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Purpose: The purpose of this guideline is to provide guidance to clinicians who offer vasectomy services., Materials and Methods: A systematic review of the literature using the search dates January 1949-August 2011 was conducted to identify peer-reviewed publications relevant to vasectomy. The search identified almost 2,000 titles and abstracts. Application of inclusion/exclusion criteria yielded an evidence base of 275 articles. Evidence-based practices for vasectomy were defined when evidence was available. When evidence was insufficient or absent, expert opinion-based practices were defined by Panel consensus. The Panel sought to define the minimum and necessary concepts for pre-vasectomy counseling; optimum methods for anesthesia, vas isolation, vas occlusion and post-vasectomy follow up; and rates of complications of vasectomy. This guideline was peer reviewed by 55 independent experts during the guideline development process., Results: Vas isolation should be performed using a minimally-invasive vasectomy technique such as the no-scalpel vasectomy technique. Vas occlusion should be performed by any one of four techniques that are associated with occlusive failure rates consistently below 1%. These are mucosal cautery of both ends of the divided vas without ligation or clips (1) with or (2) without fascial interposition; (3) open testicular end of the divided vas with MC of abdominal end with FI and without ligation or clips; and (4) non-divisional extended electrocautery. Patients may stop using other methods of contraception when one uncentrifuged fresh semen specimen shows azoospermia or ≤ 100,000 non-motile sperm/mL., Conclusions: Vasectomy should be considered for permanent contraception much more frequently than is the current practice in the U.S. and many other nations. The full text of this guideline is available to the public at http://www.auanet.org/content/media/vasectomy.pdf., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether sperm harvesting and cryopreservation at the time of vasectomy reversal is cost-effective., Design: Model of actual costs and results at five institutions., Setting: Multicenter study comprising five centers, including university hospitals and private practices., Patient(s): Men undergoing vasectomy reversal., Intervention(s): We established two models for vasectomy reversal. The first model was sperm harvesting and cryopreservation at the time of vasectomy reversal. The second model was sperm harvesting at the time of IVF only if the patient remained azoospermic after vasectomy reversal. Vasectomy reversal procedures modeled included bilateral vasovasostomy and bilateral epididymovasostomy. The costs for each procedure at the five institutions were collated and median costs determined., Main Outcome Measure(s): Median cost of procedure and calculated financial comparisons., Result(s): The median cost of testicular sperm extraction/cryopreservation performed at the time of bilateral vasovasostomy was $1,765 (range, $1,025-$2,800). The median cost of microsurgical epididymal sperm aspiration or testicular sperm extraction with cryopreservation performed at the time of epididymovasostomy was $1,209 (range, $905-$2,488). The average of the median costs for percutaneous sperm aspiration or testicular sperm aspiration for those patients with a failed vasectomy reversal was $725 (range, $400-$1,455)., Conclusion(s): Sperm retrieval with cryopreservation at the time of vasectomy reversal is not a cost-effective management strategy.

Patients who inquire about microsurgical correction of vasal and epididymal obstructions should be informed about the postoperative rates of both return of sperm to the semen and pregnancy. They also should be informed about the possibility of a successful outcome, depending on their individual circumstances. The various preoperative, intraoperative, and postoperative factors that influence success rates are discussed in this article.

Objective: To report a live birth with IVF-ET and intracytoplasmic sperm injection (ICSI) using sperm retrieved from a moribund man being maintained on life support systems., Design: Case report., Setting: Nonprofit private teaching hospitals., Patient(s): A 27-year-old man who was decorticate after an accident., Intervention(s): Epididymal sperm retrieval and sperm cryopreservation, pastoral psychologic counseling, and subsequent IVF-ET with ICSI., Main Outcome Measure(s): Pregnancy and delivery., Result(s): Birth of a healthy child after IVF-ET with ICSI and single blastocyst transfer., Conclusion(s): First report in peer-reviewed medical literature of a live birth after sperm retrieval from a moribund man.

