sidney glina - · pdf filesidney glina faculdade de medicina do abc instituto h. ellis...
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Sidney Glina
Faculdade de Medicina do ABC
Instituto H. Ellis
Editor-in-Chief of the International Brazilian Journal of
Urology (www.intbrazjurol.com.br)
Vasectomy reversal: is there still a role?
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Conflict of Interest:
In the last 2 years I have been:
- Speaker for Besins, Lilly, Aché,
Eurofarma
- Member of Advisory Board of Aché,
Besins, EMS and Lilly
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Vasectomy as a contraceptive method
• Brasil: 2.1% of men1
• São Paulo: 6.1% of men1
• USA: 526 000 vasectomies in 2002 (10/10000
men between 25 and 49 y.o.)2
1. Vieira EM, Badiani R, Fabbro AL, Rodrigues
Jr. AL. Rev Saúde Pública 2002; 36:263-70
2. Barone MA, Hutchinson PL, Johnson CH,
Hsia J, Wheeler J. J Urol. 2007; 177:1205-6.
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Fertility after vasectomy
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Vasectomy Reversal
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Epidydimal sperm retrieval and ICSI
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USA:Reversals in 2 to 6% of vasectomised men 1 (almost 30000 reversals/year2)
UK: 40 thousand vasectomies/year and 2400 reversals/year 3
Netherland: 35000 vasectomies in 2004 and 2.6% of them went through reversal 4
Vasectomised men want to be father again?
1. Assisted reproductive technology success rates. National summary and fertility clinic reports. CDC Reproductive Health Information Source
2. Schwarzer et al., Current Status of Vasectomy Reversal, Nature Reviews, 10:195, 2013 3. McVicar CM, O'Neill DA, McClure N, Clements B, McCullough S, Lewis SE Hum Reprod. 2005;20(10): 4. Hepp SM, Meuleman EJ. 2795-800. Ned Tijdschr Geneeskd. 2006; 150:611-4
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Reasons for vasectomy
reversal
» New marriage 78,5 %
» Improvement of social economical conditions 8,6 %
» Regret (vasectomy w/out children) 4,3 %
» Desire for a child of other sex 3,2 %
» Child death 2,1 %
» Religious issue 1,0 %
Glina S e Dultra A – 2007
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Dr. Gynecologist
ICSI
the
best!
There is no
result after
more than 2
years of
vasectomy!
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Time since vasectomy and pregnancy rates
Vasectomy reversal
Belker et al., Results of the 1469 microsurgical vasectomy reversals by the Vasovasostomy
Study Group. J. Urol, 145:505, 1991.
Patency (%) Pregnancy (%)
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Vasectomy reversal 747 cases
Bolduc S, Fischer MA, Deceuninck G, Thabet M.
Can Urol Assoc J. 2007;1:388-94.
Pa
ten
cy r
ate
(%)
Pre
ga
na
nc
y r
ate
(%)
Years of vasectomy Years of vasectomy
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Dr. Gynecologist
ICSI is
the
best!
You are too
old to get
pregnant after
vasectomy
reversal
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Silber et al (N=4010, single center)1
Gerrard et al (N=294, multicenter)2
Hinz et al (N=212, single center)3
Maternal age and pregnancy rates
Vasectomy reversal
Maternal Age <30 30- <35 35- <40 >40
Pregnancy
(%)
92 87 77 54
Maternal
Age
<29 30-39 >40
Pregnancy
(%)
67 78 42
Maternal
Age
20-24 25-29 30-34 35-39 >40
Pregnancy
(%)
67 52 57 54 14
1 Silber, S., et al. Microscopic Vasectomy Reversal, J Androl, 25(6):845, 2004.
2 Gerrard, E., et al. Effect of female partner age on pregnancy rates after vasectomy reversal, Fertil Steril, 87(6):1340, 2007
3 Hinz, S., et al. Fertility Rates following vasectomy reversal: importance of age of the female partner, Urol Int, 81:416, 2008.
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Dr. Urologist
Reversal
is the
best!
There are risk
to the partner!
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Risks to Partner with IVF/ICSI Ovarian Hyper-stimulation Syndrome
(OHSS)
• High dose gonadotropins → OHSS1
• Severe form ~1%2
• Potentially fatal
• Due to massive estrogen production in mother → tense ascites with hydrothorax
• If not treated immediately → kidney failure, clotting disorders, PE and liver dysfunction
5* 1. Shmorgan D et al., J Obst Gyn Can, 33:1156-1162, 2011. 2. Alper MM et al., J Exp Clin Assist Reprod, 6:3-6, 2009
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Dr. Urologist
Reversal
is the
best!
ICSI is too
expensive!
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Fertility after vasectomy:
analysis of cost
$ ICSI $ Vaso-vaso
Pavlovich & Schlegel 72.521(MESA) 25.475
Kolettis & Thomas 51.024 (MESA) 31.099
Donovan e cols. 35.579 (MESA) 14.892
Deck & Berger 103.940 (TESA) 28.530*
Meng e cols. 39.506 (TESA) 38.983**
Lee e cols. 55.317(MESA) 21.304
53.356 (TESE)
Cost of baby at home
*Women > 37 years old (75% e 17%) **Without indirect costs
Lee et al - Urol Clin N Am 2008; 35:289:301
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Dr. Urologist
Reversal
is the best
Epididymal
punction can
destroy the
epididymus
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PESA effect on the epididymus
• 50 rats with vasectomy
•10 animals/group, 1 to 5 PESAs
• Sp + in all PESAs
• All animals showed histological alterations (fibrosis) after
2nd PESA
Saade RD, Neves PA, Glina S, D'Ancona CA, Dambros M, Lúcio MA
J Urol. 2008 ;179:381-4
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Low risk, outpatient procedure
mean OR time- 110 minutes
complications- 0.3% hematoma/ 0.8% infection
Anesthesia- local or general
Vasectomy Reversal
Schwarzer et al., Current Status of Vasectomy Reversal, Nature Reviews, 10:195, 2013
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• Spontaneous pregnancy
• Partner saved of any intervention
Consenso Infertilidade SBU - Int Braz J Urol, 2003;29(supl 5):35-8
Benefits of vasectomy
reversal
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• Anesthetic risk for the patient
• Worse results with longer time since
vasectomy
• Depends on surgeon skills
• Need for contraception
Consenso Infertilidade SBU - Int Braz J Urol, 2003;29(supl 5):35-8
Disadvantadges of
vasectomy reversal
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• Pregnacy achievement more rapid?
• No need for contraception.
Consenso Infertilidade SBU
Int Braz J Urol, 2003;29(supl 5):35-8
Benefits of PESA(MESA)/ICSI
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• Ovarian Hyperstimulation syndrome
• High cost
• Multiple pregnancy
• Can impair a futures vasectomy reversal
Consenso Infertilidade SBU
Int Braz J Urol, 2003;29(supl 5):35-8
Disadvantadges of PESA(MESA)/ICSI
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American Society of Reproductive Medicine*
Optimal treatment would allow the couple to conceive naturally
“Vasectomy reversal has been shown to be more cost effective than sperm retrieval and assisted reproduction”
Practice Committee Recommendations
*American Society of Reproductive Medicine, Practice Committee, Fert Steril,
90(3):213, 2008.
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“Microsurgical reconstruction, in cases
that are feasible, is a more cost-
effective approach and typically
yields better pregnancy rates than
sperm retrieval combined with ICSI”
Ramasamy and Schlegel. Vasectomy and vasectomy
reversal. Ind J Urol, 27(1): 92, 2011.