Vasectomy Reversal

There are many reasons to reverse a vasectomy like remarriage following a divorce or starting a family over after the loss of a wife or child. Regardless of your reason, there are now advanced methods to restore your fertility. How do you know the options that are right for you? By arming yourself with the latest information, you can make informed decisions with your doctor.

What is a vasectomy reversal?
A vasectomy reversal restores fertility by reconnecting the severed sperm duct, or vas, which is located in each side of the scrotum. The procedure, which can be accomplished through various approaches, including microsurgery, restores the passage for sperm to reach a female egg.

What are the different types of vasectomy reversals?
What are the different types of vasectomy reversals?

Reversals are generally performed in an outpatient area of a hospital or in an ambulatory surgery center. The operation may be performed with local, epidural ("saddle block"), spinal or general anesthesia. The choice will depend on the preference of the surgeon, patient and anesthesiologist.

Once the patient is anesthetized, the urologist will make small incisions (cuts) on each side of the scrotum and first remove the scarred ends of the vas at the point of blockage created by the vasectomy. The urologist will then extract a fluid sample from the end closest to the testicle to examine the fluid to see if it contains sperm.

The presence of sperm in the fluid is an indication that there is no obstruction between the testicle and the location in the tube from which the fluid was obtained, and particularly that there is no blockage in the tube in the epididymis. When sperm are present in the fluid, the passage can be reestablished by reconnecting the ends of the vas. The medical term for reconnecting the ends of the vas is vasovasostomy. This may be accomplished with one of several methods.

If the urologist uses a "modified one-layer" method (figure 2), he/she actually places a series of tiny stitches through the entire thickness of the vas (from the exterior into the central canal) to join the ends. Once these full thickness stitches (the first "layer") are tied, a second set, or "layer," of stitches that only pierce the outer portion of the vas is placed between each adjacent pair of full thickness stitches. The modified one-layer method is used by surgeons who reconnect the ends of the vas without microsurgery, as well as by some surgeons who use microsurgery.

Urologists use microsurgery to produce better results using high-powered microscopes that magnify structures from five to 20 times their actual size. An operating microscope allows the urologist to manipulate stitches smaller in diameter than an eyelash to join the ends of the vas. The "two-layer" vasovasostomy method (figure 3), preferred by many urologists who use microsurgical techniques, involves placing six to eight tiny stitches to join the edges of the inner lining of the vas. This series of stitches is the first "layer." Then, another series of stitches (the second"layer") is placed to connect the outer portion of the two cut ends of the vas.

Which vasovasostomy method actually produces better results?
Several reports have shown no difference in outcomes between the modified one-layer (figure 2) and two-layer (figure 3) microsurgical methods of vasovasostomy. When microsurgery is used, the methods shown in Figures 2 and 3 both result in return of sperm to the semen in 75 percent to 97 percent of patients and pregnancy in 30 percent to 75 percent of female partners, depending upon the length of time from the vasectomy until the reversal (see next section).

If the urologist does not find sperm in the fluid sample, it may be because the original vasectomy created back pressure that caused a break in the tube in the epididymis. Because any break in this single, continuous tube can result in a blockage, the urologist will have to employ a more complicated reversal technique called a vasoepididymostomy. In this procedure, the urologist must bypass the blockage in the epididymis by connecting the upper end of the vas to the tube in the epididymis above the point of the blockage. Figure 4 shows how this approach was formerly performed without magnification.

Surgeons have since improved upon the low success rates of that method with a microsurgical method of vasoepididymostomy. It allows the surgeon actually to see the opening that he or she creates in the tiny tube in the epididymis. The ability to see the opening permits the surgeon to join the inner lining of the vas to the edge of the opening in the tube of the epididymis, and then to join the outer portion of the vas separately to the outer lining of the epididymis (figure 5). With the method shown in figure 5, 60 percent to 80 percent of patients have sperm return to their semen and 20 percent to 40 percent of their partners experience a pregnancy.

When performed under appropriate circumstances, vasovasostomy yields better results than vasoepididymostomy. However, you may need a combination of the two techniques, with a vasovasostomy done on one side and a vasoepididymostomy on the other side.

What can be expected after a vasectomy reversal?
Recovery from a vasectomy reversal should be relatively swift and fairly comfortable. Any pain that might be experienced after surgery can be controlled with oral medications. About 50 percent of men experience discomfort that is similar to the level they had after the original vasectomy. Another quarter report less pain than accompanied the vasectomy. A final 25 percent say the pain is somewhat greater than after the vasectormy. The reassuring news is that any pain severe enough to require medication rarely lasts longer than a few days to a week.

Most patients are back to normal routine and light work within a week. Urologists usually want their patients to refrain from heavy physical activity for about four weeks. If your job requires strenuous work, you should discuss with your surgeon the earliest time you can return to work. You will be advised to wear a jockstrap for support for several weeks. You will also be restricted from having sex for at least two weeks.

It takes on average one year to achieve a pregnancy after a vasectomy reversal. Some pregnancies occur in the first few months after the reversal procedure, while others do not occur until several years later.

One of the main factors influencing pregnancy rates is the obstructive interval, which is the duration of time between your original vasectomy and the reversal. As the table below shows, rates of both the return of sperm to semen and subsequent pregnancy are highest when the reversal is performed relatively shortly after the vasectomy.

