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Original Article
240
Efficacy of Intraoperative Mitomycin-C in Vasovasostomy
Procedure: A Randomized Clinical Trial
Farzad Allameh, M.D., M.P.H.1*, Jalil Hosseini, M.D.2, Hamidreza Qashqai, M.D.3, Hamzeh Mazaherylaghab, Ph.D.4
1. Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2. Men's Health and Reproductive Health Research Center (MHRHRC), Reconstructive Urology Department, Shohada-e-Tajrish
Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3. Urology Department, Imam Sajjad Hospital, Iran University of Medical Sciences, Shahriar, Iran
4. Faculty of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran
Abstract
Background: Two-six percentage of vasectomized men will ultimately seek vasectomy reversal, which late stricture
and obstruction after operation are relatively common. To nd a method for improving vasovasostomy outcomes, we
used intra-operative local mitomycin-C (MMC) preventing possible brosis and stricture.
Materials and Methods: In this randomized clinical trial, 44 patients were assigned to two groups randomly during
a one-year study and the data of 40 patients were analyzed. The patients were followed up for 6 months after surgery.
The case group (n=19) was treated by vasovasostomy with intra-operative local MMC. The control group (n=21)
underwent standard vasovasostomy.
Results: Mean sperm count in MMC group was signicantly higher than the controls. The sperm count of more than
20 million/ml was respectively 53% and 14% in MMC and control groups. In a subgroup where the interval between
vasectomy and reversal was 5-10 years, post-reversal azoospermia was absent in MMC group, but 50% of the controls
were still azoospermic. In addition, 80% of MMC group had more than 20 million/ml sperms, but all of the controls
had less than 20 million/ml sperms. No signicant complication was seen.
Conclusion: Intra-operative local MMC in vasovasostomy can be regarded as a safe and efcient technique which
has several advantages including lower cost. Increase of sperm count is the main effect of local MMC applica-
tion that is more prominent when the interval between vasectomy and reversal is 5-10 years (Registration number:
IRCT2015092324166N1).
Keywords: Clinical Trial, Mitomycin C, Sperm Count, Vasectomy Reversal, Vasovasostomy
Citation: Allameh F, Hosseini J, Qashqai H, Mazaherylaghab H. Efcacy of intraoperative mitomycin-C in vasovasostomy procedure: a randomized clinical trial.
Int J Fertil Steril. 2019; 13(3): 240-244. doi: 10.22074/ijfs.2019.5664.
Introduction
Approximately 6-8% of married couples (about 42-60 mil-
lion men), experience vasectomy as contraception (1). Sur-
veys suggest that 2-6% of vasectomized men will ultimately
seek for vasectomy reversal (2). The most common indica-
tions for vasectomy reversal are divorce, death of spouse or
child and relief from post-vasectomy pain syndrome (3).
A meta-analysis on 32 studies about vasovasostomy with
6633 patients revealed that mean post-procedure patency
and pregnancy rates were 89.4 and 73.0%, respectively, with
the mean obstruction interval of 7.2 years. No statistically
signicant difference in vasovasostomy outcomes was seen
in the comparison of single versus multilayer anastomosis.
Obstructive interval less than 10 years was a predictor of
higher patency and pregnancy rates (4). Other analyses and
studies had less patency or pregnancy rates, 60-86% and 25-
53%, respectively (5-7). The main predictors for success of
the reversal procedure were the time between vasectomy and
reversal, as well as female partner age (6, 8). History of con-
ception with the current partner versus remarriage (7), aver-
age testicular volume (9), presence of a sperm granuloma,
use of surgical clips instead of suture at vasectomy, presence
and quality of vasal uid and sperm in vasal uid during
surgical exploration, in addition to increased α-glucosidase
in the postoperative semen also had a favorable impact on
patency (5, 10). Some studies reported that smoking of the
male or female partner and obstructive interval did not cor-
relate with postoperative success (7, 11).
