Vasectomy reversal: is there still a role? Sidney Glina. Faculdade de Medicina do ABC. Instituto H. Ellis

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1 Vasectomy reversal: is there still a role? Sidney Glina Faculdade de Medicina do ABC Instituto H. Ellis Editor-in-Chief of the International Brazilian Journal of Urology ( glinas@terra.com.br

2 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

3 Vasectomy as a contraceptive method Brasil: 2.1% of men 1 São Paulo: 6.1% of men 1 USA: 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: Barone MA, Hutchinson PL, Johnson CH, Hsia J, Wheeler J. J Urol. 2007; 177:

4 Fertility after vasectomy

5 Vasectomy Reversal

6 Epidydimal sperm retrieval and ICSI

7 Vasectomised men want to be father again? USA:Reversals in 2 to 6% of vasectomised men 1 (almost reversals/year 2 ) UK: 40 thousand vasectomies/year and 2400 reversals/year 3 Netherland: vasectomies in 2004 and 2.6% of them went through reversal 4 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, McVicar CM, O'Neill DA, McClure N, Clements B, McCullough S, Lewis SE Hum Reprod. 2005;20(10): 4. Hepp SM, Meuleman EJ Ned Tijdschr Geneeskd. 2006; 150:611-4

8 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

9 There is no result after more than 2 years of vasectomy! ICSI the best! Dr. Gynecologist

10 Time since vasectomy and pregnancy rates Vasectomy reversal Patency (%) Pregnancy (%) Belker et al., Results of the 1469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J. Urol, 145:505, 1991.

11 Patency rate(%) Preganancy rate(%) Vasectomy reversal 747 cases Years of vasectomy Years of vasectomy Bolduc S, Fischer MA, Deceuninck G, Thabet M. Can Urol Assoc J. 2007;1:

12 You are too old to get pregnant after vasectomy reversal ICSI is the best! Dr. Gynecologist

13 Maternal age and pregnancy rates Vasectomy reversal Silber et al (N=4010, single center) 1 Maternal Age < < <40 >40 Pregnancy (%) Gerrard et al (N=294, multicenter) 2 Maternal Age Pregnancy (%) Hinz et al (N=212, single center) 3 Maternal Age Pregnancy (%) > < > Silber, S., et al. Microscopic Vasectomy Reversal, J Androl, 25(6):845, Gerrard, E., et al. Effect of female partner age on pregnancy rates after vasectomy reversal, Fertil Steril, 87(6):1340, Hinz, S., et al. Fertility Rates following vasectomy reversal: importance of age of the female partner, Urol Int, 81:416, 2008.

14 There are risk to the partner! Reversal is the best! Dr. Urologist

15 Risks to Partner with IVF/ICSI Ovarian Hyper-stimulation Syndrome (OHSS) High dose gonadotropins OHSS 1 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 1. Shmorgan D et al., J Obst Gyn Can, 33: , Alper MM et al., J Exp Clin Assist Reprod, 6:3-6, *

16 Reversal is the best! ICSI is too expensive! Dr. Urologist

17 Fertility after vasectomy: analysis of cost Cost of baby at home $ ICSI $ Vaso-vaso Pavlovich & Schlegel (MESA) Kolettis & Thomas (MESA) Donovan e cols (MESA) Deck & Berger (TESA) * Meng e cols (TESA) ** Lee e cols (MESA) (TESE) *Women > 37 years old (75% e 17%) **Without indirect costs Lee et al - Urol Clin N Am 2008; 35:289:301

18 Reversal is the best Epididymal punction can destroy the epididymus Dr. Urologist

19 Saade RD, Neves PA, Glina S, D'Ancona CA, Dambros M, Lúcio MA J Urol ;179:381-4 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

20 Vasectomy Reversal Low risk, outpatient procedure mean OR time- 110 minutes complications- 0.3% hematoma/ 0.8% infection Anesthesia- local or general Schwarzer et al., Current Status of Vasectomy Reversal, Nature Reviews, 10:195, 2013

21 Benefits of vasectomy reversal Spontaneous pregnancy Partner saved of any intervention Consenso Infertilidade SBU - Int Braz J Urol, 2003;29(supl 5):35-8

22 Disadvantadges 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

23 Benefits of PESA(MESA)/ICSI Pregnacy achievement more rapid? No need for contraception. Consenso Infertilidade SBU Int Braz J Urol, 2003;29(supl 5):35-8

24 Disadvantadges 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

25 Practice Committee Recommendations 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 * American Society of Reproductive Medicine, Practice Committee, Fert Steril, 90(3):213, 2008.

26 Microsurgical reconstruction, in cases that are feasible, is a more costeffective 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.

Effect of female partner age on pregnancy rates after vasectomy reversal

MALE FACTOR Effect of female partner age on pregnancy rates after vasectomy reversal Edward R. Gerrard, Jr., M.D., a Jay I. Sandlow, b Robert A. Oster, Ph.D., c John R. Burns, M.D., a Lyndon C. Box, M.D.,