Evaluation of Vasectomy Trends in the United States

Effects of antisperm antibodies post vasectomy reversal on pregnancy rates

OBJECTIVE

To investigate the correlation between antisperm antibodies (ASAs), pregnancy rates, and the method of conception following vasectomy reversal. This is particularly relevant as patients undergoing vasectomy reversal often express concerns about the potential inhibitory effects of ASAs on achieving pregnancy. Additionally, the American Urological Association guidelines for vasectomy emphasize the need for further research to address this question.

PATIENT AND METHODS

We conducted a retrospective analysis involving chart reviews and phone interviews with individuals who underwent vasectomy reversal at our institution between May 2015 and April 2023. Patients who underwent vasectomy reversal for reasons other than fertility, as well as those lacking postoperative semen analysis with ASA data, were excluded. We classified patients based on low (below 50%) or high (50% or above) ASA levels determined by their initial postoperative semen analysis. The primary outcome measured was the pregnancy rate, including details on the method of conception.

RESULTS

A total of 145 patients were subjected to chart review. The median age at the time of surgery was 43 years, with a median obstruction interval of 7.7 years. The median age of their partners was 29 years. The majority (80%) of patients underwent bilateral vasovasostomy. Among them, 60 patients (41.4%) exhibited low (< 50%) ASA levels, while 85 (58.6%) had high (≥ 50%) ASA levels. Follow-up phone interviews were completed by 48 patients. Among them, the 19 men with low ASA levels, 13 (68.4%) achieved pregnancy, with 6 (31.6%) experiencing spontaneous conception. For the 29 men with high ASA levels, 21 (72.4%) achieved pregnancy, including 11 (38%) through spontaneous conception. The p-value from Fisher's exact test was 0.2.

CONCLUSIONS

Our findings suggest that ASA levels do not show a significant association with either the pregnancy rate or the method of conception following vasectomy reversal.

Rising vasectomy volume following reversal of federal protections for abortion rights in the United States

In June 2022 the United States Supreme Court issued a ruling in the case Dobbs v. Jackson that overturned Roe v. Wade, the 1973 ruling establishing a federally protected right to abortion in the United States. Anecdotal reports suggested increased vasectomy volume following this event; however, no published data exist. We sought to describe trends in vasectomy consultation before and after the Dobbs v. Jackson ruling (referred to as pre- and post-Dobbs herein). Following IRB approval, we reviewed charts of all adults seeking vasectomy consultation in July-August 2021 and July-August 2022 at a large healthcare organization. We then aggregated vasectomy procedural billing data from 2018 to present. The primary outcome was volume of vasectomy consultation appointments and the secondary outcome was number of vasectomies performed. In July-August 2021 (Pre-Dobbs), 116 men attended vasectomy consultation versus 142 men in July-August 2022 (Post-Dobbs). Median age Post-Dobbs was significantly younger than Pre-Dobbs (35 vs 38 years, respectively, p = 0.01) with a significant increase in Post-Dobbs men under 30 seeking vasectomy (p = 0.005). A total of 16.9% (24/142) of Post-Dobbs men were childless, compared to 8.6% (10/116) of Pre-Dobbs men (p = 0.05). Of those with children, median number of offspring was unchanged at 2. Billing data showed a significant increase in vasectomy procedural volumes Post-Dobbs. While overturning Roe v Wade directly impacted female reproductive rights, number of vasectomy consultations and procedures increased significantly following this decision. Younger men, especially those under 30, as well as childless men were significantly more likely to seek consultation Post-Dobbs compared to the prior reproductive legal climate. While longer-term data are needed, findings indicate that men are invested in maintaining reproductive autonomy for themselves and their partners.

Vasovasostomy: A systematic review and meta-analysis comparing macroscopic, microsurgical, and robot-assisted microsurgical techniques

BACKGROUND AND OBJECTIVES

Vasovasostomy is a cost-effective procedure for the reversal of vasectomy. A water-tight adequately blood-supplied mucosal anastomosis is required for better outcomes. This review aimed to compare the outcome of vasovasostomy performed by three different techniques: macroscopic, pure microsurgical, and robot-assisted microsurgical techniques.

METHODS

Scopus, Web of Science, PubMed, Embase, and Cochrane library databases were searched for relevant studies from January 1901 to June 2023. We conducted our quantitative syntheses using the inverse variance method in OpenMeta software. The study's protocol was registered on PROSPERO.

RESULTS

This review involved 95 studies of different designs, with a total sample size of 48,132. The majority of operations were performed bilaterally, and participants were monitored for up to 10 years. The pooled patency rate was the highest following robot-assisted vasovasostomy (94.4%), followed by pure microsurgical vasovasostomy (87.5%), and macroscopic vasovasostomy (83.7%). The pooled pregnancy rate following purely microsurgical vasovasostomy was higher than that of macroscopic vasovasostomy (47.4 vs. 43.7%). Definitive pregnancy rates in robotic vasovasostomy are yet to be determined.

CONCLUSION

Patency outcomes for vasovasostomy were best with robot-assisted microsurgical technique, followed by pure microsurgical technique, and conventional macroscopic technique. Further investigations of robot-assisted microsurgical vasovasostomy outcomes and randomized control trials are required to support this evidence.

Antisperm Antibody Levels After Vasectomy Reversal Are Not Associated With Pregnancy Rates or Method of Conception

OBJECTIVE

To examine the relationship between antisperm antibody (ASA), pregnancy rates, and method of conception following vasectomy reversal, given that before and after vasectomy reversal, patients wonder if ASAs will prevent them from achieving pregnancy and American Urological Association vasectomy guidelines call for additional research to answer this question.

METHODS

We performed retrospective chart review and phone interview of patients who underwent vasectomy reversal at our institution from 1/1/2000 to 12/31/2018. We excluded patients who underwent vasectomy reversal for pain, or without postoperative semen analysis with ASA. We categorized patients as having low (<50%) or high (≥50%) ASA levels using the first postoperative semen analysis. Our primary outcome was pregnancy rate, including method of conception. Differences in pregnancy rates were tested using Fisher exact test.

RESULTS

Two hundred and four patients were chart reviewed. Median age at time of surgery was 40years and median obstruction interval was 7.3years. Median partner age was 32years. One hundred sixty-four (80%) patients underwent bilateral vasovasostomy. Eighty-five patients (42%) had low (<50%) ASA levels and 119 (58%) had high (≥50%) ASA levels. Sixty-seven patients completed phone interviews. Of 27 men with low ASA levels, 19 (70%) achieved a pregnancy with 16 (59%) spontaneous pregnancy. Of 40 men with high ASA levels, 30 (75%) achieved a pregnancy with 16 (40%) spontaneous pregnancy. The Fisher exact test P-value was .2.

CONCLUSION

ASA levels are not associated with pregnancy rate or method of conception after vasectomy reversal. These findings can improve patient counseling before and after vasectomy reversal.

