Infertility Analysis of International Practice Patterns Regarding Postvasectomy Fertility Options Ola Blach, Anand N. Shridharani, and Jay I. Sandlow OBJECTIVE MATERIALS AND METHODS
RESULTS
CONCLUSION
To review the management of postvasectomy fertility options by urologists with vs without andrology fellowship and compare the features of practice in the USA vs UK. We conducted an audit of all American Urological Associationeaffiliated urologists regarding their practice in managing men requesting vasectomy reversal (VR). Standards of practice were assessed against 10 index parameters deemed, by 1 UK study, to reflect best practice. Fisher exact test was used to test the hypothesis that management of postvasectomy fertility options and practice of VR are no different when undertaken by urologists with vs without andrology training and no different in the USA vs UK. Three hundred twenty-five of 645 US respondents (50.4%) practiced VR vs 178 of 213 (83.6%) in the UK; only 11.9% in the US and 10% in the UK performed >25 and >15 (P 25 to reflect the greater incidence of VR in the USA. Three further parameters were added to reflect the recommendations of the Practice Committee of the AUA on the VR practice.12 These were used to assess the differential performance between the urologists with and without andrology fellowship training who counsel couples seeking to parent after previous vasectomy and perform VR. The performance of respondents against the same 10 indices and their type of practice (private group, private hospital, academic, or solo) were also examined 1066
according to the number of procedures undertaken per annum. Fisher exact test was used to test the hypothesis that the management of fertility options after previous vasectomy and the practice of VR are no different when undertaken by urologists with and without andrology fellowship training and no different based on the number of procedures undertaken per annum. The results of this study were then compared with the data from the national survey of UK,9,11 so as to determine the differences in VR practice between the 2 countries and suggest improvements to the practice in each country on the basis of the results. Finally, the respondents were invited to add any comments about the subject they wished to share.
RESULTS A total of 7581 surveys were sent, and 645 responses were received (response rate 8.5%). Of those, 325 (50.4%) urologists practiced VR. Most, 54.1%, performed 1-5 VR/ year; 20.4% performed 6-10, 13.5% carried out 11-25, with just 11.9% performing >25 per year. The results are displayed in Table 1. With regards to preoperative counseling, most urologists (62.6%) preferred to counsel both partners together at the initial appointment, but only 9.7% insisted on doing so, and almost a quarter, 24.2%, had no preference. As many as 92.2% of urologists routinely discussed other options for parenting preoperatively, including IVF/ICSI (96.1%), donor intrauterine insemination (74.9%), and adoption (76.2%); however, 2.8% offered no other information apart from that on VR. In addition, 63.3% considered themselves fully conversant and aware of IVF treatment for postvasectomy fertility, 27.8% had a rough idea, whereas 5.4% were uncertain of who would be a good candidate for it; IVF was not available to 3.5%. Encouragingly, all urologists provided some preoperative counseling about the expected outcome of VR. However, only 36.7% quoted their own audited results, whereas most, 62.9%, relied on figures quoted from literature. Of all the urologists who practiced VR at the time of this study, 49.4% performed vasovasostomy only, whereas 50.6% were able to convert from vasovasostomy to vasoepididymostomy when indicated. Three quarters (74.8%) of urologists routinely evaluated the intraoperative vas fluid for microscopic examination; where no sperm were seen, half (51.4%) performed vasoepididymostomy instead, 40.6% continued with vasovasostomy only, and 8% stopped and referred the patient elsewhere. Less than half performed synchronous sperm retrieval at the time of VR, either routinely (10.5%) or when specifically asked (37.1%). The vast majority of urologists used intraoperative magnification when performing VR: 83.4% used an operating microscope, 16.3% used loupes, with just 1 urologist (0.3%) using no form of magnification. Microscopic 2-layer closure was the most popular method of anastomosing vas (51.4%), followed by modified UROLOGY 83 (5), 2014
Table 1. Differential performance of the urologists with and without andrological training against the 10 indices of “best practice” USA Urologists (309) Andrology Trained
Nonandrology Trained
Index Parameter
N 74
% 23.9
N 235
% 76.1
Perform >25 VR/year Insist or prefer seeing both partners Discuss all options for parenting in detail Fully conversant with criteria for IVF/ICSI Individualized information about expected outcome Quote own outcomes Quote figures from literature Use of intraoperative magnification Use an operating microscope Use of loupes intraoperatively Routinely/if asked retrieve sperm at the time of VR Routinely evaluate intraoperative vas fluid Perform vasoepididymostomy when no sperms seen Perform microscopic 2 layer closure
29 63 60 72 74 44 30 74 74 — 67 70 71 53
39.2 85.1 81.1 97.3 100 59.5 40.5 100 100 — 90.5 94.6 95.9 71.6
8 161 120 122 234 68 166 234 184 50 80 160 89 106
3.4 68.5 51.1 51.2 99.6 28.9 70.6 99.6 78.3 21.3 34 68.1 37.9 45.1
P Value .0001 .0046 .0001 .0001 1 .0001 .0001 1 .0001 .0001 .0001 .0001 .0001 .0001
IVF/ICSI, in vitro fertilization with intracytoplasmic sperm injection; VR, vasectomy reversal.
