Editing Infertility: Management (section)

===Vasovasostomy/Vasoepididymostomy===
*Microsurgical reconstruction is done by anastomosing the vas to the most distal site in continuity with the testis, documented by identifying sperm at this region of the reproductive tract. [https://pubmed.ncbi.nlm.nih.gov/33295257/ '''★''']
*Higher patency and pregnancy rates after reconstruction are associated with [https://pubmed.ncbi.nlm.nih.gov/33295257/ '''★''']
**Bilateral vasovasostomy
**More distal epididymal anastomoses (compared to epididymal anastomoses) for vasoepididymostomy
**Presence of intact sperm at the site of reconstruction
**Shorter obstructive interval
*'''Preoperative Evaluation'''
**'''Couples desiring conception after vasectomy should be counseled that surgical reconstruction, surgical sperm retrieval, or both reconstruction and simultaneous sperm retrieval for cryopreservation are viable options[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
***Limited data exist comparing outcomes for strategies for men interested in fertility after vasectomy.
***Surgical sperm retrieval will require the use of ART/ICSI to achieve a pregnancy.
***Microsurgical reconstruction of the male reproductive tract may be the preferable alternative to sperm retrieval and ICSI when the female partner has normal fertility potential
***For couples with female factors that require ART, sperm retrieval and IVF is often the preferred option for management.
***For couples interested in fertility who are farther out from vasectomy (e.g., over 25 years after vasectomy), microsurgical reconstruction with vasoepididymostomy may have lower success rates and sperm cryopreservation at the time of reconstruction should be considered.
**'''Men with vasal or epididymal obstructive azoospermia should be counselled that microsurgical reconstruction may be successful in returning sperm to the ejaculate.[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
**'''Before attempted surgical reconstruction of the reproductive tract, adequate spermatogenesis should be documented. A prior history of natural fertility pre-vasectomy is usually adequate'''
**'''Contraindications:'''
***'''Non-obstructive azoospermia'''
**'''Physical Examination'''
***'''Testis: small or soft testes suggest impaired spermatogenesis and predict a poor outcome'''
***'''Epididymis: an indurated irregular epididymis often predicts secondary epididymal obstruction, necessitating vasoepididymostomy'''
***'''Sperm granuloma: suggests that sperm have been leaking at the vasectomy site.'''
****Sperm are highly antigenic, and an intense inflammatory reaction occurs when sperm escape outside the reproductive epithelium.
****'''The granuloma vents the high pressures away from the epididymis and is associated with a better prognosis for restored fertility'''
****Rarely symptomatic
***'''Hydrocele:''' '''the presence of a hydrocele in the presence of excurrent ductal system obstruction is often associated with secondary epididymal obstruction'''
***'''Vasal gap: when a very destructive vasectomy has been performed, most of the scrotal straight vas may be absent or fibrotic and the patient should be advised that inguinal extension of the scrotal incision will be necessary to mobilize adequate length of vas to enable a tension-free anastomosis'''.
***'''Scars from previous surgery: operative scars in the inguinal or scrotal region should alert surgeon to the possibility of iatrogenic inguinal obstruction (hernia repair) or vasal or epididymal obstruction (hydrocelectomy, orchiopexy)'''
**'''Laboratory Tests'''
***Semen analysis with centrifugation and examination of the pellet for sperm should be performed preoperatively.
****Complete sperm with tails are found in 10% of preoperative pellets a mean of 10 years after vasectomy. Under these circumstances sperm are certain to be found in the vas on at least one side, indicating a favorable prognosis for restored fertility.
***Serum anti-sperm antibody studies: the presence of serum anti-sperm antibodies corroborates the diagnosis of obstruction and the presence of active spermatogenesis
***Serum FSH: men with small soft testes should have serum FSH measured; an elevated FSH predicts impaired spermatogenesis and a poorer prognosis
*'''Surgical Approaches'''
**'''Scrotal Incision'''
***'''Bilateral high vertical scrotal incisions provide the most direct access to the obstructed site in cases of vasectomy reversal'''
***'''If the vasal gap is large or the vasectomy site is high, this incision can easily be extended toward the external ring'''
***The testis should be delivered with the tunica vaginalis left intact
**'''Inguinal Incision'''
***'''An inguinal incision is the preferred approach in men when obstruction of the inguinal vas deferens from prior herniorrhaphy or orchiopexy is strongly suspected'''
*'''Maneuvers to gain vasal length what a large vasal gap is present (sequential):'''
*#'''Separate the cord structures from the vas''' with blunt dissection using a gauze-wrapped index finger
*#'''Dissect the entire convoluted vas''' '''free''' '''of its attachments''' (additional 4-6 cm of length) to the epididymal tunica, allowing the testis to drop upside down.
*#*'''The convoluted vas should not be unraveled. This disturbs the blood supply at the anastomotic line'''
*#'''Reroute vas under the floor of the inguinal canal''' by extending the incision to the internal inguinal ring and cutting the floor of the inguinal canal cut, as in a difficult orchiopexy
*#'''Dissect the epididymis off the testis''' '''from the vasoepididymal (VE) junction to the caput epididymis''' (additional 4-6 cm of length)
*#*'''See Epididymis Anatomy Notes'''
*#*'''The epididymis can be intentionally dissected off the testis and mobilized to the caput, with the inferior and medial epididymal arteries intentionally ligated without adverse consequence. As long as the superior epididymal artery remains intact, the blood supply to the epididymis will be adequate'''
*#'''With this combination of maneuvers, up to 10-cm gaps can be bridged'''