The most common early complication of vasovasostomy
is hematoma. The hematomas are perivasal and very small,
thus they usually require no surgical drainage. Wound infec-
tion is another possible early complication. Late complica-
tions include sperm granuloma at the anastomotic site (5%).
Late stricture and obstruction are relatively common (12-
Received: 15/July/2018, Accepted: 19/January/2019
*Corresponding Address: P.O.Box: 1666663111, Urology and Nephrology Re-
search Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Email: farzadallameh@sbmu.ac.ir Royan Institute
International Journal of Fertility and Sterility
Vol 13, No 3, October-December 2019, Pages: 240-244
Int J Fertil Steril, Vol 13, No 3, October-December 2019 241
18% in 12 months). With microsurgical techniques, patency
can reach to 70-90% (12). Some newer techniques are intro-
duced to obtain better results including laser tissue solder-
ing (13), angled cutting for increasing vasal surface area, in-
creasing neovascularity and decreasing brosis (14), using a
double-ringed instrument designed to facilitate handling and
dissecting vas away from perivasal tissue in an atraumatic
fashion (15) and application of the brin glue (16).
Several surgeons have used mitomycin-C (MMC) as
an antibrotic adjunct to ab-externo trabeculectomy and
Dacryocystorhinostomy (DCR). It seems that intra-oper-
ative local MMC with a controlled concentration is a safe
agent for reducing brosis (17, 18). MMC is an antimi-
totic and cytotoxic agent that crosslinks DNA. This agent
inhibits DNA synthesis, cellular RNA synthesis and nu-
clear division. MMC also induces apoptosis and inhibits
protein synthesis by hampering synthesis of the collagen
using broblasts (19-22). In animal models, studies on
grafted tissue in mice have revealed that the differentia-
tion of grafts was signicantly inhibited by MMC (23).
In human studies, broblasts showed a dramatic struc-
tural response to MMC, including intracellular edema,
pleomorphic and vesicular mitochondria changes, dilat-
ed smooth and rough endoplasmic reticulum, as well as
chromatin condensation (24).
Evidence for MMC-induced carcinogenicity is consid-
ered sufcient for animals, but inadequate for humans. As
such, MMC is classied by International Agency for Re-
search on Cancer (IARC) as possibly carcinogenic agent
to humans (group 2B). A meta-analysis studied the effect
of varying concentrations of MMC and treatment dura-
tions on cellular proliferation and viability of the bro-
blasts. They found MMC at 0.4 mg/ml beyond the 5 min-
utes, and 0.5 mg/ml concentration at all time-points were
lethal and caused extensive cell deaths, compared to con-
trols. The minimum effective concentration appeared to
be 0.2 mg/ml for 3 minutes (25). In a systematic review,
it was found that intra-operative MMC adjunct in trab-
eculectomy appears to reduce the relative risk of failure,
and no signicant increase in permanent sight-threatening
complications was detected. They reported that MMC
was administered intra-operatively in concentrations of
0.1-0.5 mg/ml concentrations of saline for durations vary-
ing from 1-5 minutes (26). Local injection of MMC in
the site of Internal Ureterotomy (IU) was also studied by
several groups, reported that submucosal MMC injection
reduced the stricture rate from 50% to 10%, after IU (27).
The important point is that all of the previous studies
have examined MMC as an anti-brotic agent for oph-
thalmologic surgeries and internal urethrotomies. But
intra-operative local MMC has not been studied in vaso-
vasostomy yet. Therefore, our study is performed to de-
termine the overall safety and efcacy of intra-operative
local MMC as the anti-brotic agent in vasovasostomy.
Materials and Methods
In this randomized clinical trial, 58 patients, visited for
vasectomy reversal in Shohada-e-Tajrish Hospital (Teh-
ran, Iran) between January and October 2016, were en-
rolled.
