Persistent spermatozoa after vasectomy: a survey of British urologists

OBJECTIVES: To determine the rate of, and main indications for, repeat vasectomy in our department, and to assist in policy-making procedures by determining how urologists in England and Wales manage those men who show small but persistent quantities of motile or non-motile spermatozoa in their ejaculate after vasectomy. SUBJECTS AND METHODS: A retrospective review of all of the vasectomies and repeat vasectomies performed by the Urology Department at Southmead Hospital during a 14-month period was undertaken to determine the rate of and indications for repeat vasectomy. Subsequently, every consultant urologist in England and Wales was canvassed with a questionnaire to determine whether they repeated vasectomy in the presence of persistent motile or non-motile sperms and if so, after what time interval. Any experience of pregnancies arising from these groups was also assessed, and any relevant comments invited. RESULTS: The local review revealed that 5% of all vasectomies were repeated within 6-36 months. Of these, 87% were performed because of persistent sperms in post-vasectomy semen samples, the majority of which showed sperm concentrations of one in 50 to one in 100 high-power fields. A response of 56% was obtained to the questionnaire and of those responding, 23% never repeated a vasectomy where there were presistent non-motile sperms, but almost all urologists would eventually repeat vasectomy where motile sperms were present. The median interval between the first and second vasectomies was 6 months and 12 months for motile and non-motile sperm, respectively. Apart from those cases already published, there was little experience of pregnancy arising from men with persistently few motile or non-motile sperms. CONCLUSIONS: The risk of pregnancy occurring in the presence of non-motile sperms was estimated to be less than the established risk of late recanalization, and this survey provides both logical and medico-legal support for issuing a 'special clearance' to men with few persistent non-motile sperm after vasectomy, providing the risks of pregnancy are properly discussed and documented. For motile sperm, however, there appears to be a stronger precedent for repeating the vasectomy. The technique used for post-vasectomy semen analysis was also an important consideration when determining any policy regarding such cases.     

The fate of cryopreserved sperm acquired during vasectomy reversals

PURPOSE: Intraoperative sperm banking has been recommended during vasectomy reversal. These specimens are maintained as insurance for possible future intracytoplasmic sperm injection. We evaluated the fate of specimens collected intraoperatively from 48 vasectomy reversal patients. MATERIALS AND METHODS: Of 75 men 48 (64.0%) agreed to intraoperative sperm banking during vasectomy reversal. A total of 135 vials of epididymal sperm, 81 vials of testicular tissue and 13 vials of vasal sperm were cryopreserved. RESULTS: Among couples who stored sperm 10 (20.8%) voluntarily discarded the specimens within 4 months of vasectomy reversal. Specimens from 31 couples (64.5%) remain in storage. Seven couples (14.6%) have used frozen sperm for intracytoplasmic sperm injection. In 3 of these couples the men were azoospermic after surgery, 2 men had 10,000 to 15,000 sperm per ml. in the ejaculate with limited motility and 2 had 1 to 2 million sperm per ml. with limited motility. The 7 women who underwent intracytoplasmic sperm injection ranged between 37 and 39 years old, which was older than the mean age of the remaining study group (32.7 years). With intracytoplasmic sperm injection fertilization was achieved in all cases and 20 of 47 eggs (42.5%) developed into embryos. Of 7 women 4 achieved biochemical pregnancies (57.1%) and 2 (28.6%) delivered newborns with epididymal sperm. Natural pregnancy occurred in 7 of 16 vasectomy reversal couples (43.7%) who were followed at least 18 months postoperatively but the time to pregnancy averaged 1 year. CONCLUSIONS: Cryopreservation of sperm collected at vasectomy reversal is recommended for patients undergoing vasoepididymostomy or vasovasostomy. The couples who used the cryopreserved sperm for intracytoplasmic sperm injection included husbands whose postoperative ejaculate remained azoospermic or severely oligospermic and wives who were approaching 40 years old. Only a limited number of couples (14.6% of the study group) have used the cryopreserved sperm but the delivered newborn rate (28.6%) was comparable to other intracytoplasmic sperm injection data. The natural pregnancy rate after vasectomy reversal was 43.7% but the time to pregnancy after surgery was lengthy (average 1 year). These findings may be helpful for counseling couples who are planning vasectomy reversal surgery and may be considering intraoperative sperm banking.     

