of tissue, and the use of fibrin glue or fulguration of the lumen are all useful methods for minimizing the rate of recanalization. The use of minimally invasive techniques can, on the one hand, increase the chance of later refertilization, but, on the other hand, it can also greatly increase the chance of recanalization by up to 50% (Goldstein 1983). The occurrence of sperm granuloma is likewise correlated with surgical procedures used and varies considerably. The data in the literature vary between 3% and 75%. In terms of refertilization chances, a sperm granuloma can be evaluated positively as it reduces pressure in the epididymis and epididymal tubule and thus reduces the risk of a “blow-out.” This is an intraoperative tubal rupture, requiring epididymovasostomy, which may be made impossible by the anatomical localization of the rupture.

It is important to explain acute complications to the patient and particularly to make him aware of the possibility of failure; he must be informed that, in individual cases, recanalization may occur even when postoperative semen analysis shows azoospermia on several occasions. If recanalization is to be completely excluded, the duct should be resected over several centimeters. Furthermore, polyorchidism and a duplex vas must be ruled out. For liability reasons, it is advisable to perform histological examinations of the resected parts of the duct to demonstrate the resection in complete tubal diameter.

9 Vasectomy and Long-Term Morbidity

Complaints of congestion, a feeling of obstruction or heaviness in the testis and epididymis, and pain of different degrees are occasionally described by the patient, but are usually temporary. Chronic epididymal pain is in all events rarely seen; its appearance is sparsely documented in the literature. Sperm antibodies in the serum can be found in up to 70% of those sterilized (Heidenreich et al. 1994; Adams and Wald 2009). Their presence is often associated with sperm granulomas. If refertilization is desired, we are not influenced by the presence of sperm antibodies nor by the titer, but perform refertilization in any case.

In the past, various diseases have been causally attributed to vasectomy. Based on monkey studies, in 1978 it was concluded that vasectomy could enhance arteriosclerosis. Several large-scale investigations involving over 10,000 men determined that vasectomized men bore no higher risk for arteriosclerosis, diabetes mellitus, or immunological diseases (Nieschlag 1987; Giovanucci et al. 1992). The risk of cardiovascular diseases after vasectomy is not increased in the long term, as Manson et al. reported in the “Physicians’ Health Study” in 1999. A few years ago, a possibly higher incidence of prostate carcinoma in vasectomized males was suggested by retrospective investigations (Giovanucci et al. 1993). Further research on this topic has since followed. A large observational study by Byrne et al. found no correlation between vasectomy and prostate cancer (Byrne et al. 2017). Davenport et al. found a marginally higher rate of prostate cancer in vasectomized patients (hazard ratio 1.05; 95% CI, 1.01–1.11) (Davenport et al. 2019). However, a causal explanation could not be identified. An obvious explanation would be the closer urologic follow-up and treatment of vasectomy patients; hence, these patients have a higher rate of prostate cancer screening and PSA determination.

10 Psychosexual Effects

The history of vasectomy has already shown that psychosexual effects associated with vasectomy need not always be negative. On the contrary, the fact that the problem of contraception has been responsibly resolved usually has a positive effect on a relationship (Weidner and Weissbach 1992). The fear of unwanted pregnancy may disappear and sexual enjoyment may increase (Vaughn 1979; Miltsch and Senn 1999; Bertero et al. 2005). Conversely, those men who are pressured into being vasectomized (e.g., vasectomy camps!), whose religion discourages or even forbids such procedures, and whose partners are opposed to it or who are not sufficiently informed may experience vasectomy as associated with increased conflicts and complications. Thus, the initial situation of the person, the expectations he places in vasectomy, and how well informed he is are key factors for success. Correct information, pre-surgical counseling, and postoperative care and attention are important. These measures can prevent fear concerning a loss of male identity and masculinity.

From the present state of knowledge, vasectomy does not promote a higher risk for the development of prostate carcinoma.

The long-term benefits and effectiveness of vasectomy continue to be discussed controversially (Jequier and Pryor 1998), even to the extent of spurious arguments that cryopreservation of sperm may replace refertilization or—even worse—replace information and counseling about vasectomy.