Patient and public involvement statement
The main priority of these patients was to have the op-
portunity of becoming a father. It was indicated to the
patients that this method may not improve the outcome
of vasovasostomy procedure and they preferred to partici-
pate in this trial. All patients were fully informed about
the method of trial and subsequently they were blindly
sub-grouped. All recruited and conducted participants
were informed about the trial results by email after data
analysis.
In this randomized controlled trial (RCT) the burden of
the intervention such as pain and surgical site infection,
or hematoma were assessed by patients and also residents
of urology in the outpatient clinic and they were then re-
corded in our database.
Inclusion criterion was ‘males who underwent vasec-
tomy and wanted reversal of vasectomy. Exclusion crite-
ria were testicular atrophy, history of urethral or bladder
neck surgery, history of previous vasovasostomy, history
of scrotal region radiotherapy, history of chemotherapy,
age of partner out of fertility range and any situation sug-
gesting the need for vasoepididymostomy.
Six patients had testicular atrophy, history of previ-
ous vasovasostomy and age of their partners was out of
fertility range. Eight patients were candidates for vasoe-
pididymostomy, because of previous scrotal surgery or
manipulation like percutaneous sperm aspiration (PESA).
Hence, all of them were excluded from the allocation.
Finally, 44 consecutive patients were allocated randomly
into two groups: the case group (n=22) was candidate for
vasovasostomy in addition to intra-operative local MMC.
The control group (n=22) was allocated for standard vasova-
sostomy. Randomization was performed by a random num-
ber table and opaque envelopes were used for allocation.
The primary endpoints included presence of sperm in
semen, sperm count more than 20 million/ml, sperm mo-
tility rate and normal morphology rate in sperms. The sec-
ondary endpoints include hematoma, inammatory reac-
tion, tissue necrosis and any sign of surgical site infection.
As mentioned before, all patients were informed about the
disease, method of study and treatment possibilities. They
had been informed about the possible complications and
other applicable managements. Then, an informed con-
sent was taken from each patient.
The proposal of this study was approved by Shahid
Beheshti Medical University (SBMU) Ethical Commit-
tee (IR.SBMU.MSP.REC.1395.100) and research board
of Infertility and Reproductive Health Research Center
(IRHRC). Ethical issues were respected based on Dec-
laration of Helsinki. The RCT was approved and docu-
mented by IRCT (IRCT2015092324166N1).
Allameh et al.
Int J Fertil Steril, Vol 13, No 3, October-December 2019
242
Initial pre-operative evaluations included detailed medi-
cal history, complete physical examination and sperm anal-
ysis. In MMC group, pre-operation evaluation included
laboratory tests and cardiovascular consultation. In the op-
erating room, under spinal anesthesia, the procedure was
carried out using bilateral high vertical incision of scrotum.
After nding each vas deferens and preparing the site of
anastomosis, two ends of vas deferens were oated in 0.2
mg/ml MMC solution for 5 minutes, and they were then
washed by normal saline. Finally, anastomosis was per-
formed microscopically (CARL ZEISS F170 T surgical
microscope binoculars 10×/22B; Zeiss, Germany) using
modied two-layered vasovasostomy. Two 5-0 poly-pro-
pylene sutures were placed at 5 and 7 o’clock positions in
the sero-muscular layer to approximate two ends of the vas.
Next, four 8-0 poly-propylene sutures were sequentially
placed inside out in the mucosa of the vasal ends, at 3, 6, 9,
and 12 o’clock positions and tied up. Two additional sero-
muscular sutures were placed at 1 and 11 o’clock positions
to complete the anastomosis. In the control group, vaso-
vasostomy procedure was carried out as the MMC group,
except for oatation in MMC solution. All surgeries were
performed by the same surgical team.
Upon nishing the procedure, patients in both groups
were in complete bed rest the day after operation. The
second day after surgery, they were discharged provid-
ing the tests and general condition were normal. Patients
were advised to have relative rest at home for two weeks,
avoiding intercourse for one month and to have scrotal
support for at least one week. The patients were informed
about possible early and late complications, in addition
to the time of next necessary following up visits. The pa-
tients were followed up at 1, 3, and 6 months after sur-
gery by a complete history and a physical examination to
monitor the complications (hematoma, inammatory re-
action, tissue necrosis and any sign of operation failure).
