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Repeat Vasovasostomy vs MESA/TESE with ICSI in Patients with Failed Vasovasostomy

Soo Woong Kim, M.D. Department of Urology, Seoul National University College of Medicine, Seoul, Korea. Repeat Vasovasostomy vs MESA/TESE with ICSI in Patients with Failed Vasovasostomy. Vasovasostomy.

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Repeat Vasovasostomy vs MESA/TESE with ICSI in Patients with Failed Vasovasostomy

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  1. Soo Woong Kim, M.D. Department of Urology, Seoul National University College of Medicine, Seoul, Korea Repeat Vasovasostomy vs MESA/TESE with ICSI in Patients with Failed Vasovasostomy

  2. Vasovasostomy - highly successful procedure: patency rate; 84-90%, pregnancy rate; 48-52% - substantial failure rate in achieving patency Failed Vasovasostomy - repeat vasectomy reversal: worthwhile procedure vasovasostomy or epididymovasostomy - other options: MESA or TESE in conjunction with ICSI/IVF Introductions

  3. repeat vasectomy reversal References Patency rate(%) Pregnancy rate(%) Belker et al. 75.1(148/197) 43.3(52/120) Fox 63.6(14/20) 27.3(6/22) Donovan et al. 77.8(14/18) 44.4(8/18) Matthews et al. 67.2(43/64) 26.6(17/64) Hernandez & Sabanegh 78.8(26/33) 30.8(8/26) Our series 91.9(57/62) 57.1(24/42) Overall 76.6(302/394) 39.4(115/292) Repeat VR vs ICSI 1. Treatment Outcome

  4. MESA or TESE in conjunction with ICSI • obstructive azoospermia: • failed VR, irreparable genital tract obstruction, CAVD, etc • pregnancy rate/1 cycle of ICSI: 56%(52-60) • - delivery rate/1 cycle of ICSI: 29%(14-35) • pregnancy rate in repeat VR: 39.4%(26.6-57.1) • normal pregnancies in all cases • in our series: pregnancy rate; 57.1%(24/42) • delivery rate; 52.4%(22/42)

  5. 2. Costs in other countries • epididymovasostomy vs ICSI/newborn: 31,000$ vs 51,000$ • Kolettis & Thomas, 1997 • vasovasostomy vs ICSI/newborn: 5,400DM vs 28,800DM • Heidenreich et al., 2000 • repeat VR vs ICSI/newborn: 14,900$ vs 51,000$ • Donovan et al., 1998 in Korea - vasovasostomy vs ICSI: 약 200만원 vs 300만원

  6. 3. Safety • possible transmission of foreign DNA • Chane et al., 2000 • complications of ART: hyperovulation, oocyte retrieval, ET • Schenker & Ezra, 1994 • multiple birth 4. Development of ICSI • application of ICSI in patent not pregnant patients s/p VR • high patency rate: 76.6%(63.6-91.9) • avoidance of repeat MESA or TESE

  7. 1. Causes of Failed Vasovasostomy obstruction of the anastomotic site • anastomosis of the scarred ends of the vas • cauterization on the surface of the transected vasal end • anastomotic tension secondary epididymal obstruction • ‘epididymal blowout’: Silber, 1979 • vasal obstruction  pressure   rupture of epididymal duct Vasovasostomy vs Epididymovasostomy

  8. 2. Controversies - when sperm are absent in the vasal fluid - surgical principle: EV d/t 2o epididymal obstruction - our opinion: the incidence of epididymal blowout is much lower than that to be thought in cases of failed VR cases We repeated only vasovasostomy following failed vasovasostomy regardless of the findings in the intravasal fluid.

  9. 3. Rationale of VV in Failed VV - vasovasostomy in cases of bilateral intravasal azoospermia: patency rate; 60.2%(50/83), pregnancy rate; 30.8%(20/65) - incidence ofintravasal azoospermia is related with duration of obstruction; 9%  2 years, 27% > 15 years - repeat VR in failed vasovasostomy: Royle & Hendry, 1985 obstruction of anastomotic site; 52.2%(12/23) secondary epididymal obstruction; 17.4%(4/23) - analyses of repeat VR in failed vasovasostomy:

  10. epididymovasostomy • microsurgical single tubular anastomosis Silber, 1987 • difficult procedure requiring considerable microsurgical skill • patency rate; 70%(58-85) pregnancy rate; 31%(27-42)

  11. our series • microsurgical VV in failed VV regardless of detection of sperm • in the intravasal fluid during operation • patency rate; 91.9%(57/62) pregnancy rate; 57.1(24/42) % patency % pregnancy bilateral sperm present 95.7(22/23) 60.0(9/15) unilateral sperm present 100(10/10) 57.1(4/7) bilateral sperm absent 86.2(25/29) 55.0(11/20) overall 91.9(57/62) 57.1(24.42)

  12. considerations - anastomotic tension during the first vasovasostomy: mobilization of a sufficient length - local anesthesia ? - increased rate of anastomosis in convoluted vas: accurate anastomosis – modified one-layer VV ?

  13. - guideline for EV in failed VV: 5 of 62 cases of our series; persistent azoospermia s/p VV 4 of these 5 cases; bilat. absence of sperm in the vasal fluid 4 of 62 cases(6.5%); suspicious epididymal obstruction - mean interval to pregnancy: 11.7 mos.(2-48) pregnancy within 12 mos.; 18/24(75%) - whether previous VV has been done with adequate skills ?

  14. Conclusions - Even in the era of ICSI, repeat vasectomy reversal should be given favorable considerations in cases with failed vasovasostomy. - We recommend that microsurgical vasovasostomy should be performed preferentially in repeat vasectomy reversal cases. - Further studies are needed to establish the guideline for epididymovasostomy in repeat vasectomy reversal cases.

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