Vasovasostomy and Vasoepididymostomy

Vasovasostomy (VV) and vasoepididymostomy (VE) are surgical procedures designed to bypass an obstruction in the male genital tract. These procedures are usually performed to restore fertility, although they are occasionally undertaken to relieve pain, such as in postvasectomy pain syndromes.

Vasovasostomy involves the anastomosis of segments of the vas deferens above and below an obstruction. The vast majority of vasovasostomies are performed to reverse a prior vasectomy, but the procedure is occasionally indicated for repair of an iatrogenic vasal injury secondary to prior surgery (eg, inguinal herniorrhaphy).

Vasoepididymostomy is a technically more demanding procedure than vasovasostomy. It involves anastomosis of the vas deferens to the epididymis in order to bypass an epididymal obstruction. This obstruction may be secondary to long-standing vasal obstruction resulting in damage to an epididymal tubule (epididymal blowout) or may result from epididymal infections or trauma.

Surgical procedures to remove genital tract obstructions and to restore fertility have been attempted for almost 100 years. In 1903, Martin et al first reported a technique for vasoepididymostomy to treat an obstructed epididymis due to gonococcal infection. He described anastomosing the vas to a cut end of the epididymis using fine silver wires. This fistula technique of anastomosis remained the standard for nearly 75 years, until advances in technique and instrumentation made direct, single tubule anastomosis feasible.

In 1978, Silber first reported a technique for directly anastomosing the mucosa of the vas deferens to a single epididymal tubule.[1] While this required more technical skill and magnification than the fistula technique, it allowed precise alignment of the vasal and epididymal lumens, resulting in markedly improved fertility rates.

Quinby reported the first successful vasovasostomy for vasectomy reversal in 1919. The anastomosis was performed over a strand of silkworm gut that was later removed. By 1948, O'Conor reported a practice survey revealing that 18% of urologists had performed a vasal anastomosis procedure at least once and that the operation was successful in up to 40% of patients.[2] Various techniques have been tried since O'Conor's survey, including the use of stents and adhesive materials to improve patency rates for the macroscopic anastomosis.

The next major advance occurred when Owen[3] and Silber[4] separately reported their techniques for microsurgical anastomosis in 1977. Silber reported patency rates of up to 94% using the 2-layer microsurgical technique for vasal anastomosis. This is the current gold standard for vasectomy reversal.

More recently, newer literature has emerged investigating the use of robotic-assisted vasovasostomy with promising results. The handful of studies available, notably from Parekattil et al and Kavoussi, have found similar rates of patency compared with microsurgical technique.[5, 6]  A systematic literature review reported vasal patency rates of 88-100% for robot-assisted vasovasostomy and 55-61% for robot-assisted vasoepididymostomy.[7]

The potential benefits of the robotic technique vs the microsurgical approach appear to be decreased operative time, mildly increased patency rates, and decreased learning curve for the surgeon. Increased cost, as well as decreased magnification compared to the microsurgical technique are the main disadvantages.[8]

Azoospermia (the absence of sperm in the ejaculate) can result from an obstructed genital tract or a failure of spermatogenesis in the testicle. Vasovasostomies are indicated for an obstruction at the level of the vas deferens, while vasoepididymostomies are used to treat epididymal obstructions. The site of obstruction can often be discerned by examination of the fluid from the vasal end or from the epididymal tubule, as described below. The goal of both procedures is to restore genital tract patency and ultimately to allow conception. These procedures are not indicated for nonobstructive causes of azoospermia.

Frequency

Vasectomy remains one of the most commonly performed operations in the United States and throughout the world. Despite careful preoperative counseling, between 3-6% of the men who undergo vasectomy ultimately desire a vasectomy reversal (VR). Restoring fertility and relief from postvasectomy pain syndrome (PVSP) have been cited as the top reasons for a reversal.[8]  

Primary genital tract obstruction occurs in 7.4% of infertile males who have not undergone a prior vasectomy. While the cause may be multifactorial (eg, including epididymal trauma, infection, congenital hypoplasia of the ductal system), a significant number of these patients are candidates for vasoepididymostomy for restoration of the patency of the seminal tract.

Causes of vasal and epididymal obstruction are outlined in Table 1 (see image below). Vasal obstruction is usually the result of an intentional division for sterilization, although it occasionally may be caused by iatrogenic injury during surgical procedures (eg, herniorrhaphies).