Trends in vasectomy and sexually transmitted diseases in Chile: findings from robust national databases

A controversy about the increase or decline of vasectomy is emerging; however, the evidence is still scarce in Latin America. This ecological study analyzed the vasectomy and sexual transmitted diseases (STD) trends over a period of 10 years in Chile and determined if there is any relationship between them. We conducted a mixed ecological study using secondary and representative data on the number of vasectomies and STD cases from 2008 to 2017. Vasectomy rates were calculated for age-specific groups of men aged 20-59 years, and specific STD (HIV, chlamydia, gonorrhea, trichomoniasis, and syphilis) for the same period. Multivariate negative binomial regression models were fitted to evaluate rate trends and relationships. The mean vasectomy age was 40.3 years, with no significant differences between the years of the study (p = 0.058). The overall vasectomy rate significantly increased from 2008 to 2017 (p < 0.001), with differences between age groups (p < 0.001). The most significant increase was observed in men aged 30-49 (p < 0.001). The STD rates significantly increased (p < 0.05) during the study period. A significant positive correlation was found between vasectomy and gonorrhea incidence rates (p = 0.008) and an inverse correlation was found with hepatitis B incidence rates (p = 0.002). Vasectomy trends and STD rates significantly increased from 2018 to 2017 in Chile. especially among men aged 30-49 years. The relationship between vasectomy and STD increments suggests a new risk factor for reproductive and sexual health policies to aid controlling the HIV and STD epidemic.

Uncovering the interhospital price variations for vasectomies in the United States

Due to the historic lack of transparency in healthcare pricing in the United States, the degree of price variation for vasectomy is largely unknown. Our study aims to assess characteristics of hospitals reporting prices for vasectomy as well as price variation associated with hospital factors and insurance status. A cross-sectional analysis was performed in October, 2022 using the Turquoise Database which compiles publicly available hospital pricing data. The database was queried for vasectomy prices to identify the cash (paid by patients not using insurance), commercial (negotiated by private insurers) and Medicare and Medicaid prices for vasectomies. Hospital characteristics of those that reported a price for vasectomy and those that did not were compared and pricing differences based on hospital ownership and reimbursement source were determined using multivariable linear regression analysis. Overall, only 24.7% (1657/6700) of hospitals reported a price for vasectomy. Those that reported a price had more beds (median 117 vs 80, p < 0.001), more physicians (median 1745 vs 1275, p < 0.001). They were also more likely to be nonprofit hospitals (77% vs 14%, p < 0.001) and to be in well-resourced areas (ADI 91.7 vs 94.4, p < 0.001). Both commercial prices and cash prices for vasectomy were lower at nonprofit hospitals than at for-profit hospitals (commercial: $1959.47 vs $2861.56, p < 0.001; cash: $1429.74 vs $3185.37, p < 0.001). Our study highlights the current state of pricing transparency for vasectomy in the United States. Patients may be counseled to consider seeking vasectomy at a nonprofit hospital to reduce their costs, especially when paying with cash. These findings also suggest a need for new policies to target areas with decreased price transparency to reduce price disparities.

Driving Time and Compliance With Postvasectomy Semen Analysis Drop-Off

OBJECTIVE

Current literature demonstrates low rates of compliance with postvasectomy semen analysis (PVSA). This study sought to determine factors that correlate with noncompliance with PVSA.

METHODS

A retrospective chart review was conducted for patients who underwent vasectomy within our institution. ArcGIS was used to securely calculate the shortest driving time from each patient's home to the single PVSA drop-off site. Kruskal-Wallis and chi-square tests analyzed characteristics of patients who did and did not submit PVSA samples, and odds ratios were calculated via multivariable logistic regression.

RESULTS

Overall, 515 of 850 patients met inclusion criteria and 219 (42.5%) of these had no recorded PVSA. Of those with a PVSA, 59% were completed within 16 weeks. Compliance with PVSA was associated with a shorter median driving time (30.6 minutes vs 34.2 minutes), more vasectomy in the operating room (19% vs 10%), and attending a follow-up appointment (40% vs 17%) (P < .005 for all). Age at vasectomy, race, ethnicity, BMI, paternity, and location of preoperative consultation did not significantly differ between the groups. Each 30 minutes of driving time was associated with a 48% reduction in the odds of a patient submitting PVSA at any time (OR 0.52 [0.37, 0.73]).

CONCLUSION

As driving time to a drop-off center appears to be a significant barrier to PVSA compliance, providers should consider alternative collection methods such as at-home or in-office semen analysis.

The percentage of men counseled by urologists who received a vasectomy mildly increased after the publication of the AUA vasectomy guideline

This retrospective cohort study explored whether the publication of the vasectomy guideline by the American Urological Association in December 2012 increased the percentage of men counseled by urologists who received a vasectomy. We used commercial health insurance claims between 2010 and 2015 to identify the initial sterilization counseling visit for men aged 18-64 and whether each of them received a vasectomy within six months of that visit. A difference-in-differences analysis isolated the effect of the guideline on the percentage of men counseled by urologists who received a vasectomy, exploiting suspected variation in guideline exposure and adherence between urologists and non-urologists. In total, 226 012 men had an initial sterilization counseling visit, of which 182 204 (80.6%) were counseled by urologists and 43 808 (19.4%) were counseled by non-urologists. The percentage of men counseled by urologists who received a vasectomy mildly increased by 1.5% (p = 0.002) after the publication of the guideline. Therefore, the percentage of men who receive a vasectomy may in part be explained by practice guidelines and clinicians' willingness to consider the procedure, and future research should investigate how clinicians arrive at their decisions to recommend a vasectomy and whether a standardized counseling protocol would ensure consistency.

Male Contraception

Approximately 40 to 50% of pregnancies are unintended. Contraceptive use significantly reduces the risk of unintended pregnancy. Approximately 70% of couples' contraceptive use is female and 30% is male, attributable to the reliance on condoms and vasectomies. Unfortunately, many women cannot use currently available contraceptives due to medical contraindications or side effects. At the same time, men want additional safe and effective contraceptive methods. Because of this, work to develop novel, safe, and effective male contraceptives is underway. This review will briefly discuss the pros and cons of condoms and vasectomies, and then describe research into the development of novel methods of male contraception, by the mechanism of action of the contraceptive. First, we will discuss male contraceptives that block sperm transmission. Next, we will discuss male contraceptives that impair sperm production. Lastly, we will discuss male contraceptives that impair sperm function.

Trends in the Vasectomy Rate Among Privately Insured Men Aged 18-64 in the United States Between 2014 and 2021

OBJECTIVE

To update trends in the vasectomy rate among privately insured men aged 18-64 in the United States (U.S.) between 2014 and 2021.

MATERIALS AND METHODS

We used commercial health insurance claims data between 2014 and 2021 to calculate the annual vasectomy rate in men aged 18-64 in the U.S. We performed these calculations nationally and by age group, marital status, maternal age of a wife, number of children, U.S. Census Bureau region, geography, geographical region, and state. We calculated the absolute and relative changes in these rates from 2014 to 2021 to study how much and how quickly they changed.

RESULTS

The vasectomy rate among privately insured men aged 18-64 in the U.S. increased by 0.11%-a 26% change-from 2014 (0.427%) to 2021 (0.537%). The absolute changes were greatest in men with 3 or more children (0.489%), with 2 children (0.295%), with a wife not of advanced maternal age (0.276%), and aged 35-44 (0.243%). The relative changes were greatest in men with no children (61%), with a wife of advanced maternal age (40.8%), who were single (40.6%), and aged 18-24 (36.7%). In every region except the Northeast, the absolute and relative changes were greater in rural geographies compared to urban geographies.

CONCLUSIONS

The vasectomy rate among privately insured men aged 18-64 in the U.S. increased between 2014 and 2021. Further investigation is needed to ensure demand for vasectomies may continue to be met.

Telehealth Sterilization Consultation Does Not Impact Likelihood of Vasectomy: A Retrospective Institutional Analysis

OBJECTIVE

To evaluate if telehealth consultations would impact the likelihood of patients following through with vasectomies.

