Procedure: VASOEPIDIDYMAL ANASTOMOSIS (VEA)

1. Patient Details

I, __________________ (patient/next of kin/legal guardian), aged ____ years, voluntarily consent for Vasoepididymal Anastomosis for ____________________. Major illness/comorbidities: ____________________.

2. Authorization

I authorize Dr. __________ and the surgical team, assistants and trainees under supervision to perform the procedure.

3. Nature of Procedure

VEA is a microsurgical procedure to bypass epididymal obstruction by connecting the vas deferens to an epididymal tubule under an operating microscope. Bilateral surgery, conversion to vasovasostomy, or abandonment of reconstruction may be necessary depending on operative findings.( if the sperms are not found in intra operative findings)

4. Benefits

Restore sperm transport, improve fertility potential, allow natural conception where possible and reduce need for ART.

5. No Guarantee

No guarantee of return of sperm, fertility or pregnancy is there.

The success rate of the procedure( patency rates) ranges from 50-80 % depending on the findings and case to case basis.

IVF/ICSI or sperm retrieval may still be required.

6. Risks

General risks: bleeding, infection, hematoma, anaesthetic complications, pain, wound problems. Procedure-specific risks: failure of reconstruction, persistent azoospermia, anastomotic blockage, sperm granuloma, hydrocele, chronic scrotal pain, injury to epididymis/vas/testis, testicular atrophy (rare), need for repeat surgery.

7. Fertility Outcomes

Patency approximately 50–80%; natural pregnancy approximately 20–50%, depending on female partner fertility, obstruction duration and other factors.

8. Postoperative Course

Scrotal support, avoid intercourse 3–4 weeks, avoid heavy lifting 4 weeks, semen analysis after 6–8 weeks and follow-up thereafter.

9. Alternatives

Observation, sperm retrieval (PESA/MESA/TESE/Micro-TESE), IVF/ICSI, donor sperm, adoption.

10. Blood Transfusion

I consent to blood transfusion if necessary and understand associated rare risks.

11. Anaesthesia

Risks and benefits of anaesthesia have been explained.

12. Photography/Data

I consent to anonymized photography/video and academic use.

13. Intraoperative Decision

I authorize modification or extension of the procedure if medically necessary.

14. Team Based Care

Residents/fellows may participate under supervision.

15. Patient Declaration

I understand the procedure, risks, benefits, alternatives and expected outcomes. My questions have been answered. I voluntarily consent.

Patient to write:
‘I have understood the procedure, risks, benefits and alternatives explained to me in a language I understand.’

__________________________________________

Signatures

Patient Name & Signature: ______________________   Date: ______ Time: ______

Doctor Name & Signature: ______________________   Date: ______ Time: ______

Witness Name & Signature: _____________________   Contact: ______________

Attendant Consent (If Applicable)

Reason patient unable to consent: __________________________
Attendant Name: __________________ Relationship: __________ Signature: __________ Contact: __________