Sperm flagellar activity is modulated by cAMP. In target tissues, vasoactive intestinal peptide (VIP) stimulates adenyl cyclase activity, which elevates intracellular cAMP levels and activates protein kinase activity. This study investigated the effects of VIP on motility of sperm from 17 subjects. Motile activities, monitored before (0 min, baseline) and for 40 min after incubation with VIP (0.2 microgram/mL cell suspension), were analyzed by computer-assisted semen analysis. The data (mean +/- SEM) are expressed as percentages of baseline values and changes were compared by trend analysis for interval level measures by repeated measures analysis of variance orthogonal polynominal contrasts. The addition of VIP significantly increased motile sperm concentration (110 +/- 17% [10 min], 132 +/- 15% [20 min], 152 +/- 18% [30 min], 125 +/- 18% [40 min]; p < .02) and sperm with rapid straight-line motility (V > 25 microns/s) (167 +/- 20%, 174 +/- 19%, 173 +/- 23%, 141 +/- 16%; p < .02). Mean track speed (micron/s) was increased (125 +/- 12%, 134 = 9%, 129 +/- 12% and 126 +/- 12%; p < .02), while mean progressive velocity, amplitude of head displacement, and beat frequency were not affected by VIP. These results indicate that VIP stimulates sperm motile activity by cAMP-mediated phosphorylation of axonemal proteins.

Purpose: After intracytoplasmic sperm injection was established to facilitate in vitro fertilization in men with the most severe semen abnormalities, the use of testicular sperm to achieve conception became feasible. We investigated the use of a method of percutaneous needle aspiration previously used for diagnostic purposes to obtain testicular sperm for intracytoplasmic sperm injection., Materials and Methods: A method of percutaneous aspiration of sperm was developed to facilitate intracytoplasmic sperm injection. A total of 69 testicular aspirations were performed for diagnostic purposes and 179 to obtain sperm on the day of egg retrieval for couples undergoing in vitro fertilization with intracytoplasmic sperm injection. The procedures were performed in an outpatient facility. Most patients received intravenous sedation and a few received only local anesthesia., Results: Sperm adequate for intracytoplasmic sperm injection were obtained in all men with obstructive azoospermia, including those with significant testicular atrophy and those with anejaculation or necrospermia. Adequate numbers of sperm for intracytoplasmic sperm injection were retrieved less reliably in men with nonobstructive azoospermia. The number of sperm correlated positively with testicular size. Morbidity and discomfort were nonexistent. Sperm were obtained from 43 of 69 men undergoing diagnostic and 170 of 179 men undergoing therapeutic aspiration. Sperm motility ranged from 0 to 20% and viability from 55 to 85%., Conclusions: Percutaneous testicular sperm aspiration is a cost-effective method to retrieve sperm for intracytoplasmic sperm injection in select men with obstructive azoospermia, anejaculation and necrospermia, and some with nonobstructive azoospermia.

Müllerian inhibiting substance (MIS) is a hormone present in seminal plasma, but its role is unknown. In this study, the effects of MIS on sperm survival in fresh and cryopreserved specimens were investigated. Fresh sperm motility and viability (n = 12) were evaluated in specimens after 0, 0.5, 1, 3, 5, and 22 hours of incubation in the presence or absence of MIS. Motile and nonmotile sperm were evaluated in Cell-Vu counting microscope slides, and viability was assessed by eosin-nigrosin exclusion. Sperm cryopreserved for 2 weeks in TES (N-Tris[hydroxymethyl]methyl-2-aminoethanesulfonic acid)-Tris-glycerol-egg yolk buffer and 4% glycerol with or without MIS were thawed at room temperature (n = 6) and were evaluated for motility and viability using identical methods to those used with fresh sperm. The effects of MIS were examined by coincubation with monoclonal anti-MIS antibody (6E11; n = 6). In fresh and cryopreserved sperm incubated with MIS, both motility and viability were higher than in the absence of MIS (P < 0.03; Wilcoxon signed rank test) at 5 and 22 hours. Coincubation with anti-MIS antibody eliminated the effects of MIS. Longevity of sperm motility and viability are improved both in fresh and cryopreserved sperm in the presence of MIS and may have potential for use in assisted reproductive technology.

