Based on the 2012 AUA vasectomy guidelines,
which recommend only a single uncentrifuged
PVSA Fnding of azoospermia or RNMS, repeat data
analysis revealed that the occlusive success rate
and, thus, compliance improved to 97.6% (949 pa-
tients) (p
<
0.001, see table). A total of 921 patients
(94.7%) with azoospermia or RNMS on the Frst
PVSA met the criteria for occlusive success, while
another 28 achieved azoospermia or RNMS on the
second PVSA (part
B
of Fgure). The remaining
patients with greater than 100,000 nonmotile sperm
per ml or any motile sperm were lost to followup. On
the Frst PVSA 897 patients (92.3%) were azoosper-
mic on initial uncentrifuged semen analysis, as
would be recommended by the guidelines. However,
in 254 of those men (28.3%) RNMS was identiFed on
centrifuged pellet analysis only and they were not
cleared based on the institutional protocol. Also, all
3 repeat vasectomies were done due to continued
RNMS but they would have been unnecessary based
on the criteria for success deFned by the guidelines.
While it might be predicted that no unintended
pregnancies would have occurred based on these
criteria, it is likely that many of these men
continued to use some form of contraception.
A total of 1,919 combined PVSAs were performed.
When data were reanalyzed according to the 2012
AUA vasectomy guidelines, 896 PVSAs would not
have been necessary (see table). PVSA with centri-
fuged pellet analysis currently costs $150 at our
institution.
Therefore,
if
the
AUA
vasectomy
guidelines had been used throughout the study
period, approximately $134,400 in total health care
expenditure would have been saved.
Based on the criteria used for the 2012 AUA va-
sectomy guidelines the men in this study could have
returned to unprotected intercourse much earlier. A
total of 337 patients who underwent more than 1
PVSA for RNMS would otherwise have been cleared
for unprotected intercourse right away under the
2012 guidelines. However, after the Frst PVSA they
returned for an additional PVSA at a mean
±
SD
of 227.7
±
487.4 days (mean
±
SE 227.7
±
26.4,
median 21), resulting in lost work hours. On rean-
alysis according to the guidelines occlusive success
was achieved in 949 men at a mean
±
SD of 3.0
±
24.4 days (mean
±
SE of 3.0
±
0.8, median 0) after
the Frst PVSA. Accordingly, a signiFcant time sav-
ings would have been realized in men using alter-
native forms of contraception for a much longer
period after vasectomy.
DISCUSSION
Vasectomy provides a reliable method of contra-
ception because obstruction of the vas deferens
prevents sperm from passing completely through
the genital tract into the ejaculate. Since the pro-
cedure goals are to achieve azoospermia and
contraception, traditional approaches used to deFne
vasectomy success focus on azoospermia as the Fnal
end point.
Evidence-based data led the AUA vasectomy
guideline committee to include RNMS in the ejacu-
late in the deFnition of vasectomy occlusive success.
1) The percent of men who ultimately achieve
complete azoospermia after vasectomy varies.
7,8
Although the failure rate has remained constantly
low at 1/2,000 men,
5
PVSA studies reveal that up to
33% have RNMS remaining in the ejaculate 12
weeks after vasectomy.
14
2) Performing 2 consecu-
tive azoospermic PVSAs is not critical because it is
possible for sperm to return to the ejaculate when
there is late recanalization, even after 2 consecutive
azoospermic PVSAs.
5,14
Lemack and Goldstein
analyzed preoperative semen samples of 186 sterile,
vasectomized men before vasectomy reversal with
an average of 10.7
±
5.6 years since vasectomy.
15
Of
the men 16 (8.6%) had RNMS, while 2 (1.1%) had
motile sperm in the ejaculate. 3) Perhaps the most
important point is that men with RNMS show a
contraceptive failure rate similar to that of azoo-
spermic men after vasectomy.
11,16
e
18
Even when
motile sperm are found in the Frst PVSA, more
than 50% of patients ultimately achieve delayed
success.
19
The purpose of this study was to compare our
traditional approach to post-vasectomy determina-
tion of occlusive success with that of the 2012 AUA
vasectomy guidelines.
4
With the recent introduction
of RNMS into the deFnition of occlusive success we
hypothesized that the guidelines would decrease the
number of PVSAs, thus decreasing costs, improving
the success rate and compliance with followup,
Institutional laboratory post-vasectomy followup protocol vs AUA vasectomy guidelines in 972 patients each
Institutional*
AUA*
Difference
No. PVSAs†
1,919
1,023
896
% Occlusive success (No. pts)†:
34.7 (337)
97.6 (949)
62.9
No. repeat vasectomies†
3
0
3
Total PVSA cost ($)†
287,850
153,450
134,400
Mean/median days to occlusive success after PVSA 1†
227.7/21
3.0/0
21
*No unintended pregnancy with contraception achieved in all patients.
†p
<
0.001.
172
IMPACT OF VASECTOMY GUIDELINES ON OUTCOMES