Background: A retrospective review was made of patients who received vasectomy reversal from 1989 to 1998 at Chang Gung Memorial Hospital (CGMH) in Linkou, Taiwan. The patency rate and partner pregnancy rates were also analyzed.
Methods: Seventy patients underwent a vasovasostomy at CGMH from 1989 to 1998. Postoperative semen analysis and achievement of pregnancy in a partner were examined. Various preoperative factors were also examined and analyzed.
Results: Patients ranged from 30 to 58 (average, 40.8±6.5) years old. The most common reason for requesting a vasovasostomy was divorce (42.3%). The patency rate was 85.7% (36/42), and the pregnancy rate was 40.6% (13/32). However, if patients receiving a vasovasostomy for reasons other than to achieve pregnancy (i.e., pain, erectile dysfunction, or infertility of the wife) were excluded, the pregnancy rate reached 50.0% (13/26). Three patients received a second vasovasostomy; patency was noted in 2, and pregnancy was achieved in the partner of 1. Of the 5 patients receiving a vasovasostomy due to post-vasectomy pain syndrome, 3 felt that their condition had improved.
Conclusion: The patency and pregnancy rates of vasovasostomies in CGMH were 85.7% and 50.0%, respectively. Repeat surgery could be considered an effective means of restoring fertility if an initial vasovasostomy failed. Moreover, a vasovasostomy appeared to be an effective means of treating post-vasectomy pain syndrome.
(Chang Gung Med J 2002;25:453-7)

Key words: vasovasostomy, vasectomy reversal, patency rate, pregnancy rate.

A vasectomy is a safe and effective means of permanent contraception employed by nearly 7% of all married couples and performed on approximately 500,000 men annually in the US. Surveys suggest that 2% to 6% of all vasectomized men ultimately seek reversal, and a vasovasostomy is the most-common method used.(1)
Quinby and O崟onor performed the first vasovasostomy in 1915, while O崟onor reported the first one in 1948.(2) Macroscopic vasovasostomy with and without loupe magnification was extensively used between 1948 and 1977.(2,3-10) Although several authors still advocate use of the macroscopic technique,(8,9,11-17) a literature review suggests that superior results are obtained when performing a microscopic rather than a macroscopic or loupe magnification vasovasostomy.(10)
This study reports on 70 patients receiving microsurgical vasectomy reversal at CGMH from 1989 to 1998. Various preoperative factors and postoperative results are examined.

METHODS

Seventy consecutive vasectomy reversals performed at CGMH from 1989 to 1998 were retrospectively reviewed. The chart records of 6 patients were lost, and only 64 patients could be followed-up. Various preoperative factors, including the age when the vasovasostomy was performed, the duration between vasectomy and vasovasostomy, and the reason for seeking a vasovasostomy, were examined. A modified 1- or 2-layer microsurgical vasovasostomy was performed in all patients using 9-0 or 10-0 nylon sutures under microscopic magnification.
Patency was defined as the presence of sperm in the follow-up semen analysis. The pregnancy rate of partners was also calculated. Statistical analysis of the comparison of the patency and pregnancy rates based on the obstruction interval was performed using Chi-squared test. A value of p<0.05 was considered statistically significant.

RESULTS

Ages of the patients ranged from 30 to 58 years, with a mean age of 40.8±6.5 years. The most common reason for seeking a vasovasostomy was divorce in 22 (42.3%) patients. Other reasons included the desire to have more children (12), the loss of a son or daughter (7), the desire to have a boy (5), post-vasectomy pain syndrome (5), and erectile dysfunction after vasectomy (1) (Table 1). The obstruction interval ranged from 4 months to 25 years, with a mean of 7.8±5.0 years.
Among all patients, 42 had postoperative semen analyses, and sperm was found in the semen of 36 (85.7%). Thirty-two patients could be tracked in terms of whether or not they had gotten a partner pregnant; 13 couples achieved conception, and the pregnancy rate was 40.6%. Notably, the pregnancy rate reached 50.0% (13/26) if patients who received a vasovasostomy for reasons other than to achieve pregnancy (3 for pain and 1 for erectile dysfunction) and patients whose wives were infertile (2) were excluded.
When patients were grouped based on the duration of obstruction of < 8 years and ?8 years, the patency rates were 86.4% and 85.0%, respectively (p=0.899). In addition, the pregnancy rates were 57.1% and 41.7%, respectively (p=0.431) (Table 2).
Three patients received a second vasovasostomy; sperm in the semen after the operation was noted in 2, and a pregnant partner was achieved by 1. Five patients received a vasovasostomy for post-vasectomy pain syndrome; 1 was lost to follow-up, and 3 of the remaining ones felt that their symptoms had improved.

DISCUSSION

Vasovasostomies have become popular in Taiwan in recent years owing to changes in marital concepts. The most common reason for a vasovasostomy in our study, similar to that of a Western study,(18) was divorce and the desire to have children with a new partner. Although the desire to have more children, particularly a boy (32.7%), with the same partner was not noted in the Western study, this was found in an Eastern study(19) (Table 1).
Several factors appear to determine the success of a vasovasostomy. The pregnancy rate after vasectomy reversal is inversely related to the duration of the obstructive interval. Silber indicated that men with obstructive intervals of 5 years or less had a high likelihood of being fertile.(2) Based on Belker掇 study, new obstructive interval guidelines may be useful when advising patients about the likelihood of a successful vasectomy reversal.(18) Table 3 summarizes the results of other studies.(18-23) In this study, the overall patency and pregnancy rates were 85.7% and 50.0%, respectively. The pregnancy rate seemed to decrease with duration of obstruction although it was statistically insignificant, while the patency rate did not appear to obviously change. This could be due to the small number of cases in our study.
Of the patients receiving vasovasostomies for post-vasectomy pain syndrome, 75% (3/4) felt that their pain had been relieved. This finding corresponds to that of Stanley et al.,(24) which reported 27 of 32 patients noting improvement.
Three patients received a second vasovasostomy. Sperm in the semen was noted in 2 patients, and conception was noted in 1. Table 4 summarizes the results of other studies.(18,19,25,26)
Some patients remain azoospermic even after a repeat vasovasostomy. Microscopic epididymal sperm aspiration combined with intracytoplasmic sperm injection is indicated for these patients and has a remarkable success rate for men with problems of obstructive azoospermia.(27) This technique is considered an adjuvant for patients with failed repeat vasectomy reversal.

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From the Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung Memorial Hospital, Taipei.
Received: Nov. 23, 2001; Accepted: Apr. 9, 2002
Address for reprints: Dr. Ming Li Hsieh, Division of Urology, Department of Surgery, Chang Gung Memorial Hospital. 5, Fu-Shing Street, Kweishan, Taoyuan 333, Taiwan, R.O.C. Tel.: 886-3-3281200 ext. 2137; Fax: 886-3-3274541; E-mail: mlhshmcs@ms19.hinet.net