Purpose: The binding of Müllerian inhibiting substance (MIS) to human sperm was investigated using immunohistological techniques., Materials and Methods: Sperm from 5 normal donors and 6 subfertile men were studied. Whole or thin-sectioned sperm were incubated without or with recombinant human MIS (0.5 microg./ml.). MIS binding was identified under light microscopy (LM) using rabbit anti-human MIS antibodies tagged with goat IgG-horseradish peroxidase and diaminobenzidine as substrate, or by scanning and transmission electron microscopy (SEM and TEM) using gold labeled goat IgG. Intracellular MIS binding in sperm sections was examined by TEM. Antibodies were omitted in the controls., Results: Under LM, DAB staining was present on sperm incubated with or without MIS and absent on controls. Using SEM, gold particles were found primarily on the surfaces of the sperm head with less binding to the tail. With TEM, the clustering of gold particles around the head of sperm represents MIS binding, but very few or no gold particles could be found associated with the sperm tail. MIS binding was also found associated with intracellular structures, but only within the head of the sperm. Overall, less gold particle binding was present in subfertile compared with normal sperm., Conclusions: These results suggest that MIS is bound to the sperm surface and sperm from normally fertile men have increased MIS binding. The function of MIS in sperm is unknown, but the presence of MIS binding suggests a direct role(s) in sperm function.

Purpose: Intracytoplasmic sperm injection during in vitro fertilization involves the microinjection of a single sperm into each egg from the partner. Pregnancies have resulted from this powerful new technology when fewer than 100 motile sperm were present in the semen, or when sperm were obtained from the epididymis or testicle by open operations or needle aspirations. Some surgeons have cryopreserved sperm obtained from the vas or epididymis during vasectomy reversals. However, cryopreservation of nonmotile sperm serves no useful purpose., Materials and Methods: We performed a retrospective analysis of 603 vasectomy reversals in which the intraoperative vasal and/or epididymal fluid was examined microscopically. The motility of the sperm obtained intraoperatively was used as a gauge for the potential use of such sperm for in vitro fertilization and intracytoplasmic sperm injection after cryopreservation and thawing, should the vasectomy reversal fail., Results: Motile sperm were present in the intraoperative vasal or epididymal fluid in 35% of all vasectomy reversals (34% of first and 39% of repeat procedures). The percentage of reversals in which motile sperm were present in the intraoperative fluid was not related to the time from vasectomy until reversal., Conclusions: The absence of motile sperm in the intraoperative vasal or epididymal fluid precludes consideration of sperm cryopreservation during vasectomy reversals. Although to our knowledge the minimum percentage of sperm motility needed for in vitro fertilization and intracytoplasmic sperm injection after cryopreservation and thawing has not been established, our results provide surgeons with information to judge the merit of sperm harvesting and cryopreservation during vasectomy reversals.

Purpose: The American Urological Association convened the Clinical Guidelines Panel on Erectile Dysfunction to analyze the literature regarding available methods for treating organic erectile dysfunction and to make practice recommendations based on the treatment outcomes data., Materials and Methods: The panel searched the MEDLINE data base for all articles from 1979 through 1994 on treatment of organic erectile dysfunction and meta-analyzed outcomes data for oral drug therapy (yohimbine), vacuum constriction devices, vasoactive drug injection therapy, penile prosthesis implantation and venous and arterial surgery., Results: Estimated probabilities of desirable outcomes are relatively high for vacuum constriction devices, vasoactive drug injection therapy and penile prosthesis therapy. However, patients must be aware of potential complications. The outcomes data for yohimbine clearly indicate a therapy with marginal efficacy. For venous and arterial surgery, based on reported outcomes, chances of success do not appear high enough to justify routine use of such surgery., Conclusions: For the standard patient, defined as a man with acquired organic erectile dysfunction and no evidence of hypogonadism or hyperprolactinemia, the panel recommends 3 treatment alternatives: vacuum constriction devices, vasoactive drug injection therapy and penile prosthesis implantation. Based on the data to date, yohimbine does not appear to be effective for organic erectile dysfunction and, thus, it should not be recommended as treatment for the standard patient. Venous surgery and arterial surgery in men with arteriolosclerotic disease are considered investigational and should be performed only in a research setting with long-term followup available.

