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Vasectomy ReversalThis page discusses the following topics:
IntroductionVasectomies have become one of the most common methods of birth control in the United States and world-wide. It is estimated that in this country approximately 500,000 men undergo a vasectomy each year. About 2% to 6% of men who have had a vasectomy will eventually request a vasectomy reversal. Usually this occurs as a result of a divorce and remarriage (often to a childless spouse), but often a change in circumstances (e.g. economic) within the same marriage will motivate couples. While today there are a variety of options available, most couples’ strong preference is to conceive their own biological child rather than pursuing adoption, donor-sperm insemination, surrogate parenthood, etc. Pregnancy can be accomplished either through Assisted Reproductive Technology or Vasectomy Reversal. Assisted Reproductive TechnologyAssisted Reproductive Technology (ART) refers to the process of producing a pregnancy with sperm and eggs which are fertilized outside of the female. In couples where the male partner has had a vasectomy, sperm retrieval can be accomplished through a variety of techniques. MESA (Micro-epididymal Sperm Aspiration) refers to the technique of obtaining sperm surgically using an operating microscope. MESA is an outpatient procedure performed through a small scrotal incision, often under local anesthesia (unless a vasectomy reversal is to be performed at the same time, in which case general anesthesia is usually required). PESA (Percutaneous Epididymal Sperm Aspiration) refers to the technique of obtaining sperm ‘non-surgically’ by withdrawing them through a fine needle placed through the scrotal skin into the epididymis. In TESE (Testicular Sperm Extraction) sperm are obtained from testicular tissue removed by performing a testicular biopsy. Finally, in a TESA (Testicular Sperm Aspiration) procedure, sperm can be obtained by extracting them from the testicle using a fine needle. PESA, TESE, and TESA are usually performed under local anesthesia. Following sperm and egg retrieval, fertilization is usually accomplished through ICSI (Intra-cytoplasmic Sperm Injection), the process of injecting a single sperm into a single egg. ART is highly successful, and offers an alternative for men who do not want to undergo a vasectomy reversal. Each approach has advantages and disadvantages that must be considered before making a choice. Certain circumstances (age, number of children desired, economics) may influence your decision. The total cost of vasectomy reversal is less than the combined costs of sperm retrieval and ICSI. Male ReproductionSperm are produced in small channels in the testicle known as the ‘semeniferous tubules.’ Sperm production takes about 72 days. Immature sperm leave the testicle and enter the epididymis, a delicate convoluted tubule with an inner diameter of 0.2 mm. If the epididymal tubule were straight it would be 14 ft. long, but it is folded on itself and extends only the length of the testicle. Sperm spend 7 days in the epididymis during which time maturation occurs (acquire the ability to fertilize an egg). Mature sperm then travel through the convoluted and straight portions of the vas deferens into the ejaculatory duct and urethra where fluid from the seminal vesicles and prostate are added to form the ejaculate. Sperm constitute only 2% of the total ejaculate volume. After a vasectomy, sperm production continues in the testicle and sperm remain in the epididymis and the testicular end of the vas deferens. At the time of a vasectomy reversal fluid obtained from the testicular end of the vas deferens may or may not contain sperm. The absence of sperm may indicate a ‘blowout’ (known as a sperm granuloma) in the epididymis due to backpressure. Sperm granulomas are important since they usually cause epididymal obstruction. In some patients the ‘blowout’ will occur at the site of the vasectomy rather than in the epididymis. This has a beneficial effect as it releases pressure within the epididymis and prevents epididymal obstruction. Sperm granulomas at the vasectomy site can usually be felt as a small ‘knot’ in the mid or upper scrotum. Sperm granulomas in the epididymis cannot be detected on examination. After relief of the obstruction by a successful vasectomy reversal, the testicle can resume production of normal healthy sperm. The ProcedureIn cases where no ‘blowout’ has occurred in the epididymis, a vaso-vasostomy (reconnection of the two severed ends of the vas deferens) is performed. This procedure is generally performed through small (1/2-1") scrotal incisions, usually under a general anesthetic, although in some cases local anesthesia may be used. The ends of the vas are identified and scar tissue is removed. The freshly cut ends of the vas are then reconnected using an operating microscope and fine non-absorbable suture material. Since the lower segment of the vas deferens is convoluted, a vaso-vasostomy is technically more difficult to perform here than in the upper straight segment of the vas. A vaso-vasostomy usually takes between two and three hours to perform. If a blowout has occurred in the epididymis, a vaso-epididymostomy (connection of vas deferens to epididymis) will be required. This procedure requires a 2" incision and is always performed under a general anesthetic due to the need for a larger incision and longer operating time (4-5 hrs.). The vas deferens is connected to the delicate epididymal tubule just above the blowout in order to preserve as much functional length of the epididymis as possible (for sperm maturation). Should a Vaso-vasostomy or Vaso-epididymostomy be Performed?The decision to perform either a vaso-vasostomy or vaso-epididymostomy is an important one since a vaso-vasostomy is a technically easier procedure to perform and has a higher success rate. However, if there is an obstruction (blowout) in the epididymis, a vaso-vasostomy will fail. Unfortunately, there is no way to determine pre-operatively whether there is an obstruction in the epididymis, therefore the final decision regarding which operation to perform is usually made at the time of surgery. If the obstructive interval is short (less than 5 years), or if there is a granuloma at the vasectomy site, it is likely that a vaso-vasostomy will be performed. As the interval between the vasectomy and vasectomy reversal increases, the likelihood of a blowout in the epididymis increases. At ten years, approximately twenty-five to fifty percent of men will have a blowout and therefore will require a vaso-epididymostomy. At surgery the fluid from the lower (testicular) end of the vas is examined immediately under a standard microscope. The presence or absence of sperm and the obstructive interval are then considered in making the decision to perform either a