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Vasectomy is a very common operation and has been accepted as a method of family planning by ≈ 42 million couples worldwide. While it is usually a well-tolerated and highly effective form of birth control, it has a risk of significant morbidity in ≈ 1% of patients [1]. One particularly troubling complication after vasectomy is chronic testicular pain, which has been defined as intermittent or constant, unilateral or bilateral testicular pain for ≥ 3 months. The pain is intense enough to interfere with the patient’s daily activities and prompts him to seek medical attention [2]. The definition of chronic testicular pain after vasectomy has developed with time, as have the names of this syndrome. Various terms have been applied to this condition, including postvasectomy orchalgia, congestive epididymitis, and chronic testicular pain. Currently the syndrome is generally termed postvasectomy pain syndrome (PVPS) [3]. In this article we review the salient diagnostic and therapeutic features of this vexing medical problem.

OBJECTIVES To investigate the use of a newly designed stent in the reconstruction of the vas deferens. MATERIALS AND METHODS In 26 New Zealand White rabbits, 13 conventional one-layer microscopic reconstructions were compared with 13 stented reconstructions of the vas deferens. The newly designed nonabsorbable polymeric stent was shaped to facilitate the rejoining of the two loose ends of the vas deferens, using a central ridge to prevent migration. Semen was collected before and after surgery, using an artificial vaginal system (26 samples before and 115 after surgery). The individual and average total sperm count, motility and progressive motile sperm density (PMSD), were compared after surgery for both groups. After the final semen analysis, rabbits were killed and patency was assessed histologically at the site of the anastomosis. RESULTS After an initial decline the mean total sperm count increased in both groups. The increase was significantly larger (P = 0.05) in the stented rabbits. The mean motility and PMSD showed no significant differences between both groups (P = 0.11 and 0.71, respectively). Histological examination of the anastomosed area showed partial obstruction (>50% narrowing of the original lumen) in five of the 13 conventionally treated rabbits, with no strictures in the stented group. Despite the narrowing in the conventional group the patency rates were not affected. The mean (range) operating time for the conventional and stented groups was 132 (99–168) and 98 (62–113) min, respectively (P

OBJECTIVE To investigate the current incidence of vasectomy reversal procedures, the techniques used and which practitioners use them. PATIENTS AND METHODS Using a questionnaire, 130 general surgeons and urologists practising in Merseyside and North Wales were surveyed. RESULTS The response rate was 74%, with 24 urological surgeons and 14 general surgeons undertaking vasectomy reversal. Annually, urological surgeons carried out significantly more procedures than did general surgeons, at 8.5 and 5.3 (P = 0.029), respectively. They were also more likely to use double-layer closure and microsurgical techniques, whilst significantly less likely to use stents. Urologists reported significantly greater patency rates, at 76% and 52% (P = 0.017), respectively, with no significant differences in subsequent pregnancy rates (30% vs 25%). Only one practitioner checked tubal patency in the female partner before vasectomy reversal. CONCLUSIONS The use of vasectomy reversal is a cost-effective treatment for men wanting paternity after vasectomy. The technique used by the clinician and proper audit of the results require close attention; it would also appear to be obvious that all the partners of men seeking a vasectomy reversal should have their fertility status established before reversal, something that is clearly not done at present.

Objectives To examine trends in vasectomy and vasovasostomy, and the surgical complications and factors associated with reversal after vasectomy, and paternity after vasovasostomy. Patients and methods Procedure rates were estimated from 1980 to 1996 in the population of Western Australia. Linked hospital morbidity records were used in the follow-up of men after vasectomy to estimate the risks of complications and reversals. Records of vasovasostomies were linked to the paternity field on birth registrations. Independent effects of the study factors were examined using Cox regression. Results There was little net change in vasectomy rates, whereas vasovasostomy rates increased in men aged 30–49 years. Risks of surgical complications were low and decreased for vasovasostomy. At 12–15 years after vasectomy, the risk of reversal levelled at 2.4% in the total cohort and at 11.1% in men aged 20–24 years. The risk of vasovasostomy was 69% greater after vasectomy performed in 1994–96 than in 1980–84 (P = 0.011). The factors strongly associated with reversal were age

