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Vasectomy Reversal

Vasectomy Reversal

A vasectomy is a surgical procedure that blocks the flow of sperm through the vas deferens. The surgeon cuts through the vas deferens (see above left illustration) and then places a clip or suture on the cut ends. A vasectomy reversal attempts to restore the flow of sperm through the vas deferens.

It is usually performed by an experienced microsurgeon using specialized instruments, including an operating microscope. There are two types of vasectomy reversals: vasovasostomy and vasoepididymostomy.

Vasovasostomy

A vasovasostomy is the operation most frequently performed for vasectomy reversal. It entails stitching the cut ends of the vas deferens together (see above center and right illustrations).

Vasoepididymostomy

If excessive swelling or scarring has occurred in the epididymis, sperm may be blocked from getting to the vas deferens. If a blockage has occurred in the epididymis, merely connecting the two cut ends of the vas deferens (as is done in a vasovasostomy) will not solve the problem. To bypass the blockage in the epididymis, a vasoepididymostomy must be performed.

A vasoepididymostomy is performed by connecting the vas deferens directly to the epididymis as shown in the above illustrations. One end of the vas deferens is stitched directly to the epididymis.

Frequently asked questions about vasectomy reversals:

 

What are the success rates associated with vasectomy reversal?

Results of recent studies indicate that following microsurgical vasovasostomy sperm appears in the semen in approximately 85 to 97% of men. Approximately 50 percent of couples subsequently achieve a pregnancy.

Following microsurgical vasoepididymostomy, sperm appears in the semen in approximately 65% of men. Approximately 20 percent of couples subsequently achieve a pregnancy.

Is vasectomy reversal a common procedure?

Current estimates are that about one percent of men who have undergone a vasectomy will eventually want reversal surgery. About 500,000 men have vasectomies each year in the United States. While the number of men requesting vasectomy has remained approximately the same, the number of men requesting vasectomy reversal has increased.

Why do men want vasectomy reversals?

The leading reason that men elect to have vasectomy reversal is to father a child after remarriage following divorce or death of a spouse. Others seek vasectomy reversal after the death of a child. A small percentage of men seek reversal for relief of scrotal pain attributed to the vasectomy, a desire to restore fertility independent of any change in marital status, or because of religious beliefs.

Can all vasectomies be reversed?

From a surgical standpoint, it is rare that a vasectomy cannot be reversed.
In the past, if the epididymis was blocked or a large segment of the vas deferens was removed during the vasectomy, a vasectomy reversal procedure was considered to be too complicated and was unlikely to be successful. Today, however, the development of new microsurgical techniques has provided a way to bypass an epididymal blockage and correct a shortened vas deferens. These new techniques have led to improved pregnancy rates following vasectomy reversal even in the most extreme cases.

Does health insurance cover vasectomy reversal?

Not necessarily. It is important to check with your health insurance plan to identify what costs of vasectomy reversal may be covered. The costs of vasectomy reversal will include: the surgeon’s fee, the hospital’s fee for the use of the operating room and ambulatory care facility, and the fee for anesthesia. These costs can range from approximately $5,000 to $15,000.

How do I select a surgeon?

The skill and experience of the surgeon who performs your reversal surgery is one of the main determinants of your postoperative success. It’s a good idea to ask your potential surgeon whether he or she can perform a vasoepididymostomy using an operating microscope. During surgery, the surgeon needs to be experienced in assessing the vas fluid quality, evaluating signs of epididymal blockage, and determining the best location for a vasoepididymostomy if needed. A vasoepididymostomy is necessary in approximately one-third of cases, and the need for it can only be definitively determined during surgery.

Does it matter how long ago I had a vasectomy?

While the length of time from vasectomy to reversal surgery correlates with success, no interval is considered too long to perform reversal surgery.