An epididymal obstruction can be congenital or can result from an epididymal infection, trauma, or prior vasectomy. Congenital epididymal obstruction may occur in conjunction with atresia of the vas deferens, rendering surgical reconstruction impossible. This is usually associated with a cystic fibrosis genetic mutation, and these men may have no other phenotypic manifestations of cystic fibrosis. Some of these patients have a normal vas deferens and dysjunction of the vas deferens with the epididymis, and they may benefit from vasoepididymostomy.

Inflammatory obstruction of the epididymis can result from bacterial epididymitis. Neisseria gonorrhoeae usually affects only the distal epididymis, allowing a surgical bypass of the vas to the more proximal epididymis using a vasoepididymostomy.

Trauma to the epididymis is a relatively uncommon cause of an epididymal obstruction but may result from epididymal injury during scrotal surgeries (eg, spermatocelectomy, hydrocelectomy, testis biopsy).

An epididymal obstruction following vasectomy is the most likely cause of an epididymal obstruction. The buildup of high intraluminal pressures within the epididymis after a vasectomy can result in rupture of the delicate epididymal tubule, resulting in obstruction (eg, epididymal blowout). This phenomenon is more common in men who desire a reversal more than 10 years after their vasectomy and in patients in whom vasovasostomy has previously failed.

Patients who desire vasovasostomy for vasectomy reversal self-refer for evaluation. All other patients present for an evaluation of infertility after a trial of unprotected intercourse. A careful physical examination suggests the diagnosis of vasal or epididymal obstruction that is amenable to a vasovasostomy or vasoepididymostomy, respectively. Men with a genital tract obstruction have testes of normal size (>20 mL volume or 4 cm length) and consistency. The epididymis feels prominent proximal to a site of obstruction and feels flat (empty) distal to an obstructed tubule. Dilatation of the entire epididymis suggests an obstruction at either the junction of the epididymis with the vas deferens or within the vas deferens itself.

The indications for a vasovasostomy include vasectomy reversal and relief of postvasectomy pain syndrome. The latter indication is uncommon and remains of controversial efficacy. Prior to undertaking a vasovasostomy for vasectomy reversal, the female partner should be evaluated by a gynecologist to exclude concurrent female causes of infertility. A vasoepididymostomy is performed for the treatment of a genital tract obstruction at the level of the epididymis.

Both vasal and epididymal obstruction are suggested by azoospermia in the presence of a normal semen volume. Low-volume azoospermia (< 1.5 mL) is more suggestive of ejaculatory duct obstruction than vasal or epididymal obstruction. Patients must have active sperm production in the testes to be considered a candidate for a vasoepididymostomy. For this reason, a testis biopsy is usually performed at the time of or prior to planned reconstruction to document active spermatogenesis. The authors prefer to conduct a biopsy at the time of reconstruction, as this avoids the inevitable scarring that can further complicate reconstruction at a later date.

To understand the surgical bypass procedures needed to restore sperm flow, it is important to understand the basic anatomy and physiology of the seminal tract. Sperm is produced and then released into the seminiferous tubules. The sperm transits through the rete testis, efferent ductules, and into the epididymal tubule. See image below.

Epididymis

The epididymis consists of a single, highly convoluted tubule that is covered with tunica vaginalis. By convention, the epididymis is divided into the following anatomic segments: (1) the caput (head), (2) the corpora (body), and (3) the cauda (tail).

The proximal epididymis is involved in sperm maturation, whereas the distal region is the area of sperm storage. Vasoepididymal anastomosis to the more proximal epididymal tubule results in lower pregnancy rates because this bypasses a region of vital importance for sperm development.

Vas deferens

At the terminal end of the epididymis, a thick muscle wall that forms the proximal end of the vas deferens surrounds the tubule. The vas deferens follows the spermatic cord, courses through the inguinal canal, and enters the pelvis via the internal inguinal ring. From the pelvis, the vas travels behind the bladder and joins with the ipsilateral seminal vesicle to form an ejaculatory duct, which enters the prostate posteriorly. Contraction of the muscular wall of the vas deferens serves to propel sperm from the epididymis into the prostatic urethra via the ejaculatory ducts.

For more information about the relevant anatomy, see Male Reproductive Organ Anatomy and Ductus Deferens (Vas Deferens) and Ejaculatory Duct Anatomy.

