VASECTOMY REVERSAL
Men have a variety of reasons for seeking a reversal of their vasectomy. Changing life circumstances with the same or a different partner is the most common. For some men, religious beliefs or relieving scrotal pain play a role in making the decision.
In most cases, a vasectomy reversal is the best available first option for a couple interested in having a child after the man has undergone a vasectomy. It is the most natural, least invasive and most cost-effective method of producing a pregnancy. If successful, the man's sperm may be of adequate quantity to allow for natural conception. If this does not occur, there may be adequate sperm for the ejaculate to be processed and placed inside the woman's uterus (intrauterine insemination or IUI). This may be done without the woman taking fertility medications (either by mouth or injection). The alternative to vasectomy reversal is sperm retrieval combined with in-vitro fertilization. This is more invasive and expensive, and the woman must undergo this process each time a conception is attempted.
There are, however, certain situations where reversing a vasectomy
is not the preferred method of producing a pregnancy. A woman who would need IVF in any event (e.g., her tubes are completely blocked) would be a typical example of a patient for whom another avenue would be appropriate. Another example would be an older woman who is nearing the end of her reproductive life cycle and may not want to wait the 4 months to a year it may take for the sperm to come through to the ejaculate after a vasectomy reversal.
Vasectomy Procedure
To understand this procedure, you must first understand some basic anatomy in the region in which the procedure is done. The sperm are made in the testes (testicles). They then travel and are collected into a structure outside the testis called the epididymis. The epididymis is a thin, walled tube that runs down the center of the back of the testis. As it gets closer to the bottom of the testis, the epididymis becomes thicker and straighter. Eventually, when it reaches the scrotum, it straightens out completely and becomes quite thick.
This is the vas deferens and this is the tube that carries the sperm.
When a physician performs a vasectomy, he is not affecting sperm production, just the flow of the sperm to the testes. He is cutting the vas deferens, the tube that carries the sperm. The inside of the tube is often sealed and the two ends tied and buried at different levels in the scrotum so that they cannot reconnect themselves. A few doctors may specifically damage the epididymis, although this is unnecessary and inadvisable as it makes the
possibility to reverse a vasectomy
much more difficult.
When a man ejaculates, he pushes out fluid containing mature sperm. However, most of the fluid that he ejaculates comes from organs other than the testicles (the prostate, seminal vesicles, bulborethral glands). The fluids do not contain sperm. This is why men who have had a vasectomy still have normal ejaculation with significant fluid. However, there are no sperm in it.
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Vasectomy Reversal Unlike a vasectomy, a vasectomy reversal is a very complicated and time-consuming operation requiring very specific expertise. It is performed under an "operating microscope," a microscope that stands over the patient.
During the procedure, the physician looks through the microscope at a highly magnified view. This allows him to manipulate the small, fine instruments by hand.
In theory, a vasectomy reversal should merely involve reconnecting the two ends of the vas deferens that were cut during the vasectomy. This, in and of itself, is a difficult process because of the minute scale. The diameter of the vas deferens is approximately the width of a piece of spaghetti and the threads (sutures) are finer than a human hair.
However, the procedure is further complicated by the fact that, over time, pressure builds up in the area where the sperm and fluid are being produced in the testicles but cannot be released. This pressure may cause the epididymis, which is very thin walled, to leak and scar, creating a blockage closer to the testis. If the two disconnected ends of the vas are reconnected but there is scar tissue and blockage at the level of the epididymis, the sperm will not be transported out and the vasectomy reversal will not be successful. It is, therefore, critical that during the course of the procedure the surgeon assess if this type of scarring and blockage has occurred and operates accordingly.
Therefore, the microsurgeon's first job in the operating room is to evaluate at what point whole sperm appear in the vas deferens. The microsurgeon generally begins at the very end of the vas deferens and makes minute incisions sequentially, back toward the testicle, and evaluates the quality of the sperm and fluid found there using a separate, high-powered microscope also present in the operating room. The sperm quality is generally categorized into 5 grades:
mainly normal motile sperm
mainly normal non-motile sperm
mainly sperm heads, without tails
only sperm heads
no sperm
The point at which the microsurgeon will usually make the reconnection (or anastamosis) is the first point at which fluid with sperm in it or fluid that, due to its color, indicates there is no blockage closer to the testicles is found. If there are whole sperm or if there is a certain quality to the fluid, then a vas-to-vas connection or anastomosis may be made. This is called a vasovasostomy. If there are no whole sperm and there is thick white fluid, the vas should usually be connected to the epididymis at the level above the blockage. This is called a vaso-epididymostomy.