Data from the largest research study on vasectomy reversal reveals progressively less favorable results as the time from vasectomy to reversal increases. These are the rates for 1,247 men studied who underwent vasovasostomy:

Years between
vasectomy
and reversal
Sperm Return  Pregnancy Rate 
< 3 97% 76%
3 – 8 88% 53%
9 – 14 79% 44%
> 15 71% 30%

 

 

 

Can my doctor predict the outcome of my vasectomy reversal by examining me before surgery?
Your doctor will examine you before surgery by physically palpating your scrotum to determine the firmness and size of the testicles. If you have one or more shrunken testicles, this may indicate irreversible testicular failure; therefore surgery may not be able to restore fertility.

If your doctor encounters an engorged and perhaps firm epididymis, this indicates that an epididymal blockage may be present. While not definitive, these findings may suggest that a vasoepididymostomy will need to be performed. On the other hand, if the epididymis is not engorged, a vasovasostomy is still not guaranteed.

Your doctor will also attempt to determine the length of the vas deferens that has remained after vasectomy (vas remnant) during the same scrotal examination. The longer the vas remnant, the better the chance for vasovasostomy and future success.

Lastly, disorders of the testicles such as varicoceles (an engorgement of the veins surrounding the testicles which cause damage) can be detected by your physician. These disorders may need to be corrected at a later date if vasectomy reversal surgery alone does not lead to pregnancy.

I’ve already had a vasectomy reversal with no success. Does it make sense to try it again?

A frequent cause of reversal surgery failure is that a vasovasostomy was performed when, on the basis of intraoperative findings, a vasoepididymostomy was indicated. Some other reasons for vasovasostomy failure are inaccurate approximation of the vas due to poor surgical technique, and blockage from scarring as a result of disruption of the blood supply. Success rates after repeat reversal surgery are slightly lower than success rates after first reversals, mainly because the duration of vas obstruction is longer for repeat reversal surgery.

One study reported that, following repeat reversals, sperm were present in the semen of three-fourths (150 out of 199) of men postoperatively and that pregnancy was reported in 52 out of 120 couples (43%) who were evaluated for pregnancy. These results are very similar to those of first reversals and many men feel that these results are high enough to warrant another try.

Is in-vitro fertilization (IVF) a better option for me than vasectomy reversal?

For men who have undergone a vasectomy, sperm is obviously absent from the ejaculate. Therefore, since the IVF procedure requires sperm, sperm must be retrieved from the testicle or epididymis through a minor surgical procedure. The procedure for obtaining sperm is less complicated than reversal surgery, but entails local anesthesia, and insertion of a needle into the scrotum (into the testicle or epididymis) to obtain sperm.

The cost of one cycle of IVF can range from $8,000 to $15,000 depending on the array of infertility factors involved and whether sperm retrieval procedures for the man is necessary. Because of the expense, lower pregnancy rates, and potential side effects from hormonal therapy for the female partner, reversal surgery, and in most cases, repeat reversal surgery are options of first choice for vasectomized men. IVF is an option to consider if vasectomy reversal is unsuccessful, rather than as an alternative to surgery.

We don’t plan on trying to conceive right away. When would be the best time for me to have a vasectomy reversal?

Even if you plan to postpone attempts to conceive, for most couples, it is probably best not to delay the reversal procedure. Keep in mind that the average time interval from a vasectomy reversal until pregnancy is 12 months, and it takes 24 months postoperatively until the highest percentage of pregnancies is achieved.

Also, the longer the interval between vasectomy and reversal, the less the chance that pregnancy after reversal would occur. When you have the option, sooner is better.

Will I be able to go home the day of the surgery?

The surgery may be performed either in an ambulatory surgery center or hospital, generally on a day-surgery basis. In most cases, the man arrives in the morning and leaves the hospital the same day.

What type of anesthesia is used?

Vasectomy reversal may be performed with local, regional or general anesthesia, depending on the preference of surgeon and patient. General anesthesia is commonly used because it affords maximum patient comfort considering the length and nature of the surgery.

How long will the surgery take?

Microsurgical vasovasostomy averages 2 to 3 hours, while vasoepididymostomy may take as long as 5 hours. The patient is then observed in the recovery room for an additional 3 hours.