Müllerian inhibiting substance (MIS), produced by testicular Sertoli cells, is present in adult male serum. The first aim of this study was to determine if MIS is present in seminal plasma. Using an enzyme-linked immunosorbent assay (ELISA), we measured MIS concentrations in seminal plasma from 23 donors exhibiting normal (WHO criteria) sperm qualities, and 169 patients with subnormal sperm parameters. The second aim of this study was to examine a potential relationship between MIS and sperm motility. MIS concentrations in seminal plasma ranged from 0.5 to 3.6 ng/ml in donors and from 0.5 to 17.8 ng/ml in patients. Motility index (MI, mean +/- SEM) for all patient samples was lower compared with donors (113.3 +/- 3.2 and 198.3 +/- 13.5, P < 0.00001), while mean MIS concentration +/- SEM) was higher (4.2 +/- 0.3 and 1.4 +/- 0.2, P < 0.0003). When the patients were stratified into Groups I (motility < 50%, n = 42) and II (motility > 50%, n = 127), the MI (mean +/- SEM) values were 62.3 +/- 3.8 and 130.2 +/- 2.7 respectively (P < 0.0001 for both compared with donors) and mean MIS concentrations (+/- SEM) were 5.4 +/- 0.6 and 3.9 +/- 0.3, respectively (P < 0.0001 and P < 0.001 compared with donors). The inverse relationship between MIS concentration in seminal plasma and motility index suggests that MIS may have a function in modulating motility.

Before patients with obstructive azoospermia undergo surgical reconstruction, testicular biopsy is required to establish that spermatogenesis is normal. To perform the corrective surgical procedure at the same time as the testicular biopsy, a touch imprint method of processing the biopsy specimen has replaced frozen section processing, which distorts the germinal cells. We report a rapid, simple method of staining a touch imprint specimen in the operating room. It requires less than 5 minutes and can be performed by the andrology laboratory technologist, operating room staff, or the surgeon, thereby avoiding the need to transport the biopsy specimen to the pathology laboratory.

Objective: To create an alloplastic spermatocele capable of repeated sperm aspiration. The alloplastic spermatocele has long been a theoretical solution to infertility for those patients with congenital absence of the vas deferens or irreversible obstruction of the male reproductive ductal system. Recent studies have suggested that sperm from efferent ducts are capable of fertilization. Clinical use of alloplastic spermatoceles for collection of epididymal sperm has resulted in unacceptably low pregnancy rates. Improvement in spermatocele function may occur if a microsurgical anastomosis is performed to the epididymis., Design: A newly designed alloplastic spermatocele was implanted in 17 mature male rabbits. The faceplate of the device had a 0.7-mm orifice, allowing direct precise microsurgical anastomosis to a specific loop of the epididymal tubule., Results: Sperm retrieval was possible in 16/17 (94%) animals. Repeated successful aspirations (total of 73) were performed in all but one animal. The total number of sperm collected per spermatocele averaged 115 x 10(6) (range 0 to 734 x 10(6)). The sperm motility varied widely between animals and specimens, with a maximum average of 21.6% motile sperm/aspirate per animal. All spermatoceles eventually occluded (mean time of occlusion 14 days; range 3 to 30 days). The prostheses with the attached epididymides were examined histologically., Conclusions: This prototype alloplastic spermatocele allows repeated high density sperm retrieval over a short period of time. Low sperm motility may be less problematic clinically as new techniques of IVF become available.

Patients with neurologic ejaculatory dysfunction who wish to have a child commonly undergo electroejaculation, which, unfortunately, may fail to stimulate either antegrade or retrograde ejaculation of sperm. Even when sperm are obtained with electroejaculation, conception still may not be achieved. We describe the achievement of a pregnancy after the intrauterine insemination of sperm obtained from microsurgical aspiration of the vas deferens. The intrauterine insemination of electroejaculated sperm had failed to achieve a pregnancy on three previous occasions. The relative merits of vas sperm aspiration and electroejaculation as part of the assisted reproduction regimen for men who have neurologic ejaculatory dysfunction are discussed.

Microsurgical techniques have been used to perform a variety of urologic procedures. Basic microsurgical principles are discussed in this article and information is presented regarding instrumentation techniques and the operation of microscopes and microsurgical instruments. Many useful hints to increase the ease of performing microsurgery are discussed and clearly defined.

Andrologists sometimes experience difficulty deciding if a patient is azoospermic because of obstruction or because of testicular failure to produce sperm. When the testicular biopsy reveals that relatively small numbers of mature sperm are being produced, azoospermia may be the clinical manifestation of this condition. However, some patients who have ductal obstruction also have decreased levels of testicular sperm production ("hypospermatogenesis"). This discussion will concern: (a) the evidence that partial ductal obstruction may exist; (b) the clinical manifestations of partial ductal obstruction; (c) methods of diagnosis of partial ductal obstruction; and (d) treatment of partial ductal obstruction.

