Shane T. Russell, MD

Approximately 500,000 vasectomies are performed each year in the United States, and between 3-8% of these men will eventually change their mind and wish to have further children.  Following vasectomy, sperm continue to be made by the testicles, but they cannot travel out the the blocked vas deferens, so they are reabsorbed by the body. 

What are my options for fertility if I have had a vasectomy?

Two options exist for men who wish to have biologically-related children but have had a prior vasectomy.  These options are vasectomy reversal and sperm extraction combined with IVF/ICSI.  Making the right choice between these two depends on several factors, such as how long ago the vasectomy was performed, age of the female partner, and personal preferences of the couple.  Each couple must be evaluated on an individual basis and given the information needed to make the right choice for their unique situation.

Vasectomy Reversal

The procedure 

The goal of vasectomy reversal is to surgically re-establish the flow of sperm from the testicle through the vas deferens.  This can be performed in one of two ways, depending upon where the vas deferens is reattached beyond the blockage.  One option is to attach one end of the vas deferens to the other after removing the blocked region, which is called a vasovasostomy (or 'vas-to-vas' connection).  The other option is to connect the vas deferens to the epididymis, which is the structure that wraps around the side of the testicle, and is where the sperm typically mature.  This is called a vasoepididymostomy (or 'vas-to-epididymis' connection).  A vas-to-vas connection has a higher chance of success, and is always performed if possible.  However, if the end of the vas deferens closest to the testicle is blocked, then the only chance for success is to perform a vas-to-epididymis connection.  The chance of needing a vas-to-epidiymis connection increases with the length of time that has passed since the vasectomy was performed.  Which of these procedures will be necessary (vas-to-vas or vas-to-epididymis) cannot be known until the time of surgery, when the previously tied of vas deferens is opened up and the fluid which then comes out is examined under a microscope.  Favorable fluid (clear, sperm, sperm parts present) indicates that the vas deferens is not blocked and a vas-to-vas connection can be performed.  Typically the whole outpatient procedure takes approximately 3 to 3.5 hours if the surgeon is doing a careful two-layered microsurgical reanastomosis. Experts in the field agree that the use of an operating microscope and extremely fine suture are mandatory for good outcomes. 

What are the success rates for vasectomy reversal?

Success rates are usually measured in terms of patency rates, defined as the successful return of sperm to the ejaculate.  Typically sperm enter the ejaculate within 3-6 months following reversal surgery. 

Choosing a Vasectomy Reversal Surgeon

The two most important considerations to consider when you are choosing where to have your vasectomy reversal are:

    1) Price

           -There procedures are almost never covered by insurance so

                reasonable pricing is essential.

    2) Choice of Surgeon

            -Technique and microsurgical skills are extremely important in providing

                 the best chances of success.

It is imperative to evaluate both of these aspects when choosing a vasectomy reversal surgeon.  Extremely low prices (<$3000-4000 total cost) should raise suspicion of potentially sub-optimal surgical technique.  However, very high prices (>$10,000) are not necessarily associated with better quality outcomes, as the high costs are often due to expensive hospital operating room facility fees. 

The key is to find a microsurgical specialist (see below) with affordable rates.

My practice strives to offer very competitive pricing while employing the most recent microsurgical advances and training to provide the best chance of successful fertility outcomes at a reasonable price.

Price Quote/Free Phone or Email Consultation

For a price quote or free phone/email consultation, please contact Dr. Russell directly by leaving a message on his email or Dayton office number and he will get back in contact with you:

                Email:    vasreversalohio@gmail.com

            Phone (Dayton office): 937-434-6344

 On your email or phone message, please provide the following information:

