Repeat Vasovasostomy vs MESA/TESE with ICSI in Patients with Failed Vasovasostomy

Soo Woong Kim, M.D.Department of Urology, Seoul National University

College of Medicine, Seoul, Korea

Introductions

Vasovasostomy - highly successful procedure:

patency rate; 84-90%, pregnancy rate; 48-52%

- substantial failure rate in achieving patency

Failed Vasovasostomy - repeat vasectomy reversal: worthwhile procedure vasovasostomy or

epididymovasostomy

- other options: MESA or TESE in conjunction with ICSI/IVF

Repeat VR vs ICSI 1. Treatment Outcome repeat vasectomy reversal

References Patency rate(%) Pregnancy rate(%)

Belker et al. 75.1(148/197) 43.3(52/120)Fox 63.6(14/20) 27.3(6/22)Donovan et al. 77.8(14/18) 44.4(8/18)Matthews et al. 67.2(43/64) 26.6(17/64)Hernandez & Sabanegh 78.8(26/33) 30.8(8/26)Our series 91.9(57/62) 57.1(24/42)

Overall 76.6(302/394) 39.4(115/292)

MESA or TESE in conjunction with ICSI

- obstructive azoospermia: failed VR, irreparable genital tract obstruction, CAVD, etc- pregnancy rate/1 cycle of ICSI: 56%(52-60)- delivery rate/1 cycle of ICSI: 29%(14-35)

- pregnancy rate in repeat VR: 39.4%(26.6-57.1) normal pregnancies in all cases- in our series: pregnancy rate; 57.1%(24/42) delivery rate; 52.4%(22/42)

2. Costs

in other countries- epididymovasostomy vs ICSI/newborn: 31,000$ vs 51,000$ Kolettis & Thomas, 1997- vasovasostomy vs ICSI/newborn: 5,400DM vs 28,800DM Heidenreich et al., 2000- repeat VR vs ICSI/newborn: 14,900$ vs 51,000$ Donovan et al., 1998

in Korea

- vasovasostomy vs ICSI: 약 200 만원 vs 300 만원

3. Safety- possible transmission of foreign DNA Chane et al., 2000- complications of ART: hyperovulation, oocyte retrieval, ET Schenker & Ezra, 1994- multiple birth

- application of ICSI in patent not pregnant patients s/p VR

- high patency rate: 76.6%(63.6-91.9)

- avoidance of repeat MESA or TESE

4. Development of ICSI

Vasovasostomy vs Epididymovasostomy 1. Causes of Failed Vasovasostomyobstruction of the anastomotic site

- anastomosis of the scarred ends of the vas- cauterization on the surface of the transected vasal end- anastomotic tension

secondary epididymal obstruction

- ‘epididymal blowout’: Silber, 1979

- vasal obstruction pressure rupture of epididymal duct

We repeated only vasovasostomy following failed

vasovasostomy regardless of the findings in the

intravasal fluid.

- when sperm are absent in the vasal fluid

- surgical principle: EV d/t 2o epididymal obstruction

- our opinion: the incidence of epididymal blowout is much lower than that to be thought in cases of failed VR cases

2. Controversies

- vasovasostomy in cases of bilateral intravasal azoospermia: patency rate; 60.2%(50/83), pregnancy rate; 30.8%(20/65)

- incidence of intravasal azoospermia is related with duration of obstruction; 9% 2 years, 27% > 15 years

- repeat VR in failed vasovasostomy: Royle & Hendry, 1985 obstruction of anastomotic site; 52.2%(12/23)

secondary epididymal obstruction; 17.4%(4/23)

- analyses of repeat VR in failed vasovasostomy:

3. Rationale of VV in Failed VV

References % requiring at

least 1 EV

% patency

in group I

% patency in

group II

overall

patency rate

% pregnancy

in group I

% pregnancy

in group II

overall

pregnancy rate

Belker et al 33.0

(65/197)

82.9

(131/158)

43.6

(17/39)

75.1

(148/197)

51.6

(48/93)

14.8

(4/27)

43.3

(52/120)

Fox 0

(0/22)

63.6

(14/20)

- 63.6

(14/20)

27.3

(6/22)

- 27.3

(6/22)

Donovan et al 55.6

(10/18)

84.6

(11/13)

60.0

(3/5)

77.8

(14/18)

46.2

(6/13)

40.0

(2/5)

44.4

(8/18)

Matthews et al 56.3

(36/64)

86.5

(32/37)

40.7

(11/27)

67.2

(43/64)

35.1

(13/37)

14.8

(4/27)

26.6

(17/64)

Hernandez &

Sabanegh

73.2

(30/41)

88 (not

available)

69 (not

available)

79 (not

available)

46 (not

available)

15 (not

available)

31 (not

available)

Our series 3.2

2/62

91.9

(57/62)

- 91.9

(57/62)

57.1

(24/42)

- 57.1

(24/42)

epididymovasostomy

- microsurgical single tubular anastomosis Silber, 1987 - difficult procedure requiring considerable microsurgical skill - patency rate; 70%(58-85) pregnancy rate; 31%(27-42)

our series

- microsurgical VV in failed VV regardless of detection of sperm in the intravasal fluid during operation

- patency rate; 91.9%(57/62) pregnancy rate; 57.1(24/42)

% patency % pregnancy

bilateral sperm present 95.7(22/23) 60.0(9/15)unilateral sperm present 100(10/10) 57.1(4/7)bilateral sperm absent 86.2(25/29) 55.0(11/20)

overall 91.9(57/62) 57.1(24.42)

considerations - anastomotic tension during the first vasovasostomy: mobilization of a sufficient length - local anesthesia ?

- increased rate of anastomosis in convoluted vas: accurate anastomosis – modified one-layer

VV ?

- guideline for EV in failed VV: 5 of 62 cases of our series; persistent azoospermia

s/p VV 4 of these 5 cases; bilat. absence of sperm in the vasal fluid 4 of 62 cases(6.5%); suspicious

epididymal obstruction

- mean interval to pregnancy: 11.7 mos.(2-48) pregnancy within 12 mos.; 18/24(75%)

- whether previous VV has been done with adequate skills ?

Conclusions - Even in the era of ICSI, repeat vasectomy reversal should

be given favorable considerations in cases with failed

vasovasostomy.

- We recommend that microsurgical vasovasostomy should

be performed preferentially in repeat vasectomy reversal

cases.

- Further studies are needed to establish the guideline for epid

idymovasostomy in repeat vasectomy reversal cases.