Fertility outcome after repeat vasoepididymostomy

Purpose: Historically, epididymal obstruction has been treated with surgica l reconstruction. We determine whether it is worthwhile for patients to und ergo repeat surgical reconstruction after failed vasoepididymostomy or whet her they should be advised only to undergo sperm acquisition for assisted r eproductive technique. Materials and Methods: A total of 18 patients underwent repeat vasoepididym ostomy performed by a single urologist (A. J. T.). Cases were divided based on the etiology of obstruction into groups 1-prior vasectomy (4), 2-congen ital (7) and 3-inflammatory (7). Data were available regarding time of obst ruction between initial and repeat vasoepididymostomy, quality of epididyma l fluid, levels of anastomoses, semen analyses at least 12 months after sur gery for all 18 men and pregnancy rates based on more than 18 months of fol lowup in 12. Results: Mean patient age at repeat vasoepididymostomy was 40.6 years (50.5 , 36 and 39.4 years for groups 1, 2 and 3, respectively). Mean interval bet ween vasectomy and initial vasoepididymostomy was 12.3 years (range 10 to 1 8). Mean interval between initial and repeat vasoepididymostomy was 19 mont hs (range 12 to 41). Of the patients 10 underwent unilateral and 8 bilatera l anastomoses, for a total of 26 repeat anastomoses. Overall patency rate w as 66.7% (12 of 18) with sperm. in the ejaculate in 75, 85 and 43% of patie nts in groups 1, 2 and 3, respectively. The patency rates according to the levels of the anastomosis were 66.7, 62.5 and 100% in the caput, corpus and cauda, respectively. Natural conception occurred in 3 of 12 couples (25%, 2 caput and 1 caudal anastomosis) during a mean followup of 23 months (rang e 13 to 34). All 3 cases had congenital obstruction. Pregnancy was achieved in 2 group 1 cases with cryopreserved sperm extracted at repeat vasoepidid ymostomy, and in 1 ease each in groups 1 and 2 with microsurgical epididyma l, sperm aspiration and intracytoplasmic sperm injection. Conclusions: After repeat vasoepididymostomy two-thirds of men have sperm i n the semen. Natural conception occurred in 25% of patients (3 of 12) follo wed for more than 18 months. Inability to establish pregnancy in the remain ing 7 of 9 patients with sperm in the semen with a followup longer than 18 months may be due to epididymal dysfunction or partial obstruction and subs equent poor sperm quality. Aspiration of motile sperm and cryopreservation were possible in II of 18 cases at repeat vasoepididymostomy and should be recommended in case azoospermia remains or occurs after surgery. It appears worthwhile to offer patients repeat vasoepididymostomy after a failed init ial procedure.