METHODS

We utilized electronic medical records from the past 5 years to retrospectively evaluate male patients undergoing a sterilization consult. Telehealth consultations have been offered since March 2020 due to the COVID-19 pandemic. Patients were stratified to in-office or telehealth consultation. We then utilized billing codes to determine if patients underwent a vasectomy. Percentages of patients who subsequently underwent vasectomy were compared using Chi-square analysis. Logistic regression was performed to identify factors associated with completing vasectomy.

RESULTS

There were a total of 369 patients who underwent a telehealth male sterilization consultation and 1664 patients who were seen in the office. We found that 66.9% of telehealth patients ultimately underwent a vasectomy (n.ß=.ß247) compared to 64.3% of patients who were seen via office assessment (n.ß=.ß1070) (X2 =.ß0.646, p.ß=.ß.724). Younger age was the only variable on univariate logistic regression that was associated with completing vasectomy (p.ß=.ß.002) via either an in-person or televisit, while body mass index, race, and ethnicity were not significant.

CONCLUSION

Only 2/3 of the men completing a vasectomy consult receive a subsequent vasectomy. Both in-office and telehealth consultations resulted in comparable rates of vasectomy. This is the first study to report on the likelihood of following through with a surgical procedure comparing in-office vs.ßtelehealth assessment in male sexual and reproductive medicine. As vasectomy consultations continue to rise, clinicians can be reassured by the effectiveness of telehealth consultations prior to vasectomy.

Vasectomy has No Impact on Future Lower Urinary Tract Symptoms Diagnoses: A Retrospective Cohort Claims Database Analysis

Purpose

The aim of this study was to assess whether there is an association between vasectomy and benign prostatic hyperplasia with associated lower urinary tract symptoms (BPH/LUTS) due to inflammatory etiology.

Materials and Methods

We assessed the incidence of BPH/LUTS in men who had undergone vasectomy in a matched cohort analysis using the TriNetX Research Network. We identified men aged 30 to 60 years who underwent vasectomy and had a follow-up visit within 6 months to 5 years after vasectomy from January 2010 through December 2022 and compared them with matched controls. Outcomes recorded include diagnoses of BPH (N40, N40.1), BPH-related medication prescriptions, and BPH-related procedures. We accounted for confounding variables through propensity score-matching for age; race; and history of comorbid medical conditions: hyperlipidemia (International Classification of Disease-10: E78), metabolic syndrome (E88.81), overweight or obesity (E66), testicular hypofunction (E29.1), hypertension (I10-I16), nicotine dependence (F17), and obstructive sleep apnea (G47.33).

Results

There was no significant difference in BPH diagnosis between postvasectomy men vs controls (0.84% vs 0.80%, RR: 0.95, 95% CI 0.86-1.05) or BPH/LUTS diagnosis (0.48% vs 0.44%, RR: 0.92, 95% CI 0.81-1.05) within 6 months to 5 years after vasectomy, respectively. No differences in BPH medication prescription (0.94% vs 0.84%) or rate of BPH procedures (0.022% vs 0.017%) were detected between the 2 groups.

Conclusions

This study suggests that vasectomy does not increase the risk of BPH development and/or LUTS worsening compared with the general population, providing assurance to both patients and health care providers who may consider vasectomy as a safe family planning option.

Infertility, pregnancy and breastfeeding in kidney transplantation recipients: Key issues

Chronic kidney disease (CKD), especially in advanced stages, is an important cause of infertility. In CKD patients, infertility has been linked to multiple factors. The pathophysiology of infertility related to CKD is complex and forked. Correction of modifiable factors can improve fertility in both genders. In males as well as females, successful kidney transplantation offers good chances of restoration of reproductive function. In female renal allograft recipients, recovery of reproductive functions in the post-transplant period will manifest as restoration of normal menses and ovulation. Owing to this improvement, there is a significant risk of unplanned pregnancy, hence the need to discuss methods of contraception before transplantation. In kidney transplant recipients, different contraceptive options for pregnancy planning, have been used. The selection of one contraception over another is based on preference and tolerability. Pregnancy, in renal transplanted females, is associated with physiologic changes that occur in pregnant women with native kidneys. Immunosuppressive medications during pregnancy, in a recipient with a single functioning kidney, expose the mother and fetus to unwanted complications. Some immunosuppressive drugs are contraindicated during pregnancy. Immunosuppressive medications should be discussed with renal transplant recipients who are planning to breastfeed their babies. In addition to antirejection drugs, other medications should be managed accordingly, whenever pregnancy is planned.

Sedated masculinity: the use of anaesthesia during vasectomy in Israel

Vasectomy is considered a permanent form of contraception for men that can help reduce reproductive inequality. Its underutilisation in the context of the threats it may pose to perceptions of traditional masculinity has been closely investigated, but the lived experience of the procedure itself has been largely overlooked. This paper examines the experience of having a vasectomy in Israel, focusing on the recommended form of anaesthesia. Drawing on 15 semi-structured interviews with Israeli men who have experienced vasectomy, we found that the choice of anaesthesia has a significant impact on the meaning and experience of vasectomy. Unlike the widespread use of local anaesthesia during vasectomy in other countries, vasectomy in Israel is performed almost exclusively under twilight sedation administered intravenously. Based on our findings, we argue that framing vasectomy as an operation that requires sedation is related to views of masculinity and reproduction. Our data suggest that vasectomy in Israel is constituted as a potentially traumatic event, and anaesthesia is employed to protect patients from feelings of embarrassment and discomfort. We conclude that the prevailing method of sedation perpetuates the silencing and marginalisation of vasectomy as a contraceptive method, and consequently, its very limited accessibility in Israel.

A new approach to postvasectomy semen analyses eliminates the need to evaluate a fresh specimen

BACKGROUND

According to current guidelines, confirmation that vasectomy results in sterility depends on microscopic examination of postvasectomy semen for the presence of spermatozoa. Guidelines established in 2012 require examination of a fresh specimen within 2 h of collection, which necessitates the patient making an appointment with either the surgeon's office or a licensed clinical laboratory. Twenty-five to 42% of patients fail to comply with postvasectomy semen analysis (PVSA).

OBJECTIVES

To determine if an at-home semen collection kit can substitute for the evaluation of a fresh specimen and improve patient compliance with postvasectomy spermatozoa assessment.

MATERIALS AND METHODS

The kit contains a patented aldehyde-fixative that maintains spermatozoa and semen cells in suspension for quantitation. Patients order a PVSA kit to be delivered to their home and can collect a semen specimen and return it to the laboratory through regular US mail.

RESULTS

From January 2011 through December 2018, 6096 men undergoing vasectomy by 184 urologists in 33 states in the US ordered PVSA kits, of which 5408 (89%) returned at least one for analysis. Of those, 398 men (7.4%) returned the first kit with greater than 10,000 spermatozoa/ml within a year of vasectomy, of which only 4.4% contained greater than 100,000 spermatozoa/ml 12 weeks postsurgery. This suggests that fewer than 5% of postvasectomy patients might need follow-up fresh semen analyses, greatly easing the logistical burden of PVSA. Ninety percent of surgeons returning a patient satisfaction questionnaire said their patients "never" complained about using PVSA kits.

DISCUSSION AND CONCLUSION

These data support the adoption of a new standard for PVSA that does not involve an initial evaluation of a fresh semen specimen.

