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Vasectomy Reversal

Although a vasectomy is carried out for permanent contraception (birth control), it is not unusual for a man to request its reversal.

Sperm flows from the testicles into a long thin tube (epididymis) which coils up around the back of the testis. Close to the bottom of the testis the tube becomes thicker, more muscular, and straightens to become the vas deferens. The vas deferens then runs to the urethra (urinary passage) and conducts sperm at the time of ejaculation.

Vasectomy is a minor procedure in which the vas deferens on each side of the scrotum (the "sac") is divided and blocked. When the vas deferns is blocked after a vasectomy, the ejaculation fluid (semen) is free of sperm and the egg produced by the woman cannot be fertilized to start a pregnancy.


After a vasectomy, the testicles continue to produce sperm. The unused sperm degenerate and are absorbed by the body. A vasectomy reversal (also known as a vasovasostomy) aims to reconnect the two ends of the vas deferens so that sperm can once again be mixed to the semen. Achieving a pregnancy after a vasectomy reversal may be more difficult than before the vasectomy due to a number of factors. In some cases, scarring of the vas deferens or epididymis, or changes in sperm quality may occur after the vasectomy. The longer the interval from the vasectomy to its reversal, the less likely a pregnancy can be achieved.

Success rates for vasectomy reversal vary depending on many factors, including your partner`s fertility and time from vasectomy. Your urologist has discussed the potential of recovering your fertility.

The ability to restore sperm in your semen is very high after a vasectomy reversal and the pregnancy rates are good when the reversal is done within 3 years of the vasectomy. However, the success of the procedure drops significantly after 9 years.

Vasectomy reversal is not normally covered by health insurance companies. The discussion with your urologist will have included information about success rates and costs. As well, there are alternatives to vasectomy reversal including adoption, use of donated sperm and assisted reproductive techniques (ART). ART may involve sperm being taken from the testis and injected into an ovum (egg) taken from the ovary of your partner. The costs of ART may be considerable with modest success rates.

The procedure


The vasectomy reversal will be carried out as a day case procedure. The surgery is often done under general anaesthesia and the patient is asked to have nothing to eat for six hours before your surgery.

In the operating room one or two incisions will be made in the scrotum or the suprapubic area. The incision is usually longer than the original vasectomy incision in order to expose both cut ends of the vas deferens to adequately rejoin them.

During the surgery the urologist will determine if the vas deferens is in satisfactory condition to permit adequate flow of sperm through the rejoined tube. The two healthy ends of the vas above and below the obstruction will be joined. The procedure can take 2-4 hours given its intricacy and the common use of magnification.

Occasionally, the vas deferens is too scarred to permit effective sperm flow. In this case, the urologist may need to bypass this scarred part of the tube and connect one end of the vas deferens directly to the epididymis. This type of surgery, called a vaso-epididymostomy is more technically challenging, with a lower success rate.


After the procedure

One should be accompanied home after your vasectomy reversal and you should not drive for 24 hours until the anaesthetic has completely worn off. One should avoid strenuous physical activity, heavy lifting, or exercise for about one week. Any strain may cause bleeding or swelling of the scrotum. Application of an ice pack intermittently after the procedure will minimise pain and swelling. Pain is usually adequately controlled with over-the-counter pain killers (neurofen). One may need a prescribed painkiller that can be used as required for a few days after the surgery.

Most men have no problem after a vasectomy reversal. There is a small risk of infection requiring treatment with antibiotics. Occasionally, men have scrotal pain that persists for a few weeks or months. Over time, this usually resolves completely without specific treatment. Normally, a small lump will persist at the site of the vasectomy reversal. A vasectomy reversal should not affect your sexual function nor will you notice any change in your semen.

Sexual activity should be postponed for several weeks after the vasectomy reversal. Sperm may return to the semen immediately after the procedure. The urologist will advise the optimal timing of intercourse to achieve a pregnancy. This occurs around the mid-point of your partner`s menstrual cycle, when ovulation (egg release) occurs.

There is often a significant delay in the appearance of large numbers of sperm in the semen after a vasectomy reversal. If the semen tests show large numbers of healthy sperm, the possibility of pregnancy is good. Unfortunately, restoring sperm to the semen after vasectomy reversal does not always result in a pregnancy.

Many couples have achieved pregnancy following vasectomy reversal.

Vasectomy Reversal:Vasovasostomy and Epididymovasostomy Details

Vasectomy reversal is receiving increasing attention in urologic practice. The most common situation involves the remarriage of a man who has previously had a vasectomy and now desires additional children. Vasectomy reversals are also requested by couples who have long-standing marriages but simply have decided to have additional children. Fortunately, microsurgery has advanced significantly in the past several years so that reversing a procedure once thought of as permanent is now highly possible.

Vasectomy reversal: Outpatient Procedure

Vasectomy reversal can generally be performed on an outpatient basis, allowing the patient the opportunity of returning to his home or a nearby hotel rather than having to stay in the hospital. This saves considerable expense and makes the overall experience much more pleasant.
Operating time for a vasectomy reversal typically ranges from 2 to 4 hours, depending on the complexity of the surgery. A general anesthetic is usually used. It is recommended that out-of-town patients stay in Athens one day following surgery prior to returning home. Post-operative care should include an office visit two or three weeks following surgery to evaluate the healing process and a semen analysis at six weeks. Monthly semen analyses are then obtained for approximately 4-6 months or until the analysis results stabilize.

