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.
Fox
Donovan et al.
Matthews et al.
Hernandez & Sabanegh
Our series
75.1(148/197)
63.6(14/20)
77.8(14/18)
67.2(43/64)
78.8(26/33)
91.9(57/62)
43.3(52/120)
27.3(6/22)
44.4(8/18)
26.6(17/64)
30.8(8/26)
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 200만원 vs 300만원
3. Safety
- possible transmission of foreign DNA
Chane et al., 2000
- complications of ART: hyperovulation, oocyte retrieval, ET
Schenker & Ezra, 1994
- multiple birth
4. Development of ICSI
- 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
Vasovasostomy vs Epididymovasostomy
1. Causes of Failed Vasovasostomy
obstruction 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
2. Controversies
- when sperm are absent in the vasal fluid
o
- surgical principle: EV d/t 2 epididymal obstruction
- our opinion: the incidence of epididymal blowout is much
lower than that to be thought in cases of failed VR cases
We repeated only vasovasostomy following failed
vasovasostomy regardless of the findings in the
intravasal fluid.
3. Rationale of VV in Failed VV
- 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:
References
Belker et al
Fox
Donovan et al
Matthews et al
Hernandez &
% requiring at
% patency
% patency in
overall
% pregnancy
% pregnancy
overall
least 1 EV
in group I
group II
patency rate
in group I
in group II
pregnancy rate
33.0
82.9
43.6
75.1
51.6
14.8
43.3
(65/197)
(131/158)
(17/39)
(148/197)
(48/93)
(4/27)
(52/120)
0
63.6
-
63.6
27.3
-
27.3
(0/22)
(14/20)
(14/20)
(6/22)
55.6
84.6
60.0
77.8
46.2
40.0
44.4
(10/18)
(11/13)
(3/5)
(14/18)
(6/13)
(2/5)
(8/18)
56.3
86.5
40.7
67.2
35.1
14.8
26.6
(36/64)
(32/37)
(11/27)
(43/64)
(13/37)
(4/27)
(17/64)
73.2
(6/22)
88 (not
69 (not
79 (not
46 (not
15 (not
31 (not
Sabanegh
(30/41)
available)
available)
available)
available)
available)
available)
Our series
3.2
91.9
-
91.9
57.1
-
57.1
2/62
(57/62)
(57/62)
(24/42)
(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
unilateral sperm present
bilateral sperm absent
95.7(22/23)
100(10/10)
86.2(25/29)
60.0(9/15)
57.1(4/7)
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
epididymovasostomy in repeat vasectomy reversal cases.