vaso-vasostomy or vaso-epididymostomy. In general, a vaso-vasostomy is performed if the vas fluid contains sperm, or if no sperm are present but the fluid is watery. A vaso-epididymostomy is performed if the vas fluid is thick, pasty and no sperm are present. If a vaso-epididymostomy is to be performed, fluid from the epididymal tubule is sampled until sperm are found at which point the vas and epididymis are connected. AnesthesiaVaso-vasostomy: In a well-motivated patient, when operating time is expected to be short, local anesthesia can be used. However, general or spinal anesthesia is our preference since unanticipated factors (extensive scar tissue or unusually long gap between the ends of the vas deferens) may result in prolonged operating time and many patients find it difficult to remain still under an operating microscope for several hours. In addition, general or spinal anesthesia will allow us to perform a vaso-epididymostomy should it be necessary. Vaso-epididymostomy: Due to the need for longer operating time and larger incisions, general or spinal anesthesia is always required. Recovery After SurgeryBoth vaso-vasostomy and vaso-epididymostomy are performed as out-patient (same day) surgery. Depending on which procedure is performed, a few days (up to a week) off of work may be required, and no strenuous physical activity or sexual intercourse is permitted for 4 weeks. Oral analgesics (Vicodin, Tylenol/Codeine, Ibuprofen) are provided for post-operative pain control. Return to ‘full activity’ is usually possible by six weeks but due to the nature and location of the surgery, it is not unusual for patients to experience sensitivity for up to three months or longer. Significant complications (such as bleeding, infection) occur in only 1-2% of patients. Follow-upPatients are seen for a ‘wound check’ one week after surgery. The first post-operative semen analysis will be performed at six weeks. Patients are given a specimen container and asked to obtain a fresh semen specimen (less then 2 hours old) at home for examination in the office. A minimum of three ejaculations should occur before obtaining a sample. Additional analyses will be performed at three monthly intervals thereafter. After a successful vaso-vasostomy, one can expect to see sperm in the semen at between six and twelve weeks. Absence of sperm in the semen six months post-operatively invariably means failure. Following a vaso-epididymostomy, sperm usually return to the semen during the three-to-six month interval, but may not be seen for up to one year. Again, absence of sperm at one year usually means failure. ResultsThe results of a vasectomy reversal are measured by the patency rate (return of sperm to the semen) and pregnancy rate. Results depend on several factors, primarily the choice of procedure (vaso-vasostomy or vaso-epididymostomy). In general a vaso-vasostomy has a patency rate of 90% and pregnancy rate of 40-75%. If a blowout is present and a vaso-epididymostomy is required, the patency and pregnancy rates are 60% and 20-30% respectively. In addition, the pregnancy rate may be influenced by the presence of female infertility factors, age of the female partner, or anti-sperm antibodies. Following a successful vasectomy reversal the probability of pregnancy will be most influenced by the fertility status and age of the female partner. We advise a gynecological evaluation for all women whose male partners intend to undergo a vasectomy reversal. In normal women, fertility declines with age such that the probability of pregnancy for a woman less than 35 years old is 75%, and for women between 35 and 39 years old is 60%. Fifty to seventy percent of men form anti-sperm antibodies following a vasectomy. Anti-sperm antibodies may impair fertility after an apparently successful vasectomy reversal. However, routine testing for anti-sperm antibodies is not performed prior to a vasectomy reversal since in most cases antibodies will not affect fertility, and test results are often difficult to interpret. Following a vasectomy reversal, any of the assisted reproductive techniques discussed above may be employed if a pregnancy does not occur naturally due to low sperm count, low motility, anti-sperm antibodies or female infertility factors. Although pregnancy can occur as early as six weeks, or as late as several years following surgery, most will occur between twelve and eighteen months after a successful reversal. There are no data to indicate an increased incidence of fetal abnormalities occurring in children conceived following a vasectomy reversal. Repeat Vasectomy ReversalsVasectomy reversals fail to result in return of sperm to the semen in 10% to 50% of men. This usually occurs as a result of a build up of scar tissue at the surgical site, or an unrecognized ‘blowout’ in the epididymis. Furthermore, up to 10% of patients who have had a successful reversal (post-operative semen reveals sperm) will develop recurrent obstruction six to twelve months after surgery. While a failed reversal does not preclude any of the assisted reproductive techniques discussed above, many patients will benefit from a second reversal. Although second reversals are more difficult to perform due to the presence of scarring, sperm will return to the semen in 70% of patients, and pregnancy will occur in up to 40% of their female partners. Details of the first reversal, provided in the dictated operative note, may reveal information (i.e. the presence or absence of sperm in the vas fluid) that can help predict chances for success. In addition, we encourage all patients whose post-operative semen analysis reveals the presence of sperm to consider cryopreservation (sperm banking) in case late obstruction occurs. ComplicationsA vasectomy reversal is a safe surgical procedure and significant complications from the surgery itself or the general anesthesia (if required) are rare. Infections and bleeding occur in less than 2% of patients. Both result in scrotal swelling and generally resolve with antibiotics and bed rest. If oozing occurs at the time of surgery, a small drain may be left in the incision and removed one or two days later. This will prevent blood from accumulating inside the scrotum. No patient has required a transfusion, and patients are discouraged from donating their own blood for use during surgery. In ConclusionThe decision to proceed with a vasectomy reversal is often an emotional
one that should be made only after careful consideration of many factors,
including a realistic appraisal of your chances for success, financial
resources, and alternative methods for achieving pregnancy. Although we
always proceed with a sense of optimism and confidence, we cannot
guarantee the results. However, we are committed to providing you with the
best opportunity to achieve a successful outcome. |
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