Vasectomy Reversal

Only approximately 1% of US urologists hold the distinction of having completed a microsurgical fellowship in male fertility.

More specifically with regards to training, important points for patients to consider include:

1. The surgeon had primary training in urologic surgery
2. The surgeon had fellowship training in male reproductive medicine and surgery (also known as male infertility)
3. The surgeon can perform either type of reconstruction required for reversal, vasovasostomy, and epididymovasostomy
4. The surgeon performs the procedure using an operating microscope.

Searching online for a vasectomy reversal surgeon yields doctors of varying specialties sometimes without microsurgical or male infertility fellowship training that can be found advertising the procedure, often with fancy websites highlighting testimonials and attractive pricing. The old saying “You get what you pay for” applies for all types of elective surgery, vasectomy reversals included. The main cost-cutting maneuver involves attempting the procedure in the clinic without the use of general anesthesia, and occasionally even without the use of an operating microscope. This costs the patient a little less, but because it reduces overhead, it allows the surgeon to actually collect more on the procedure. By performing the procedure in the office, the outcomes are thus generally worse for several reasons. General anesthesia is not only safer, but it allows the patient to be completely asleep without any pain. General anesthesia also keeps the patient completely still while the surgeon operates with the microscope, as any small movements can compromise the results.

There are ways to offer a prediction prior to surgery for which may be required, and this prediction is based on time since vasectomy and certain aspects of the physical examination of the vasectomy sites and the testicles. The initial consultation with the surgeon should provide some realistic chances of each type based on the particular patient’s history and physical examination. However, the surgeon will only find out for sure which procedure will be required during the middle of the operation, after examination of the fluid in the vas deferens with a separate microscope in the operating room.

Vasovasostomy

The simpler, more common, and more effective approach is called vasovasostomy. With this procedure, a reconnection of the vas deferens tube right at the site of the previous vasectomy is performed. This can only be implemented if the fluid in the vas deferens has a favorable quality and is found to contain sperm. The surgeon then removes the vasectomy site and reconnects the two ends in two layers with sutures that are so tiny they are barely visible to the naked eye. In these cases, if one side is a vasovasostomy, the procedure’s overall success rate for sperm to return to the ejaculate is usually over 90%.

Epidiymovasostomy

The more difficult method of reconstruction, which not all surgeons are trained to perform, is called epididymovasostomy. This becomes necessary if the fluid quality is not favorable, and/or if there is no sperm present. Epididymovasostomy is more common in patients with longer vasectomy intervals. This situation indicates that a secondary blockage may have developed in the more proximal, delicate tubules of the epididymis where the sperm maturate on their way to the vas deferens. This secondary blockage is often called an epididymal blowout, due to prolonged backpressure in the system. During the epididymovasostomy procedure, a “bypass” is performed by re-attaching the vas deferens from above the vasectomy site down directly to the epididymis, effectively bypassing the secondarily obstructed part of the epididymis. The likelihood of needing an epididymovasostomy increase as the time since vasectomy increases, particularly if the time is greater than 10 years. The success of epididymovasostomy is, on average, 50-60%. The reason for the lower success is the delicate nature of the reconnection, which is recognized to be the tiniest reconnection of any two structures in the human body able to be performed through modern surgical techniques. Therefore, because epididymovasostomy has slightly lower success rates, the general success rates of vasectomy reversal decline the farther out a man is from his initial vasectomy. The good news is that most men have two testicles, and therefore two separate procedures during a vasectomy reversal, and two chances for success.

Sperm recovery rates for the current techniques of epididymovasostomy are approximately 80% at best, usually approximately 60%, with a lower pregnancy rate of approximately 20-40%. These numbers are derived from studies where patients had undergone bilateral (both sides) vasovasostomy or bilateral epididymovasostomy. Because most vasectomy reversals involve procedures on two testicles, if the procedures performed are ultimately a vasovasostomy on one side and epididymovasostomy on the other side, the sperm recovery rates generally reflect the higher rates of a vasovasostomy.

It is best to take between 1-2 weeks off of work, depending on how physically demanding the job. Strenuous, physical, and sexual activity should be avoided for two weeks. For several days after the procedure, scrotal support is necessary, and pain medication may be required. The pain experienced for the first 1-2 days may be best relieved by pain medications, intermittent ice packs, and some extra couch time, as a mild amount of swelling and bruising is common. There will be two incisions on either side of the scrotum, with skin stitches that reabsorb on their own in about 2 weeks. There are no dressings or special care needed for the incision.

For a nominal increase in the cost of the procedure, and no additional risk, sperm are obtained during the reversal procedure to be cryopreserved (frozen). This sperm would only be later necessary in the event of a failed reversal, in which case there would be enough frozen sperm to proceed to IVF without an additional sperm extraction procedure.