microscopic 1-layer closure (36.4%); macroscopic techniques were used least frequently by 12.1% (combined). Most urologists learned microsurgical skills during their residency (46.6%) or fellowship (23.3%) in a microsurgery laboratory (13.1%) or self-taught (8.6%). Seventy-four urologists were fellowship trained in andrology or male infertility, whereas 235 performed VR without subspecialty training; responses from the 16 who did not provide this information were excluded from this part of the analysis. Differential performance of the urologists with and without andrological training against the 10 indices of “best practice” is summarized in Table 1, along with P values for the Fisher exact test. Broadly, concordance with all 10 parameters was significantly higher among the urologists with fellowship training in andrology or male infertility, as they were more likely to counsel couples about all fertility options, be conversant in IVF/ICSI, provide individualized outcomes data, and use microsurgical techniques. Those urologists also had a higher annual caseload, with 76.3% of the urologists fellowship trained in andrology performing >25 VR/year (Table 2). Similarly, performance of the respondents against the same 10 indices also improved with the increasing number of procedures undertaken per annum (Table 2). No clear relationship, however, was found between the type of practice (private group, private hospital, academic, or solo) and the annual VR caseload (Table 2). A number of differences in the management of fertility options after previous vasectomy also existed between the USA and the UK (Table 3). US urologists performed more VR each year, offered more detailed information on all fertility options and likely outcomes, and used microsurgical techniques better. Unlike the UK urologists, however, they less frequently counseled infertile couples together and referred patients to specialist centers UROLOGY 83 (5), 2014
for IVF/ICSI. Importantly, in both countries, the urologists with specialist andrology training and high case volumes seemed to achieve better concordance with the indices of “best practice”.
COMMENT Pragmatic management of previously vasectomized patients seeking to parent again is a complex process, requiring good understanding of the advantages and disadvantages of all treatment options, factors influencing their outcomes, and potential morbidities. Best practice guidelines are available to clinicians from sources such as the American and the Royal College of Obstetricians and Gynecologists,13 American Society for Reproductive Medicine, Human Fertilization and Embryology Authority,14 and the World Health Organization.15 These bodies suggest that infertile couples, including those with secondary infertility after previous vasectomy, should be evaluated and counseled together.16 Protocols further stipulate that couples who select VR for fertility restoration should be specifically counseled regarding the impact of factors such as age of the female partner,17 time since vasectomy,18 previous surgery to the region (including previous reversal attempts), and past fertility history of both the male and female partner on their treatment. Encouragingly, discussion of the alternative methods of parenting other than VR and factors affecting treatment outcomes was a routine part of the preoperative counseling by the vast majority of respondents in this study. Nevertheless, it seems beneficial for urologists to counsel the couples together, as the decision to parent after previous vasectomy is ultimately made by both partners, and the treatment result is influenced by both male and female fertility factors.18 1067
Table 2. Relationship between the annual case volume and the subspecialty interest, the differential performance against the 10 indices of “best practice”, and the practice type Number of Vasectomy Reversals per Annum 1-5 Proportion of Responses Urologists with andrology fellowship training Urologists without andrology fellowship training Index parameters Insist or prefer seeing both partners Discuss all options for parenting in detail Fully conversant with criteria for IVF/ICSI Individualized information about expected outcome Quote own outcomes Quote figures from literature Use of intraoperative magnification Use an operating microscope Use of loupes intraoperatively Routinely retrieve sperm at the time of VR Routinely evaluate intraoperative vas fluid Perform vasoepididymostomy when no sperms seen Perform microscopic 2-layer closure Practice Private group Private hospital Academic Solo
6-10
>25
11-25
N 170
% 54.1
N 65
% 20.4
N 43
% 13.5
N 38
% 11.9
10 156
5.8 91.8
14 50
21.5 76.9
21 21
48.8 48.8
29 8
76.3 21.1
116 92 84 166 39 127 167 124 43 63 118 61 86
68.2 54.1 49.4 97.6 22.9 74.7 98.2 72.9 25.3 37.1 69.4 35.9 50.6
51 36 43 65 28 37 64 59 5 29 42 34 31
78.5 55.4 66.2 100 43.1 56.9 98.5 90.8 7.7 44.6 64.6 52.3 47.7
32 26 34 42 20 22 42 40 2 27 36 30 22
74.4 60.5 79.1 97.7 46.5 51.2 97.7 93 4.7 62.8 83.7 69.8 51.2
31 29 36 38 27 11 38 37 1 30 37 36 22
81.2 76.3 94.7 100 71.1 28.9 100 97.4 2.6 78.9 97.4 94.7 57.9
104 15 14 27
61.2 8.8 8.2 15.9
29 6 8 15
46.8 9.2 12.3 23.1
15 2 17 4
34.9 4.7 39.5 9.3
14 2 13 6
36.8 5.2 34.2 15.8
Abbreviations as in Table 1.