Pilot Study: Next-generation Sequencing of the Semen Microbiome in Vasectomized Versus Nonvasectomized Men

BACKGROUND

Approximately half a million vasectomies are performed every year in the USA. There is a paucity of literature on the impact of male sterilization on the semen microbiome and whether it prompts microbiota dysbiosis.

OBJECTIVE

To investigate if vasectomy induces changes in the seminal microbiome via comparison of semen samples from men before and after vasectomy, and if the seminal microbiome profiles for vasectomized men follow a particular pattern with respect to diversity and abundance.

DESIGN, SETTING, AND PARTICIPANTS

From July 2021 to February 2022, we prospectively collected and analyzed semen samples from 58 men at one outpatient clinic. Eighteen men provided a semen sample before and 3 mo after vasectomy. We also collected semen samples from 22 fertile nonvasectomized men and from a further 18 vasectomized men at 3 mo after vasectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Semen microbiome α-diversity, beta-diversity, and relative abundance were compared initially between paired and then between unpaired vasectomized and nonvasectomized samples. Analysis of variance (ANOVA), permutational multivariate ANOVA, and analysis of the composition of microbiomes with bias correction were used to assess differences.

RESULTS AND LIMITATIONS

In both paired and unpaired sets of samples, a decreasing trend for α-diversity in semen after vasectomy was observed. Shannon diversity, the relative abundance of species with an abundance >2%, and composition were not significantly changed. Sphingomonas, Brevundimonas, and Paracoccus abundance decreased after vasectomy, while Corynebacterium abundance increased. The results may be limited by the sample size and lack of demographic heterogeneity.

CONCLUSIONS

Vasectomy is followed by a decrease in α-diversity and changes in the relative abundance of bacterial species in the semen microbiome. Further investigation is necessary to understand the clinical significance of these changes after vasectomy.

PATIENT SUMMARY

We evaluated changes in the bacteria species in semen after vasectomy. We found that vasectomy decreased the richness and evenness of bacteria species in semen, but the overall bacterial community remained similar. Further studies are needed to assess the implications of changes in semen bacteria after vasectomy.

Male contraception is coming: Who do men want to prescribe their birth control?

OBJECTIVE

To assess men's preferences for healthcare provider from whom they would obtain hormonal male contraceptive (HMC) methods.

STUDY DESIGN

We asked participants from 3 clinical trials of investigational HMC methods-an oral pill (11β-Methyl-19-nortestosterone-17β-dodecylcarbonate, 11β-MNTDC), intramuscular or subcutaneous injection (Dimethandrolone undecanoate), and transdermal gel (Nestorone and testosterone)-to rank their top 3 preferred HMC providers from a list including: men's health doctor (urologist/andrologist), hormonal doctor (endocrinologist), reproductive health doctor (OB/GYN), family planning clinician (community health worker, midwife, nurse practitioner), regular doctor (family medicine/internal medicine), and community pharmacist. We examined preferences based on their rankings and conducted bivariate analyses. Collapsing the various specialists (men's health doctor, hormonal doctor, reproductive health doctor, and family planning clinician) into a single provider type, we examined participant demographics against provider preference (regular doctor, pharmacist, or specialist).

RESULTS

Participants across the 3 trials (n = 124) ranked their regular doctor (44%) and community pharmacist (18%) as their most preferred HMC provider; these preferences did not differ significantly by trial and drug formulation. Specialists in family planning (13%), men's health (12%), reproductive health (10%), and hormones (4%) were least frequently ranked as their preferred provider. Older and higher educated participants more often preferred specialists over regular doctors and pharmacists (p = 0.02 and p = 0.01).

CONCLUSIONS

Despite receiving contraceptive steroid hormones and care from endocrinologists and family planning specialists in a clinical trial, participants would prefer to obtain contraception from their regular doctor.

IMPLICATIONS

As most men expect to obtain hormonal male contraceptives from their regular doctor when commercially available, primary care physicians should become familiar with HMCs and be prepared to provide counseling and options accordingly.

Patient opinions on sexual and reproductive health services in primary care in rural and urban clinics

OBJECTIVES

Primary care providers are a major source of sexual and reproductive health care in the United States, particularly in rural areas, and not all providers offer the same services. This study aimed to understand patient preferences and expectations around reproductive health services including abortion care in a primary care setting and if those expectations differed by urban or rural setting.

STUDY DESIGN

An anonymous survey was distributed to all patients 18 years or older in 4 primary care clinics in Idaho, Washington, and Wyoming over a 2-week period. The survey asked patients about which reproductive health services should be available in primary care.

RESULTS

The overall response rate was 69% (745/1086). For all queried reproductive health services except for aspiration abortion, the majority of respondents reported that primary care clinics should have that service available. Forty-two percent of respondents reported that aspiration abortion should be available in primary care. Overall, most respondents reported that medication abortion (58%) and miscarriage management (65%) should be available in primary care. More respondents in urban clinics thought IUD services (84% vs 71%), medication abortion (74% vs 37%), and aspiration abortion (52% vs 28%) should be accessible in primary care compared to those in rural-serving clinics.

CONCLUSIONS

This study of 4 primary care clinics in Idaho, Washington, and Wyoming, spanning urban and rural settings, highlights that most patients desire contraception services and miscarriage management to be available in primary care.

IMPLICATIONS

Increasing training may help meet patient desires for access to reproductive services in primary care, however, further exploration of barriers to this care is warranted. High rates of respondents desiring miscarriage management access highlights the need to train more primary care clinicians to provide full spectrum miscarriage management options.

Vasectomy Regret or Lack Thereof

Background

Vasectomy is a procedure that results in permanent yet reversible sterility and remains a great contraceptive option for many. Previous research studies have highlighted frequency of vasectomy utilization, defining characteristics of individuals who opt for this method, various surgical techniques, and the risks and benefits associated with the procedure. What remains to be defined is why or why not individuals may experience post-vasectomy regret and whether the previous characteristics correlate.

Objective

The objective of this review is to synthesize information regarding reasons individuals may regret their vasectomy and seek reversal, what options exist for accomplishing the reversal, and patients' fertility prognosis post-vasovasostomy.

Methods

This review utilized a combination of secondary and tertiary data analysis across a wide scope of academic databases pertaining to the topic of interest.

Results

Typically, most males who have sought a vasectomy are satisfied with their decision, however, approximately 6% of this population seeks reversal. Key factors influencing vasectomy regret include age at the time of vasectomy, parental status, pre- and post-operative relationship status, unresolved physical and psychosexual problems, and development of chronic scrotal pain following the procedure. Few options exist for vasectomy reversal including microsurgical reconstructive vasectomy reversal (VR) and sperm extraction for in vitro fertilization. There is no guarantee that fertility will be restored in any case but a major predictive factor for success is the time interval prior to reversal.

Conclusion

Vasectomy is intended to be a permanent form of contraception; however, a minor chance remains that individuals may experience post-operative regret due to various factors. This warrants proper comprehensive counseling by the patient's provider regarding benefits and risks, procedural outcomes, opportunities for reversal, and fertility prognosis.

A 16 Year Overview of Vasectomy and Vasectomy Reversal in the United Kingdom

BACKGROUND

There is no current research to explain the trends in vasectomy and vasectomy reversals in the United Kingdom, leaving little understanding of the social phenomena involved.

OBJECTIVE

This study aimed to provide an overview of vasectomy as a main method (or primary method) of contraception and vasectomy reversals among men in the United Kingdom aged >16 years.

STUDY DESIGN

Descriptive statistics were generated from the National Health Service's publicly accessible datasets from 2004/2005 to 2019/2020, including data from 1,621,105 men.

