Shane T. Russell, MD
Male Reproductive Medicine
Vasectomy Reversal
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 4 hours if the surgeon is doing a careful two-layered microsurgical reanastomosis.
Meticulous technique- the key to success
The tendency of the body is to produce scar tissue as it heals. Excessive scar tissue formation in the vas deferens following attempted reversal invariably leads to a failed procedure. To minimize the risk of the vasal repair closing off due to scar tissue, attention to detail and a non-rushed, meticulous surgical technique must be employed. Experts in the field agree that the use of an operating microscope and extremely fine suture are mandatory for good outcomes. I employ general anesthesia to minimize patient movement during the procedure in order to maximize precision of the repair. This is an outpatient procedure.
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 6 months following reversal surgery.
The general patency rates for microsurgical vasectomy reversal are 80-90% or more for a vas-to-vas connection and 50-55% for vas-to-epididymis connection.
The natural pregnancy rates (not needing artificial insemination or IVF) following vasectomy reversal involve many factors which need to be considered, such as the age of the female partner, etc. However, in general, the natural pregnancy rates are up to 60% with a vas-to-vas connection, and 30-40% with a vas-to-epididymis connection.
Questions to ask your prospective vasectomy reversal surgeon
1) Does your surgeon use an operating microscope?
Studies have shown inferior results with repairs that do not utilize an operating microscope. The best results use suture that can barely be seen with the naked eye and require the use of a stationary operating microscope to accurately see and manipulate.
2) How long does your surgeon anticipate the operating time to be? (time actually spent operating, not getting checked in or placed under anesthesia)?
Meticulous attention to detail during a microsurgical reanastomosis is absolutely necessary to maximize the chances that your body will not re-block the connected vas tubes with scar tissue during the healing process. Any repair that takes less than 3 hours of operative time raises the suspicion of an attention to detail that is less than optimal.
3) Is your surgeon fellowship trained in infertility?
Is your surgeon a general urologist who happens to offer vasectomy reversal, or is infertility their specialty to which they have devoted extra time for formal training in the most effective microsurgical techniques?
4) Is your surgeon able to perform a vas-to-epididymis connection if needed?
As described above, if ‘favorable’ fluid is not found upon opening up the tied end of the vas deferens, then that tube is blocked and a vas-to-epididymis connection is needed. If your surgeon does not have the experience to perform a vas-to-epididymis connection, then he/she will not be able to give you the procedure you need for a successful outcome on that side. Most general urologists do not know how to properly perform the technically challenging vas-to-epididymis connection, which is typically only learned as part of formal infertility fellowship training.
Your first attempt at vasectomy reversal offers the best chance of success.
Any subsequent attempts at reversal are going to have more scar tissue buildup and decreasing success rates. Do not be shy about asking your prospective surgeon the above questions if you are interested in optimitizing your chances of success. Sometimes the least expensive surgical price you can find leads in the end to more procedures and greater overall cost.
Please include: 1) how long ago your vasectomy was performed
2) the age of your female partner
3) any other fertility problems you or your partner
might have