The urologist will request a semen analysis every two to three months after surgery until your sperm count either stabilizes or pregnancy occurs. Unless a pregnancy occurs, a sperm count is the only way to determine surgical success. While sperm generally appear in the semen within a few months after a vasovasostomy, it may take from three to 15 months after a vasoepididymostomy.

In either case, if the reversal works, the patient should remain fertile for many years. The possibility of subsequent pregnancies is an important advantage of this procedure over sperm retrieval techniques for in vitro fertilization (see frequently asked questions). Only approximately 5 percent of patients who have sperm appear in the semen after a vasectomy reversal later develop scarring in the reconnected area, which could block the passage of sperm again.

Frequently asked questions:

Who performs vasectomy reversals?
Urologists are the surgical specialists who most frequently perform vasectomy reversals. Since not everyone focuses on this procedure, make sure to ask your urologist how many he or she has done Ñ and to what level of success. Also, if your urologist recommends a microsurgical approach, you have the right to ask about his or her experience and success rates with this technique especially since this is a technique that requires additional training.

Can all vasectomies be reversed?
Almost all vasectomies can be reversed. However, if the vasectomy was performed during the repair of a hernia in the groin, there may be more difficulty reconnecting the ends of the vas. Rarely, reconnection of the ends of the vas is not possible because such a long segment of the vas was removed during the vasectomy procedure.

Should I have a vasovasostomy or a vasoepididymostomy?
It is not possible to determine before the reversal operation which procedure will be best for you. The urologist necessarily must determine this during the vasectomy reversal procedure. If sperm are present in the fluid that is obtained from the end of the vas that is connected to the testicle, then a vasovasostomy is performed. If sperm are absent from the fluid obtained from the end of the vas that is connected to the testicle, the urologist then uses several criteria to determine which operation is best for you. The urologist will inspect the epididymis to determine if a blockage is present in the tube within the epididymis. If a blockage is seen, then a vasoepididymostomy will be required.

If no blockage is apparent, then the appearance of the fluid that is obtained from the end of the vas connected to the testicle may help determine which operation is best for you. In general, watery appearing fluid influences the urologist to perform vasovasostomy even though sperm are not present in the fluid, while creamy appearing fluid suggests that vasoepididymostomy is required when sperm are not present in the fluid. Several other factors also may be considered to help the urologist determine which operation is best for you. Some patients may require a vasovasostomy on one side and a vasoepididymostomy on the other side.

Is age a factor in conceiving after a vasectomy reversal?
Your age should not influence the result of your vasectomy reversal. Most men continue to produce sperm from their testicles for many years after their partners have entered menopause and are no longer ovulating, or producing eggs. In fact, a woman's fertility starts declining in her mid-30s, with significant impairment beginning around age 37.

If female age is a factor, your partner should check with her gynecologist to see if she is still ovulating before you agree to a reversal. Abnormal results from a simple blood test to measure hormone levels on the third day of menstruation indicate a significantly lowered chance of fertility. But do not be deceived by a normal reading. It does not always guarantee that she will be able to get pregnant.

Are there alternatives to vasectomy reversal?
Yes. Your doctor can obtain sperm from the testicle or epididymis by either a needle aspiration or surgery. But the sperm may not be useful for simple, inexpensive office artificial inseminations. Instead, the sperm that are obtained by such methods require the more complex, expensive ($5,000 to $15,000) in vitro fertilization (IVF) techniques using intracytoplasmic sperm injection (ICSI).

Most centers report a 30 percent to 35 percent pregnancy rate each time IVF with ICSI is performed if the female partner is younger than 37, but much lower rates if she is older. Since studies consistently show that vasectomy reversals are more cost-effective in achieving pregnancy than obtaining sperm for IVF with ICSI, your better option is with the reversal.

If a vasectomy reversal fails, should I consider a repeat reversal?
The success rates for repeat reversals are generally 8 percent to 10 percent lower than for first reversals. In making a recommendation, your urologist will no doubt review the record of your previous procedure. If sperm were present in fluid obtained from the lower end of the vas during that operation, he or she will probably perform a repeat vasovasostomy, a less complicated procedure than a vasoepididymostomy, but more likely to produce success.

How expensive is a vasectomy reversal?
Costs vary widely, ranging between about $5,000 and $12,000. Those amounts include fees for the surgeon and anesthesiologist as well as costs for the hospital or outpatient facility. Most insurance companies do not pay for this procedure. Therefore, you should discuss the finances of your operation early to see if your insurance company might be the exception to the rule.

Will a vasectomy reversal relieve pain in the testicle that developed after my vasectomy?
It is fortunate that only a very small percentage of men develop pain in the testicle after a vasectomy that is sufficiently severe for them to inquire about a vasectomy reversal to relieve pain. Because such situations are rare, there are few reports of groups of patients who undergo vasectomy reversals to relieve pain in the testicle. Most of these reports indicate that the majority of patients who undergo a vasectomy reversal for relief of pain in the testicles indeed are relieved of their pain. However, your urologist cannot determine in advance that your pain definitely will be relieved if you undergo a reversal.