Ideally, patients should be provided with personalized information on predicted reconstructive outcomes.9 As the post-VR vasal patency and subsequent live birth rates vary greatly between different surgeons (with pregnancy rates reportedly ranging from 31% to 63%12), it has been suggested9 that surgeons’ own outcomes should be quoted in preference to figures from literature. This may, however, be difficult to achieve in practice: although all urologists in this study provided some preoperative counseling about the expected outcome of VR, only a third quoted their own results. In addition, we are not aware, based on the survey, if VR surgeons preoperatively stated whether they were able to perform a vasoepididymostomy in the appropriate setting. Live birth rates after VR are harder to audit than vasal patency rates, partly because of loss of patients to follow-up, and partly because of the pathophysiologic changes to the ductal system after vasectomy and VR,5 as evident from the discrepancy between the vasal patency and pregnancy rates, and the impact of the female partner on pregnancy outcome. Nevertheless, it is the authors’ opinion that reasonable attempts should be made by surgeons to audit at least the vasal patency rates. The surgical approach and technique used are of crucial importance to yielding maximum outcomes for infertile couples; thus, VR should ideally be performed using optical magnification provided by an operating microscope. This was appreciated by all but one urologist in the study who did not use any form of intraoperative magnification when performing VR. Access to an operating microscope is also necessary for microscopic closure 1068
of the vas, which is considered to provide superior results to macroscopic closure techniques.12 The microscopic 2layer and the modified 1-layer anastomosis were the 2 most commonly used techniques of vas closure. Although the 2-layer closure was preferred by most urologists (51.4% vs 36.4%), both have been reported to yield comparable results.12 Thus, the choice between them should be down to individual preference and experience with either technique. Although sperm retrieval and cryopreservation during VR are advocated by some, others believe it to be neither beneficial nor cost effective.19,20 The split in the opinions was reflected in this study by the fact that less than half of the urologists performed synchronous sperm harvesting at the time of VR. However, 3 quarters of the respondents practiced, as recommended,12 intraoperative microscopic analysis of the fluid collected from the remainder of vas deferens to guide the choice between the 2 available VR techniques: vasovasostomy and vasoepididymostomy. The choice between vasovasostomy and vasoepididymostomy depends on the urologist’s personal experience in performing the latter. In this study, only half of the respondents were able to convert from vasovasostomy to vasoepididymostomy when indicated; as recommended12 although almost all those who were not experienced in vasoepididymostomy either continued with vasovasostomy only or stopped and referred the patient elsewhere, thus preserving the option of a later vasoepididymostomy, if necessary. As vasoepididymostomy needs to be performed in cases of secondary epididymal obstruction and is a more technically challenging UROLOGY 83 (5), 2014
Table 3. Differential performance of the urologists with and without andrological training practicing in the USA compared with those practicing in the UK against the 10 indices of “best practice” USA Urologists
UK Urologists
Andrology Trained Nonandrology Trained
Andrology Trained Nonandrology Trained
Index Parameter Perform >25 (US) or > 15 (UK) VR per year Insist or prefer seeing both partners Discuss all options for parenting in detail Fully conversant with criteria for IVF/ICSI Individualized information about expected outcome Use an operating microscope Use of loupes intraoperatively Routinely/if asked retrieve sperm at the time of VR
N 74
% 23.9
N 235
% 76.1
P Value
N 61
% 32.4
N 121
% 64.3
P Value
29
39.2
8
3.4
.0001
15
24.6
5
4.1
.0001
63
85.1
161
68.5
.0046
46
85.2
77
80.2
.5122
60
81.1
120
51.1
.0001
34
63.0
42
43.8
.0277
72
97.3
122
51.2
.0001
29
53.7
22
22.9
.0003
45
86.5
68
70.8
.0421
74
100
234
99.6
1
74
100
184
78.3
.0001
21
40.4
25
26.3
.0950
—
—
50
21.3
.0001
28
53.8
48
50.5
.7324
67
90.5
80
34
.0001
9
17.6
10
10.4
.3010
Abbreviations as in Table 1.
procedure, VR should preferably be performed by an experienced microsurgeon with requisite formal training in both procedures; reassuringly, 25 VR/year. Similarly, performance of the respondents against the same 10 indices also improved with the increasing number of procedures undertaken per annum. This supports the notion that experienced specialists with formal training and caseloads that support the maintenance of microsurgical skills may be best equipped to manage patients seeking to parent after previous vasectomy. A prospective study, however, is necessary to determine whether these differences in UROLOGY 83 (5), 2014
practice standards and annual case volumes translate into different success rates, as measured by vasal patency and live birth rates, between the urologists with and without fellowship training in andrology. A number of differences in the management of fertility options after previous vasectomy also existed between the urologists practicing in the USA and the UK, reflecting the fundamental differences in the health care systems that prevail in each country. Fewer vasal reconstructions were performed in the UK, where only 5.3% urologists9 were able to offer VR as a National Health Servicee funded procedure. However, in both countries, VR was the most affordable and cost-effective option for selffunding couples. US urologists in this study offered more detailed information on all fertility options and likely outcomes and used microsurgical techniques better compared with UK urologists, where significantly fewer had access to operating microscopes.11 Synchronous sperm harvesting and cryopreservation at the time of VR were also more widely practiced by the US urologists because of the concerns over its cost-effectiveness and practical considerations, such as sperm processing and storage, which, in the UK, are only available to a small number of urologists practicing within specialist assisted reproductive technology units.11 Unlike in the UK, where patients and their partners are typically referred from primary care (family practice) for specialist management together, US urologists less frequently counseled the infertile couples together and referred them to specialist centers for IVF/ICSI. Fewer US urologists also audited their own outcomes as measured by live birth rates compared with the UK, where fewer patients are subsequently lost to follow-up because of more robust 1069