*'''When to Perform Vasoepididymostomy'''
**'''A vasovasostomy is performed when:'''
**#'''Copious, crystal clear, water-like fluid squirts out from the vas and no sperm are found in this fluid'''
**#'''If microscopic examination of the vasal fluid reveals the presence of sperm with tails'''
**'''If no fluid is found''', a 24-gauge angiocatheter sheath is inserted into the lumen of '''the testicular end of the vas and barbotaged with 0.1 mL of saline while the convoluted vas is vigorously milked.''' '''The barbotage fluid is expressed onto a slide and examined'''
***'''Men with large sperm granulomas''' often have virtually no dilation of the testicular end of the vas and little or no fluid initially; however, '''with barbotage and vigorous milking, invariably sperm can be found in this scant fluid and vasovasostomy is performed'''
***'''If there is no sperm granuloma, and the vas is absolutely dry and spermless after multiple samples have been examined, vasoepididymostomy is indicated'''
***'''If the fluid expressed from the vas is found to be thick, white, water insoluble, and toothpaste-like''' in quality, microscope examination rarely reveals sperm. Under these circumstances, '''the tunica vaginalis is opened and the epididymis inspected. If clear evidence of obstruction is found—that is, an epididymal sperm granuloma with dilated tubules above and collapsed tubules below—vasoepididymostomy is performed.''' When in doubt, or if not very experienced with vasoepididymostomy, vasovasostomy should be performed.
****Vasoepididymostomy should only be performed on an epididymal tubule containing sperm
**'''Relationship between gross appearance of vasal fluid and microscopic findings'''
***'''UrologySchool.com Summary'''
****'''Clear/thin, water vasal fluid: vasovasostomy'''
****'''Thick/dry vasal fluid: vasoepididymostomy'''

*'''Multiple Vasal Obstructions'''
**'''See section on arterial supply in Vas Deferens Anatomy Chapter Notes'''
**'''Simultaneous vasovasostomies at two separate sites will usually lead to devascularization of the intervening segment with fibrosis and necrosis'''
*'''Varicocelectomy and Vasovasostomy'''
**See Varicocelectomy Chapter Notes
**'''When varicocelectomy is properly performed, all spermatic veins are ligated and the only remaining routes for testicular venous return are the (deferential) vasal veins'''
**'''Varicocelectomy in men with a history of vasectomy with or without reversal requires careful preservation of the testicular artery as the primary remaining testicular blood supply as well as preservation of some avenue for venous return since the vasal arteries and veins are likely to be compromised from either the original vasectomy or the reversal itself'''
*Anastomotic Techniques: Keys to Success
*#Mucosa-to-mucosa approximation
*#Leakproof anastomosis
*#Tension-free anastomosis
*#Good blood supply
*#Healthy mucosa and muscularis
*#Good atraumatic anastomotic technique
*Microsurgical Multilayer Microdot Method
**The microdot technique ensures precise suture placement by exact mapping of each planned suture.
**Exactly 6 mucosal sutures are used for every anastomosis
*'''Crossed Vasovasostomy'''
**'''Used to connect a healthy testicle to the contralateral unobstructed vas'''
**'''Indications (2):'''
***'''Unilateral obstruction of the inguinal vas deferens or ejaculatory duct associated with contralateral:'''
***#'''Atrophic testis'''
***#'''Epididymal obstruction'''
***#*It is preferable to perform one anastomosis with a high probability of success (vasovasostomy) than two operations with a much lower chance of success (e.g., unilateral vasovasoepididymostomy and contralateral TURED
*'''Postoperative Management'''
**Scrotal support at all times (except in the shower), even when sleeping, for 6 weeks postoperatively. Thereafter, scrotal support is worn during athletic activity until pregnancy is achieved.
**Desk work is resumed in 3 days. No heavy work or sports are allowed for 3 weeks.
**'''No intercourse or ejaculation is allowed for 3 weeks postoperatively.'''
**Semen analyses are obtained at 1, 3, and 6 months postoperatively and every 6 months thereafter. '''If azoospermia persists at 6 months, a redo vasovasostomy or vasoepididymostomy will be necessary'''
*'''Postoperative Complications'''
**'''The most common complication is hematoma'''
**'''Progressive loss of motility followed by decreasing counts indicates stricture'''
***'''Because of the risk of late stricture and obstruction, cryopreservation of semen specimens as soon as motile sperm appear in the ejaculate is strongly recommended'''