         1. How many years ago (approximately) the vasectomy was performed

         2. Age of your female partner

         3. Any other known fertility problems (male or female side)

How to Identify a Microsurgical Specialist

Vasectomy reversals are very demanding and technically challenging procedures.  A patient’s first attempt at reversal is his best, and sometimes only, chance at success.  Urologists who wish to offer the most advanced and successful reversal techniques to their patients typically devote an extra 1 to 2 years to intensive microsurgical training (called a ‘fellowship’) to learn these specialized skills.  The term ‘general urologist’ denotes a urologist who has not undertaken advanced fellowship training and has not specialized into one particular field, but instead treats a wide variety of urologic issues such as prostate problems, kidney stones, etc.  Most urologists are general urologists, and less than 1% pursue advanced training to become a microsurgical specialist.  Since technique and training play such a vital role in optimal vasectomy reversal outcomes, it is important to have a microsurgical specialist, not a general urologist, perform your reversal procedure.

The challenge is to identify which urologists are microsurgical specialists.  The good news is that most regions of the country have at least one microsurgical specialist practicing in the area.  The difficult part is that any general urologist who offers vasectomy reversals may claim to be a ‘specialist’ in that procedure.  Luckily, one simple question can be used to help definitively differentiate a general urologist from a true microsurgical specialist:

Prior to making an initial consultation appointment, ask the doctor’s scheduler or nurse if the doctor has completed a formal 1 to 2 year fellowship in male infertility and microsurgery. 

If they have, then you have identified a microsurgical specialist; if not, then that doctor is a general urologist.  If the scheduler or nurse does not know, cannot find out, or offers some other form of training or experience that the doctor has, then that doctor is almost certainly a general urologist (the staff of microsurgical specialists almost invariably know the fellowship status of their physician).  Not to say that general urologists are not good surgeons- most do an excellent job of treating kidney stones, prostate problems, etc.  But they have not devoted an extra 1 to 2 years of intensive training to learning the most advanced microsurgical techniques to ensure the best possible fertility outcomes for their vasectomy reversal patients.

Decoding vasectomy reversal practice claims

1) Fellowship trained microsurgical specialist 

As described above, these urologists have chosen an extra 1 to 2 years to train intensively in the latest microsurgical techniques in order to offer their vasectomy reversal patients the highest chances of success.  Virtually all microsurgical specialists have the following characteristics in common:

                a. Use an operating microscope- to allow superior visualization of the operating field for precision surgery.  General urologists often use loupes (pronounced ‘loops’) which are less powerful magnifying devices worn on the head.  Loupes do not allow as high a degree of magnification, and therefore the tiny vasal structures are less well visualized during the procedure.

                b. Take at least 3 hours of operating time.  Microsurgical specialists take this long to perform their vasectomy reversals because they know that meticulous surgical technique is necessary for optimal reversal outcomes.   The latest, most effective microsurgical techniques take at minimum 2.5 to 3 hours to perform correctly and with proper attention to detail. Reversal procedures that take 2 hours or less should certainly raise suspicion that either the latest microsurgical techniques are not being used, or that attention to detail is less than optimal.

                c. Use 10-0 or 9-0 suture.  In surgery, the higher the number, the smaller the suture (i.e. 10-0 suture is much thinner than 8-0 suture).  The vas deferens is a very small, delicate structure, and precise surgery requires the use of very fine suture.  Almost all microsurgical specialists use size 10-0 or 9-0 suture.  If a urologist uses larger suture (no finer than 8-0 or 7-0) then he or she may not be using modern updated microsurgical techniques.

2) Other forms of training than formal 1-2 year fellowship

                a. Residency- this is the standard urology training which every general urologist goes through.  If a urologist says that he learned microsurgery during his residency, then he just a received standard basic urologic education, not advanced fellowship training.

                b. Post-graduate course- 1-2 week courses are offered by some programs to give brief updates on male infertility and microsurgery.  This is not the same as fellowship training, as it is impossible to squeeze 1 to 2 years of intensive fellowship training into a 1-2 week course.

3) Experience in microsurgery

Many urologists claim to be microsurgical specialists because they have been in practice many years and have performed hundreds or thousands of procedures.  However, just because a urologist has been treating patients for many years does not mean that he or she necessarily offers the most successful, updated, modern microsurgical techniques.  Performing an outdated technique hundreds or thousands of times does not make that technique any less outdated.

