Sidney Glina

Faculdade de Medicina do ABC

Instituto H. Ellis

Editor-in-Chief of the International Brazilian Journal of

Urology (www.intbrazjurol.com.br)

glinas@terra.com.br

Vasectomy reversal: is there still a role?

Conflict of Interest:

In the last 2 years I have been:

- Speaker for Besins, Lilly, Aché,

Eurofarma

- Member of Advisory Board of Aché,

Besins, EMS and Lilly

Vasectomy as a contraceptive method

• Brasil: 2.1% of men1

• São Paulo: 6.1% of men1

• USA: 526 000 vasectomies in 2002 (10/10000

men between 25 and 49 y.o.)2

1. Vieira EM, Badiani R, Fabbro AL, Rodrigues

Jr. AL. Rev Saúde Pública 2002; 36:263-70

2. Barone MA, Hutchinson PL, Johnson CH,

Hsia J, Wheeler J. J Urol. 2007; 177:1205-6.

Fertility after vasectomy

Vasectomy Reversal

Epidydimal sperm retrieval and ICSI

USA:Reversals in 2 to 6% of vasectomised men 1 (almost 30000 reversals/year2)

UK: 40 thousand vasectomies/year and 2400 reversals/year 3

Netherland: 35000 vasectomies in 2004 and 2.6% of them went through reversal 4

Vasectomised men want to be father again?

1. Assisted reproductive technology success rates. National summary and fertility clinic reports. CDC Reproductive Health Information Source

2. Schwarzer et al., Current Status of Vasectomy Reversal, Nature Reviews, 10:195, 2013 3. McVicar CM, O'Neill DA, McClure N, Clements B, McCullough S, Lewis SE Hum Reprod. 2005;20(10): 4. Hepp SM, Meuleman EJ. 2795-800. Ned Tijdschr Geneeskd. 2006; 150:611-4

Reasons for vasectomy

reversal

» New marriage 78,5 %

» Improvement of social economical conditions 8,6 %

» Regret (vasectomy w/out children) 4,3 %

» Desire for a child of other sex 3,2 %

» Child death 2,1 %

» Religious issue 1,0 %

Glina S e Dultra A – 2007

Dr. Gynecologist

ICSI

the

best!

There is no

result after

more than 2

years of

vasectomy!

Time since vasectomy and pregnancy rates

Vasectomy reversal

Belker et al., Results of the 1469 microsurgical vasectomy reversals by the Vasovasostomy

Study Group. J. Urol, 145:505, 1991.

Patency (%) Pregnancy (%)

Vasectomy reversal 747 cases

Bolduc S, Fischer MA, Deceuninck G, Thabet M.

Can Urol Assoc J. 2007;1:388-94.

Pa

ten

cy r

ate

(%)

Pre

ga

na

nc

y r

ate

(%)

Years of vasectomy Years of vasectomy

Dr. Gynecologist

ICSI is

the

best!

You are too

old to get

pregnant after

vasectomy

reversal

Silber et al (N=4010, single center)1

Gerrard et al (N=294, multicenter)2

Hinz et al (N=212, single center)3

Maternal age and pregnancy rates

Vasectomy reversal

Maternal Age <30 30- <35 35- <40 >40

Pregnancy

(%)

92 87 77 54

Maternal

Age

<29 30-39 >40

Pregnancy

(%)

67 78 42

Maternal

Age

20-24 25-29 30-34 35-39 >40

Pregnancy

(%)

67 52 57 54 14

1 Silber, S., et al. Microscopic Vasectomy Reversal, J Androl, 25(6):845, 2004.

2 Gerrard, E., et al. Effect of female partner age on pregnancy rates after vasectomy reversal, Fertil Steril, 87(6):1340, 2007

3 Hinz, S., et al. Fertility Rates following vasectomy reversal: importance of age of the female partner, Urol Int, 81:416, 2008.

Dr. Urologist

Reversal

is the

best!

There are risk

to the partner!

Risks to Partner with IVF/ICSI Ovarian Hyper-stimulation Syndrome

(OHSS)

• High dose gonadotropins → OHSS1

• Severe form ~1%2

• Potentially fatal

• Due to massive estrogen production in mother → tense ascites with hydrothorax

• If not treated immediately → kidney failure, clotting disorders, PE and liver dysfunction

5* 1. Shmorgan D et al., J Obst Gyn Can, 33:1156-1162, 2011. 2. Alper MM et al., J Exp Clin Assist Reprod, 6:3-6, 2009

Dr. Urologist

Reversal

is the

best!

ICSI is too

expensive!

Fertility after vasectomy:

analysis of cost

$ ICSI $ Vaso-vaso

Pavlovich & Schlegel 72.521(MESA) 25.475

Kolettis & Thomas 51.024 (MESA) 31.099

Donovan e cols. 35.579 (MESA) 14.892

Deck & Berger 103.940 (TESA) 28.530*

Meng e cols. 39.506 (TESA) 38.983**

Lee e cols. 55.317(MESA) 21.304

53.356 (TESE)

Cost of baby at home

*Women > 37 years old (75% e 17%) **Without indirect costs

Lee et al - Urol Clin N Am 2008; 35:289:301

Dr. Urologist

Reversal

is the best

Epididymal

punction can

destroy the

epididymus

PESA effect on the epididymus

• 50 rats with vasectomy

•10 animals/group, 1 to 5 PESAs

• Sp + in all PESAs

• All animals showed histological alterations (fibrosis) after

2nd PESA

Saade RD, Neves PA, Glina S, D'Ancona CA, Dambros M, Lúcio MA

J Urol. 2008 ;179:381-4

Low risk, outpatient procedure

mean OR time- 110 minutes

complications- 0.3% hematoma/ 0.8% infection

Anesthesia- local or general

Vasectomy Reversal

Schwarzer et al., Current Status of Vasectomy Reversal, Nature Reviews, 10:195, 2013

• Spontaneous pregnancy

• Partner saved of any intervention

Consenso Infertilidade SBU - Int Braz J Urol, 2003;29(supl 5):35-8

Benefits of vasectomy

reversal

• Anesthetic risk for the patient

• Worse results with longer time since

vasectomy

• Depends on surgeon skills

• Need for contraception

Consenso Infertilidade SBU - Int Braz J Urol, 2003;29(supl 5):35-8

Disadvantadges of

vasectomy reversal

• Pregnacy achievement more rapid?

• No need for contraception.

Consenso Infertilidade SBU

Int Braz J Urol, 2003;29(supl 5):35-8

Benefits of PESA(MESA)/ICSI

• Ovarian Hyperstimulation syndrome

• High cost

• Multiple pregnancy

• Can impair a futures vasectomy reversal

Consenso Infertilidade SBU

Int Braz J Urol, 2003;29(supl 5):35-8

Disadvantadges of PESA(MESA)/ICSI

American Society of Reproductive Medicine*

Optimal treatment would allow the couple to conceive naturally

“Vasectomy reversal has been shown to be more cost effective than sperm retrieval and assisted reproduction”

Practice Committee Recommendations

*American Society of Reproductive Medicine, Practice Committee, Fert Steril,

90(3):213, 2008.

“Microsurgical reconstruction, in cases

that are feasible, is a more cost-

effective approach and typically

yields better pregnancy rates than

sperm retrieval combined with ICSI”

Ramasamy and Schlegel. Vasectomy and vasectomy

reversal. Ind J Urol, 27(1): 92, 2011.