11 Refertilization

11.1 History of Refertilization Surgery

Isolated cases of vasovasostomy following accidental dissection of the vas deferens, mostly during hernia surgery, have been reported since the beginning of this century. After World War II, true refertilization surgery, namely vasovasostomy and epididymovasostomy, following deliberate ligation of the ducts became more frequent, and in 1948, O’Connor presented the first national survey on vasovasostomy. It is astonishing that at that early stage nationwide surveys were implemented to establish the indications, frequency, and success of refertilization surgery. In the USA, such surveys were repeated in 1973 (Derrick et al. 1973) and in 1979 (Wicklund and Alexander 1979).

In German-speaking countries, the following situation prevails (Engelmann et al. 1990): Along with the increase in vasectomies, there is a rising number of patients who wish to reverse the procedure. Of the many reasons, three concerns emerge. First, the higher divorce rate plays an essential role; the main reason for refertilization is divorce followed by remarriage or a new partnership. The second most frequent request comes from couples whose family planning had been completed by vasectomy, but who now have changed their minds or who have suffered the unexpected death of one of their children. The third reason is improved economic standing and the resulting possibility of being able to afford offspring.

Refertilization vasovasostomy has been performed for more than 40 years, but the technique has undergone major changes during that time. Initially, the macroscopic one-layer anastomosis technique, perhaps even with splinting of the small vas lumen, was applied. Increasing use of the operating microscope brought with it excellent postoperative results reported mainly by Silber (1977). This prompted the development of microscopic two-layer anastomosis without splints. Improved surgical results affected the mechanical patency of anastomosis, which must be considered the true control parameter of surgical quality. However, there is a discrepancy between surgical patency of the restored vas deferens and pregnancy rates, which are distinctly lower. Today, refertilization surgery is largely performed with optical devices, i.e., with loupe magnification or surgical microscopes. Patency rates of 90% are common and are achieved by many.

11.2 Current Demand and Frequency of Refertilization

The potential demand for refertilization surgery can be roughly extrapolated from the number of sterilization vasectomies performed, from the divorce rate and from other (secondary) parameters. It has been estimated to be 250,000–300,000 in the USA per year (Cos et al. 1983). In German-speaking countries, a survey taken in 1990 revealed that the vasectomy reversal rate was 3.5% and requests for reversal were twice as high (Engelmann et al. 1990). In Sweden, the refertilization rate was 0.5–5.4/100,000 residents (Ehn and Liljestrand 1997). In the USA, the refertilization rate has shown to be around 2% (Sharma et al. 2013).

11.3 Vasovasostomy

11.3.1 Indications, Counseling, Consent, and Costs

The typical patient desiring refertilization contacts his physician, usually his urologist, often the same one who performed the vasectomy. The indication is the patient’s request, which in turn arises from the arguments described above. As for other surgery, refertilization requires truthful counseling. Invasiveness is comparable to that of vasectomy, with the exception that vasovasostomy requires more difficult surgical techniques. For this reason, general anesthesia is recommended and hospitalization of 1–2 days should be planned. As a general rule, we estimate patency rates of 80%; pregnancy rates are lower, at 60%. If vasectomy was performed more than 5 years prior, we reduce these estimates by a further 20%. The surgeon’s experience with this operation (both positive and negative) should be considered. The possibility of a “blow-out” in the epididymis or even in the rete testis should be mentioned. This would then necessitate epididymovasostomy or can make surgery impossible for technical reasons.

In most countries, including Germany, expenses for surgical refertilization are not covered by insurers as a general rule. In some special cases, such as the death of a child with concomitant parental distress, or persistent pain due to sperm granuloma, exemptions are granted. In these cases, cost transfer agreements should be arranged preoperatively. According to Heidenreich et al. (2000) and Schroeder-Printzen et al. (2003), the expenses per childbirth after vasovasostomy account for only a fifth of those after MEAS/TESE and ICSI.

11.3.2 Vasovasostomy Technique

The patient is placed in supine position; usually, a scrotal incision bilaterally or in the median of the raphe scroti is chosen. Less frequently an inguinal or infrapubic approach is used. Usually, the surgeon operates while seated, avoiding interference with the operating table pillar; the operating microscope should be placed before the patient is positioned. Operating time of 2–3 h should be anticipated; for this reason, an indwelling catheter is sometimes inserted. Differing techniques have been described: initially macroscopic techniques with or without splinting of the lumen, followed by microsurgical techniques with loupe magnification or the operating microscope.

