Introduction: Fertility options following vasectomy include vasectomy reversal (VR) and/or sperm retrieval with IVF/ICSI. Needle aspiration of the epididymis poses a theoretical risk of epididymal scarring and obstruction and may have implications on the operative approach during VR and post- operative outcomes. As such, many couples are discouraged from considering VR following PESA. The current study investigates the intra-operative (vasal fluid, sperm quality, anastomotic technique) and post-operative outcomes (patency, semen parameters) of VR following PESA.
Methods: A prospective patient data series of 2023 VRs performed by a single surgeon between 2007-2020 was reviewed to identify men who had undergone sperm retrieval via PESA prior to VR. Intra-operative findings related to vasal fluid characteristics, vasal sperm quality and anastomotic technique (vasovasostomy - VV/vasoepididymostomy - VE) were correlated with PESA details (side/location). Post-operative semen parameters and patency rates were compared among patients with a pre-VR PESA vs. men with no history of PESA prior to VR.
Results: A total of 28 men were identified who underwent uni- or bilateral PESA prior to VR. Mean patient age was 43.5 years and mean obstructive interval was 11.7 years. 44% and 66% of men reported having a bilateral and unilateral PESA, respectively. Overall, bilateral VV was performed in 82% of cases, with VE (all unilateral) in 18% of patients. Among patients requiring VE, 80% had a PESA performed on the same side and no sperm were identified upon microscopic vasal fluid analysis on the side of the PESA during VR. Among all testicular/vasal units where a PESA was performed on that side, favorable vasal fluid characteristics (non-paste-like) were identified in 81% of cases and intra-operative microscopic vasal fluid analysis confirmed the presence of sperm in 82% of men. Compared to an aged-matched sample of patients (n=28) with no history of PESA prior to VR, post-operative patency rates (motile sperm in ejaculate) were equivalent (94% PESA+VR, 94% VR). Mean total motile sperm counts (TMC) were 18.4 among PESA + VR patients compared to 23.4 among patients who underwent VR without PESA.
Conclusions: Among men with a previous vasectomy and PESA, VR remains an option for couples wishing to conceive. Intra-operatively, favorable vasal fluid characteristics and sperm quality allowed for VV to be performed in >80% of men. Post-operative patency rates and semen parameters compared favourably to patients without a history of PESA prior to VR. Our results challenge the notion that PESA significantly alters reconstructive success of VR, offering the potential for natural fertility for this subset of men.
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