RESULTS

Although men are increasing their use of contraceptive services, the number of men having vasectomies and vasectomy reversals has decreased significantly.

CONCLUSION

The researchers propose that more rigorous techniques for capturing data are required to understand vasectomy in the United Kingdom. There is also an urgent need for research on vasectomy in the United Kingdom and globally, not only to explain the behavioral trends found in this study, but also to explain the global trend.

Post-Vasectomy Semen Analysis: Optimizing Laboratory Procedures and Test Interpretation through a Clinical Audit and Global Survey of Practices

PURPOSE

The success of vasectomy is determined by the outcome of a post-vasectomy semen analysis (PVSA). This article describes a step-by-step procedure to perform PVSA accurately, report data from patients who underwent post vasectomy semen analysis between 2015 and 2021 experience, along with results from an international online survey on clinical practice.

MATERIALS AND METHODS

We present a detailed step-by-step protocol for performing and interpretating PVSA testing, along with recommendations for proficiency testing, competency assessment for performing PVSA, and clinical and laboratory scenarios. Moreover, we conducted an analysis of 1,114 PVSA performed at the Cleveland Clinic's Andrology Laboratory and an online survey to understand clinician responses to the PVSA results in various countries.

RESULTS

Results from our clinical experience showed that 92.1% of patients passed PVSA, with 7.9% being further tested. A total of 78 experts from 19 countries participated in the survey, and the majority reported to use time from vasectomy rather than the number of ejaculations as criterion to request PVSA. A high percentage of responders reported permitting unprotected intercourse only if PVSA samples show azoospermia while, in the presence of few non-motile sperm, the majority of responders suggested using alternative contraception, followed by another PVSA. In the presence of motile sperm, the majority of participants asked for further PVSA testing. Repeat vasectomy was mainly recommended if motile sperm were observed after multiple PVSA's. A large percentage reported to recommend a second PVSA due to the possibility of legal actions.

CONCLUSIONS

Our results highlighted varying clinical practices around the globe, with controversy over the significance of non-motile sperm in the PVSA sample. Our data suggest that less stringent AUA guidelines would help improve test compliance. A large longitudinal multi-center study would clarify various doubts related to timing and interpretation of PVSA and would also help us to understand, and perhaps predict, recanalization and the potential for future failure of a vasectomy.

The Omission of Genitourinary Physical Exam in Telehealth Pre-Vasectomy Consults Does Not Reduce Rates of Office Procedure Completion

OBJECTIVE

To determine whether the omission of pre-procedure genitourinary exam for vasectomy inherent to a virtual consultation reduces the likelihood of successfully completing in-office vasectomy. Currently, the AUA Vasectomy guidelines encourage in-person examination when possible, though COVID-19 has catalyzed the uptake of virtual consultations at many institutions. We hypothesized that rates of completed in-office vasectomy do not significantly differ between patients examined during consultation in the office and those seen virtually with no exam.

METHODS

Virtual vasectomy consults from April to December 2020 were retrospectively reviewed and compared to a size-matched, randomly-selected control group who underwent in-office vasectomy consultation. The primary outcome was completion of in-office bilateral vasectomy. Baseline demographic characteristics were compared. Fisher's exact test and Student's t-test were performed on categorical and continuous variables, respectively.

RESULTS

Of 211 patients who underwent virtual vasectomy consultation during the study period, 153 presented for in-office vasectomy. They were compared to 153 vasectomies from the in-person consult cohort. No demographic differences were observed between virtual and in-office consult groups. No statistical difference was observed in completion rates of in-office vasectomy, which was 97.4% (149/153) in the virtual consult cohort and 98.7% (151/153) in the in-office consultation cohort (p = 0.68).

CONCLUSIONS

Rates of completed in-office vasectomy did not significantly differ based on consult platform, suggesting that a pre-vasectomy physical exam is not required to predict successful completion of the procedure. Telehealth should be utilized as an additional platform to improve access for male contraceptive procedures in a young and busy population.

Assessing Vasectomy-Related Information on YouTube: An Analysis of the Quality, Understandability, and Actionability of Information

This study aims to critically appraise the quality of vasectomy-related health information currently available on YouTube to better address patient information needs moving forward. A YouTube search was performed using the keyword “vasectomy.” The first 100 videos were assessed, with irrelevant and duplicate videos excluded. Two independent reviewers evaluated the remaining videos using the DISCERN instrument for evaluating the quality of information and the Patient Education Materials Assessment Tool for Audiovisual materials (PEMAT-A/V) for assessing the understandability and actionability of materials. Source characteristics and markers of bias and misinformation were also collected. Seventy-eight videos were included in the study, with a mean duration of 6.6 minutes and mean of 216,672 views. The median DISCERN score was poor at 28 (IQR 22–33) out of a possible 80 with mean PEMAT-AV Understandability and Actionability scores of 67.6% (±16.7%) and 33.8% (±36.2%), respectively. A medical doctor was present in 61 (78.2%) of the videos, of which 53 (86.9%) were urologists and 38 (62.2%) promoted their personal practice or institution. False statements regarding vasectomy were made in 14 (17.9%) videos. Notably, no significant difference was noted in quality, understandability, or actionability of videos created by those with personal promotion to those without. The quality of information regarding vasectomy on YouTube is poor and reaches a wide audience. Continued appraisal and creation of YouTube videos that contain quality, understandable and actionable information by urologists is necessary to ensure patients are well-informed.

Outpatient Vasectomy: Safe, Reliable, and Cost-effective

Vasectomy is a safe, effective, and practical option for permanent contraception in men. Vasectomy is a surgical procedure used in men to disrupt and occlude the vas deferens, which delivers sperm from the testicles. By interrupting sperm transport, this procedure provides permanent sterilization. Vasectomies are typically done under local anesthesia in outpatient settings, and patients usually go home within an hour of the surgery. Surgical techniques used for vasectomy vary widely throughout the world, with limited evidence to guide the most effective approach. Current vasectomy guidelines largely rely on information from observational studies, with few controlled clinical trials.

Practice patterns of vasal reconstruction in a large United States cohort

We aimed to characterise diverse practice patterns for vasal reconstruction and to determine whether surgeon volume is associated with vasoepididymostomy performance at the time of reconstruction. We identified adult men who underwent vasal reconstruction from 2000 to 2020 in Premier Healthcare Database and determined patient, surgeon, cost and hospital characteristics for each procedure. We identified 3,494 men who underwent either vasovasostomy-alone (N = 2,595, 74.3%) or any-vasoepididymostomy (N = 899, 25.7%). The majority of providers (N = 487, 88.1%) performed only-vasovasostomy, 10 (1.8%) providers performed only-vasoepididymostomy and 56 (10.1%) providers performed both. Median total hospital charge of vasoepididymostomy was significantly higher than vasovasostomy ($39,163, interquartile range [IQR]$11,854-53,614 and $17,201, IQR$10,904-29,986, respectively). On multivariable regression, men who underwent procedures at nonacademic centres (OR 2.71, 95% CI 2.12-3.49) with higher volume surgeons (OR 11.60, 95% CI 8.65-16.00) were more likely to undergo vasoepididymostomy. Furthermore, men who underwent vasoepididymostomy were more likely to self-pay (OR 2.35, 95% CI 1.83-3.04, p < .001) and more likely had procedures in the Midwest or West region (OR 2.22, 95% CI 1.66-2.96 and OR 2.11, 95% CI 1.61-2.76, respectively; p < .001). High-volume providers have increased odds of performing vasoepididymostomy at the time of reconstruction but at a significantly higher cost. These data suggest possibly centralising reconstructive procedures among high-volume providers.