exchange of information between primary and specialist care in the National Health Service. Importantly, in both countries, urologists with specialist andrology training and high case volumes seemed to achieve better concordance with the indices of “best practice”, supporting the drive toward subspecialist management of infertile couples. Several limitations to this study should be considered. Infertile couples should ideally be managed by multidisciplinary teams, involving urologists, gynecologists, and reproductive endocrinologists, to ensure thorough review of their problems and balanced consideration of the treatment options available to them. Furthermore, different options may be presented to them by different specialists. Ours was a cross-sectional study, describing survey-based data from urologists only; it remains unknown how many postvasectomy patients undergo IVF/ ICSI in the USA and how many have previously attempted reversal procedures. Had the same questions been presented to gynecologists and reproductive endocrinologists, the answers could potentially differ. In future, this could serve as basis for a further cross-sectional study investigating variations in counseling and management of infertile couples by doctors with different specialty interests. With regards to the study design, a questionnaire-based audit was undertaken of all active AUA members, and links to the survey have been E-mailed to 7581 members, excluding any international, trainee, student, or allied members. As the questions asked were tailored to qualified urologists performing VR in the USA, this is unlikely to have led to any significant selection or exclusion bias. Of note, our study period was limited to 2 weeks only, unlike in the UK, where it extended to 2 months, thus significantly impacting on the response rate of 8.5%. Had the study period been longer, the response rate could potentially have been similar to the one in the UK study (29%). This also highlights the limitations of E-mailgenerated questionnaire-based audits and their general resentment by the medical profession.
CONCLUSION The current management of secondary infertility after previous vasectomy and the practice of VR are characterized by wide variation in preoperative counseling, surgical technique, and postoperative follow-up. Significant differences exist in the standards of practice among the urologists performing VR, both in the US and the UK. Generally, concordance with the indices of “best practice” improves with specialist andrology training and
1070
the increasing number of procedures undertaken per annum. On the basis of these differences, outcomes data should be analyzed to determine if success rates differ, and if so, guidelines should be established. References 1. Barone MA, Hutchinson PL, Johnson CH, et al. Vasectomy in the United States, 2002. J Urol. 2006;176:232-236. 2. HES. Hospital Episode Statistics. NHS; 2005:6. 3. Marie Stopes International. Vasectomy - your questions answered. Available at: http://www.mariestopes.org.uk/documents/Vasectomy %20-%20your%20questions%20answered.pdf. Accessed August 31, 2012. 4. Cook LA, Van Vliet HAAM, Lopez LM, et al. Vasectomy occlusion techniques for male sterilisation. Cochrane Database Syst Rev. 2007; 18:CD003991. 5. Bernie AM, Osterberg EC, Stahl PJ, et al. Vasectomy reversal in humans. Spermatogenesis. 2012;2:273-278. 6. Goldstein M. Vasectomy reversal. Compr Ther. 1993;19:37-41. 7. Pile JM, Barone MA. Demographics of vasectomy - USA and international. Urol Clin North Am. 2009;36:295-305. 8. Shridharani A, Sandlow JI. Vasectomy reversal vs. IVF: which is better? Curr Opin Urol. 2010;20:503-509. 9. Grey BR, Sinclair AM, Thompson A, et al. UK urologists’ management of secondary azoospermia following previous vasectomy. BAUS Audits. 2010. 10. Sharlip ID, Belker AM, Honig S, et al. Vasectomy: AUA guideline. J Urol. 2012;188:2482-2491. 11. Grey BR, Sinclair AM, Thompson A, et al. UK practice regarding reversal of vasectomy 2001-2010: relevance to best contemporary patient management. BJU Int. 2012;110:1040-1047. 12. Practice Committee of the American Society for Reproductive Medicine. Vasectomy reversal. Fertil Steril. 2006;86:S268-S271. 13. Moody J. Fertility Assessment and Treatment for People with Fertility Problems: RCOG Clinical Guideline. London: Royal College of Obstetricians and Gynaecologists; 2004. 14. HFEA. Code of Practice. 6th ed. London: Human Fertilisation and Embryology Authority; 2004. 15. Rowe P. WHO Manual for the Standardized Investigation and Diagnosis of the Infertile Couple. Cambridge: Cambridge University Press; 1997. 16. School of Public Health, University of Leeds. The Management of Subfertility. Effective Healthcare, Vol. 1. Leeds: School of Public Health; 1992:1-240. 17. Gerrard ER Jr, Sandlow JL, Oster RA, et al. Effect of female partner age on pregnancy rates after vasectomy reversal. Fertil Steril. 2007; 87:1340-1344. 18. Belker AM, Thomas AJ Jr, Fuchs EF, et al. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol. 1991;145:505-511. 19. Schrepferman CG, Carson MR, Sparks AE, et al. Need for sperm retrieval and cryopreservation at vasectomy reversal. J Urol. 2001; 166:1787-1789. 20. Boyle KE, Thomas AJ Jr, Marmar JL. Sperm harvesting and cryopreservation during vasectomy reversal is not cost effective. Fertil Steril. 2006;85:961-964. 21. Grilli R, Minozzi S, Tinazzi A, et al. Do specialists do it better? The impact of specialization on the processes and outcomes of care for cancer patients. Ann Oncol. 1998;9:365-374.