Objective To determine, in failed vasectomy reversal, the usefulness of a revised anastomosis using microsurgery in achieving sperm in the ejaculate and fertility, and to relate the outcome to the site of the anastomosis, length of time from vasectomy, and presence or absence of sperm in the vas at surgery. Patients and methods In a series of 28 patients with confirmed anastomotic obstruction undergoing vasectomy reversal (over a 10-year period), a microsurgical technique using an oblique end-to-end two-layer interrupted anastomosis with 10/0 Nylon was used to establish vasal continuity. Subsequent seminal analysis at 3–6 months and ensuing paternity were related to several variables. The results were compared with those obtained after 137 cases of primary microsurgical vasovasostomy. Results Sperm was restored to the ejaculate in 16 (57%) of the patients and successful fertilization was reported in nine (32%). The interval between vasectomy and reversal surgery was relevant to the outcome, with four out of four men having sperm in the ejaculate within 5 years and three achieving paternity. However, the fertility rate was still moderate after an interval of 6–10 years (two of six) and at > 10 years (four of 18). The presence of sperm in the ejaculate was related to whether or not sperm were found in the testicular end of the vas at operation, but absence did not preclude a successful outcome. The overall results were not significantly different from those after primary microsurgical reversal surgery. Conclusion Microscopic vasovasostomy after previous obstructive failure provides the patient with a further reasonable chance of becoming fertile; although diminishing with time from vasectomy, even after a prolonged period there can be success. The absence of sperm at the time of vasovasostomy does not necessarily indicate failure, but in these cases the presence of thick creamy fluid in the vas predicts a poor outcome, and alternative methods of management should be considered. A microsurgical technique extending, if necessary, well into the convoluted part of the vas, is recommended. Microsurgical skills, relevant equipment and adequate time are required.

Objectives To determine the incidence of intravasal azoospermia (IVA) and evaluate which factors before and during surgery influence outcome, by prospectively and intentionally performing bilateral vasovasostomies (VVs) only in men with intraoperative IVA. Patients and methods Using a multilayer technique, 472 men underwent microsurgical reconstructive procedures. Intravasal fluid was examined for sperm by the surgeon and a pathologist. Strict enrolment criteria included total absence of sperm or sperm parts and bilateral VV as a treatment procedure. Patients were followed up by semen analysis and paternity assessed only by naturally conceived pregnancies. Results Of the 472 patients, 27 (5.7%) had bilateral IVA; 15 of these patients were available for a follow-up of 1–47 months. Eleven patients had identical gross appearance of intravasal fluid bilaterally. Of these patients, five had sperm in the ejaculate after surgery (three with clear intravasal fluid and two with no fluid). Bilaterally different vasal fluid was found in four men. Unilateral clear fluid was present in three patients, two of whom had sperm in semen analysed after VV. Overall, there was sperm in the ejaculate in seven of 15 patients with IVA; five of these seven had clear fluid in at least one vas deferens. One patient with unilaterally clear fluid achieved paternity by a naturally conceived pregnancy. The difference between the mean (sem) obstruction interval in men who had sperm in a semen sample after VV, at 16.7 (3.30) years, and in persistently azoospermic patients, at 15.5 (1.89) years, was not statistically significant (P = 0.741). Conclusion The results of VV in patients with IVA are unsatisfactory; the patency rate is higher in men with copious clear fluid in at least one vas. The obstructive interval in patients with IVA does not appear to influence the outcome of VV.

Objective To compare the outcome of a modified one-layer and two-layer vasovasotomy (VV) in two groups of similar men undergoing vasectomy reversal. Patients and methods The charts and surgical records of all surgical procedures performed on men undergoing a modified one- or two-layer VV between June 1992 and July 1994 were retrospectively reviewed. A successful outcome (patency) was defined as sperm present at follow-up (mean follow-up 8 weeks). A modified one-layer VV was used in 17 men (group 1) and a two-layer VV in 23 (group 2). Results Sperm were present in both groups if surgery was undertaken after vasal obstruction lasting 96 months. The mean operative duration was 96 min for a modified one-layer VV and 167 min for the two-layer VV. Conclusions The simpler and faster modified one-layer VV provides sufficient accuracy for successful vasectomy reversal in most cases. For most patients, both procedures have equivalent patency.