Macrosurgical techniques. Initially, surgical techniques without magnification and relatively coarse suturing material of 4-0 or 5-0 were used. Results were relatively poor because of complications such as sperm leakage and bad anatomical adaptation of the lumen. The advantages lay in simple and rapid performance of surgery and for these reasons some surgeons prefer macroscopic techniques even today. As late as 1999, Feber and Ruiz saw advantages in the shorter operating time, reduced costs, and the need for fewer surgical skills (despite a patency rate of 87% and pregnancy rate of 50%).

Silber (1977) made a great contribution when he described the anatomical peculiarities of the severed vas, with sizes differing between the dilated side proximal to the testis and the non-dilated side, and demonstrated that good operating results were best achieved with anatomically correct adaptation of the lumina.

Microsurgical techniques. In our view, using solely macrosurgical techniques for refertilization is obsolete. While they may be applied for vas anastomosis, although inferior in patency, patent epididymovasostomy is achieved purely by coincidence or not at all. Whether loupes with a two to eightfold magnification or an operating microscope with the advantage of variable magnification and increased field of vision is used depends on the personal preference of the surgeon, even though the best patency results are achieved with the operating microscope.

In the event of scrotal vasectomy, we dissect the ends of the vas deferens via a lateral scrotal incision. The scarred ends of the vas are excised. Patency of the proximal vas deferens is determined after insertion of a small flexible Teflon cannula by careful injection of saline solution. The fluid emerging from the distal vas end is assessed in the operating room under the operating microscope. If necessary, the epididymis is digitally massaged to obtain fluid. If no fluid is present, a “blow-out” must be assumed and the epididymis is examined. In such case, we perform epididymovasostomy. Typically, whitish or yellowish fluid emerges containing viable or dead sperm. In this event, surgery is continued as vasovasostomy.

The best anatomical adaptation of the lumen is achieved using a two-layer technique by which mucosal approximation is accomplished with six interrupted sutures using 9-0 or 10-0 suturing material. Special vasovasostomy needles that are doubly armed and whose degree of curvature is adapted to the size of the vas have proven useful. The vas ends can be aligned by using an approximator, facilitating placement of sutures. First, the inner mucosal layer is sutured and should ensure a leak-proof connection. Precise positioning of the sutures will ensure optimal patency rates; Goldstein et al. (1998) were able to achieve rates of 99.5% using their “microdot marking technique” and eight mucosa stitches. The mechanical strength of the anastomosis is achieved through the second muscular layer, also using 9-0 or 10-0 sutures, however, with a single-sided and spatulated cutting needle. The short scrotal wound is closed in two layers. A well-fitting dressing supporting the scrotum is preferred by most patients and is left in place for a few days (Figs. 46.3, 46.4, 46.5, 46.6, 46.7, 46.8, 46.9, and 46.10).

Fig. 46.3

Clean cuts of the two ends of the vas and careful bipolar hemostasis

Fig. 46.4

Tension-free adaptation of the two ends of the vas by use of an approximator. Anastomosis of the mucosa is performed with nylon 10-0 double sutures

Fig. 46.5

Adaptation of the muscle layer of the vas by nylon 9-0 sutures

Fig. 46.6

A tubule is prepared and incised longitudinally

Fig. 46.7

Adaptation of the muscle layer of the vas and the tunica of the epididymis at the posterior circumference by nylon 9-0 single sutures

Fig. 46.8

Anastomosis between the tubule and the mucosa of the vas by nylon 10-0 doubly armed sutures

Fig. 46.9

Adaptation of the muscle layer of the vas and the tunica of the epididymis. Interrupted sutures at the anterior circumference with nylon 9-0 sutures

Fig. 46.10

Ligation of the epididymal tunic

Robot-Assisted Technique. With the progression of operative procedures in the direction of robot-assisted operations, the vasovasostomy has also found its place in the array of robotic interventions. The postulated benefits include better overview, redundancy of tremor, and lower rates of fatigue of the surgeon. Marshall et al. described similar patency rates at 88% compared to traditional microscopic methods, however higher costs and longer operation times (Marshall et al. 2017; Gözen et al. 2020).