Vasectomy and human immunodeficiency virus type 1 in semen

PURPOSE: Human immunodeficiency virus type 1 (HIV) is cultured more often from seminal cells than seminal plasma. Because vasectomy causes dramatic reductions in seminal cells and also eliminates secretions from proximal sites in the male reproductive tract, vasectomy may change the potential infectiousness of semen. MATERIALS AND METHODS: We used polymerase chain reaction (PCR) assays to measure HIV ribonucleic acid (RNA) in seminal plasma and HIV deoxyribonucleic acid (DNA) in seminal cells from 46 asymptomatic, seropositive men before and after vasectomy. RESULTS: HIV RNA levels in semen correlated only weakly with blood levels (r = 0.22, p = 0.03). Of 183 semen specimens assayed for cell-free HIV RNA and proviral DNA 37 (20%) were positive for HIV RNA only, 41 (22%) were positive for HIV DNA only, and 18 (10%) were positive for RNA and DNA. Thus, detection of HIV RNA in seminal plasma was not associated with detection of HIV DNA in seminal cells. HIV RNA was present in 23 of 82 specimens (28%) (mean 2.87 log copies/ml.) before vasectomy and in 38 of 121 specimens (31%) after vasectomy (mean 2.81 log copies/ml.). CONCLUSIONS: These findings suggest that direct measurement of HIV levels in semen is necessary to assess the potential for sexual transmission, most cell-free HIV in seminal plasma arises distal to the vas deferens, and vasectomy may have minimal impact on the infectiousness of HIV seropositive men on sexual partners.     

Linear palmo-plantar porokeratotic hamartoma

We report a case of 30-year-old man with generalized seizure, who had received phenytoin (PHT) for more than 6 years, but developed decrease in sperm count and motility. After PHT had been discontinued and valproate (VPA) had been administered for 3 months, his sperm activity became normalized. The decrease in sperm motility was the most important cause of his infertility. Sperm motility has been reported to be inversely correlated with the ratio of the concentrations of antiepileptic drugs in the plasma and semen. In our case, the ratio was 0.21 for PHT and 0.08 for VPA. We wish to emphasize the importance of measuring the concentration of antiepileptic drugs in the semen of infertile young males if they are on anticonvulsants.     

Transurethral resection of partially obstructed ejaculatory ducts: seminal parameters and pregnancy outcomes according to the etiology of obstruction

PURPOSE: We determine how transurethral resection of the ejaculatory ducts performed for infertility affects seminal parameters and pregnancy outcomes in patients with partial ejaculatory duct obstruction due to a congenital or acquired etiological factor. MATERIALS AND METHODS: Based on history and physical examination, hormonal profiles, semen analyses, transrectal ultrasonography and vasography findings partial ejaculatory duct obstruction was diagnosed in 14 men a mean of 30 years old who presented for infertility evaluation. Patients were grouped according to congenital or acquired cause of obstruction. Transurethral resection of the ejaculatory ducts was performed using the standard resectoscope loop technique. Clinical outcome was assessed by postoperative analyses of seminal parameters and pregnancy reports. RESULTS: Transurethral resection of the ejaculatory ducts significantly improved semen quality (ejaculate volume and percentage of sperm motility) in all patients in the congenital group, while all but 1 (83%) had an improved sperm count. Pregnancy was achieved via sexual intercourse by 66% of the patients an average of 5.7 months postoperatively. Of the acquired etiological factor group 37.5% had improved semen quality after transurethral resection of ejaculatory duct and 12.5% achieved pregnancy via sexual intercourse. Postoperative complications occurred at a similar rate in each group (33%). However, complications in the congenital etiology group were minor, while 25% of the men in the acquired group had significant impairment of seminal parameters after transurethral resection of the ejaculatory ducts. CONCLUSIONS: Semen quality improvement and pregnancy outcome after transurethral resection of the ejaculatory ducts for partial ejaculatory duct obstruction differ significantly according to the main etiological cause of obstruction. An equivocal diagnosis of partial obstruction and technical problems during transurethral resection of the ejaculatory ducts may contribute to failure. However, in some cases the reason for failure remains unclear.     