Men's Vasectomy Knowledge, Attitudes, and Information-Seeking Behaviors in the Southern United States: Results From an Exploratory Survey

Vasectomy is one of the few options men have to manage their reproductive capacity and take on a more equitable role in pregnancy prevention. While the method is underused throughout the United States, the southern states have a lower prevalence rate compared to the rest of the country. Existing survey research does not assess what men know or think about the procedure as a means of understanding why this is the case. We created and conducted an exploratory survey to assess men’s knowledge, attitudes, and information-seeking behaviors about vasectomy in the Southern United States. We used targeted Facebook advertising to recruit men ages 25–70 years living in 7 southern states to complete an online survey (n = 397). Using regression analyses, we identify that participants who had a vasectomy knew more about the procedure than participants who had not. Participants who had not had a vasectomy had less positive attitudes about the procedure across all six attitude subscales compared to participants with vasectomies. We highlight potential avenues for future research to understand why this may be the case. Finally, the majority of participants knew someone who had had a vasectomy. This suggests that men disclose having a vasectomy to others. The interpersonal dynamics around vasectomy decision-making and disclosure remain unknown and a viable area for future research. Findings from this exploratory survey may be used by public health officials interested in implementing campaigns to increase knowledge about vasectomy and reduce stigma, which may encourage more positive attitudes about the procedure.

Vasectomy utilization in men aged 18-45 declined between 2002-2017: Results from the United States National Survey for Family Growth Data

BACKGROUND

Vasectomy remains a safe, simple and effective contraceptive options. Conflicting data on the trend of vasectomy use among men have been described previously at various snapshots in time over the last two decades.

OBJECTIVES

This paper seeks to describe the trend of vasectomy utilization in the last 15 years using a nationally representative United States survey.

MATERIALS AND METHODS

We analyzed data from male respondents aged 18 to 45 years of the Cycle 6 (2002), 2006-2010, 2011-2013, 2013-2015, and 2015-2017 National Survey of Family Growth (NSFG) surveys. Population estimates are calculated based on the official NSFG instructions, accounting for the complex survey design. Multivariate logistic regression models are used to study demographic and socioeconomic factors associated with vasectomy use in men.

RESULTS

Baseline characteristics for men undergoing vasectomy do not differ significantly across survey years. Increased age, White race, marital status, higher education level, birthplace within the United States, higher household income, non-Catholic affiliation, and higher number of biological kids have significant positive associations with vasectomy use. After accounting for factors associated with vasectomy utilization, there was a significant temporal decline in vasectomy utilization rates in all age groups across survey years which remained in subgroup analyses of all men greater than 25, 30, and 35 of age.

DISCUSSION

This is the first population-based analysis of US data to observe a decline in vasectomy utilization over the past two decades. The decline was statistically significant after accounting for all demographic and socioeconomic factors.

CONCLUSION

There is a steady decline in the prevalence of vasectomy use in men from 2002 to 2017. Given the limited contraceptive options for men and the importance of contraception and family planning in the US, further research is needed to understand the temporal decline. This article is protected by copyright. All rights reserved.

A qualitative exploration of men's perceptions of the terms "male sterilization" versus "vasectomy" in the southern United States

OBJECTIVES

Clinical literature and contraception information guides use the terms "male sterilization" and "vasectomy" interchangeably. We investigate the meanings men attach to "sterilization" and how those meanings compare to perceptions of "vasectomy."

STUDY DESIGN

Cisgender, heterosexual men, ages 25 to 67, living across seven U.S. southern states participated in individual telephone interviews from May to December 2019. Interviews explored men's experiences with contraception, including their perception of the term "sterilization." We audio-recorded and transcribed the interviews and conducted thematic analyses using an inductive approach.

RESULTS

While most participants described "vasectomy" as a relatively benign procedure, they described "sterilization" as "sinister," "bleak," and "barbaric." Participants' discussions of sterilization invoked associations with eugenicist practices and specific historical examples of forced sterilization. While some participants recognized that vasectomy is a means of achieving sterilization, most viewed the term "sterilization" as incongruous with the modern medical procedure of "vasectomy," precisely because sterilization has been used as a form of reproductive oppression.

CONCLUSION

Our findings suggest that men have strong affective responses to the term "sterilization." Participants' knowledge of historical eugenicist practices has implications for the acceptability of vasectomy as a permanent contraceptive option in our contemporary context.

IMPLICATIONS

The phrase "male sterilization" can be associated with eugenics and coercive reproductive practices. Using the term for reproductive counselling, education, or research purposes may have implications for the acceptability of vasectomy as a permanent contraceptive option.

Vasovasostomy and vasoepididymostomy: indications, operative technique, and outcomes

The basic principles of vasal reconstruction have endured since their initial description over a century ago, yet the nuances and technical approaches have evolved. Prior to performing vasectomy reversal, the clinician should perform a focused history, physical and laboratory assessment, all of which are critical for patient counseling and preoperative planning. Operative success is contingent on appropriate intraoperative decision making and technical precision in completing a tension-free, watertight, and patent anastomosis. Outcomes of vasectomy reversal differ on the basis of the type of reconstruction required, reconstructive technique, and patient-specific factors. Here we review the indications, surgical techniques, and outcomes of vasectomy reversal.

Vasectomy: a guidelines-based approach to male surgical contraception

Except for condom use, vasectomy is the only approved form of male contraception. The American Urological Association published guidelines on vasectomy in 2012, which clearly outlined patient counseling, vasectomy techniques to maximize successful occlusion, and postvasectomy care. However, there are certainly areas of further improvement to be addressed. Vasectomy is severely underutilized compared with tubal ligation for sterilization, likely due to lack of patient awareness. Although the majority of vasectomies are performed in the office with local anesthesia, some patients are still routinely prescribed narcotics for postprocedural pain, despite the well-described opioid pandemic. Finally, although patients are counseled on the necessity of a postvasectomy semen analysis to confirm sterility prior to the discontinuation of alternative contraceptives, more than 50% of men do not complete this test. Therefore, alternative strategies must be pursued to improve patient compliance.

"The Back-up Vasectomy Reversal." Simultaneous Sperm Retrieval and Vasectomy Reversal in the Couple With Advanced Maternal Age: A Cost-Effectiveness Analysis

OBJECTIVE

To determine the cost-effectiveness of different fertility options in men who have undergone vasectomy in couples with a female of advanced maternal age (AMA). The options include vasectomy reversal (VR), sperm retrieval (SR) with in vitro fertilization (IVF), and the combination of VR and SR with IVF, which is a treatment pathway that has been understudied.

MATERIALS AND METHODS

Using TreeAge software, a model-based cost-utility analysis was performed estimating the cost per quality-adjusted life years (QALY) in couples with infertility due to vasectomy and advanced female age over a period of one year. The model stratified for female age (35-37, 38-40, >40) and evaluated four strategies: VR followed by natural conception (NC), SR with IVF, VR and SR followed by failed NC and then IVF, and VR and SR followed by failed IVF and then NC. QALY estimates and outcome probabilities were obtained from the literature and average patient charges were calculated from high-volume centers.

RESULTS

The most cost-effective fertility strategy was to undergo VR and try for NC (cost-per-QALY: $7,150 (35-37 y), $7,203 (38-40 y), and $7,367 (>40 y)). The second most cost-effective strategy was the "back-up vasectomy reversal": undergo VR and SR, attempt IVF and switch to NC if IVF fails.