11.3.3 Results of Vasovasostomy

Results of vasovasostomy are quite variable, depending on whether one reads reports by individual authors or results from surveys. Similar variations are seen depending on whether patency rates are compared, describing surgical success, or pregnancy rates, which is the factor that most interests patients. Individual authors report patency rates of 100% and pregnancy rates slightly below. Nationwide surveys report average results more accurately: In 1948, O’Connor had a cumulative success rate of 38–40%; in 1973, Derrick calculated a patency rate of 38% and pregnancy rate of 11–26%. In 1990, Deindl found a cumulative patency rate of 73% in German-speaking Europe and a pregnancy rate of 47%. Centers with a high operating frequency, with skillful techniques and thin sutures, achieve better results. The time period between sterilization vasectomy and refertilization plays a role; even if these limits are arbitrary, the best results can be expected within the first 2 years, while 10 years after vasectomy the chances for refertilization are markedly reduced (Belker et al. 1991).

11.3.4 Complications Following Vasovasostomy

The rate of acute complications is comparable with that for vasectomy or scrotal exploration, but for different reasons. Specific long-term complications result from re-obstruction after initial patency. A 3% chance of such obstruction because of scar tissue formation must be expected. If patients remain azoospermic following refertilization, it is probably due to surgical failure or a more distal “blow-out” that had not been verified at the time of surgery. In these cases, re-operation is indicated. Oligozoospermia can be the result of partial obstruction—in such cases re-operation may be successful—or due to limited testicular production. If vasectomy dates back more than 5 years, we inform all patients about the option of concomitant cryo-TESE.

11.4 Epididymovasostomy

If the epididymal tubule is damaged by a “blow-out,” epididymovasostomy must be carried out. For technical reasons, this procedure is only successful at the corpus or the cauda epididymidis. In the caput region, the diameter of the tubule is too small to accomplish fully patent anastomosis. Epididymovasostomy urgently requires microsurgical techniques, preferably using an operating microscope. We prefer to employ the end-to-side technique; others prefer side-to-side. After excising an oval window of the epididymal tunica, a single tubule containing sperm is chosen and is opened longitudinally. By placing four interrupted 11-0 sutures, anastomosis of the tubule with the mucosa of the vas deferens is completed. The anastomosis is then finished by means of further interrupted sutures between the epididymal tunica and the muscularis of the vas (Figs.  46.6, 46.7, 46.8, 46.9, and 46.10).

End-to-end anastomosis is more difficult. The patency rates of microsurgical tubular vasectomy are between 39 and 100%, including single-case reports. The average patency rate is 45% and pregnancy rates are 18% (Deindl 1990).

11.5 Future Developments in Surgical Refertilization

Refertilization surgery will become more common in future along with contraceptive vasectomy. The good results achieved have reached a stable level and have not seen any further improvements during the past 10 years. Microsurgical training must continue to be emphasized for the surgeons involved.

The intraoperative harvesting of sperm which—cryopreserved—can be made available for later ICSI in case of a non-patent anastomosis (especially in the case of epididymovasostomy) should be discussed with patients even during the initial consultation (Djerassi and Leibo 1994). For those who wish to have children after vasectomy, surgical refertilization remains the method of choice from the standpoint of costs and chances for success.

We do not believe in abstaining from refertilization surgery and instead first harvesting testicular sperm by TESE or—even worse—epididymally for use with ICSI. This method can by no means measure up to “conventional” refertilization surgery—either in terms of pregnancies achieved, the cost and effort involved, or with regard to complication rates.

12 Future Development of Vasectomy

Both from a demographic and political point of view, as well as for the individual selecting a contraceptive method, vasectomy represents a highly safe option that can be performed rapidly at low cost, with few inconveniences for the patient. Without doubt, it is superior to the equivalent female operation. It is hoped that changes in the understanding of the male role and better knowledge will bring about wider acceptance of vasectomy, especially in view of the fact that it is no longer to be considered final as in a high percentage of patients refertilization can be achieved by vasectomy reversal.

Key Points

• Vasectomy.

• Sterilization.

• Contraception.

• Vasovasostomy.