Objective To evaluate changes in histology and semen variables after using an elastomeric-hydrogel matrix plug as a reversible vasectomy device in dogs, and to determine the potential applications for improving fertility after vasectomy reversal. Materials and methods Semen samples from six adult male dogs were obtained after left vasal ligation, placement of the plug in the right vas deferens, and subsequent removal of the plug. The vasa, epididymides and testes were evaluated histologically in four of the dogs after removal of the implant. Results No sperm were present in the ejaculate after the plug was removed. Histological sections showed intraluminal spermatids in areas where the plug had been placed. The lumen was occluded, secondary to foreign-body giant-cell reaction, at the vasotomy suture site, but other areas of the vas previously containing the implant remained patent after it was removed. Conclusions There were no sperm in the ejaculate after the plug was removed because the vasal lumen was occluded as a result of an inflammatory reaction to the suture material. In contrast, areas that had contained the implant but without a vasotomy suture were not inflamed. We suggest that further trials comparing various suture materials are carried out to determine if patency rates can be improved during vasotomy closure or vasovasostomy.

OBJECTIVES To compare the outcome of loupe-assisted, modified one-layer vasovasostomy (MOLV) and conventional microsurgical MOLV for vasectomy reversal. PATIENTS AND METHODS We retrospectively analysed data for 74 patients who had a MOLV between 1993 and 2003; 42 had the standard microsurgical (x10-16) MOLV (group 1, mean age 40.5 years, SD 6.3, range 30-58) and 32 a loupe-assisted (x 3) MOLV (group 2, mean age 41.3 years, SD 6, range 28-64). With general anaesthesia, each operation was performed as an outpatient procedure or with hospitalization for one night after surgery. The patients' characteristics, patency rate, paternity rate, and operative duration were compared. RESULTS The mean (SD, range) duration of obstruction was 8.1 (5.0, 0.33-25) years in group 1 and 9.2 (4.8, 0.33-27) years in group 2. The postoperative patency and pregnancy rates were 91% and 43% for group 1 and 89% and 39% for group 2. There were no complications during or after surgery in either group, but the surgery was significantly faster for group 2. CONCLUSIONS There was no significant difference in the patency and paternity rates between loupe-assisted and microsurgical MOLV. The surgery was significantly faster with the loupe-assisted method. Because of the shorter operation duration and less expensive instruments required that should reduce the cost, the loupe-assisted MOLV should be considered as the best choice for simple vasectomy reversal.

Study Type - Practice trends (survey) Level of Evidence 2c What's known on the subject? and What does the study add? Approximately 6% of men who have had a vasectomy subsequently decide to have it reversed. For such men there are various options available, including vasal reconstruction, surgical sperm retrieval with assisted reproductive techniques, use of donated sperm or adoption. The decision-making process with regard to the most appropriate management is challenging and the urologist requires both an intimate knowledge of the advantages and disadvantages of each of the available options and the opportunity to counsel a couple appropriately. The study confirms that patient management after previous vasectomy is a complex process, demanding detailed knowledge about the availability and outcomes of alternatives to vasectomy reversal. It recommends that couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome and the available management options and their costs. Urologists should also have appropriate facilities to offer intra-operative demonstration of and, potentially, storage of sperm.To review the management of men presenting for reversal of vasectomy amongst consultant members of the British Association of Urological Surgeons (BAUS) between 2001 and 2010. • To make recommendations for contemporary practice.Three consecutive questionnaire-based surveys were undertaken by BAUS consultant members in 2001, 2005 and 2010. • Standard questionnaires were sent on each occasion asking urologists about their counselling of couples regarding options in achieving a conception, expectation of outcome from reconstructive surgery and the techniques of vaso-vasostomy used. • In 2005 additional information was obtained about the availability of fertility treatments and sub-specialization of the urologist and in 2010 about the eligibility criteria for in-vitro fertilization (IVF) treatment and synchronous sperm retrieval.Overall there was a 47% response rate with80% of respondents still performing vaso-vasostomy. • More than 75% of respondents were doing15 procedures a year and50% of respondents counselled couples about other management options. • Only 41% gave their personalized outcomes from vaso-vasostomy, whilst80% were using some form of magnification intra-operatively. • Members of the BAUS section of andrology were more likely to discuss options for becoming a parent and criteria for IVF treatment, to present their individualized outcomes from vaso-vasotomy and to carry out15 procedures a year than urologists with no andrological affiliation.• Patient management after previous vasectomy is a complex process necessitating detailed knowledge concerning the availability and outcomes of alternatives to vaso-vasostomy. • Couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome. • Vaso-vasostomy should no longer be seen as a procedure within the remit of any adequately trained urologist but as one option to be considered by a sub-specialist with access to appropriate micro-surgical training and assisted reproductive technologies.