CONCLUSION

In couples with a history of vasectomy and female of AMA, it is most cost-effective to undergo a VR. If the couple opts for SR for IVF, it is more cost-effective to undergo a concomitant VR than SR alone.

[Vasectomy : Current information]

Vasectomy is considered to be the simplest, most effective and cheapest method of fertility control in men, with a significantly lower risk of morbidity and mortality compared to tubal ligation in women. Patient informed consent is particularly important and should include potential irreversibility, surgical options, anesthesia, possible complications as well as postoperative behavior and the need for re-evaluation. There are different access routes available with conventional and no-scalpel vasectomy as well as different techniques for closing the ends of the vas deferens. To confirm sterility the European Association of Urology (EAU) recommends that an ejaculate analysis should be performed 3 months after the procedure and after approximately 20 ejaculations. Complications are relatively rare, although particularly vasectomy failure due to recanalization has to be considered. Approximately 3-6% of vasectomized men strive for a refertilization, which with experienced surgeons is successful in about 90% of cases.

Is Opioid-free Post-Vasectomy Analgesia a Pain? A Single Surgeon Experience

OBJECTIVE

To determine the impact of transitioning from opioid to non-opioid analgesia post-vasectomy on unplanned opioid prescriptions and health encounters.

METHODS

A retrospective review for patients who underwent vasectomy from October 2018 through December 2019 was performed. Beginning February 1^st, 2019, patients were counseled to take scheduled acetaminophen and ibuprofen in lieu of acetaminophen with codeine, with an opioid prescription only provided upon request. Analysis was performed comparing 200 consecutive patients before and after this transition. Baseline patient characteristics, unplanned postoperative encounters for pain within 30 days of vasectomy, and associated narcotic prescriptions were compared between groups.

RESULTS

400 patients were included, consisting of 200 patients pre and 200 patients postintervention. There were no differences in socioeconomic characteristics between groups. No differences between the pre- and postintervention groups were observed in terms of generating telephone calls to clinic (9% vs 11%, P = .5), clinic visits (2.5% vs 2.5%, P = 1), or ED visits (0% vs 1%), P = .5) for the pre and postintervention cohorts, respectively.

CONCLUSIONS

Patients that are not prescribed opioids after vasectomy do not generate additional phone calls, clinic, or ED visits compared to those that were routinely prescribed prior to our institutional change. We have permanently discontinued the routine use of opioids for post-vasectomy analgesia. Other physicians performing vasectomy should consider making this change as well.

Point-of-care semen analysis of patients with infertility via smartphone and colorimetric paper-based diagnostic device

Male infertility affects millions of males worldwide and is rising in prevalence due to social and environmental conditions. However, men often feel too embarrassed to receive a semen analysis in the hospital due to social stigmas. To overcome this problem, we developed a 3-(4,5-Dimethyl-2-thiazolyl)-2,5-diphenyl-2H-tetrazolium bromide test strip to distinguish semen samples with low total motile sperm concentration from those with normal motile sperm concentration. This is a point-of-care colorimetric semen analytical method with a one-step, inexpensive, equipment-free evaluation process, and adequate accuracy validated in a 42-sample clinical trial. In this study, results were evaluated visually and with a smartphone application. Using visual observation methods, the area under the curve (AUC) was 0.71 (95% of confidence interval = 0.55-0.86; p = 0.021), sensitivity was 41%, specificity was 95%, positive predictive value was 90%, negative predictive value (NPV) was 59.4%, and accuracy was 67%. Using a smartphone recording and analytical system, AUC was 0.766 (95% of confidence interval = 0.612-0.92; p = 0.003), sensitivity was 96%, specificity was 65%, PPV was 75%, NPV was 92.9%, and accuracy was 80.9%. This work demonstrated a screening tool that could elevate semen analysis to the level of routine healthcare and provide for private, in-home self-assessment.

Scheduling Appointments for Postvasectomy Semen Analysis Has No Impact on Compliance

BACKGROUND

A postvasectomy semen analysis (PVSA) is recommended 8-16 wk after vasectomy to ensure azoospermia. Patient compliance with submitting a semen sample for PVSA has historically been low. To increase patient compliance, a policy change was made to schedule patients for PVSA appointments instead of a previous "drop-in" option.

OBJECTIVE

To compare patient compliance for PVSA when scheduling appointments as opposed to a "drop-in" appointment 8-16 wk after the procedure.

DESIGN SETTING AND PARTICIPANTS

Ethical approval was obtained to retrospectively evaluate patients undergoing vasectomy. A total of 400 patients were evaluated, 200 consecutive patients before and 200 after the policy change. Patients were excluded from analysis if they had other surgeries at the same time of vasectomy or if the vasectomy was a repeat procedure.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Percent of patients attending PVSA and time to PVSA were assessed. Nominal data were compared using chi-square analysis and interval data were compared using Student unpaired t test.

RESULTS AND LIMITATIONS

Thirteen patients were excluded from analysis: six before and seven after the policy change. Compliance rates were similar before and after the policy change (144/194 [74%] and 154/193 [80%], p = 0.19). There was no difference in the time from vasectomy to PVSA between groups (before: mean [standard deviation] 69 [55] d vs after: 74 (63) d, p = 0.44). This study is limited by its retrospective design.

CONCLUSIONS

Scheduling appointments for PVSA has no impact on compliance rates or the time between vasectomy and semen analysis when compared with "drop-in" appointments.

PATIENT SUMMARY

Sterility after a vasectomy is guaranteed by delivering a semen sample. Many men do not deliver this sample, and sterility cannot be guaranteed. This study found that scheduling appointments did not increase the number of men who delivered a semen sample compared with "drop-in" appointments.

The vasal fluid proteomic profile and microscopic sperm presence at time of vasectomy reversal

Background

The microscopic characteristics of vasal fluid at time of vasectomy reversal (VR) guide operative decision making and predict fertility outcomes. The proteomic profile of this vasal fluid has not been described or correlated with the microscopic fluid appearance. To characterize the vasal fluid proteome at time of VR and evaluate the variation of the vasal fluid proteome with respect to microscopic presence of sperm.

Methods

A prospective cohort study was conducted enrolling twenty-five men undergoing VR for infertility and/or pain at a University-affiliated hospital. Vasal fluid samples obtained at time of VR were grouped based on presence of sperm on light microscopy at time of VR. Proteomic profiles were generated using liquid chromatography/ tandem mass spectrometry, and MS/MS protein spectral counts compared between individuals and treatment groups, controlling for less than 5% protein false discovery rate (FDR). Proteins were matched with the human swissprot database using the Comet search engine, and categorized by Gene Ontology (GO) terms.

Results

There was large variability between the 46 vasal fluid samples collected, with 1,692 unique proteins detected. The three most abundant proteins were Lactotransferrin, Cysteine-rich secretory protein 1, A-kinase anchor protein 4. There was no correlation between the proteome and microscopic sperm presence. Prevalent GO terms included viral process, signal transduction, innate immune response, protein folding and spermatogenesis.

Conclusions

We describe the proteome and the most common proteins in vasal fluid at time of VR. Numerable sperm, testis and epididymis specific proteins were present even in the absence of sperm on microscopy. Further evaluation is needed to determine if a protein biomarker may better guide operative decision making and predict VR fertility outcomes.