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No unusual preoperative tests are needed before a vasectomy reversal. Hospitals, ambulatory surgery facilities, or anesthesiologists may require standard tests. A vasectomy reversal can be done using local, regional, or general anesthesia and the choice of anesthesia depends on the patient's and the surgeon's preference. Local anesthesia is administered by infiltrating the drug through the spermatic cord and through the tissue immediately above the vasectomy site.
For reasons that have not been clearly determined by medical science, it may take you a long time to see resulting sperm, even when the reversal is successful. The success of the procedure cannot be judged until an entire year has passed from the surgery. However, the semen analysis is checked during this period to see at what point there is sperm and to determine its quality. Many men who have a vasovasostomy (vas-to-vas connection) will see sperm fairly soon after the operation. Other men, especially those who have had vaso-epididymostomies, may need to wait a full year.
The chances of resulting sperm in the ejaculate after a vasectomy reversal are excellent. Although this does not guarantee pregnancy, the chances of a subsequent pregnancy are still high. However, the chance of pregnancy declines with increasing time from the reversal procedure.
If a vasectomy reversal was performed less than 3 years after the vasectomy, the man has a 97% likelihood of having sperm in the ejaculate and the couple has a 76% chance of becoming pregnant. At 3 to 8 years, 88% of the men will have sperm and 53% of the couples will become pregnant. At 9 to 14 years, 79% of the men will have sperm and 44% of couples will become pregnant. If a vasectomy reversal was performed over 15 years after the vasectomy, 71% of men will have resulting sperm and 30% of the couples will become pregnant.
Keep in mind that the sperm produced from the resulting vasectomy reversal can also be used with additional assisted reproductive techniques to significantly increase the chances of a pregnancy.
Some patients may have had an unsuccessful vasectomy reversal and still may be potential candidates for another vasectomy reversal. Sometimes, the first vasectomy reversal is unsuccessful because the connection, “vas-to-vas”, was not made appropriately or because microsurgical techniques were not applied correctly. Patients who are candidates for a second reversal procedure are those who have high quality fluid (in sperm count or color) somewhere in the vas or epididymis and those whose surgery was very close to the head of the epididymis. In these cases, when the process is repeated, the rate of conception is still considered high enough for a patient to seriously consider undergoing a second procedure.
However, some patients may not be good candidates for a second reversal attempt. The second time the procedure is attempted may be more difficult because there is more scar tissue after the first operation. Also, there is less vas left on the urethral side and the connection must also be made closer to the testes on either the vas or the epididymis. Re-operating is not always possible and depends on the level where the initial reconnection was made and how much scar tissue can be anticipated.
The longer the wait after a vasectomy, the higher the likelihood is of scarring and blockages. Also, often after a long-standing vasectomy, men will develop sperm antibodies, an immunologic response to their own sperm. These antibodies can make fertilization more difficult despite adequate numbers of sperm. A laboratory specializing in fertility testing can check for their presence and, if found, the man can be treated accordingly. Particular situations need to be discussed with a specialist who can review all the relevant information in your circumstances.
Many patients ask whether or not they should have their physician aspirate (remove) the sperm from the epididymis for in-vitro fertilization (IVF) and skip a vasectomy reversal. Although there are cases when sperm aspiration is necessary, it is not a recommended first step for most couples.
Sperm can be procured directly from the testis, from the epididymis, or from the end of the vas, and then used to inject into a partner's oocytes (eggs). However, only small quantities of sperm can be harvested this way. Aspirated semen tends to have low numbers of motile sperm and generally commits women to a full cycle of IVF for every attempt at pregnancy. This means that each attempt at fertilization requires that the oocytes(eggs) be removed from the man's partner. This involves a series of injections, ultrasounds, and a procedure to remove the eggs. Usually this is done through the vagina under anesthesia. The pregnancy rate for this procedure is very high, but it does involve a fair amount of cost and intervention.