The varicocele and male infertility

Varicocele is accepted as a common cause of male subfertility, even though many men with varicocele appear to have normal fertility. The pathophysiology of the varicocele effect on fertility remains unclear, but the association of varicocele with decreased testicular size, abnormal testicular histology, and abnormal semen parameters is clearly established. Because a small varicocele may impair fertility, it must be diligently sought, and the Doppler stethoscope may be helpful in establishing the diagnosis when a venous thrill is equivocal during the Valsalva maneuver in a standing patient. Abnormal semen parameters should be demonstrated in subfertile males with varicocele prior to advising varicocelectomy. Decreased sperm motility or a "stress pattern" in the semen should be documented; however a decreased sperm count may or may not be present. Various surgical approaches are available. When suprainguinal approaches have been used, failures have been shown to be attributable to secondarily incompetent cremasteric system veins. When high inguinal approaches are used, unsuccessful operations are probably secondary to a failure to identify one of the several venous tributaries that may be present at this level. The surgeon's approach should be based on available data, and his patients should be informed that failures are possible with any method of varicocelectomy until experience indicates otherwise. In most series, improvement in semen quality and pregnancy rates have been reported in a significant percentage of patients undergoing varicocelectomy for infertility. However, prior to subjection of the patient to varicocelectomy, the wife of the varicocele patient should be thoroughly studied (and treated when indicated).     

Paternal age and fertility

Variations of the male partner fertility according to his age are difficult to study, because of bias represented by some decrease of both sexual activity and fecundity of the female partner beyond 35 years old. The few studies which are available show that sperm concentration as percentage of normal forms, are stable with age. The percentage of motility is the only parameter which decreases systematically with age according to all studies. Nevertheless, sperm fertilizing capacity does not seem to be decreased. FIVNAT data allow to analyse almost 30,000 IVF cycles for tubal sterility; they confirm the absence of an important alteration of semen characteristics with age. Despite a significant decrease--even moderate--of the mean fertilization rates, the pregnancy rates remain roughly constant for a given range of maternal age.     

Relation between semen quality and fertility: a population-based study of 430 first-pregnancy planners

BACKGROUND: Semen analysis is part of the routine assessment of infertile couples. WHO defines a sperm concentration above 20x10(6) per mL seminal fluid as normal. We studied the association between semen quality and the probability of conception in a single menstrual cycle in Danish couples with no previous reproductive experience. METHODS: In 1992-94, we invited 52,255 trades-union members aged 20-35 years, who lived with a partner and had no children to take part in the study; 430 couples agreed. The couples discontinued use of contraception, and were followed up for six menstrual cycles or until a pregnancy was verified within this period. Each man was asked to provide a semen sample at enrolment (which was analysed without freezing). Women kept a daily record of vaginal bleeding and sexual activity. The association between semen quality and likelihood of pregnancy was assessed by logistic regression, adjusted for sexual activity and female factors associated with low fertility. RESULTS: There were 256 (59.5%) pregnancies among the 430 couples: 165 (65.0%) among those with a sperm concentration of 40x10(6)/mL or more and 84 (51.2%) among those with lower sperm concentrations. The probability of conception increased with increasing sperm concentration up to 40x10(6)/mL, but any higher sperm density was not associated with additional likelihood of pregnancy. The proportion of sperm with normal morphology was strongly related to likelihood of pregnancy independently of sperm concentration. Semen volume and motility were of limited value in pregnancy prediction. INTERPRETATION: Our study suggests that the current WHO guidelines for normal semen quality should be used with caution. Some men with sperm counts above the lower limit of the normal range defined by WHO may in fact be subfertile.     

