presence, gross fuid quality, microscopic sperm characteristics,

and surgeon, only microscopic sperm characteristics (bilateral

or unilateral whole spermatozoa vs. other) were signiFcantly

associated with postoperative patency (OR: 14.2; 95% CI: 5.8

–

34.9;

DISCUSSION

It has been over 20 years since the landmark study o± the VV

Study Group, yet these results are still o±ten cited to patients

desiring VR. A review o± the VR literature shows postoperative

patency ranging ±rom 69% to 98% (Ratana-olarn

et al.

, 1982;

Patel & Sigman, 2008), with pregnancy success ranging ±rom

37% to 93% (Chiang, 1996; Silber & Grotjan, 2004). Patency and

pregnancy a±ter VV depend on multiple ±actors such as surgeon

experience, age o± the ±emale partner, whether the ±emale part-

ner is the same be±ore and a±ter VR, OI, intravasal fuid quality,

and microscopic assessment ±or spermatozoa (Belker

et al.

1991; Kolettis

et al.

, 2002, 2003a,b,c). This retrospective study

represents an attempt to review the data ±rom two experienced

microsurgeons on the outcomes o± bilateral VV. We examined

the infuence o± perioperative variables on postoperative patency

to better counsel patients undergoing VV. We ±ound that among

all ±actors evaluated, intraoperative microscopic exam o± the

vasal fuid was most strongly associated with success±ul outcome

±ollowing VV.

Patency in our study was similar to the VV Study Group at

98%. Unlike the VV Study Group, we did not Fnd that a longer OI

or the absence o± sperm granuloma on physical exam were asso-

ciated with success ±ollowing VR. Our data suggested that gross

fuid quality might be associated with outcome, showing that it

was perhaps better to have clear fuid. However, on multivari-

able analysis, fuid quality became insigniFcant; consequently

we cannot draw a strong conclusion regarding the impact o±

gross fuid characteristics. O± note, we restricted our analysis to

men who underwent VV only. There±ore, it is tempting to specu-

late whether gross fuid quality would have been more strongly

associated with surgical outcome had we included men who

underwent EV.

We conFrmed the known association between the presence o±

intravasal spermatozoa during VV and having a success±ul

patency outcome. SpeciFcally, we showed that the odds o± post-

operative patency were approximately 14 times higher given the

presence o± intravasal whole spermatozoa as opposed to merely

having sperm ±ragments or azoospermia. These odds, while not

directly comparable to the 4

odds we identiFed in the recent

meta-analysis due to a di±±erence in the way the independent

variable was modeled, are in agreement with our meta-analysis

(Scovell

et al.

, 2014). Given the heterogeneity o± the studies

included in the meta-analysis, it is a challenge to compare OR

±rom the meta-analysis to the OR in the present study. The take

home message should be that intraoperative identiFcation o±

whole spermatozoa during VR is positively associated with suc-

cess±ul patency.

Our study is limited by the ±act that it is retrospective in nat-

ure. The patients who were included were highly selected by the

surgeons because the surgeons thought that they would have the

best chance o± post-operative success with VV. All men who were

included in the study had normal serum ±ollicle stimulating hor-

mone (²SH) levels and testis volumes. Azoospermia ±ollowing

VR could have been secondary to testis ±ailure rather than a ±ail-

ure o± the operation. I± men with post-VR azoospermia actually

had testis ±ailure and were patent, the observed OR would have

been artiFcially increased. Un±ortunately, we do not have testis

volume or ²SH measurements to report. There±ore only 24 o±

1331 men had a ±ailed VV. Because o± the relatively small num-

ber o± events, our statistical power may be limited to detect asso-

ciations regarding pregnancy success. We were unable to assess

the e±±ects o± age o± the ±emale partner or whether the ±emale

partner was the same be±ore and a±ter VR on outcomes in this

cohort. We used 1

million motile spermatozoa as criteria

±or patency. We realize that this may not be su±Fcient to achieve

a pregnancy through natural conception. The study was ±ocused

on intraoperative fuid quality and microscopic Fndings as it

relates to return o± spermatozoa to ejaculate. A total o± 410 men

o± 1331 men reported pregnancies. The study is limited in that

we cannot calculate a pregnancy rate because we do not have

pregnancy data on the remaining men.

Per±orming EV rather than VV is an intraoperative decision

(both surgeons in this study per±ormed EV only ±or bilateral

intravasal azoospermia and unilateral or bilateral creamy fuid)

and it remains di±Fcult to determine who will have epididymal

obstruction and need a EV prior to surgery. Our study popula-

tion was limited to those men undergoing VV ±or VR and we

excluded men undergoing EV. Given the wide variations in

Table 3

Associations between perioperative factors and postoperative patency

LCI

UCI

Univariate effects estimates

Age (1-year increase)

1.0

0.9

1.0

0.268

OI (1-year increase)

0.9

1.0

0.051

Granuloma (Bilateral or unilateral present vs. absent)

1.8

0.4

7.8

0.413

Gross Fuid quality (Bilateral or unilateral clear/opaque vs. other)

3.4

1.3

8.6

0.010

Microscopic characteristics (Bilateral or unilateral whole spermatozoa vs. other)

12.0

5.4

26.8

Surgeon (#1 vs. #2)

4.0

1.3

11.9

0.014

Multivariate effects estimates

Age (1-year increase)

1.0

0.9

1.1

0.845

OI (1-year increase)

0.9

1.0

0.064

Granuloma (Bilateral or unilateral present vs. absent)

1.2

0.2

5.5

0.844

Gross Fuid quality (Bilateral or unilateral clear/opaque vs. other)

1.3

0.5

3.9

0.581

Microscopic characteristics (Bilateral or unilateral whole vs. other)

14.2

5.8

34.9

Surgeon (#1 vs. #2)

3.8

1.0

14.9

0.052

The multivariate ORs were adjusted for age, OI, granuloma presence, gross Fuid quality, microscopic characteristics, and surgeon. OR, odds ratio; LCI, lower 95% con±-

dence interval; UCI, upper 95% con±dence interval; OI, obstructive interval.

534

Andrology

, 2015, 3, 532–535

2015 American Society of Andrology and European Academy of Andrology

R. Ramasamy and D.A. Mata

et al.

ANDROLOGY