There are certain situations where this is clearly the preferred method of producing a pregnancy. A woman who would need IVF in any event (e.g., her tubes are completely blocked) would be a typical example of a patient for whom a sperm retrieval technique would be appropriate. Another example would be an older woman who is at the end of her reproductive life cycle and may not want to wait the 4 months to a year it may take for the sperm to come through to the ejaculate.
If, however, a woman knows she will not need IVF independently, then a vasectomy reversal is a better first option than sperm retrieval. The man's sperm will generally be of better quality and quantity and she can try to get pregnant during mass cycles without having additional costs. In most cases, a vasectomy reversal is the most natural, least invasive and most cost effective method of producing a pregnancy. Before a man undergoes a vasectomy reversal, his woman partner should undergo a gynecological evaluation to assure that she has adequate fertility potential.
A vasectomy reversal is a more significant surgery than the vasectomy, and you will usually have some modest discomfort. You will need to wear a scrotal support for several weeks afterward, and excessive lifting, straining, or intercourse will be prohibited for approximately 6 weeks following the surgery.
The doctor may prescribe antibiotics, but they are optional and are not always necessary as it is rare that infection develops. If pain occurs, oral analgesics can effectively be prescribed.
Semen analyses should be obtained every 6 to 8 weeks, until sperm concentration and motility are substantial or until a pregnancy occurs. When concentration and motility of sperm become normal, analyses should still be obtained every 4 to 5 months to ensure that they remain normal. This type of seminal monitoring assures that there has been no delayed obstruction due to scar tissue formation (i.e. occurring after the return of sperm). Obstruction as a complication of surgery may be experienced by 3% to 6% of patients.
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Often, patients will choose to bank sperm. If, over the course of the next year, they find that the vasectomy reversal was not successful, the banked sperm can be used for IVF. That is, the banked sperm can be injected directly into eggs that are harvested from the partner; the male partner does not have to undergo an additional procedure at that time to procure sperm. As banking sperm can be fairly expensive, you will need to decide in advance of your procedure whether or not you want your sperm banked. If you do decide to have your sperm banked, your surgeon will evaluate your sperm during the surgery and decide if the sperm can be banked, and if so, from what exact location he has the best chance of harvesting viable sperm. For example, if the surgeon finds motile sperm during a vasovasostomy, it can be banked and used directly for the IVF. If there are no motile sperm, then a testicular biopsy may also simultaneously be performed to obtain sperm for potential later use.
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When choosing your surgeon, you need to look for two areas of proficiency. The surgeon must have significant expertise in microsurgery (a very specialized field of surgery) as well as a sophisticated knowledge of the field of male infertility. This will allow him not only to conduct the appropriate type of surgery most effectively, but also allow him to analyze sperm, recommend treatment, and work with the female's infertility specialist.
Microsurgery is a highly-specialized field and microsurgical techniques and tools vary greatly from techniques used in general urologic surgery. The surgery is performed under an "operating microscope," a microscope that stands over the patient. The physician looks through the microscope at a highly-magnified view during the entire procedure, and this allows him to manipulate the incredibly small and fine instruments by hand. To visualize the minute size, you might imagine connecting a piece of spaghetti (the vas deferens) to wet tissue paper (the epididymis) with a piece of hair (the suture).
It is also critical that urologists performing the surgery have significant ongoing experience with this particular procedure. They need to be capable of evaluating the sperm quality at various points and determining where the most effective reconnection can be made. As part of their specialized training, specialists in male infertility obtain an expertise in microsurgery from exposure to a large number of varied cases during an extended training.
Your physician should also specialize in male infertility. This will enable him to assess your semen analyses over time and work effectively with your partner's physician to determine when and how the sperm should be used in order to achieve a pregnancy. For example, if low levels of sperm are obtained, this may be used with either an intra-uterine insemination or an IVF. If there are significant antibodies, intra-uterine inseminations may be considered. Ideally, your surgeon should not only be comfortable with the surgery but should also be comfortable with the field of male infertility and the interface between male and female infertility.
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