Sperm analysis was also performed 1 and 6 months after
surgery for measuring patency (presence of sperm in se-
men), sperm count, sperm morphology and motility.
These data were gathered and documented via check-
lists consisting demographical data which include the
interval between vasectomy and vasovasostomy, intra-
operative local MMC application, sperm analysis results
and any complication related to the procedure. In MMC
group, during the procedure, two patients were not com-
patible with the inclusion criteria, since they were candi-
date for vasoepididymostomy. So, they were omitted from
the study and 20 patients received allocated intervention.
In this group one patient lost the follow up. Finally, the
data of 19 patients were analyzed. In the control group, all
of the 22 patients received allocated intervention. During
follow up, one patient immigrated to another city and he
was out of reach. Therefore, the data of 21 patients were
analyzed. Figure 1 shows the CONSORT ow-diagram of
the data in this study. The data analysis method was per-
protocol and performed by SPSS (version 23.0) software
(SPSS, Chicago, USA). Fisher exact test, Independent t
test, chi-square test and likelihood ratio chi square test
were used to compare and analyze the data. P value sig-
nicance level was dened as 0.05.
Fig.1: CONSORT 2010 ow-diagram.
Assessed for eligibility (n=58)
Excluded (n=14)
•Testicular atrophy (n=2)
•Previous vasovasostomy (n=3)
•Spouse’s age out of range (n=1)
•Candidate for vasoepididymostomy (n=8)
Randomized (n=44)
Allocated to MMC (n=22)
•received allocated intervention (n=20)
•did not received allocated intervention
(n=2, who underwent
vasoepididymostomy)
Allocated to standard vasovasostomy
(n=22)
•received allocated intervention (n=22)
•did not received allocated intervention
(n=0)
Lost to follow-up (n=1, due to change in
medical center)
•Discontinued intervention (n=0)
Lost to follow-up (n=1, due to
immigration to another city)
•Discontinued intervention (n=0)
Analyzed (n=19)
•Excluded from analysis (n=0) Analyzed (n=21)
•Excluded from analysis (n=0)
Enrollment
Allocation
Follow-up
Analysis
Vasovasostomy Using MMC
Int J Fertil Steril, Vol 13, No 3, October-December 2019 243
Results
Mean age in MMC group and control group was 39.95
(± 5.55) and 40.95 (± 6.65) years, respectively (P=0.609,
Table 1). There was no early or late surgical complication
in our allocated patients. Six months after surgery, mean
sperm motility in MMC and the control group was iden-
tical (27.05 and 18.71% respectively, P=0.118). Normal
morphology rate was also the same (20.05 and 17.05%
respectively, P=0.559) (Table 1). Mean sperm count in
MMC group was higher than the controls (23.5 and 9.4
million/ml) (P=0.023), and sperm count more than 20
million/ml in MMC and the control group was 53 and
14%, respectively (P=0.017). These differences were sig-
nicant, but post reversal azoospermia in the two groups
was not different (21% in MMC group and 43% in con-
trols, P=0.186) (Table 1).
Then, we analyzed data in three subgroups based on the
interval between vasectomy and reversal (less than 5, 5-10
and more than 10 years). In the rst subgroup (less than
5 years interval), post reversal azoospermia (P=0.429)
and sperm count more than 20 million/ml (P=0.429) in
MMC and control groups were not statistically different.
In the second subgroup (5-10 years interval), post reversal
azoospermia was absent in MMC group, but 50% of the
controls were still azoospermic (P=0.023). In addition,
80% of MMC group had more than 20 million/ml sperms,
but all of the controls had less than 20 million/ml sperms
(P=0.001). In the third subgroup (more than 10 years of
interval), there was no statistical difference in post rever-
sal azoospermia (P=1.000), and sperm count more than
20 million/ml (P=0.560) in the two groups (Table 2).