UROLOGY 83 (5), 2014
RESULTS
CONCLUSION
To review the management of postvasectomy fertility options by urologists with vs without andrology fellowship and compare the features of practice in the USA vs UK. We conducted an audit of all American Urological Associationeaffiliated urologists regarding their practice in managing men requesting vasectomy reversal (VR). Standards of practice were assessed against 10 index parameters deemed, by 1 UK study, to reflect best practice. Fisher exact test was used to test the hypothesis that management of postvasectomy fertility options and practice of VR are no different when undertaken by urologists with vs without andrology training and no different in the USA vs UK. Three hundred twenty-five of 645 US respondents (50.4%) practiced VR vs 178 of 213 (83.6%) in the UK; only 11.9% in the US and 10% in the UK performed >25 and >15 (P 25 to reflect the greater incidence of VR in the USA. Three further parameters were added to reflect the recommendations of the Practice Committee of the AUA on the VR practice.12 These were used to assess the differential performance between the urologists with and without andrology fellowship training who counsel couples seeking to parent after previous vasectomy and perform VR. The performance of respondents against the same 10 indices and their type of practice (private group, private hospital, academic, or solo) were also examined 1066
according to the number of procedures undertaken per annum. Fisher exact test was used to test the hypothesis that the management of fertility options after previous vasectomy and the practice of VR are no different when undertaken by urologists with and without andrology fellowship training and no different based on the number of procedures undertaken per annum. The results of this study were then compared with the data from the national survey of UK,9,11 so as to determine the differences in VR practice between the 2 countries and suggest improvements to the practice in each country on the basis of the results. Finally, the respondents were invited to add any comments about the subject they wished to share.
RESULTS A total of 7581 surveys were sent, and 645 responses were received (response rate 8.5%). Of those, 325 (50.4%) urologists practiced VR. Most, 54.1%, performed 1-5 VR/ year; 20.4% performed 6-10, 13.5% carried out 11-25, with just 11.9% performing >25 per year. The results are displayed in Table 1. With regards to preoperative counseling, most urologists (62.6%) preferred to counsel both partners together at the initial appointment, but only 9.7% insisted on doing so, and almost a quarter, 24.2%, had no preference. As many as 92.2% of urologists routinely discussed other options for parenting preoperatively, including IVF/ICSI (96.1%), donor intrauterine insemination (74.9%), and adoption (76.2%); however, 2.8% offered no other information apart from that on VR. In addition, 63.3% considered themselves fully conversant and aware of IVF treatment for postvasectomy fertility, 27.8% had a rough idea, whereas 5.4% were uncertain of who would be a good candidate for it; IVF was not available to 3.5%. Encouragingly, all urologists provided some preoperative counseling about the expected outcome of VR. However, only 36.7% quoted their own audited results, whereas most, 62.9%, relied on figures quoted from literature. Of all the urologists who practiced VR at the time of this study, 49.4% performed vasovasostomy only, whereas 50.6% were able to convert from vasovasostomy to vasoepididymostomy when indicated. Three quarters (74.8%) of urologists routinely evaluated the intraoperative vas fluid for microscopic examination; where no sperm were seen, half (51.4%) performed vasoepididymostomy instead, 40.6% continued with vasovasostomy only, and 8% stopped and referred the patient elsewhere. Less than half performed synchronous sperm retrieval at the time of VR, either routinely (10.5%) or when specifically asked (37.1%). The vast majority of urologists used intraoperative magnification when performing VR: 83.4% used an operating microscope, 16.3% used loupes, with just 1 urologist (0.3%) using no form of magnification. Microscopic 2-layer closure was the most popular method of anastomosing vas (51.4%), followed by modified UROLOGY 83 (5), 2014
Table 1. Differential performance of the urologists with and without andrological training against the 10 indices of “best practice” USA Urologists (309) Andrology Trained
Nonandrology Trained
Index Parameter
N 74
% 23.9
N 235
% 76.1
Perform >25 VR/year Insist or prefer seeing both partners Discuss all options for parenting in detail Fully conversant with criteria for IVF/ICSI Individualized information about expected outcome Quote own outcomes Quote figures from literature Use of intraoperative magnification Use an operating microscope Use of loupes intraoperatively Routinely/if asked retrieve sperm at the time of VR Routinely evaluate intraoperative vas fluid Perform vasoepididymostomy when no sperms seen Perform microscopic 2 layer closure
29 63 60 72 74 44 30 74 74 — 67 70 71 53
39.2 85.1 81.1 97.3 100 59.5 40.5 100 100 — 90.5 94.6 95.9 71.6
8 161 120 122 234 68 166 234 184 50 80 160 89 106
3.4 68.5 51.1 51.2 99.6 28.9 70.6 99.6 78.3 21.3 34 68.1 37.9 45.1
P Value .0001 .0046 .0001 .0001 1 .0001 .0001 1 .0001 .0001 .0001 .0001 .0001 .0001
IVF/ICSI, in vitro fertilization with intracytoplasmic sperm injection; VR, vasectomy reversal.
