Vasectomy is a common procedure for permanent birth control in the US with over 520,000 performed a year. This is a form of secondary infertility. Six percent of men who have undergone a vasectomy desire a reversal with 12 times higher desire for reversal if the vasectomy was performed under the age of 30. Options for men who wish to have more children either with the same or new partner include vasectomy reversal, sperm aspiration (not undoing the vasectomy) with IVF-ICSI, donor sperm insemination, adoption or doing nothing. The decision to follow a particular option is determined on a case-by-case basis and depends on important factors such as length of time from vasectomy, experience and training of the surgeon and use of an operating microscope; age of the female partner; gynecological history of the female partner; and economic/financial issues since post vasectomy fertility management is most often not covered by insurance. A common myth is that men over 10 years should not have a vasectomy reversal – this is not correct, with the decision making based on the whole evaluation including examination and couples desires and time line as well as issues of views on family planning hopes of the couple. Vasectomy reversal is performed either as an end to end connection – removing the area of vasectomy and reconnecting, and this is called a vasovasostomy. The other type of reversal is a connection between the vas and the back of the testicle (the epididymis) called a vasoepididymostomy. The decision to perform one or the other of these operations depends on the fluid seen at the vasectomy site at the time of the vas reversal. The vasoepididymostomy is a very specialized microsurgery operation that requires significant training. Dr Nangia is trained in this operation. Vasectomy reversal is an outpatient surgery and then semen analysis checked 4 weeks after surgery and periodically there after until pregnancy occurs. Success rates are approximately 75% pregnancy if the vasectomy was performed under 3-5 years prior to approximately 30% if vasectomy was 15 or more years previously.
Sperm aspiration/retrieval techniques for use with IVF-ICSI can be performed in many ways (MESA, TESA, TESE, microTESE) depending on the situation for each patient/couple – ranging from men who have had a vasectomy to men who do not have sperm in the ejaculated semen, known as azoospermia. The reason men have no sperm in the semen and who do not have a blockage (known as non obstructive azoospermia) can be genetic, hormonal or unknown. In up to 10% of cases the genetic reason is felt to be due to missing a piece of the Y chromosome (the male chromosome), known as the AZF region. Some men may also have pieces of one chromosome on another (translocation) or too many X chromosomes. These can be checked by performing blood work. Azoospermia is not the end of the road for having biological children. Even though a man may not have sperm in the semen, there may still be pockets of sperm in the testicles that are not getting out and can be retrieved in up to 60% of cases. This does require a special type of sperm retrieval called micro TESE – which is an extensive biopsy using an operating microscope. This does have to be performed in the operating room. The number of sperm can only be used with IVF-ICSI. Genetic counseling of a couple is sometimes needed especially if a known genetic problem is found.
Another group of patients may develop infertility – those who receive chemotherapy or radiation for cancer. In these cases men should try to freeze sperm prior to treatment for later use if their counts are too low or zero. Hope is not lost in those who did not freeze and may require micro TESE or use of ART. Spinal cord injury in a young man is another reason for problems with fertility – mainly because of ejaculatory issues. In this situation special methods are required to retrieve sperm for couples to have children. Sometimes men have retrograde ejaculation – sperm going into the bladder e.g diabetics, spinal cord injuries, neurological issues, urological/prostate surgery and medications. Retrieval of the sperm from the bladder can be performed to use with assisted reproduction. Sometimes medications can be used to reverse retrograde ejaculation.
At the University of Kansas Medical Center, we have a comprehensive male infertility center that includes an andrology laboratory capable of semen analysis, cryopreservation, and other sophisticated sperm testing. Dr. Ajay Nangia works closely with the reproductive endocrinologists at KU and in the community when couples desire to pursue assisted reproduction – insemination or in vitro fertilization (IVF). Dr. Nangia is fellowship trained from the Cleveland Clinic in male infertility and microsurgery and specializes in vas and epididymis reconstruction, sophisticated sperm retrieval techniques, as well as problems of fertility following cancer and other illnesses including spinal cord injury. Dr. Nangia is a national leader in this field, as well as issues of male contraception.