Testicular function after radiotherapy to inverted 'Y' field for malignant lymphoma

Testicular function was estimated by sperm counts, hormone assays and recording of reported conceptions in 9 patients irradiated for malignant lymphoma. The treatment had been an inverted 'Y' field including the inguinal regions with, in addition, a mantle field in 8 patients. Azoospermia or severe oligozoospermia was found in all but 1 patient, and the FSH levels were uniformly elevated. Testosterone and LH were within normal limits except in 2 patients with slightly subnormal testosterone levels. 7 of the patients were married to women of fertile age, and in 3 cases the wife became pregnant and give birth to a healthy child. The time lapses from irradiation to conception were 18, 40 and 57 months. 2 of these patients had severe oligozoospermia on examination 2 and 4 months respectively from conception. Thus fertility may possibly be underestimated by sperm counting and hormone assays after this type of radiotherapy.     

Role of intracellular calcium concentration on tumor cell death from hyperthermia

PURPOSE: We determined the incidence of iatrogenic injuries to the vas deferens at a tertiary care university infertility center and the results of surgical repair. MATERIALS AND METHODS: Records of 472 patients surgically explored for obstructive azoospermia between 1984 to 1996 were reviewed. Enrollment criteria included history of inguinal, pelvic and scrotal (other than vasectomy) surgery. Conventional ipsilateral and crossover vasovasostomies and vasoepididymostomies were performed. Patency rate was defined as presence of complete sperm with tails in a postoperative semen analysis. Followup included a minimum of 2 semen analyses. Only naturally conceived pregnancies were included. RESULTS: Of 472 patients 34 (7.2%) had an iatrogenic injury to the vas deferens with a mean obstruction interval of 20.5 +/- 1.9 years. Mean patient age was 36.7 +/- 1.8 years. Iatrogenic injury to the vas deferens was secondary to bilateral inguinal hernia repair in 19 patients, unilateral hernia repair in 11, renal transplantation in 2, appendectomy in 1 and spermatocelectomy in 1. Pediatric inguinal hernia repair was the most common etiology of the vasal injury (20 patients), followed by adult inguinal hernia repair (10). A total of 36 microsurgical reconstructive procedures were performed, including 20 ipsilateral and 16 crossed vasovasostomies and vasoepididymostomies. There were 26 patients (29 procedures) available for followup (mean 21.0 +/- 3.7 months). Total patency rate per procedure was 65% and pregnancy rate was 39%. Patency and pregnancy rates per conventional ipsilateral procedures were 62.5 and 35.7% and per crossover procedures 64.2 and 42.8%, respectively. CONCLUSIONS: Pediatric inguinal hernia repair is the most common cause of iatrogenic injury to the vas deferens. Results of treatment of iatrogenic injury to the vas deferens are somewhat lower than for patients with obstructive azoospermia due to vasectomy. Iatrogenic injuries are associated with longer vasal defects, impaired blood supply and longer obstructive intervals frequently resulting in secondary epididymal obstruction. Crossover reconstruction is particularly useful when contralateral testicular atrophy is present. Intraoperatively aspirated sperm should be cryopreserved for later use in case the reconstruction fails.     

Collection of semen from men in acute phase of spinal cord injury

In chronic spinal cord injury, semen obtained by assisted ejaculation is usually abnormal. We have assessed electroejaculation early after injury in seven patients. There were no adverse effects. Initial samples contained few or no spermatozoa but as patients emerged from spinal shock, semen improved and five had specimens cryopreserved. Thereafter sperm motility and viability decreased towards the pattern of chronic spinal cord injury by day 16. Cryopreservation was not possible in one patient with many medical complications and another who started electroejaculation 15 days after injury. Semen storage within the first 2 weeks after spinal cord injury is recommended for future fertility treatment.     

Vasectomy and spermatic antibodies

Before vasectomy, 4 weeks and 3 months after the intervention the sera of 56 fertile patients were examined for the existence of sperm-agglutinating and sperm-immobilizing antibodies. Before vasectomy no antibodies with a titre of 1 : 16 could be established. 4 weeks after vasectomy in 9 sera sperm-agglutinating and in 4 sera sperm-immobilizing antibodies with a titre of 1 : 32 or more could be proved. There was a clear connection with inflammable changes at the place of the peripheral ligature (sperm granulomas). After 3 months with the exception of 2 sera the antibodies had decreased to a titre of less than 1 : 16 or they had disappeared.     