Discussion
Intra-operative MMC application is described for
DCR, trabeculectomy, and some urological surgeries.
All of these reports emphasized that MMC, as a local
antibrotic agent, is effective and safe. This trial, for the
rst time, demonstrates the effects of local intra-opera-
tive MMC in vasovasostomy. We cannot use previous
trial estimate the best sample size. So we conducted a pi-
lot study to nd if any benet exist using intra-operative
MMC in vasectomy reversal. It seems that the increase
of sperm count is the main effect of local intra-operative
MMC in vasovasostomy, but it has no effect on sperm
motility and morphology. This effect is more prominent
in both patency and sperm count more than 20 million/
ml; especially, in a subgroup with 5-10 years of interval
between vasectomy and reversal. If the interval is less
than 5 years or more than 10 years, MMC application
has no benet in the reversal outcomes. It is important
that MMC application has lower cost in comparison
with intracytoplasmic sperm injection (ICSI) or other
new techniques described for vasovasostomy, and it has
Table 1: Primary data analysis
Group Mean age (Y) Normal
morphology (%)
Motile sperms
(%)
Sperm count Mean sperm count
(m/ml)
Patency
<20 M/ml >20 M/ml Azoospermia Sperm present
MMC 39.95 ± 5.553 20.05 ± 14.69 27.05 ± 16.98 9 (47) 10 (53) (23.6 ± 2.3)×1064 (21) 15 (79)
Control 40.95 ± 6.659 17.05 ± 17 18.71 ± 15.96 18 (86) 3 (14) (9.4 ± 1.4)×1069 (43) 12 (57)
P value 0.609 0.559 0.118 0.017 0.023 0.186
Data are presented as mean ± SD or n (%). MMC; Mitomycin-C.
Table 2: Data analysis based on post-vasectomy interval
Group Patency Sperm count
Sperm present Azoospermia >20 M/ml*<20 M/ml
Interval<5 Y (n=7)
MMC 2 (50) 2 (50) 0 4 (100)
Control 3 (100) 01 (33) 2 (67)
P value 0.092 0.166
5 Y<interval<10 Y (n=18)
MMC 10 (100) 08 (80) 2 (20)
Control 4 (50) 4 (50) 0 8 (100)
P value 0.005 0.0001
Interval>10 Y (n=15)
MMC 3 (60) 2 (40) 2 (40) 3 (60)
Control 5 (50) 5 (50) 2 (20) 8 (80)
P value 0.714 0.417
Data are presented as n (%). *; Likelihood ratio chi square test, MMC; Mitomycin C, and Y; Year.
Allameh et al.
Int J Fertil Steril, Vol 13, No 3, October-December 2019
244
no side effects if the concentration is controlled. It needs
no special training and the time of surgery is relatively
the same as standard vasovasostomy.
The main limitations of our study are small sample size,
the use of very low concentration of MMC, relatively
short follow up term and not enough follow up to study
the pregnancy rate.
Conclusion
Intra-operative local MMC in vasovasostomy can be re-
garded as a safe and efcient technique which has several
advantages including lower cost. Increase of sperm count
is the main effect of local MMC application that is more
prominent when the interval between vasectomy and re-
versal is 5-10 years. However, further studies should be
conducted with larger sample sizes and different MMC
dosage, longer durations, and multi-center sampling to at-
tain more denite results.
Acknowledgements
There was no funding support and conict of interest in
this study.
Authors' Contributions
F.A.; Proposed the idea of the project, and also designed
and performed the analysis. H.Q.; Completed the study
protocols and wrote the manuscript. H.M.; Edited the
manu script, J.H.; Supervised all steps of the project. All
authors read and approved the nal manuscript.
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Vasovasostomy Using MMC