Association between the lengths of excised obstructed vas deferens segments at the time of vasovasostomy and surgical outcomes

OBJECTIVE

This study aimed to determine whether the length of the excised obstructed vas deferens at vasovasostomy (VV) performed for fertility is associated with semen parameters and/or pregnancy outcomes postoperatively.

MATERIAL AND METHODS

The patients who underwent a VV at our institution from September 2004 to December 2018 were contacted via questionnaire and a chart review was performed. Linear and logistic regression models were used to determine the associations between the length of the obstructed vas deferens removed and postoperative outcomes including sperm concentration, motility, and successful pregnancy after reversal.

RESULTS

A total of 83/170 questionnaires were returned. After exclusions, a total of 35 patients were included for analysis. The mean age of the patients at the time of surgery was 40.1 years and the mean time since vasectomy 9.3 years. The mean length of the obstructed vas deferens removed during VV was 2.25 cm. The longer the vas deferens segments removed, the more significant was the increase in sperm motility at 3 and 9 months postoperatively (p=0.011 and 0.008, respectively), but decreased sperm motility at 6 months (p=0.029). In 75.9% of the patients, sperm was present postoperatively, 23.2% achieved pregnancy through natural conception, and 55.8% achieved pregnancy using assisted reproductive techniques. There was no significant relationship between the length of the vas deferens removed and sperm concentration or pregnancy achieved after surgery.

CONCLUSION

In this cohort, the length of the excised obstructed vas deferens at VV was associated with improved sperm motility at 3 and 9 months postoperatively but not with pregnancy outcomes.

Continuing the search for a hormonal male contraceptive

This chapter discusses the mechanisms of action of hormonal male contraception, which suppresses the hypothalamic-pituitary-testis axis. When the intratesticular concentration of testosterone is subsequently suppressed to adequately low concentrations, spermatogenesis is arrested. Androgens are a necessary hormonal male contraceptive component because they not only suppress the hypothalamic-pituitary-testis axis, but also provide the male hormone necessary to maintain peripheral androgen functions. Past studies using testosterone alone and testosterone combined with progestins demonstrated contraceptive efficacy in the female partner at rates similar to combined hormonal female methods. Newer hormonal male contraceptive formulations and the alternative routes of administration are discussed, along with potential barriers, challenges, and opportunities for hormonal male contraceptive development. Novel methods that are safe, effective, reversible, user-friendly, and coitus-independent are intrinsic to equitably meet the various needs and limitations of an increasingly diverse population.

Current and future trends in men's health clinics

Men’s health is a unique field that requires a multi-disciplinary approach to appropriately treat the full spectrum of men’s health needs. Given that interest in men’s health is relatively new, the definition of a men’s health clinic continues to evolve. Originally conceived as testosterone replacement centers, men’s health clinics are increasingly understood to encompass male endocrine, surgical, urologic, physical performance, and psychological issues. As interest in men’s health continues to grow, it is important to focus on the field’s future, including pharmacies, telemedicine, and the diffusion of healthcare.

Childless Men at the Time of Vasectomy are Unlikely to Seek Fertility Restoration

OBJECTIVE

To examine whether men who were childless at the time of vasectomy sought consultation for fertility restoration.

METHODS

Retrospective chart review was performed to determine if patients without children at the time of vasectomy sought consultation for fertility restoration (defined as vasectomy reversal or sperm retrieval). If the patient had not been seen in our healthcare system within the previous 12 months, he was contacted by phone to determine whether he had sought consultation for fertility restoration.

RESULTS

Of 1656 men, 68 men (4.1%) were childless at the time of vasectomy. Fifteen patients were excluded as they were not followed in our hospital system and were unreachable by phone. Zero patients sought consultation for fertility restoration.

CONCLUSION

Our single institution study demonstrated that no men who were childless at the time of vasectomy sought consultation for fertility restoration. Given that there are no other FDA approved methods for nonbarrier sterilization for males, men with no children at the time of vasectomy should receive the same AUA guideline-recommended counseling that men with children receive.

Comparison of PESA and MESA techniques for men with obstructive azoospermia

DESIGN

Video presentation.

SETTING

University hospital.

PATIENTS

A 53-year-old male presents with a history of a vasectomy performed 7 years prior. His wife is 36 years-old and requests sperm extraction for in-vitro fertilization. On examination, his testicles were 20 cc bilaterally with a serum follicle-stimulating hormone of 5.3.

INTERVENTIONS

Percutaneous Epididymal Sperm Aspiration (PESA) and Microscopic Epididymal Sperm Aspiration (MESA).

MAIN OUTCOME MEASURES

Intraoperative technique highlighting the main steps for performing PESA and MESA, complications, and sperm retrieval outcomes.

RESULTS

This video highlights the technique for performing both PESA and MESA. We demonstrate complications and outcomes associated with both procedures. Both PESA and MESA are viable options for sperm retrieval with varying complications and sperm quality outcomes.

CONCLUSIONS

We demonstrate how to perform both PESA and MESA. Both are effective means for obtaining sperm for in-vitro fertilization with differences in technique, equipment required, complications and sperm quality outcomes.

Comparison of low-power magnification one-layer vasovasostomy with stent and microscopic two-layer vasovasostomy for vasectomy reversal

This study aimed to evaluate a simplified vasovasostomy procedure that shortens the operative time. This was a retrospective (non-randomized) study of men who underwent bilateral vasectomy and consulted for vasovasostomy (02/2014-08/2016). Eight interrupted sutures were used for one-layer full-thickness vasal anastomosis over a 20 or 22 G catheter temporarily inserted in the lumen of the anastomotic site as a stent. Control patients underwent double-layer vasovasostomy. The surgery was significantly shorter in the one-layer group (n = 23) (62 ± 8 vs. 133 ± 15 min, P < 0.001 vs. the two-layer group, (n = 19)). There was no difference in patency between the two groups (95.7 vs. 94.7%, P > 0.999). There was one case of epididymitis in each group. There were no complications like bleeding, scrotal hematoma, hydrocele, or infection. Low-power microscopic one-layer vasovasostomy with stent was simple and had a short operation time. The patency could be similar to that of two-layer vasovasostomy, but prospective studies are necessary for confirmation.

Vasectomy with vessel sealing device: comparison of different diameters

OBJECTIVES

Vasectomy is a popular and effective male surgical contraceptive method. Different techniques have been proposed to reduce failure rates and complications. In this study, we sought to compare vas deferens occlusion rates using both standard occlusion techniques and LigaSure (LSVS) for vasectomy.

MATERIAL AND METHODS

A total of nine patients underwent open radical retropubic prostatectomy at our institution. During the procedure, a total of 125 fresh vas deferens samples were obtained and divided into four groups as follows: Group 1: ligation (n = 22), Group 2; ligation and electrocauterization (n = 18), Group 3; 5 mm LSVS (n = 44), Group 4; 10 mm LSVS (n = 41). All specimens were harvested during surgery and subsequent histopathological assessments were performed to assess the luminal status of the vas deferens.

RESULTS

Histopathological evaluation revealed that the majority of vas lumens with LSVS (79.5% of Group 3 and 89.4% of Group 4) were totally occluded. With standard techniques, however, the majority of vas lumens (86.4 and 77.8% of Groups 1 and 2, respectively) maintained a tiny patency.

CONCLUSIONS

On histopathological review, the application of LSVS resulted in better occlusion rates, compared to standard ligation methods. These findings suggest a higher occlusive role for LSVS for vasectomy. Further clinical studies are needed to confirm the clinical efficacy and safety of this technique.