What constitutes a normal seminal analysis? Semen parameters of 243 fertile men

A cross-sectional study was conducted to determine the semen parameters (i.e. volume, concentration, motility, viability and normal morphology) of proven fertile males in Singapore and compare it with the World Health Organization (WHO) recommended normal values and to examine some factors that may affect spermatogenesis. A total of 243 men, whose wives were pregnant at the time of collection of semen, provided a semen sample each after sexual abstinence for 3 days. A questionnaire was used to elicit occupational exposure, alcoholic consumption, smoking history and past significant medical history. Most subjects had normal sperm volume (56.4%), concentration (79.8%), motility (69.5%) and viability (53.5%) based on WHO criteria. However, fertile men had a low mean percentage of normal sperm morphology (20.0%), although they were normally distributed. Cigarette smoking was associated with significantly lower semen volumes even after adjusting for alcohol consumption. The sperm parameters (i.e. volume, density, motility, viability and normal morphology) were not significantly associated with ethnic differences. The WHO criterion for normal sperm morphology is too stringent, and should be adopted with caution. Normal sperm morphology is but one of many parameters for assessment of fertility. Social alcohol consumption, cigarette smoking, and 'recent fever' did not appear to affect sperm quality in this group of fertile men.     

The result of intracytoplasmic sperm injection is not related to any of the three basic sperm parameters

High success rates have been reported for the use of intracytoplasmic sperm injection (ICSI) in alleviating essentially andrological infertility. However, neither the relationship between any of the sperm parameters and the result of ICSI nor the minimal sperm requirements for ICSI have been investigated so far. In this paper, our objective was therefore to study the relationship between three basic sperm parameters (total sperm count, sperm motility and morphology) and the outcome of ICSI by retrospective analyses of fertilization, embryo development and pregnancy rates in 966 micro-injection cycles, performed with ejaculated semen. The results showed that there was no important influence from either the type or the extent of sperm impairment on the outcome of ICSI. Even in the most extreme cases of male-factor infertility, where cryptozoospermia or total astheno- or total teratozoospermia was diagnosed in the initial semen sample, high fertilization and pregnancy rates were obtained by ICSI. Only one condition had a strongly negative influence on the result of ICSI: where an immotile (presumably dead) spermatozoon was injected into the oocyte. Thus the only ultimate criterion for successful ICSI is the presence of at least one living spermatozoon per oocyte in the pellet of the treated semen sample used for micro-injection.     

Patient noncompliance after vasectomy

OBJECTIVE: To determine the postoperative instruction compliance rate in men undergoing bilateral vasectomy. DESIGN: Retrospective chart review. SETTING: Private practice urological office. PATIENT(S): The records of all patients undergoing vasectomy were reviewed to determine the rate of compliance with postvasectomy follow-up instructions. It is our policy to have the patient continue to use some form of birth control until he achieves two consecutive negative semen analyses 1 month apart. In addition, we recommend a yearly semen analysis after achieving sterility to screen for the rare patient who recanalizes. Postvasectomy follow-up instructions are given to the patient both verbally and in writing. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The records of 1,892 consecutive patients undergoing vasectomy were reviewed, and the results of semen analyses were noted to determine the rate of compliance with postvasectomy follow-up instructions. RESULT(S): Six hundred forty-four men (34%) never returned after vasectomy and, therefore, no semen analyses were available for examination. Six hundred nineteen men (33%) returned for a single semen analysis. Six hundred twenty-nine men (33%) returned for a second negative semen analysis. Only 60 men (3%) completed postvasectomy follow-up instructions and returned for a yearly semen analysis. CONCLUSION(S): The rate of compliance with postvasectomy follow-up instructions for determining sterility is poor.     

