UNC urologist and professor Matt Coward, MD, sees patients to restore fertility after vasectomy, either because of a change of heart or more commonly because of an unexpected life event that has caused a man to want more children. Vasectomy reversal is the most common approach.
“Men who get vasectomies generally want a permanent solution,” says Dr. Coward, a urologic microsurgeon performing vasectomy reversals and surgical sperm retrievals in the Triangle.
“However, about 5 percent of men who get vasectomies end up getting them reversed. Because it is so successful in most cases, vasectomy reversal is often the best option for men who change their mind.”
Dr. Coward answered our questions about vasectomy reversal and other methods for restoring male fertility.
Dr. Coward, what factors predict success for a vasectomy reversal?
Success is measured by both sperm returning to the ejaculate and whether a pregnancy is achieved. There are two very important variables for success. The first is the length of time since the original vasectomy. We call this the vasectomy interval. The second is the age of the female partner.
Generally speaking, we see the best results when the vasectomy was performed in the last 10 years. While there’s no time frame past 10 years where reversal wouldn’t be recommended, we see slightly decreasing outcomes of the connection being successful and of pregnancy occurring afterward as time increases beyond a 10-year interval. That being said, the likelihood of natural conception is often similar or better than the chance of a successful pregnancy with IVF, even sometimes long after 10 years. Much of this depends on a particular patient’s anatomy and factors relating to the original vasectomy, as well as factors relating to a patient’s female partner.
When it comes to partner age, women younger than 38 are more likely to conceive and less likely to have risks for infertility. Proven fertility between two people is the most predictive for a great result. Therefore, if the couple has children who they previously conceived together prior to the vasectomy, that would be the best predictor for a successful vasectomy reversal.
Based on these factors, success ranges on average from about 80 to 97 percent. I can give an individual couple a better idea of what they might expect after a complete evaluation.
How does a vasectomy reversal work?
A vasectomy reversal restores continuity of the male reproductive tract. The vas deferens is the tube that carries sperm from each testicle, and after a vasectomy there is a surgical disconnection and scar in each vas.
A reversal is a much longer and more complex procedure than a vasectomy, and it is accomplished in an operating room setting with the patient under general anesthesia and with the assistance of an operating microscope.
The actual reconnection is performed in one of two ways, which is determined during the procedure and depends on where the blockage is located. The initial blockage is always at the original vasectomy site, but over time sperm can back up into the more delicate epididymis—the coiled tube at the back of the testicle that stores sperm—at which time a secondary obstruction can develop.
The most common procedure required during a reversal is called vasovasostomy, or vas-to-vas reconnection, during which the vasectomy clips and scar are removed and the ends are reconnected like simple plumbing. This is much more common when the vasectomy was performed within the past 10 years, and it only requires a tiny incision.
In the second, more complex procedure, called epididymovasostomy, or epididymis-to-vas reconnection, the end of the vas deferens above the vasectomy site is rerouted directly to the epididymis, bypassing the secondary obstruction. It requires a slightly larger incision. The method of reconstruction on either side is determined during the procedure as an intraoperative decision. The likelihood of needing the more complex epididymovasostomy increases when the vasectomy interval is greater than 10 years.
After the vasectomy reversal, either by vasovasostomy on each side, epididymovasostomy on each side, or one of each, sperm returns to the ejaculate just as it was prior to the vasectomy, restoring the possibility for natural conception.
What’s recovery time like?
Recovery time for a reversal on average is about a week, so I have patients take a whole week off of work. This is about twice as long as it is for the original vasectomy.
What risks and complications are possible?
Vasectomy reversal is not only highly effective but also very safe. The complication rate is less than 1 percent and primarily includes minor complications such as swelling, bruising and discomfort that improve with time.
How long will a couple have to wait to get pregnant after a vasectomy reversal?
Pregnancy can be a complicated issue with a lot of factors influencing success.
Excluding fertility issues that might be present independent of the vasectomy, a typical time to pregnancy can be between six to 12 months after the reversal.
The earliest I’ve seen is the first month after the procedure.
What are the most important factors in finding a surgeon for a vasectomy reversal?
The training and experience of the surgeon are the most important factors. A surgeon who did residency training in urologic surgery followed by a fellowship in male reproductive medicine and surgery is ideal. The fellowship aspect is incredibly important because that is the time when a surgeon learns and develops the skill to operate with a microscope. The use of the operating microscope is of utmost importance with vasectomy reversal surgical success. Additionally, the ability to perform the more complicated epididymovasostomy is almost exclusively performed by surgeons who were fellowship-trained in male reproductive medicine and surgery. Since it’s required in about 25 percent of cases, the ability to perform epididymovasostomy if necessary greatly improves the chances of success.
A surgeon physically located within a fertility clinic affords a couple the unique flexibility to learn about all of the alternatives, such as IVF, as well as to bank sperm during the procedure.
If a man gets a vasectomy reversal, can he then get another vasectomy later in life?
Yes, the vasectomy can be redone, and it’s very similar to the original vasectomy. A no-needle, no-scalpel vasectomy is often still possible. Redoing vasectomies after reversals is actually quite common, and something I have done for a number of my patients who have had successful reversals.
Why do only 5 percent of men get their vasectomies reversed?
That number might seem high or low depending on how you look at it. When I perform a vasectomy, I always hope that decision is permanent. However, people change their minds about 5 to 10 percent of the time. Every patient who desires a reversal doesn’t follow through with it because a reversal can be expensive and is typically not covered by insurance. Lastly, there are a few alternatives to growing a family that should be considered.
What alternatives should a couple consider?
The other main option would be surgical sperm retrieval combined with IVF. It’s minimally invasive with a recovery time very similar to the no-needle, no-scalpel vasectomy—about three or four days. Aside from vasectomy reversal, this is one of the most common procedures that I perform.
It’s done with a tiny incision on one side of the scrotum that’s performed in the office at UNC Fertility with either oral sedation and local anesthesia, or with a type of deep sedation some call “twilight” anesthesia. The procedure takes less than an hour and has success rates approaching 100 percent. That means that in our experience at UNC Fertility to date, 100 percent of vasectomized men who have had this procedure have had sperm successfully retrieved and banked. But, of course, you can never make a guarantee of 100 percent for an individual patient.
It should also be noted that whenever we do a vasectomy reversal, we also recommend to retrieve sperm and bank it while we are there. We do this just in case the reversal is not successful, which happens about 5 percent of the time.
After sperm is surgically extracted, the sperm is frozen until the couple is ready to undergo IVF. This is a process performed by my colleagues at UNC Fertility who treat female infertility, in conjunction with our outstanding IVF laboratory and andrology and embryology staff, with whom I work closely.
Aside from vasectomy reversal or surgical sperm retrieval with IVF, some couples may consider donor sperm or adoption.