microscopic 1-layer closure (36.4%); macroscopic techniques were used least frequently by 12.1% (combined). Most urologists learned microsurgical skills during their residency (46.6%) or fellowship (23.3%) in a microsurgery laboratory (13.1%) or self-taught (8.6%). Seventy-four urologists were fellowship trained in andrology or male infertility, whereas 235 performed VR without subspecialty training; responses from the 16 who did not provide this information were excluded from this part of the analysis. Differential performance of the urologists with and without andrological training against the 10 indices of “best practice” is summarized in Table 1, along with P values for the Fisher exact test. Broadly, concordance with all 10 parameters was significantly higher among the urologists with fellowship training in andrology or male infertility, as they were more likely to counsel couples about all fertility options, be conversant in IVF/ICSI, provide individualized outcomes data, and use microsurgical techniques. Those urologists also had a higher annual caseload, with 76.3% of the urologists fellowship trained in andrology performing >25 VR/year (Table 2). Similarly, performance of the respondents against the same 10 indices also improved with the increasing number of procedures undertaken per annum (Table 2). No clear relationship, however, was found between the type of practice (private group, private hospital, academic, or solo) and the annual VR caseload (Table 2). A number of differences in the management of fertility options after previous vasectomy also existed between the USA and the UK (Table 3). US urologists performed more VR each year, offered more detailed information on all fertility options and likely outcomes, and used microsurgical techniques better. Unlike the UK urologists, however, they less frequently counseled infertile couples together and referred patients to specialist centers UROLOGY 83 (5), 2014
for IVF/ICSI. Importantly, in both countries, the urologists with specialist andrology training and high case volumes seemed to achieve better concordance with the indices of “best practice”.
COMMENT Pragmatic management of previously vasectomized patients seeking to parent again is a complex process, requiring good understanding of the advantages and disadvantages of all treatment options, factors influencing their outcomes, and potential morbidities. Best practice guidelines are available to clinicians from sources such as the American and the Royal College of Obstetricians and Gynecologists,13 American Society for Reproductive Medicine, Human Fertilization and Embryology Authority,14 and the World Health Organization.15 These bodies suggest that infertile couples, including those with secondary infertility after previous vasectomy, should be evaluated and counseled together.16 Protocols further stipulate that couples who select VR for fertility restoration should be specifically counseled regarding the impact of factors such as age of the female partner,17 time since vasectomy,18 previous surgery to the region (including previous reversal attempts), and past fertility history of both the male and female partner on their treatment. Encouragingly, discussion of the alternative methods of parenting other than VR and factors affecting treatment outcomes was a routine part of the preoperative counseling by the vast majority of respondents in this study. Nevertheless, it seems beneficial for urologists to counsel the couples together, as the decision to parent after previous vasectomy is ultimately made by both partners, and the treatment result is influenced by both male and female fertility factors.18 1067
Table 2. Relationship between the annual case volume and the subspecialty interest, the differential performance against the 10 indices of “best practice”, and the practice type Number of Vasectomy Reversals per Annum 1-5 Proportion of Responses Urologists with andrology fellowship training Urologists without andrology fellowship training Index parameters Insist or prefer seeing both partners Discuss all options for parenting in detail Fully conversant with criteria for IVF/ICSI Individualized information about expected outcome Quote own outcomes Quote figures from literature Use of intraoperative magnification Use an operating microscope Use of loupes intraoperatively Routinely retrieve sperm at the time of VR Routinely evaluate intraoperative vas fluid Perform vasoepididymostomy when no sperms seen Perform microscopic 2-layer closure Practice Private group Private hospital Academic Solo
6-10
>25
11-25
N 170
% 54.1
N 65
% 20.4
N 43
% 13.5
N 38
% 11.9
10 156
5.8 91.8
14 50
21.5 76.9
21 21
48.8 48.8
29 8
76.3 21.1
116 92 84 166 39 127 167 124 43 63 118 61 86
68.2 54.1 49.4 97.6 22.9 74.7 98.2 72.9 25.3 37.1 69.4 35.9 50.6
51 36 43 65 28 37 64 59 5 29 42 34 31
78.5 55.4 66.2 100 43.1 56.9 98.5 90.8 7.7 44.6 64.6 52.3 47.7
32 26 34 42 20 22 42 40 2 27 36 30 22
74.4 60.5 79.1 97.7 46.5 51.2 97.7 93 4.7 62.8 83.7 69.8 51.2
31 29 36 38 27 11 38 37 1 30 37 36 22
81.2 76.3 94.7 100 71.1 28.9 100 97.4 2.6 78.9 97.4 94.7 57.9
104 15 14 27
61.2 8.8 8.2 15.9
29 6 8 15
46.8 9.2 12.3 23.1
15 2 17 4
34.9 4.7 39.5 9.3
14 2 13 6
36.8 5.2 34.2 15.8
Abbreviations as in Table 1.