4) Bargain prices

As with many things in life, you typically get what you pay for, and the same holds true for vasectomy reversals.  To my knowledge, no fellowship trained microsurgical specialist currently offers special low-price (< $3000-4000) ‘all inclusive’ deals for vasectomy reversals.  The reason: through their training, they have learned that an optimally performed vasectomy reversal requires meticulous surgical technique using an operating microscope; a process which typically takes at least 2.5-3 hours when performed properly. To perform precision surgery under an operating scope, the patient needs to be completely immobile for at least 3 hours and therefore typically requires general or regional anesthesia in an operating room or surgery center setting.  So how can ‘bargain’ reversal doctors charge so much less than other surgeons and still earn enough to make a living (and advertise on the internet)?  These ‘bargain’ doctors typically reduce the price by eliminating the anesthesia and operating room costs, which usually represent at least 50% of the total cost of a standard reversal.  In order to do this, however, the reversals then need to be performed under local anesthesia and in an office setting.  Every place is different, but if a patient is considering a ‘bargain’ reversal, ask a few questions:

     1.  Has the surgeon finished a 1-2 year fellowship in male fertility

                  microsurgery?

     2.  Will the surgery take at least 2.5-3 hours on average?

     3.  Will an operating microscope be used, not loupes (see above)?

I always recommend exploring your options fully, but in my experience, ‘bargain’ vasectomy reversal surgeons are typically general urologists (not fellowship trained microsurgical specialists), take 2 hours or less to do a reversal, and do not use an operating microscope.  Precision surgery typically translates into superior outcomes and you only get one first, best chance at reversal success.  The result: you get what you pay for, and you can never ‘buy-back’ another first chance at reversal.

5. Money-back guarantees

This sounds like a good idea on the surface: if your reversal is not successful, then you get part of the cost of the procedure back as a refund.  The reversal doctor offering the guarantee must be incredibly skilled or else he would never make a living, right?  Well, not really, as ‘guarantee’ doctors typically own the surgery center or office and therefore keep the facility fee regardless of whether the reversal is successful or not.  The most important aspect to consider, however, is how a ‘guarantee’ doctor defines ‘success’ with a reversal.  I have heard of ‘guarantee’ doctors defining a ‘successful’ vasectomy reversal as a return of 1 million or more sperm per ml to the ejaculate.  This may sound like a lot of sperm until you consider that a normal sperm count is defined as 20 million or more sperm per ml.  Many patients who have sperm counts of 1 to 10 million per ml still will need to use in-vitro fertilization to establish a pregnancy, which is a route that reversal patients are typically trying to avoid in the first place: not what I would consider to be a very ‘successful’ reversal.  This is not to say that all ‘guarantee’ doctors operate in this fashion or that they may not provide excellent surgical results, but it does not necessarily follow that these surgeons must provide superior services or else they would not be in business.  The primary question to ask these ‘guarantee’ centers is how vasectomy reversal success is defined, keeping in mind that fertility tends to decrease when sperm counts fall below 20 million sperm/ml, and a significant portion of patients with sperm counts less than 10 million/ml may need in-vitro fertilization to have a child (which typically costs at least $10,000 per cycle).

Conclusion

Your best chance at vasectomy reversal success is with the first attempt, so it makes sense to make it count by working with a fellowship trained microsurgical specialist.  These specialists are not numerous, but almost every region of the country should have one within driving distance.  It may take some research and phone calls/emails to identify who is really a specialist, as opposed to a general urologist, but it will be time well spent.  Microsurgical specialists often also provide free phone or email consultations upon request where they can directly communicate their training and credentials, as well as answer specific questions about the reversal procedure before you sit down with them for a full consultation.  A surgeon’s willingness to spend time with you prior to a reversal procedure is usually indicative of the type of service that they will provide you with during and after your procedure.  Take your time, do your research, and choose carefully.