Vasovasostomy (Vasectomy Reversal)
Introduction
Approximately 500,000 men annually elect to undergo a vasectomy. A vasectomy involves the severing of the vas deferentia, which are the tubes that lead from the testicles and epididymides, where sperm is created and stored, to the prostate. It is from the prostate that semen is expelled upon ejaculation. By cutting the vas deferentia, sperm are unable to travel to the prostate and be expelled, rendering the man sterile.
It is currently estimated that 5% of the 500,000 men annually who have undergone a vasectomy will eventually want a reversal surgery. The leading reason that men elect to have vasectomy reversal is to father a child after remarriage or after the death of a child. The procedure is performed by a highly experienced microsurgeon under an operating microscope using microsutures.
The chance for conception following reconstructive surgery depends on many factors. The most important factor is the age and fertility status of the female partner. Identifying and treating reversible conditions may improve the male partner's fertility and allow for conception through natural intercourse. Many complex factors, on the other hand, go into the decision to use microsurgical reconstruction of the male reproductive system via sperm retrieval with ICSI.
Microsurgical reconstruction of the male reproductive system often is more cost effective than sperm retrieval with IVF/ICSI. Microsurgical reconstruction allows couples to have subsequent children without additional medical treatment, whereas in others there are situations in which sperm retrieval with IVF/ICSI is a more effective choice. For example, couples with both severe male- and female- factor infertility are usually better treated with sperm retrieval and ICSI. The fertility status of the female partner is another important consideration, especially her age. Although individuals vary greatly, a woman's fertility begins to decline after the age of about 35. This means that the chance for success with both microsurgical reconstruction and sperm retrieval with ICSI decreases with increasing female partner age, especially beyond age 37.
It is important to understand that after a successful microsurgical vasectomy reversal, the average interval until pregnancy is about one year while a successful ICSI cycle pregnancy occurs within one to two months of starting hormonal therapy. The choice of either sperm retrieval with IVF/ICSI or microsurgical reconstruction should also be influenced by the pregnancy
rates achieved with ICSI by the IVF laboratory with which you are working in the local community.
Procedure: Vasovasostomy vs. Vasoepididymostomy
The vasovasostomy is the procedure most commonly referred to as a “vasectomy reversal.” This entails using microsutures to re-connect the severed ends of the vas deferentia. Occasionally the more complex vasoepididymostomy is required, in which the vas deferentia are re-attached directly to epididymides. At the time of the surgery, the doctor determines which procedure is necessary after excising the scarred ends of the vas deferens closest to the testicles and examining the fluid therein under a microscope. If sperm is present, a vasovasostomy is performed. A lack of sperm in the fluid indicates a blockage or rupture to the epididymal tubules, and a vasoepididymostomy is required. This involves attaching the vas deferens directly to the epididymis at a site that will allow sperm to flow, bypassing the blockage.
In either case, a 1-2 inch incision is made on either side of the scrotum. The
sutures will not need to be removed, as they will dissolve.
The procedure lasts approximately 4 hours.
General anesthesia is used.
Recovery & Post-operative Care
The procedure is performed at an outpatient center. Two days should be allowed for recovery. Normal sexual activity may be resumed after approximately 3 weeks of recovery. Strenuous activity can be resumed after 4 weeks.
After the procedure, slight swelling, discoloration, and discomfort in the scrotal area are to be expected, in conjunction with aching and nausea immediately after the procedure due to the anesthesia. Pain medication will be prescribed for the first two days following surgery, after which ibuprofen or acetaminophen should be sufficient.
It is recommended that ice packs be placed on the scrotum for approximately 10 minutes every half-hour for the first day in order to reduce pain and swelling.
A post-operative appointment will be scheduled 10-14 days after the surgery to ensure healing is proceeding as expected.
Microsurgical Sutures
It is with extreme precision that two layers of different-sized microsurgical sutures are used to attach the walls of the lumen of the vas deferens, which has a radius about the size of a pen-dot (0.2-0.3mm). The inner layer consists of the smaller sutures, while the outer layer consists of slightly larger sutures, sealing together the muscular walls of the vas deferens. This double-layer effect ensures that the tubes are "sealed" together. None of these sutures will need to be removed.
Regaining Fertility
The average time from surgery to conception is 12 months. One to two months after the surgery, a semen analysis is obtained to test for the presence of sperm. Analyses are repeated at 2-3 month intervals to track improvement in semen analysis parameters as the internal swelling decreases. If the surgery was successful, sperm should be present by 6 months.
After a vasovasostomy, good sperm count with poor motility can be expected after approximately 3 months. Parameters should continue to improve with time. Improvement after a vasoepididymostomy usually requires an additional 1-2 months of healing for sperm to appear in the ejaculate. Sperm should certainly be present after 18 months.
It is possible that after a successful procedure that the quality of the semen analysis parameters could decline. Ten percent of vasovasostomy and 20 percent of vasoepididymostomy patients experience this deterioration, most likely due to the build-up of scar tissue. It is for this reason that sperm banking should be considered.
Success Rates
With recent advances in microsurgical techniques, instruments and suture materials, success rates have increased dramatically. Following microsurgical vasovasostomy, sperm appears in the semen in approximately 70 to 95% of men and pregnancy without assisted reproductive technology occurs in 30-75% of couples.
While the interval between the vasectomy and the reversal is correlated with success rate, there is no “cut-off” date for a reversal. Men with intervals greater than 15 years have undergone the procedure with success. |