Vasectomy: euflavine as a spermicide

The hastening of azoospermia following vasectomy by the intravasal injection of 2.5 ml 1/1000 euflavine is discussed. In most cases, live sperm are absent from samples collected only a few days after the operation. However, there have been cases of relatively high sperm counts as late as weeks after vasectomy, though these are rare. The chance of technical error is small, because euflavine is a vivid yellow and its deposition into areas other than the vas would be evident. Failure may be due to some anatomical variation in the individual conerned. Euflavine does not appear to be toxic nor cause tissue damage. However, its use does not preclude the need for post-vasectomy seminal examination.     

Does ovarian hyperstimulation syndrome affect the quality of oocytes?

Two wives of a Muslim with severe male factor infertility had simultaneous intracytoplasmic sperm injection (ICSI) treatments. One wife developed ovarian hyperstimulation syndrome (OHSS), and 19 of 27 oocytes retrieved were subjected to ICSI but only one fertilized; the other wife had a normal response to ovarian stimulation, normal fertilization following ICSI, successful treatment and has recently delivered a live-born infant. The wife who suffered from OHSS has since had another ICSI cycle with a normal response to ovarian stimulation, a normal fertilization rate but no pregnancy. The only variable that determined the different rate of fertilization in the simultaneous ICSI cycles appears to be oocyte quality. While the results of frozen embryo replacement cycles following the decision to freeze all embryos following OHSS is generally satisfactory, it is important to counsel couples about the possible detrimental effects of OHSS on oocyte quality.     

Open versus closed epididymal sperm retrieval in men with secondarily obstructed vasal systems--a preliminary report

OBJECTIVE: To evaluate and compare sperm quality and suitability for intracytoplasmic sperm injection (ICSI) from open and percutaneous epididymal aspiration in men with obstructive azoospermia, and to determine the relevance of epididymal morphology. PATIENTS AND METHODS: A series of 20 men undergoing vasectomy reversal were evaluated by percutaneous (PESA) and open epididymal sperm aspiration (MESA) before undergoing surgery for reversal. Two samples were taken with PESA, one with the needle in situ (PESA1) and the second while withdrawing the needle (PESA2). Epididymal morphology was graded as normal, distended and grossly distended. Five men undergoing vasectomy served as a control, nonobstructed group for percutaneous aspiration. Analysis of the aspirates was performed immediately after operation with no knowledge of the treatment, and aspiration was considered successful if sperm suitable for ICSI were retrieved. RESULTS: In the obstructed group, 15 of 20 men had successful PESA and 13 of these also had successful MESA. PESA was successful bilaterally eight times compared with MESA on five occasions; two men with successful PESA had no success with MESA. PESA2 was five times more successful than PESA1. Only one PESA in the non-obstructed group was suitable for ICSI. PESA was successful in 21 of 25 distended or grossly distended epididymi compared with only three of 21 non-distended systems. CONCLUSION: PESA is a viable alternative to MESA in patients with obstructive azoospermia, particularly when associated with clinically distended epididymi.     

Cytogenetic effects of cryopreservation on human sperm: assessment using an improved method for analyzing human sperm chromosomes

OBJECTIVE: To evaluate any cytogenetic effects of cryopreservation on human sperm by comparing the frequencies of sperm chromosome anomalies and sex ratios before and after freezing. METHODS: Using in vitro fertilization of zona-free hamster oocytes, analysis of sperm chromosomes was first performed on portions of fresh human semen samples. The residual semen was then analyzed for sperm chromosomes after cryopreservation for several weeks. Sperm donors were 5 healthy men aged 26-38 years. RESULTS: A total of 166 sperm karyotypes were analyzed, 94 before freezing and 72 after freezing. The results indicated no significant differences between fresh and frozen sperm in either frequencies of aneuploidy (fresh: 0%, frozen: 2.8%) or structural anomalies (fresh: 7.5%, frozen: 9.7%). The sex ratios did not differ from the expected 1:1 ratio under either condition. CONCLUSIONS: The results of these studies indicate that cryopreservation does not exert any cytogenetic mutagenicity on human spermatozoa or alter X/Y ratio of human sperm.