Infertility
Association Between the Presence
of Sperm in the Vasal Fluid During
Vasectomy Reversal and Postoperative
Patency: A Systematic Review and
Meta-analysis
Jason M. Scovell, Douglas A. Mata, Ranjith Ramasamy, Lindsey A. Herrel, Wayland Hsiao,
and Larry I. Lipshultz
OBJECTIVE
To investigate the association between the presence of sperm in the vasal
fl
uid during vasectomy
reversal (VR) and postoperative patency.
METHODS
We performed a systematic review and meta-analysis of the English-language literature reporting
on the association between the presence of sperm in the intraoperative vasal
fl
uid (ie, whole or
parts vs none) and patency (ie, patent or not) after microsurgical vasovasostomy for men with
obstructive azoospermia due to vasectomy. Odds ratios (OR) and 95% con
f
dence intervals were
calculated to quantify the strength of the association reported by each study. Meta-analysis was
performed using a random-effects model.
RESULTS
Four case series and 2 retrospective cohort studies of a total of 1293 eligible patients were
identi
f
ed. The mean age at VR was 37.8 years, and the mean obstructive interval was 7.1 years.
The unadjusted OR of postoperative patency was 4.1 times higher (95% con
f
dence interval, 2.3-
7.3) given the presence of intravasal sperm or sperm parts as opposed to their absence at the time
of VR (Q
¼
3.4; df
¼
5;
P
¼
.6; I
2
¼
22%). The pooled OR should be interpreted with caution as
only the 2 retrospective cohort studies reported meaningful data on this association. Because of
inconsistent reporting, analysis of other vasal
fl
uid characteristics (eg, consistency) and outcomes
(eg, pregnancy) was not possible.
CONCLUSION
The presence of whole sperm or sperm parts in the vasal
fl
uid during VR is positively associated
with postoperative patency. Our review highlights the poor methodological quality of existing
evidence and underscores the need for more thorough follow up and higher standards of reporting
in future studies.
UROLOGY
85: 809
e
813, 2015.
Ó
2015 Elsevier Inc.
A
bout 175,000 to 354,000 vasectomies are per-
formed in the United States each year,
1
and up
to 6% of patients who undergo this procedure
later choose to undergo vasectomy reversal (VR).
2
A
landmark multicenter study on the outcomes of 1469
patients who underwent VR was published by the Vaso-
vasostomy Study Group in 1991.
3
They demonstrated
that a longer obstructive interval and an absence of sperm
granuloma on physical examination were associated with
decreased patency after VR. Other factors that appeared
to in
fl
uence success of VR were the character of the vasal
fl
uid and the presence of sperm or sperm parts at the time
of reversal.
During surgery, the physician
’
s decision to proceed
with vasovasostomy (VV) or epididymovasostomy (EV)
depends on the gross quality of
fl
uid expressed from the
testicular end of the vas deferens and on the microscopic
examination of the
fl
uid for sperm. Findings may include
motile or nonmotile whole sperm, sperm parts (ie, sperm
heads or tails alone), or no sperm. VV is routinely per-
formed if whole sperm are identi
f
ed in the vasal
fl
uid or if
the
fl
uid appears clear and copious, even in the absence of
sperm.
4
In contrast, when the
fl
uid quality is poor (ie,
paste-like) and sperm are absent, EV is generally required.
Modern series indicate that patency after VV approaches
99.5% when whole sperm are identi
f
ed.
5
Even in cases of
bilateral intravasal azoospermia, patency in some series
Jason M. Scovell and Douglas A. Mata contributed equally to this work.
Financial Disclosure:
The authors declare that they have no relevant
f
nancial interests.
From the Scott Department of Urology, Baylor College of Medicine, Houston, TX;
the Department of Pathology, Brigham and Women's Hospital, Boston, MA; the
Department of Urology, Emory University School of Medicine, Atlanta, GA; and the
Department of Urology, Kaiser Permanente, Oakland, CA
Address correspondence to: Larry I. Lipshultz, M.D., Department of Urology, Baylor
College of Medicine, 6624 Fannin Street, Suite 1700, Houston, TX 77030. E-mail:
larryl@bcm.edu
Submitted: June 3, 2014, accepted (with revisions): September 8, 2014
ª
2015 Elsevier Inc.
All Rights Reserved
0090-4295/15
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