During a 9-year period 1,469 men who underwent microsurgical vasectomy reversal procedures were studied at 5 institutions. Of 1,247 men who had first-time procedures sperm were present in the semen in 865 of 1,012 men (86%) who had postoperative semen analyses, and pregnancy occurred in 421 of 810 couples (52%) for whom information regarding conception was available. Rates of patency (return of sperm to the semen) and pregnancy varied depending on the interval from the vasectomy until its reversal. If the interval had been less than 3 years patency was 97% and pregnancy 76%, 3 to 8 years 88% and 53%, 9 to 14 years 79% and 44% and 15 years or more 71% and 30%. The patency and pregnancy rates were no better after 2-layer microsurgical vasovasostomy than after modified 1-layer microsurgical procedures and they were statistically the same for all patients regardless of the surgeon. When sperm were absent from the intraoperative vas fluid bilaterally and the patient underwent bilateral vasovasostomy rather than vasoepididymostomy, patency occurred in 50 of 83 patients (60%) and pregnancy in 20 of 65 couples (31%). Neither presence nor absence of a sperm granuloma at the vasectomy site nor type of anesthesia affected results. Repeat microsurgical reversal procedures were less successful. A total of 222 repeat operations produced patency in 150 of 199 patients (75%) who had semen analyses and pregnancy was reported in 52 of 120 couples (43%).

Data regarding the efficacy of vasectomy are limited, but the procedure appears to be highly effective. Efficacy may vary by the method of vas occlusion. Death attributable to vasectomy in the United States is exceedingly rare, and major perioperative morbidity is quite uncommon. No long-term adverse health effects have been documented, and much evidence supports the conclusion that vasectomy does not increase the risk of subsequent atherosclerosis. Vasectomy, like tubal sterilization, should be considered a permanent decision, because reversal surgery is expensive and requires substantial surgical expertise. Although vasectomy reversal is often successful, it cannot be guaranteed even in the best of circumstances, and when the vasectomy has caused epididymal obstruction, reversal is often unsuccessful. Vasectomy represents a safe and effective alternative to tubal sterilization for couples who decide that the male should be sterilized.

Preoperative transrectal ultrasonography was used to establish the diagnosis of ejaculatory duct obstruction and also to determine the distal level of extension of the obstructed system within prostatic parenchyma. Transrectal ultrasonography not only established the diagnosis but also enabled precise transurethral resection into the obstructed system. Prostatic ultrasound facilitates evaluation and treatment of azoospermia caused by ejaculatory duct obstruction and may eliminate the need for vasography in such cases.

The records of 1,029 consecutive patients undergoing bilateral vasectomy were reviewed. Of the 1,029 patients 375 (36%) never returned postoperatively and the partners of 2 of these 375 later became pregnant. A total of 560 patients (54%) was followed until the recommended demonstration of azoospermia occurred on 2 consecutive occasions. There were 84 patients (8%) who did not return after the first demonstration of azoospermia, while 7 (1%) still had sperm in the semen at the last examination. Three other patients had persistent nonmotile sperm postoperatively; 2 of them underwent repeat vasectomy followed by azoospermia and 1 was placed in a special clearance category of sterility as described. We discuss practical and legal considerations regarding the management of noncompliant patients.

A microsurgical laboratory model is described which uses optimally preserved human vasectomy segments. These preserved specimens retain their natural appearance and handling qualities, permitting ready availability of material for practice, which is mandatory before clinical performance. If laboratory facilities are not available, the model can be used for practice in a convenient area of the operating suite.

Routine vasectomy reversals are performed easily through scrotal incisions. However, the infrapubic incision offers easiest access to both ends of the vas deferens when the vasectomy has been performed at an unusually high level. Similarly, when unusually long segments of the vas have been removed during the vasectomy, the infrapubic incision enables the surgeon to mobilize a sufficient length of the abdominal end of the vas so that even vasoepididymostomy may be performed without tension on the anastomosis. Technical details of the infrapubic incision, which may be used with local anesthesia, are described.

A vasovasostomy may be performed on an outpatient basis with local anesthesia, but also may be performed on an outpatient basis with epidural or general anesthesia. Local anesthesia is preferred by most of my patients, the majority of whom choose this technique. With proper preoperative and intraoperative sedation, patients sleep lightly through most of the procedure. Because of the length of time often required for bilateral microsurgical vasoepididymostomy, epidural or general anesthesia and overnight hospitalization are usually necessary. Factors influencing the preoperative choice for vasovasostomy or vasoepididymostomy in patients undergoing vasectomy reversal are considered. The preoperative planned choice of vasovasostomy or vasoepididymostomy for patients having vasectomy reversal described herein does not have the support of all urologists who regularly perform these procedures. My present approach has evolved as the data reported in Tables 1 and 2 have become available, but it may change as new information is evaluated. However, it offers a logical method for planning choices of anesthesia and inpatient or outpatient status for patients undergoing vasectomy reversal procedures.