It is important to obtain a thorough history from all patients requesting VR. Important factors to consider are pre-vasectomy fertility of both the patient and his partner. The age of the partner, previous parity, and any concurrent medical issues she may have that can affect the outcome of future pregnancy.[8] By far, the most important prognostic factor for successful reversal is the occlusion duration.[9]  

Obtaining information about post-vasectomy complications such as infection or hematoma can prepare the surgeon for intra-operative peri-testicular inflammation that can make re-anastomosis more challenging.[9]  

Testosterone replacement therapy (TRT) has been well documented to negatively impact spermatogenesis. Any TRT the patient is currently taking should be discontinued well before VR as it can influence intra-operative decision-making. Inability to identify sperm on intra-operative vasal fluid can lead the surgeon to pursue the more technically challenging VE, which can also negatively impact outcomes and pregnancy rates.[8]

Patients and their partners should be counseled regarding the risk and benefits of surgical reconstruction, as well as the alternatives. In-vitro fertilization, microsurgical testicular sperm extraction, donor sperm insemination, and adoption are all viable options. Should couples proceed with vasectomy reversal, cryopreservation of sperm intra-operatively can provide more options of fertility in the future should vasectomy reversal be inadequate for natural conception.[9]  

Any history of previous inguinal or pelvic surgeries should also be documented for completeness.

Physical examination should consist of a thorough testicular exam. Documenting the presence of a palpable vasal defect, sperm granuloma, and if possible, the length of the proximal (testicular) vasal segment can be helpful in operative planning. 

Presence of a varicocele is also an important exam finding which can significantly impact fertility rate and can be surgically corrected at the time of VR.[8]

Vasectomy reversal

See the list below:

• Men who request a vasovasostomy or vasoepididymostomy reversal require no further workup as long as their scrotal examination reveals normal-sized testicles and they have not developed any fertility-impacting medical conditions (eg, history of chemotherapy, radiation therapy) since their original vasectomy.

• In the case of small testes or history of a potentially gonadotoxic insult to the testis, perform a testis biopsy at the time of, or prior to, the procedure to document normal sperm production.

• Approximately 60% of men who undergo bilateral vasectomy develop circulating antisperm antibodies afterward, and the effect of these on conception and pregnancy is controversial. While preoperative antisperm antibody testing is available, its effects on postoperative fertility is of unproven benefit.

Nonvasectomy reversal

See the list below:

• To be a candidate for a vasoepididymostomy, men with normal–semen volume azoospermia must have active sperm production, an epididymal obstruction, and a patent vas deferens. Normal serum gonadotropin levels (eg, follicle-stimulating hormone [FSH]) suggest normal spermatogenesis, although, occasionally, a patient with an interruption in the normal sperm development (maturation arrest) has normal FSH levels.

• Definitive proof of normal sperm production is required and can be provided by a testis biopsy at the same time as the planned reconstruction (or at an earlier date).

• At the time of planned reconstruction, a vasogram is performed to confirm patency of the entire vas deferens and ejaculatory duct. Performing a vasogram at an earlier time may result in scarring of the vas, rendering definitive reconstruction more difficult.

Surgical Skill

Important to the consideration of vasectomy reversal is the experience of the surgeon involved. One study found that surgeons performing >15 VV per year had significantly greater patency rates than a surgeon performing < 6 (87% v 56%, respectively).[8, 10]  Ideally, the surgeon should be prepared to perform either a VV or VE, depending on the intra-operative findings. Despite the fact that nomograms exist for predicting which patients will be best served with VV, certain men will still require the more technically challenging VE.[9]  

Obstructive Interval (OI)

Obstructive interval (time from vasectomy to VR) is an important factor of VR success. Earlier studies on this front had demonstrated precipitous decrease in reversal success when performed 10 years after vasectomy.[11] Similarly, another study found significantly higher patency rates when reversals were performed < 5 years after vasectomy compared to that of >10 years (89% vs 75%).[12] More recently, a handful of studies have demonstrated similar patency rates amongst men with an OI of ~15 years; however, the need to perform VE became increasingly more likely.[8] This observation was backed by two studies from Magheli and colleagues, as well as Fuchs et al, citing the need for VE in men with an OI of >15 years at 52% and 62%, respectively.[13, 14]  

Partner Age

Perhaps the most important factor determining the success of VR is the age of the patient's partner. It is well known that female fertility declines with age due to depleting oocyte numbers and chromosomal abnormalities of the ones remaining. A study performed by Gerrard et al. demonstrated similar patency rates (83%-90%) among patients, however, the pregnancy rates for their female partners were 14% for those >40 years of age and 56% for those < 40 years of age.[15] This finding reinforces the importance of partner age on future fertility rates and how age >40 significantly decreases the chances of successful pregnancy.