The length of surgery depends on the type of procedure, the amount of scarring present from prior surgery, the presence of and degree of inflammation, and the ease with which sperm can be identified in the vas deferens or epididymal tubule.

Where are the incisions made?

A vasectomy reversal is usually performed through incisions in the front of each side of the scrotum. The incision is vertical (up and down) so that it can be extended if more length is needed. If there is difficulty in locating the site of the vasectomy, if the vasectomy was performed at a very high scrotal level, or if a long segment of the vas deferens was removed, it may be necessary to extend the scrotal incisions up to the lower abdominal region.

What are possible complications?

Normal signs and symptoms after surgery include: slight swelling, bruising or discoloration of the scrotal area. These generally do not require a doctor’s attention. A sore throat, headache, nausea, constipation and general “body ache” due to the anesthesia and surgery may also be present. These symptoms usually resolve within a few days.

Severe complications that require additional surgery are rare. Postoperative complications that require prompt attention are wound infections and severe scrotal hematoma (black and blue bruised scrotum). A wound infection is present if you develop a fever or if your incision becomes warm, swollen, red, or painful. A hematoma is present if excessive bleeding under the skin occurs and is accompanied by a throbbing pain and a bulging of the incision site.

How much pain can I expect after surgery?

Discomfort after vasectomy reversal varies from patient to patient. In general, pain may be similar or slightly more severe than the pain experienced after the original vasectomy. Pain medication such as codeine is prescribed and is usually only necessary for one to two days after the surgery, after which acetominephin (such as Tylenol) or ibuprofen (such as Motrin or Advil) is all that is needed. To decrease the pain and swelling after surgery, ice packs are recommended, which are placed on the scrotum for approximately ten minutes every half hour for the first post-operative day. A scrotal support is worn for four weeks after the surgery to decrease discomfort and lessen swelling. Normal strenuous activity can be resumed four weeks after the surgery if indicated by your physician.

How soon can I have sex after surgery?

It is generally best to wait three weeks after the surgery before resuming any type of sexual activity.

How long after the surgery will it take for sperm to re-appear?

The first semen analysis is obtained one or two months after the surgery and again at two to three month intervals, either until sperm counts and motility are normal, or pregnancy occurs. Three months after a vasovasostomy the semen analysis often reveals a good sperm count but poor motility. After 6 months the count is usually stable or slightly improved and the motility is significantly improved. After a vasoepididymostomy, sperm usually takes longer to appear in the ejaculate, and in most cases takes at least 4 to 6 months to appear.

Is there any chance that my sperm count will decline after an initially successful vasectomy reversal?

Following an initially successful reversal surgery, where good sperm counts and motility have been obtained, a significant number of men subsequently experience significant deterioration in sperm counts. About 1 out of 10 men following successful vasovasostomy and about 2 out of 10 men following successful vasoepididymostomy will experience deterioration in sperm counts when followed for at least two years after surgery.

A decline in sperm counts after successful surgery can be caused by the formation of scar tissue which can occur from sperm leakage at the reversal site or from a disruption of the blood supply at the site of the surgery.

In light of the 10 to 20 percent of patients that deteriorate after successful surgery, sperm banking should be a consideration, particularly after a vasoepididymostomy.

What are my options if the surgery is unsuccessful?

About 14 percent of men with vasovasostomies and 40 percent with vasoepididymostomies have no sperm in their semen after surgery. If sperm are not present in the semen by six months after vasovasostomy or by 12 to 18 months after vasoepididymostomy, then the reversal surgery is considered a failure.

If surgery is unsuccessful you can consider another operation or assisted reproductive techniques such as in-vitro fertilization (IVF) with intracytomplasmic sperm injection (ICSI). For a man who has no sperm in the ejaculate after reversal surgery, sperm for IVF/ICSI can be obtained through a minor surgical procedure (sperm retrieval) which extracts sperm directly from the testicles and/or epididymis.

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