Vasectomy Reversal
Vasectomy Reversal
Although all men undergoing a vasectomy are informed that the procedure must be considered a permanent form of sterilization, a vasectomy reversal may be performed.
Although all men undergoing a vasectomy are counseled that the procedure must be considered a permanent form of sterilization, a variety of factors (e.g., remarriage, loss of a child, etc.) may cause a couple to consider having a vasectomy reversed. The ultimate measure of success of such a reconstructive procedure is pregnancy and is dependent on several factors: the age and fertility of the female partner, the age and previous fertility of the male, the method of vasectomy (conventional or no-scalpel), the surgeon's experience, the technique of vasectomy reversal (the use of optical magnification/microscope), the quality of the fluid seen coming from the vas at the time of the operation, and most importantly, the length of time since the vasectomy was performed.
In a large study of 1,500 patients from multiple institutions, the success rate correlated most highly with the length of time since vasectomy. The shorter the interval from vasectomy to reversal, the higher the success rate. In men whose obstructed interval was less than 3 years, the likelihood of sperm being present in the semen after reversal was as high as 95 percent and pregnancy was observed in 75 percent of the wives. On the contrary, when the obstructed interval was greater than 15 years, only 70 percent of men had sperm in their semen following reversal and the pregnancy rate was significantly lower at 30 percent. In most men, i.e., those with obstructed intervals between 4-14 years, the likelihood of having sperm in the semen is about 80 percent with a pregnancy rate of 45-60 percent. In interpreting these data, one should keep in mind that the age of the female partner plays an important role in the overall pregnancy rate. Men who are older, i.e., those who have had long obstructed intervals, may have older partners. This difference may account for some of the pregnancy rate difference as outlined above.
Although a high percentage of patients will have sperm present in their ejaculate following a vasectomy reversal, not all of these men are capable of initiating a pregnancy. In many such cases, the man will have developed antisperm antibodies which adversely affect sperm function. When you are seeking information regarding success rates, please keep this important factor in mind.
It is also important to realize that the longer the time period since the vasectomy, the more likely that a more complex reconstruction will be necessary. In such cases, it is usually necessary to perform a procedure called an epididymovasostomy (EV). At the time of the surgery, it may be determined that this procedure will indeed be necessary based on the quality of the fluid obtained from the vas deferens tube. This procedure connects the vas to the very small tubes of the epididymis. The epididymis is a structure situated behind the testicle where sperm are stored prior to passing into the vas deferens. The success rate for epididymovasostomy is lower than for the standard vasectomy reversal (vasovasostomy or VV). The overall success rate (as defined by a pregnancy) is about 25-40 percent.
Vasovasostomy is done on an outpatient basis. Anesthesia will be either general or spinal/epidural. Oral pain medication will be prescribed and is generally required for 24-48 hours. Tylenol® or Motrin® may then be used. An ice pack should be placed on the scrotum for the first 24 hours. We ask that you avoid heavy lifting, sports and sexual activity for four weeks. You may return to work in seven days. A semen analysis will be obtained 8-12 weeks after surgery. Some men may not have sperm for six months to a year. If the more complex epididymovasostomy is performed, repeat semen analyses may be required for up to 18 months.
The average length of time to achieve pregnancy is about one year. Up to 10 percent of patients will develop a recurrent obstruction after sperm were initially present. Many experts recommend that you consider sperm banking once the sperm count has peaked to safeguard against this occurrence. Bleeding and infection are uncommon complications. Scarring and persistent pain at the operative site occurs very rarely.
The finding of sperm within the epididymal tubule is the best predictor of success. In fact, if high quality sperm are encountered in the epididymal fluid at the time of the operation, we recommend sperm banking of this sample. This is done as an insurance policy in case the procedure is unsuccessful. These sperm can then be used for IVF with intracytoplasmic sperm injection (IVF/ICSI).
Recent breakthroughs in in-vitro fertilization have enabled us to achieve a pregnancy with a very small number of sperm. In men with production problems or obstruction not amenable to surgical reconstruction, obtaining sperm directly from the testicle or epididymis for IVF is the only option for biological parenthood.
Testicular and epididymal sperm cannot be used for intrauterine insemination due to their functional immaturity and the low number of such sperm that are retrievable. Their use requires IVF/ICSI.
The sperm may be sucked out with a small needle (aspiration) or processed out from a small piece of testis tissue (extraction). Aspiration can only be used in men with normal sperm production; it is less traumatic but removes only a very small number of sperm – too few for sperm banking, but sufficient for immediate use. Sperm aspiration/extraction with IVF/ICSI is an alternative to surgical reconstruction.