 

 

 

 

 

 

Both vasovasostomy and vasoepididymostomy are performed in an outpatient setting. Uncomplicated vasovasostomies take 2-3 hours and are often performed under local anesthesia with mild sedation. Vasoepididymostomies may take up to 4 hours; therefore, an epidural block or general anesthesia is appropriate. For both procedures, a broad-spectrum antibiotic is administered 30 minutes prior to surgery.

Vasovasostomy

A 2-cm vertical scrotal incision is made over the prior vasectomy site, and the vas deferens is mobilized. Exposing the epididymis is unnecessary; in fact, this may lead to postoperative adhesions that could further complicate a subsequent vasoepididymostomy. Care is taken to mobilize an adequate vasal length to ensure a tension-free anastomosis and to retain the perivasal vessels to allow for a well-vascularized anastomosis, thus avoiding ischemia with resultant stenosis. The presence of a sperm granuloma has been associated with better grades of sperm quality in the vas but has not been associated with better postoperative results.

The video below depicts a vasovasostomy.

The vas deferens is incised above and below the prior vasectomy site. It is then gently dilated with fine forceps and irrigated with a 24F Angiocath to verify patency. Fluid is collected from the proximal vas and microscopically examined for spermatozoa and their components. If spermatozoa or any sperm components are seen, vasovasostomy is performed. If no spermatozoa are seen, vasoepididymostomy is considered. The presence of spermatozoa is associated with the best prognosis for future fertility, although clear fluid without spermatozoa also portends a good outcome. The obstructive interval can also be factored into the decision, as the chance for epididymal obstruction increases with increasing time since the vasectomy. If available, sperm is cryopreserved in case the reconstruction fails.

It is generally accepted that the results of vasovasostomy are better after microsurgical rather than macrosurgical anastomosis, although some surgeons still report favorable results using macrosurgical techniques. Regardless, various methods have been described for performing the vasovasostomy anastomosis, depending on the degree of magnification (loupes, microscope) and the type of procedure (modified 1-layer vs formal 2-layer procedure).

The authors prefer the formal 2-layer anastomosis (see image below) performed under microscopic magnification, anastomosed to either the straight or convoluted vas. First, 9-0 nylon seromuscular sutures are placed in the posterior end of the vas at the 5- and 7-o'clock positions. Six interrupted 10-0 nylon mucosal sutures are then placed to approximate the luminal ends of the deferens. Finally, 4 additional 9-0 nylon seromuscular sutures complete the second layer of the anastomosis.

The modified 1-layer vasovasostomy (see image below) represents a viable alternative technique to the formal 2-layer anastomosis. While it does not allow as precise a mucosal realignment, the procedure is technically less demanding, requires less magnification, and produces comparable outcomes. A 9-0 nylon suture is passed through the entire vas wall, traveling full thickness through both ends. Two 8-0 nylon seromuscular sutures are placed on either side of the 9-0 suture. This pattern is repeated in each quadrant of the anastomosis, resulting in a total of 4 luminal sutures and 8 seromuscular sutures.

During the procedure, care is taken to prevent thermal damage to the vas, and only bipolar cautery or ophthalmic cautery is used to stop adventitial bleeding. Cautery is never used on the opposing transected ends of the vas.

Vasoepididymostomy

The results of vasoepididymostomy are better with microsurgical rather than macrosurgical anastomosis. Because it is often impossible to determine preoperatively if a vasoepididymostomy will be required, the surgeon should be prepared to perform whichever is necessary in a patient undergoing vasectomy reversal.

A vertical scrotal incision is made, slightly longer than that used for a vasovasostomy to allow for delivery of the testis, epididymis, and vas deferens. The vas deferens is isolated on the medial side of the spermatic cord and mobilized to the most proximal normal area, preferably the convoluted tubule. The vas deferens is then transected and tunneled through the spermatic cord structures to be positioned adjacent to the epididymis.