We examined 11 patients with acquired obstructive azoospermia resulting from irreparable obstruction of 1 vas deferens and severe damage to the contralateral testis. All of the patients underwent transseptal crossed vasovasostomy with no morbidity. Of 8 patients evaluated with postoperative semen analyses 4 (50 per cent) demonstrated total sperm counts of 29 to 205 million and 2 pregnancies (25 per cent) have been reported, with followup ranging from 5 months to 2 years. The etiologies of the vasal obstruction included previous inguinal surgery in 7 patients, vasectomy in 1, ejaculatory duct obstruction in 1, ectopic ureter in 1 and vasal agenesis in 1. Factors leading to loss of the contralateral testis were torsion in 5 patients, mumps orchitis in 2, varicocele in 1, pediatric inguinal herniorrhaphy in 1, epididymal blow out in 1 and unknown in 1. A representative case involving a unilateral ectopic ureter emptying into the seminal vesicle and subsequent contralateral testicular torsion is presented. The results indicate that a transseptal crossed vasovasostomy should be done in patients satisfying the criteria presented.

After vasectomy reversal by vasovasostomy or vasoepididymostomy motile sperm appear commonly in the semen even when only nonmotile sperm are present in the intraoperative vasal or epididymal fluid. We studied patients with bilateral congenitally absent vasa deferentia to see if relief of obstruction by implantation of an alloplastic spermatocele also benefits sperm motility in such patients. A total of 130 alloplastic spermatoceles was implanted in 91 patients. Of 21 patients with only nonmotile sperm in the epididymal fluid intraoperatively only 1 had motile sperm in the postoperative aspirates from the alloplastic spermatocele. The quality of sperm motility in the intraoperative epididymal fluid was predictive of the quality of sperm motility in the postoperative aspirates. Conception postoperatively did not occur whenever less than 20 per cent of the intraoperative epididymal sperm was motile. Thus, poor or absent sperm motility in the epididymal fluid during planned alloplastic spermatocele implantation predicts a poor postoperative result and, therefore, contraindicates implantation of the prosthesis. Pregnancy, which occurred postoperatively in 7 of 91 wives, ended in spontaneous abortion in 3 and progressed to full-term delivery in 4.

Reports of microsurgical testicular autotransplantation as a method of dealing with the high undescended testis have prompted this review. Results with various methods are compared. The increasing success being reported with division of the internal spermatic vessels (when certain principles as enumerated herein are followed) leads to the conclusion that the more technically complex method of microsurgical testicular autotransplantation will not come into general use. The opportunities for testicular homotransplantation are rare, and no definitive conclusions can be made concerning this rarely reported procedure.

This initial report from the Vasovasostomy Study Group concerns intraoperative data obtained during vasovasostomy from 639 vasa in 334 patients. These data are related to the obstructive interval (time from vasectomy to vasovasostomy) and to the presence or absence of histologically proved sperm granuloma at the old transected testicular end of the vas (vasectomy site). Rates of sperm absence from vas fluid at the testicular end increased with longer obstructive intervals and with absence of a sperm granuloma. If sperm were present in fluid at the testicular end of the vas, the quality was poorer when the obstructive interval lengthened and when sperm granuloma was absent. Vas luminal diameters at the testicular end were smaller when a sperm granuloma was present. These observations support the theory that a sperm granuloma at the vasectomy site may have a beneficial, pressure-releasing effect that could be favorable prognostically for fertility after vasovasostomy.

Techniques, results, complications, and medicolegal aspects of vasectomy are discussed in this article. Emphasis is placed on techniques that prevent spontaneous recanalization of the ends of the vas deferens after vasectomy. Factors that affect the reversibility of vasectomy are discussed. New microsurgical techniques of vasectomy reversal are described, and results of these new techniques are compared with results of nonmicrosurgical techniques of vasectomy reversal. Indications for bypass vasoepididymostomy during vasectomy reversal procedures, as well as techniques for performing vasoepididymostomy, are discussed.