Study Type - Outcomes (cohort series). Level of Evidence 2b What's known on the subject? and What does the study add? Microsurgical vasectomy reversal is an effective and cost-effective method of reinstating fertility in a man who has previously had a vasectomy. The current literature indicates that the success rate (i.e. potency and pregnancy rates) are dependent primarily on the time elapsed since vasectomy and the age of the female partner. Using a multivariate Cox regression model, evaluation of the influence of preoperative data (including smoking) and semen parameters indicates a significant influence of post-surgical sperm motility only, on time to first pregnancy. The use of assisted reproductive techniques, when natural pregnancy failed, was successful in ≈50% of couples who attempted this procedure and accounted for an absolute increase in pregnancy rate of 14%.• To determine the influence of smoking, postoperative semen characteristics and the use of an assisted reproductive technique (ART) on pregnancy rate in a contemporary series of men undergoing vasectomy reversal.• Between January 2002 and January 2009, 186 vasectomy reversals were performed. Of the 171 patients who could be contacted for follow-up, 162 attempted pregnancy and constitute the study group. • Semen analysis was performed 3 months after the procedure and at subsequent 3-monthly intervals. • Patient characteristics and surgical information were obtained from a computerized database, and follow-up data were collected by telephone interview. • A multivariate Cox regression model was used to discern possible prognosticators with respect to pregnancy outcome.• The overall patency rate was 91.4%, with a natural pregnancy rate of 44.4% and a subsequent 14.2% of patients conceiving using a ARTs resulting in a total pregnancy rate of 58.6%. Multiple pregnancies were obtained by 20.4% of couples. • Smoking of the male or female partner did not influence the probability of conception. • In a multivariate model that included, among other factors, time since vasectomy, female age and semen characteristics, only sperm motility was significantly related to natural pregnancy outcome. • The probability of obtaining a natural pregnancy within 2 years after surgery is 53% for men with sperm motility20% (WHO a+b) compared to 19% for men with sperm motility5% (P= 0.003).• A clear and significant association between sperm motility and the probability of conception was found, whereas smoking, female age and time since vasectomy appeared to have no influence on pregnancy outcome in this patient cohort. • The use of ARTs accounted for an absolute increase in pregnancy rate of 14.2%.

To investigate the current incidence of vasectomy reversal procedures, the techniques used and which practitioners use them.Using a questionnaire, 130 general surgeons and urologists practising in Merseyside and North Wales were surveyed.The response rate was 74%, with 24 urological surgeons and 14 general surgeons undertaking vasectomy reversal. Annually, urological surgeons carried out significantly more procedures than did general surgeons, at 8.5 and 5.3 (P = 0.029), respectively. They were also more likely to use double-layer closure and microsurgical techniques, whilst significantly less likely to use stents. Urologists reported significantly greater patency rates, at 76% and 52% (P = 0.017), respectively, with no significant differences in subsequent pregnancy rates (30% vs 25%). Only one practitioner checked tubal patency in the female partner before vasectomy reversal.The use of vasectomy reversal is a cost-effective treatment for men wanting paternity after vasectomy. The technique used by the clinician and proper audit of the results require close attention; it would also appear to be obvious that all the partners of men seeking a vasectomy reversal should have their fertility status established before reversal, something that is clearly not done at present.

To investigate the effect of the interval between previous vasectomy reversal on retrieval rates of epididymal and testicular spermatozoa using percutaneous epididymal sperm aspiration (PESA), or testicular sperm extraction (TESE), and the subsequent reproductive potential of these gametes in intracytoplasmic sperm injection (ICSI) cycles.Sixty-six consecutive sperm retrievals were considered in patients who were azoospermic after previous vasectomy, of whom 54 had had a previous failed reversal, the remainder deciding against a reversal. PESA and TESE retrieval rates were noted, as were the time since vasectomy and the interval between vasectomy and unsuccessful reversal. The presence of palpable epididymal cysts was noted, with their effect on sperm retrieval rates. Fertilization and pregnancy rates were analysed in subsequent ICSI cycles using freshly retrieved spermatozoa or frozen-thawed cryopreserved spermatozoa.All 66 patients had sperm retrieved successfully; the success rates for PESA were not significantly affected by previous failed reversal when compared with patients who had not had a reversal, at 14 of 54 (26%) vs five of 12 (P=0.3). The interval since vasectomy did not affect PESA retrieval rates but there was a significantly poorer retrieval rate for PESA in the presence of palpable epididymal cysts, at seven of 35 (20%) vs 12 of 23 (52%) (P=0.012). Fertilization rates were significantly lower using cryopreserved spermatozoa retrieved from either the epididymis or testis (50% vs 70%, P=0.007), although subsequent implantation and pregnancy rates were not significantly different.Surgical sperm retrieval is successful in all cases of azoospermia secondary to vasectomy, either by PESA or TESE. There are no clinical markers to indicate which patients will have successful PESA after vasectomy, although the presence of epididymal cysts is associated with significantly lower retrieval rates. The reduction in fertilising ability of cryopreserved spermatozoa does not affect clinical pregnancy rates in ICSI cycles.