Using the operating microscope, the epididymis is examined for any obvious site of obstruction. If no such area is identified, the tunica albuginea of the epididymal tail is incised, and gentle pressure is applied to extrude a single epididymal tubule. This tubule is then sharply unroofed and the expressed fluid examined for sperm. If no sperm are found, this process is repeated more proximally until sperm are found. It is important to perform the anastomosis at the most caudal level at which sperm are present in the epididymal tubule in order to maximize the likelihood of postoperative fertility.

While several types of vasoepididymal anastomosis have been described, the authors prefer the end-to-side technique described by Thomas (see image below).[16] Two 9-0 nylon sutures are used to secure the seromuscular layer of the vas to the epididymal tunic. Four 10-0 nylon sutures are then placed to secure the mucosa of the vas to the epididymal tubule. Finally, six to eight 9-0 nylon sutures are used to secure the seromuscular layer of the vas to the epididymal tunic.

Intussusception vasoepididymal anastomotic techniques provide a potentially easier approach to standard suture vasoepididymostomy. First described in the early 1990s, the intussusception technique has been described both in end-to-end and end-to-side anastomoses, with patency and granuloma rates that are comparable or superior to those of standard anastomoses. The triangulation intussusception vasoepididymostomy was first described by Berger. In this technique, the epididymal tunic is sutured to the muscularis of the vas. Three double-arm sutures are then placed in the distended epididymal tubule. The epididymal tubule is then opened and sutures are placed in the corresponding positions in the vas lumen. Later, Marmar introduced the two-suture intussusception, which has also shown promising results.

Following the procedure, the patient is discharged after recovering from anesthesia. He may return to work 3 days after the procedure. While showering is allowed within 2 days of surgery, the patient should not soak the incisions under water until 2 weeks postsurgery to avoid premature dissolution of the absorbable skin sutures. Nonstrenuous exercise may be resumed within a week after the procedure, and strenuous activities, such as jogging, may be resumed after 3 weeks. Patients are instructed to refrain from postsurgical sexual activity for a full month.

The patient returns to the office for a wound check in 7 days. A semen analysis is obtained 3 months postsurgery. In patients who have undergone vasoepididymostomy, the anastomosis is often slow to function. In this population, semen analyses are repeated quarterly for a year or until sperm are present.

If no sperm are present by 18 months postsurgery, the operation is considered a failure, and patient is advised about the alternatives (ie, repeat procedure, sperm extraction with in vitro fertilization [IVF], donor insemination, adoption). Failure typically represents an anastomotic scar, which occurs in 3%-12% of patients after vasovasostomy and 21% after vasoepididymostomy.

If the patient develops normal semen concentrations postoperatively and his wife does not conceive, consideration should be given to antisperm antibodies on the surface of the sperm.

Repeat surgical reconstructions with vasoepididymostomies and vasovasostomies can be performed, but these are technically more demanding because of extensive scarring and should be undertaken only by an experienced microsurgeon. With that caveat, the success rates for these procedures are comparable to those of initial reconstructions.

Hematoma, infection, and testicular atrophy are the main complications of both procedures. Hematoma is largely preventable by careful attention to hemostasis throughout the dissection. The authors’ practice is to close the incision in 2 separate layers, with the first consisting of the tunica vaginalis and dartos muscle and the second consisting of the dermal edges. In this way, hematomas that can plague scrotal surgery have been avoided.

Testicular atrophy remains the most dreaded complication. Atrophy results from injury to the internal spermatic artery as it traverses through the spermatic cord. In most cases, this is avoidable by careful dissection of the vas away from the adjacent cord. In addition, this injury can occur in patients receiving vasoepididymostomies if great care is not taken when the vas is tunneled through the spermatic cord and placed in proximity to the epididymis.

The most common cause of operative failure is stenosis at the site of the vasovasostomy. The delayed closure rate of initially patent anastomoses is 3%-6% per year for vasovasostomies. An aggressive vasectomy resulting in a long segment of vas removal may necessitate greater mobilization of vas, in turn leading to a greater potential for devascularization, fibrosis, and stenosis.

Vasovasostomy

Predictive models have been described to predict which patients will ultimately require a vasoepididymostomy based on the duration of obstruction and the patient’s age. As shown in Table 2 (see image below), experienced hands can obtain patency rates in excess of 90% and pregnancy rates of more than 50%.