Vasectomy Reversal Success

It should be remembered that much of the success of a vasectomy reversal depends on two factors: (1) the skill and experience of the surgeon and (2) the findings at the time of surgery. Regarding surgical skills, the individual who operates more frequently will certainly increase his technical expertise. State-of-the-art vasectomy reversal involves the use of microsurgical techniques to reconnect the vas deferens, allowing return of sperm to the semen. The use of a surgical microscope allows the surgeon to use suture material so tiny that it is difficult to see with the naked eye.


Return of Sperm and Pregnancy Success

As mentioned previously, one important factor in determining a successful outcome is the surgical findings. When the vas is opened, fluid will flow from the testicular side of the vasectomy site. If sperm are present, then we expect roughly 90% of patients to have return of sperm with an associated 60% to 70% pregnancy rate. If no sperm are present but the vasal fluid is clear and free-flowing, then the likelihood of a successful outcome decreases somewhat with the chances of subsequent pregnancy being about 40%. If sperm are not identified and the fluid that is found is thick and pasty, then a connection of the vas to the epididymis (the gland that collects the sperm from the testis) should be performed. This procedure yields a successful outcome in approximately 30% to 40% of cases. The procedure wherein the vas deferens is divided above and below the site of the previous vasectomy and then reconnected is termed a vasovasostomy. When the vas deferens must instead be connected to the epididymis, the procedure is referred to as an epididymovasostomy.


Vasovasostomy

There are a variety of techniques available for vasectomy reversal. In all cases, the surgeon’s goal is to obtain precise alignment of the ends of the vas deferens and achieve a watertight closure. Attention to these details will help prevent scarring and obstruction of the repair. The use of an operating microscope greatly facilitates the achievement of a satisfactory result.
The two most widely accepted techniques for vasectomy reversal are the so-called modified two-layer closure and strict two-layer closure.


Modified two layer closure

 


Figure 1: Vasovasostomy Modified Two-Layer Closure
In the first technique (shown in Figure 1), four to six microscopic sutures are placed through the full thickness of the vas deferens to align the inner aspect (lumen) of the two cut ends. A series of sutures are then placed in the outer layer of the two ends to prevent sperm leakage and potential scarring or breakdown.


Strict Two-Layer Closure


In the strict two-layer closure (figure 2), multiple sutures are placed in the inner aspect of each end which do not pass through the full thickness of the vas deferens.

Figure 2
Vasovasostomy Strict Two-Layer Closure
A separate layer of sutures are then used to close the outer surface as illustrated in Figure 3.


Figure 3
Results gathered from a large series of vasectomy reversals do not show a clear advantage of one technique versus the other. The choice of technique depends largely on the performance of the surgeon as well as the condition of the vas deferens at the time of surgery.


Epididymovasostomy

Experience has shown that if the vasal fluid contains no sperm and is thick and pasty, simple reconnection of the vas deferens will often meet with poor results. In this situation, the surgeon should be prepared to connect the vas directly to the epididymis (epididymovasostomy). In this procedure, the epididymis is explored and when sperm are identified, the cut end of the vas is sutured to the epididymis at that point using a microsurgical technique. Epididymovasostomy is a very technically demanding procedure and generally is only undertaken by experienced micro-surgeons.


Figure 4
Regardless of the technique used for vasectomy reversal, careful attention to detail is vital to achieving a successful outcome. As more is learned about this procedure as well as the entire field of male reproduction, the prospect of reestablishing fertility following a vasectomy is constantly improving.
In performing a vasectomy reversal, a vertical incision is made on each side of the scrotum. Holding sutures are placed in the tissue surrounding the vas above and below the site of the previous vasectomy, and the vas is divided at those two points. The limb of the vas leading to the urethra is irrigated with saline to insure that it is not obstructed. Fluid from the limb of the vas leading from the testicle is then examined microscopically for the presence of sperm. As mentioned before, the presence of sperm in this fluid indicates an improved prognosis. The vas ends are then brought into position near each other with a holding suture and joined using the microsurgical suture technique described earlier.
Homecare Following Vasectomy Reversal

Please follow the directions below after your procedure:

  • Remove all dressings from inside the athletic supporter, leaving 1-2 gauze pads for 24 hours after surgery. Continue to use scrotal support or snug underwear for 2 weeks. It is common to have a small amount of bleeding at the incision site for a few days following this surgical procedure.
  • The stitches used to close your incision do not need to be remove, they will absorb on their own within two to three weeks.
  • Apply ice packs to the scrotum for 15 minutes on and 15 minutes off tonight and tomorrow. (A bag of frozen peas makes a great ice pack for this purpose.)
  • You may shower after 48 hours but avoid vigorous scrubbing of the incision site.
  • A prescription has been given to you to alleviate pain. Take this medication as directed. Two days after your surgery acetaminophen or ibuprofen should be enough to relive your discomfort. These are non-prescription medications.
  • A normal well-balanced diet can be resumed when you return home. Make sure to include lots of fluids.
  • Normal, non-strenuous activity can be started again after 48 hours or when you feel "up to it". If any activity causes discomfort, do not continue. Wait to resume such activities as weight lifting and jogging until two weeks following surgery. Avoid bicycling or horseback riding for 6 weeks post-operatively.
  • Try to stay away from work for a week. This is encouraged but is not mandatory.
  • Avoid sexual intercourse for 14 days following surgery.

When to Call the Doctor After Your Vasectomy Reversal
If you notice any of the following symptoms:

  • Unusual amount of pain
  • A large swelling in the scrotum
  • Redness or drainage from one or both of the incision sites.

Follow-Up After Your Vasectomy Reversal
Return for an office visit for an examination about 2 to 4 weeks following surgery and again in 4 to 6 weeks for your first post-operative semen analysis.

Attention! The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with your physician for further evaluation.

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