Ideally, patients should be provided with personalized information on predicted reconstructive outcomes.9 As the post-VR vasal patency and subsequent live birth rates vary greatly between different surgeons (with pregnancy rates reportedly ranging from 31% to 63%12), it has been suggested9 that surgeons’ own outcomes should be quoted in preference to figures from literature. This may, however, be difficult to achieve in practice: although all urologists in this study provided some preoperative counseling about the expected outcome of VR, only a third quoted their own results. In addition, we are not aware, based on the survey, if VR surgeons preoperatively stated whether they were able to perform a vasoepididymostomy in the appropriate setting. Live birth rates after VR are harder to audit than vasal patency rates, partly because of loss of patients to follow-up, and partly because of the pathophysiologic changes to the ductal system after vasectomy and VR,5 as evident from the discrepancy between the vasal patency and pregnancy rates, and the impact of the female partner on pregnancy outcome. Nevertheless, it is the authors’ opinion that reasonable attempts should be made by surgeons to audit at least the vasal patency rates. The surgical approach and technique used are of crucial importance to yielding maximum outcomes for infertile couples; thus, VR should ideally be performed using optical magnification provided by an operating microscope. This was appreciated by all but one urologist in the study who did not use any form of intraoperative magnification when performing VR. Access to an operating microscope is also necessary for microscopic closure 1068
of the vas, which is considered to provide superior results to macroscopic closure techniques.12 The microscopic 2layer and the modified 1-layer anastomosis were the 2 most commonly used techniques of vas closure. Although the 2-layer closure was preferred by most urologists (51.4% vs 36.4%), both have been reported to yield comparable results.12 Thus, the choice between them should be down to individual preference and experience with either technique. Although sperm retrieval and cryopreservation during VR are advocated by some, others believe it to be neither beneficial nor cost effective.19,20 The split in the opinions was reflected in this study by the fact that less than half of the urologists performed synchronous sperm harvesting at the time of VR. However, 3 quarters of the respondents practiced, as recommended,12 intraoperative microscopic analysis of the fluid collected from the remainder of vas deferens to guide the choice between the 2 available VR techniques: vasovasostomy and vasoepididymostomy. The choice between vasovasostomy and vasoepididymostomy depends on the urologist’s personal experience in performing the latter. In this study, only half of the respondents were able to convert from vasovasostomy to vasoepididymostomy when indicated; as recommended12 although almost all those who were not experienced in vasoepididymostomy either continued with vasovasostomy only or stopped and referred the patient elsewhere, thus preserving the option of a later vasoepididymostomy, if necessary. As vasoepididymostomy needs to be performed in cases of secondary epididymal obstruction and is a more technically challenging UROLOGY 83 (5), 2014
Table 3. Differential performance of the urologists with and without andrological training practicing in the USA compared with those practicing in the UK against the 10 indices of “best practice” USA Urologists
UK Urologists
Andrology Trained Nonandrology Trained
Andrology Trained Nonandrology Trained
Index Parameter Perform >25 (US) or > 15 (UK) VR per year Insist or prefer seeing both partners Discuss all options for parenting in detail Fully conversant with criteria for IVF/ICSI Individualized information about expected outcome Use an operating microscope Use of loupes intraoperatively Routinely/if asked retrieve sperm at the time of VR
N 74
% 23.9
N 235
% 76.1
P Value
N 61
% 32.4
N 121
% 64.3
P Value
29
39.2
8
3.4
.0001
15
24.6
5
4.1
.0001
63
85.1
161
68.5
.0046
46
85.2
77
80.2
.5122
60
81.1
120
51.1
.0001
34
63.0
42
43.8
.0277
72
97.3
122
51.2
.0001
29
53.7
22
22.9
.0003
45
86.5
68
70.8
.0421
74
100
234
99.6
1
74
100
184
78.3
.0001
21
40.4
25
26.3
.0950
—
—
50
21.3
.0001
28
53.8
48
50.5
.7324
67
90.5
80
34
.0001
9
17.6
10
10.4
.3010
Abbreviations as in Table 1.
procedure, VR should preferably be performed by an experienced microsurgeon with requisite formal training in both procedures; reassuringly, 25 VR/year. Similarly, performance of the respondents against the same 10 indices also improved with the increasing number of procedures undertaken per annum. This supports the notion that experienced specialists with formal training and caseloads that support the maintenance of microsurgical skills may be best equipped to manage patients seeking to parent after previous vasectomy. A prospective study, however, is necessary to determine whether these differences in UROLOGY 83 (5), 2014
practice standards and annual case volumes translate into different success rates, as measured by vasal patency and live birth rates, between the urologists with and without fellowship training in andrology. A number of differences in the management of fertility options after previous vasectomy also existed between the urologists practicing in the USA and the UK, reflecting the fundamental differences in the health care systems that prevail in each country. Fewer vasal reconstructions were performed in the UK, where only 5.3% urologists9 were able to offer VR as a National Health Servicee funded procedure. However, in both countries, VR was the most affordable and cost-effective option for selffunding couples. US urologists in this study offered more detailed information on all fertility options and likely outcomes and used microsurgical techniques better compared with UK urologists, where significantly fewer had access to operating microscopes.11 Synchronous sperm harvesting and cryopreservation at the time of VR were also more widely practiced by the US urologists because of the concerns over its cost-effectiveness and practical considerations, such as sperm processing and storage, which, in the UK, are only available to a small number of urologists practicing within specialist assisted reproductive technology units.11 Unlike in the UK, where patients and their partners are typically referred from primary care (family practice) for specialist management together, US urologists less frequently counseled the infertile couples together and referred them to specialist centers for IVF/ICSI. Fewer US urologists also audited their own outcomes as measured by live birth rates compared with the UK, where fewer patients are subsequently lost to follow-up because of more robust 1069
exchange of information between primary and specialist care in the National Health Service. Importantly, in both countries, urologists with specialist andrology training and high case volumes seemed to achieve better concordance with the indices of “best practice”, supporting the drive toward subspecialist management of infertile couples. Several limitations to this study should be considered. Infertile couples should ideally be managed by multidisciplinary teams, involving urologists, gynecologists, and reproductive endocrinologists, to ensure thorough review of their problems and balanced consideration of the treatment options available to them. Furthermore, different options may be presented to them by different specialists. Ours was a cross-sectional study, describing survey-based data from urologists only; it remains unknown how many postvasectomy patients undergo IVF/ ICSI in the USA and how many have previously attempted reversal procedures. Had the same questions been presented to gynecologists and reproductive endocrinologists, the answers could potentially differ. In future, this could serve as basis for a further cross-sectional study investigating variations in counseling and management of infertile couples by doctors with different specialty interests. With regards to the study design, a questionnaire-based audit was undertaken of all active AUA members, and links to the survey have been E-mailed to 7581 members, excluding any international, trainee, student, or allied members. As the questions asked were tailored to qualified urologists performing VR in the USA, this is unlikely to have led to any significant selection or exclusion bias. Of note, our study period was limited to 2 weeks only, unlike in the UK, where it extended to 2 months, thus significantly impacting on the response rate of 8.5%. Had the study period been longer, the response rate could potentially have been similar to the one in the UK study (29%). This also highlights the limitations of E-mailgenerated questionnaire-based audits and their general resentment by the medical profession.