The following 3 factors portend the best surgical outcomes:

• The interval since the vasectomy was performed is one important factor. The Vasovasostomy Study Group, the largest multicenter group to assess vasovasostomy efficacy, found that an interval of less than 3 years resulted in patency rates of 97% and pregnancy rates of 76%. An interval exceeding 15 years resulted in patency and pregnancy rates of 71% and 30%, respectively.[17]  A study by Grober et al analyzed the vasectomy reversal outcomes specifically among patients with vasal obstructive intervals of greater than 10 years. The study concluded that although the interval since vasectomy has a significant effect on the type of vasectomy reversal required, provided a surgeon is proficient in both microsurgical vasovasostomy and vasoepididymostomy, favorable semen parameters and patency and pregnancy rates can be achieved in men with a vasal obstructive intervals greater than 10 years.[18]

• A second important factor is the microsurgical experience level of the surgeon. Performing the procedure without any magnification (ie, the macroscopic vasovasostomy) yields significantly inferior surgical results, with pregnancy rates ranging from 19%-55%. When the microsurgical technique is used, the success rates are markedly improved, regardless of whether the modified 1-layer or formal 2-layer anastomosis is used.

• Lastly, the presence of sperm and the quality of the fluid from the proximal vas is predictive of surgical success. Patency rates in men with sperm in the proximal vas fluid at the time of vasovasostomy exceed 90%, compared to pregnancy rates of 60% in men without sperm in the proximal vas. In the setting of no sperm in the vasal fluid, clear fluid predicts a higher success rate than thick opalescent fluid. A study by Scovell et al concluded that the presence of whole sperm or sperm parts in the vasal fluid during vasectomy reversal is positively associated with postoperative patency.[19]

Vasoepididymostomy

Vasoepididymostomy yields patency rates of 58%-85% and pregnancy rates of 11%-56%.

While the level of epididymal anastomosis does not affect patency rates, pregnancy rates are highest with the most distal epididymal anastomosis (cauda) because of the important sperm maturation that occurs during transit through the epididymis.

Several investigators have attempted to use fewer sutures, augmented by fibrin glue or laser soldering for both vasovasostomy and vasoepididymostomy procedures, allowing for a shorter operative time. In addition, robotics have been used for both vasovasostomies and vasoepididymostomies, with the hope that it may help with microsurgical technical issues, including eliminating tremor and improving dexterity with microsurgical instruments. While these techniques are not the current clinical standard, they appear to yield similar patency rates and may represent alternatives for the surgeon who performs only an occasional vasectomy reversal.

Patients are counseled about the realistic expectations for success after vasovasostomy and vasoepididymostomy. Sperm cryopreservation is offered to all patients at the time of reconstruction.

Patients who have undergone vasectomy have been shown to have a higher prevalence of antisperm antibodies and elevations in reactive oxygen species. After vasectomy reversal is performed, the elevation in reactive oxygen species may persist, contributing to infertility after vasectomy reversal. The role for anti-inflammatory medications to prevent this is currently under investigation.

The main controversy with surgical bypass procedures of the genital tract relates to advances in sperm extraction and assisted reproduction techniques. Since its advent by Palermo in 1992,[20] intracytoplasmic sperm injection (ICSI) has revolutionized the treatment of obstructive and nonobstructive azoospermia. With the success of this technique, some authorities have questioned the need for vasovasostomy and vasoepididymostomy procedures altogether. Since all patients who undergo these procedures undergo sperm extraction and cryopreservation, these samples are available for patients who have azoospermia after their procedure.

Despite advances, cost and safety issues favor surgical reconstruction over sperm extraction with ICSI. Cost analyses of vasovasostomy versus intrauterine insemination (IUI) or IVF shows a cost benefit for the former in terms of pregnancy rates, provided that patency rates exceed 79%. Similarly, a cost analysis by Kolettis and Thomas (1997) showed a significant cost advantage for vasoepididymostomy over ICSI.[21]

Vasectomy reversal should be considered the ideal option (1) when the interval since the vasectomy is less than 15 years and (2) in couples who desire more than one child. IVF may be considered in couples with an older female partner or in whom bilateral vasoepididymostomy may be required.

The safety concerns associated with ICSI, including ovarian hyperstimulation syndrome, an increased risk of multiple births, and a theoretical increased likelihood of fetal malformations (eg, hypospadias), further supports the selection of surgical reconstruction.