Is It Possible to Medically Increase Testosterone and Still Maintain Fertility? A look at Clomiphen
This is a review of a paper exploring conversion of hypogonadal (low testosterone) men from clomiphene to Natesto.
I have written previously that vasectomy is intended to be a permanent method of birth control. It generally only requires fifteen to thirty minutes to accomplish and is most commonly performed on men who have decided that they no longer desire to have additional children with their partner. But a man can change his mind.
A vasectomy is a procedure that disrupts flow of sperm through a tube called the vas deferens which transports the sperm from epididymis (a tubular structure that receives the sperm from the testicle) into the ejaculate. Typically a small piece of the vas is removed and the ends are sealed.
A vasectomy reversal typically involves removing the sealed ends and joining the pieces of vas back together. This is a bit more complicated that it sounds. The vas is a thick muscular tube and the lumen or hollow central portion of the vas is very narrow. In fact, it is smaller than a millimeter, unless dilated or stretched open. So, in order to perform a vasovasostomy , the procedure to put the tubes back together, microsurgical techniques are required in order to get the best results which, depending on the practitioner, can be a patency rate above ninety percent.
There are additional considerations. Sometimes there may be additional blockage at the level of the epididymis. In this case of a secondary blockage beyond the vasectomy, connecting one end of the vas to the other end will not accomplish much and instead a vas to epididymis connection would be required. This is called an epididymovasostomy and requires more microsurgical skill and time, but also has a lower chance of success.
Chances of successful vasectomy reversal correlate with the chance of performing a vasovasostomy. The possibility that this will be performed depends on several factors. The clearest association is with time since the vasectomy. The longer the time since the procedure, the more likely an epididymovasostomy (EV) will be required. In addition, if the original vasectomy was performed “lower” on the vas, or closer to the epididymis, that would increase the EV risk. I have also noted that smokers are more likely to require an EV.
But there is one more factor just recently described by Ostrowski et al in the January edition of the Journal of Urology: it seems that both pregnancy and live birth rates may be higher when vasectomy reversal is performed on men with the same female partner as before their vasectomy. This series reported on 534 men over a 34 year period and noted higher success on men who had reversal and then attempted to conceive with the same partner.
There are a few possibilities why this may be the case. First, average male age was fairly young at 39 years of age. Second, by definition, the population consisted of couples with proven fertility. Finally, the overall average time from vasectomy was fairly low at 5.7 years and shorter interval between vasectomy and reversal is associated with greater success.
In conclusion, Vasectomy reversal is a procedure that can be performed with a high chance of success. Those chances are modified by factors referenced above. In situations where there is increased risk of performing an EV, simultaneous surgical sperm retrieval may be a consideration and is a tactic I employ frequently.
