Editing CUA: Vasectomy (2016) (section)

== Post-vasectomy semen analysis ==

* '''See Figure 1 from Original CUA Guideline'''
* '''Timing'''
** '''AUA: 2-4 months after vasectomy'''
** '''CUA guidelines: 3 months''' '''after vasectomy'''
*** AUA: the choice of time to do the first post-vasectomy semen analysis should be left to the judgment of the surgeon. The longer the time period before the first post-vasectomy semen analysis, the better the chance that the post-vasectomy semen analysis will show azoospermia or rare non-motile sperm but the longer the time that the patient must use another method of contraception.
*** One study demonstrated that the fastest motile sperm clearance rates occurred when mucosal cautery was combined with fascial interposition, and the slowest rates occurred when ligation was used. The method of vas occlusion may be considered regarding timing of the first post-vasectomy semen analysis.
** '''Men or their partners should use other contraceptive methods until vasectomy success is confirmed by post-vasectomy semen analysis'''
* '''Vasectomy success (can abandon contraception):'''
** '''AUA: 1 sample that shows azoospermia OR only rare non-motile sperm (≤ 100,000 non-motile sperm/mL)'''
** '''CUA: 1 sample that shows azoospermia OR 2 samples that show only rare non-motile sperm'''
*** '''Patients should be told that semen samples should be collected after an abstinence period of 2-7 days, how to collect the semen sample, maintaining the sample at body temperature, and submitting the sample within 30‒60 minutes after production.'''
*** '''To properly evaluate sperm motility, a fresh uncentrifuged semen sample should be examined by direct microscopy within 2 hours after ejaculation. Centrifugation may interfere with sperm motility'''. '''If no sperm are seen, the centrifuged sample should be examined for the presence of motile and immotile sperm.'''
*** CUA: The evaluation of 2 post-operative semen samples is a better predictor of success than the evaluation of a single semen sample
*** Couples should be reminded about the risk of late failure despite azoospermia or rare immotile sperm on initial testing. In most cases, late failure is first identified as a pregnancy and later confirmed by semen analysis documenting presence of motile sperm.
**** The reappearance of sperm (mostly immotile) after documented azoospermia in 2 post-vasectomy semen samples may occur in up to 10% of patients. '''The reappearance (or persistence) of immotile sperm years after vasectomy has not been associated with documented pregnancies'''.
*** A self-post-vasectomy semen analysis home test has been approved by the FDA and is available for clinical use. This test is sensitive to sperm counts >250,000/ml, but the test does not assess for sperm motility. If two tests are performed and both are negative, then the negative predictive value of a sperm count >250,000 sperm/mL is 99.9%. However, the 250,000 sperm/mL cut-off is significantly higher than the cut-off most commonly used to declare a man sterile after vasectomy. The most commonly used cut-off in the literature and the definition of vasectomy success used in this guideline is ≤100,000 non-motile sperm/mL.
* '''Vasectomy failure'''
** '''May be due to'''
**# '''Technical failure resulting from a surgical error''' (such as occluding one vas twice without occluding the other vas)'''; characterized by persistently normal or nearly normal motile sperm counts and sperm motility after vasectomy'''
**# '''Failure to identify vas duplication on one side (very rare situation)'''
**# '''Recanalization at the vasectomy site;''' should be suspected if motile sperm or rising sperm concentrations are seen after a routine post-vasectomy semen analysis has shown azoospermia or rare non-motile sperm. Recanalization can be either transient or persistent based on the results of serial post-vasectomy semen analysis.
** '''AUA'''
*** '''If a post-vasectomy semen analysis demonstrates ANY motile sperm prior to 6 months, additional post-vasectomy semen analysis should be performed at intervals of 4-6 weeks for up to 6 months after vasectomy for further evaluation'''
**** ≈30-50% of men with recanalization eventually achieve azoospermia or rare non-motile sperm over a period of 6 months after vasectomy due to fibrosis of the vas and occlusion of the recanalization. Therefore, the decision to repeat the vasectomy should not rely on a single semen analysis showing motile sperm within 6 months after vasectomy.
**** '''Repeat vasectomy should be done if the number of motile sperm increases in subsequent semen analyses or if motile sperm persist for >6 months after vasectomy.'''
*** '''If > 100,000 non-motile sperm/mL persist beyond 6 months after vasectomy, trends of serial post-vasectomy semen analysis and clinical judgment should be used to decide whether the vasectomy is a failure and whether repeat vasectomy should be considered (CUA Guidelines consider this failure and recommend repeat vasectomy)'''
**** The decision to consider vasectomy a failure if >100,000 non-motile sperm/mL persist should be based on clinical judgment that includes the trend of sperm counts, the patient’s preferences and the patient’s tolerance for the risk of pregnancy.
** '''CUA'''
*** '''If a post-vasectomy semen analysis demonstrates ANY motile sperm OR >100,000 non-motile sperm''', '''patients must continue the use of other contraceptive measures and repeat semen analysis in 4-8 weeks'''
**** '''If repeat testing shows'''
***** '''Azoospermia or <100,000 non-motile sperm, contraception can be abandoned'''
***** '''Persistence of motile or > 100,000 non-motile sperm at 6 months after the initial procedure, a repeat vasectomy is indicated'''
** If a man reports that his wife has become pregnant and his semen analysis reveals azoospermia, the physician should inform him that the pregnancy could have been due to a transient recanalization despite the semen analysis results