To examine trends in vasectomy and vasovasostomy, and the surgical complications and factors associated with reversal after vasectomy, and paternity after vasovasostomy.Procedure rates were estimated from 1980 to 1996 in the population of Western Australia. Linked hospital morbidity records were used in the follow-up of men after vasectomy to estimate the risks of complications and reversals. Records of vasovasostomies were linked to the paternity field on birth registrations. Independent effects of the study factors were examined using Cox regression.There was little net change in vasectomy rates, whereas vasovasostomy rates increased in men aged 30-49 years. Risks of surgical complications were low and decreased for vasovasostomy. At 12-15 years after vasectomy, the risk of reversal levelled at 2. 4% in the total cohort and at 11.1% in men aged 20-24 years. The risk of vasovasostomy was 69% greater after vasectomy performed in 1994-96 than in 1980-84 (P = 0.011). The factors strongly associated with reversal were age30 years and being single, divorced or separated at the time of vasectomy. Paternity was achieved after an estimated 53% of vasovasostomies. Successful reversal was more likely if the man was younger at vasectomy and the time elapsed was comparatively short. Compared with vasovasostomies performed in 1980-84, the success rate of those in 1994-96 was almost four times higher.Population rates of vasectomy are stable but the risk of seeking a reversal has increased. Outcomes after vasovasostomy have improved. Care should be taken during the counselling of men before vasectomy, and especially in those aged30 years.

To determine the incidence of intravasal azoospermia (IVA) and evaluate which factors before and during surgery influence outcome, by prospectively and intentionally performing bilateral vasovasostomies (VVs) only in men with intraoperative IVA.Using a multilayer technique, 472 men underwent microsurgical reconstructive procedures. Intravasal fluid was examined for sperm by the surgeon and a pathologist. Strict enrolment criteria included total absence of sperm or sperm parts and bilateral VV as a treatment procedure. Patients were followed up by semen analysis and paternity assessed only by naturally conceived pregnancies.Of the 472 patients, 27 (5.7%) had bilateral IVA; 15 of these patients were available for a follow-up of 1-47 months. Eleven patients had identical gross appearance of intravasal fluid bilaterally. Of these patients, five had sperm in the ejaculate after surgery (three with clear intravasal fluid and two with no fluid). Bilaterally different vasal fluid was found in four men. Unilateral clear fluid was present in three patients, two of whom had sperm in semen analysed after VV. Overall, there was sperm in the ejaculate in seven of 15 patients with IVA; five of these seven had clear fluid in at least one vas deferens. One patient with unilaterally clear fluid achieved paternity by a naturally conceived pregnancy. The difference between the mean (SEM) obstruction interval in men who had sperm in a semen sample after VV, at 16.7 (3. 30) years, and in persistently azoospermic patients, at 15.5 (1.89) years, was not statistically significant (P = 0.741).The results of VV in patients with IVA are unsatisfactory; the patency rate is higher in men with copious clear fluid in at least one vas. The obstructive interval in patients with IVA does not appear to influence the outcome of VV.

To compare the outcome of a modified one-layer and two-layer vasovasotomy (VV) in two groups of similar men undergoing vasectomy reversal.The charts and surgical records of all surgical procedures performed on men undergoing a modified one- or two-layer VV between June 1992 and July 1994 were retrospectively reviewed. A successful outcome (patency) was defined as sperm present at follow-up (mean follow-up 8 weeks). A modified one-layer VV was used in 17 men (group 1) and a two-layer VV in 23 (group 2).Sperm were present in both groups if surgery was undertaken after vasal obstruction lasting36 months. The modified one- and two-layer VV had equal patency (88% and 90%, respectively) when undertaken after an obstructed interval of 36-96 months; outcomes were poorer if surgery was performed after96 months. The mean operative duration was 96 min for a modified one-layer VV and 167 min for the two-layer VV.The simpler and faster modified one-layer VV provides sufficient accuracy for successful vasectomy reversal in most cases. For most patients, both procedures have equivalent patency.