CONCLUSION The current management of secondary infertility after previous vasectomy and the practice of VR are characterized by wide variation in preoperative counseling, surgical technique, and postoperative follow-up. Significant differences exist in the standards of practice among the urologists performing VR, both in the US and the UK. Generally, concordance with the indices of “best practice” improves with specialist andrology training and
1070
the increasing number of procedures undertaken per annum. On the basis of these differences, outcomes data should be analyzed to determine if success rates differ, and if so, guidelines should be established. References 1. Barone MA, Hutchinson PL, Johnson CH, et al. Vasectomy in the United States, 2002. J Urol. 2006;176:232-236. 2. HES. Hospital Episode Statistics. NHS; 2005:6. 3. Marie Stopes International. Vasectomy - your questions answered. Available at: http://www.mariestopes.org.uk/documents/Vasectomy %20-%20your%20questions%20answered.pdf. Accessed August 31, 2012. 4. Cook LA, Van Vliet HAAM, Lopez LM, et al. Vasectomy occlusion techniques for male sterilisation. Cochrane Database Syst Rev. 2007; 18:CD003991. 5. Bernie AM, Osterberg EC, Stahl PJ, et al. Vasectomy reversal in humans. Spermatogenesis. 2012;2:273-278. 6. Goldstein M. Vasectomy reversal. Compr Ther. 1993;19:37-41. 7. Pile JM, Barone MA. Demographics of vasectomy - USA and international. Urol Clin North Am. 2009;36:295-305. 8. Shridharani A, Sandlow JI. Vasectomy reversal vs. IVF: which is better? Curr Opin Urol. 2010;20:503-509. 9. Grey BR, Sinclair AM, Thompson A, et al. UK urologists’ management of secondary azoospermia following previous vasectomy. BAUS Audits. 2010. 10. Sharlip ID, Belker AM, Honig S, et al. Vasectomy: AUA guideline. J Urol. 2012;188:2482-2491. 11. Grey BR, Sinclair AM, Thompson A, et al. UK practice regarding reversal of vasectomy 2001-2010: relevance to best contemporary patient management. BJU Int. 2012;110:1040-1047. 12. Practice Committee of the American Society for Reproductive Medicine. Vasectomy reversal. Fertil Steril. 2006;86:S268-S271. 13. Moody J. Fertility Assessment and Treatment for People with Fertility Problems: RCOG Clinical Guideline. London: Royal College of Obstetricians and Gynaecologists; 2004. 14. HFEA. Code of Practice. 6th ed. London: Human Fertilisation and Embryology Authority; 2004. 15. Rowe P. WHO Manual for the Standardized Investigation and Diagnosis of the Infertile Couple. Cambridge: Cambridge University Press; 1997. 16. School of Public Health, University of Leeds. The Management of Subfertility. Effective Healthcare, Vol. 1. Leeds: School of Public Health; 1992:1-240. 17. Gerrard ER Jr, Sandlow JL, Oster RA, et al. Effect of female partner age on pregnancy rates after vasectomy reversal. Fertil Steril. 2007; 87:1340-1344. 18. Belker AM, Thomas AJ Jr, Fuchs EF, et al. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol. 1991;145:505-511. 19. Schrepferman CG, Carson MR, Sparks AE, et al. Need for sperm retrieval and cryopreservation at vasectomy reversal. J Urol. 2001; 166:1787-1789. 20. Boyle KE, Thomas AJ Jr, Marmar JL. Sperm harvesting and cryopreservation during vasectomy reversal is not cost effective. Fertil Steril. 2006;85:961-964. 21. Grilli R, Minozzi S, Tinazzi A, et al. Do specialists do it better? The impact of specialization on the processes and outcomes of care for cancer patients. Ann Oncol. 1998;9:365-374.
UROLOGY 83 (5), 2014
